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Effective: December 1, 2006 |
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23.30.05ar1 - LTCF, SIS-EW No Community Spouse (Archive) |
Archived: October 1, 2008 |
This section provides policy on when to begin or end using an LTC income calculation for a client residing in an LTCF or receiving Elderly Waiver (EW) services whose income is at or below the Special Income Standard (SIS) and who does not have a community spouse.
Note: A client without a community spouse receiving EW whose income is above the SIS does not use an LTC income calculation. A community income calculation is always used.
Reminder: Only a client who has established or anticipates establishing a Continuous LTC/EW Period may use a long-term care (LTC) income calculation to determine MA eligibility.
For more information on when to use a LTC income calculation, see Choosing the Appropriate Income Calculation.
Begin the LTC Income Calculation for the month following the month of one of the following:
l Admission to the LTCF or medical hospital.
l Receipt of SIS-EW services.
Note: Clients may receive the same services EW provides through another program, such as Alternative Care (AC), before they receive EW. In these circumstances the LTC income calculation cannot begin until the month following the begin date of services received under EW.
Use a community income calculation when determining eligibility for months prior to using the LTC income calculation.
Example:
Peter, a widowed client, enters an LTCF on December 3. His placement is anticipated to last four months. He applies for MA on December 12 and requests two months retroactive coverage.
Action:
Use a community income calculation for the months of October through December. Begin using an LTC income calculation in the month of January.
Example:
Theodore lives in the community and receives AC services. On September 15 his case manager determines he is eligible for EW. He applies for MA on September 20 and is approved on October 10 retroactive to September 1. His income is below the SIS.
Action:
Begin the LTC income calculation on October 1, the first calendar month after his case manager determined he was eligible for EW. Use a community budget and a monthly spenddown, if applicable, for September.
If a client is receiving MA with a six-month spenddown prior to using a LTC income calculation calculate a shortened spenddown for the months prior to the start of the LTC calculation.
Example:
Alfred is enrolled in MA with a six month spenddown. He is not married. His current certification period is May through October. On August 12 Alfred is admitted permanently into an LTCF.
Action:
Recalculate May through August with a shortened spenddown. Begin the LTC income calculation for September, the month following the month of admission.
End the LTC Income Calculation for the month before the month of one of the following:
l Discharge from the LTCF.
l End of SIS-EW services.
Redetermine eligibility for the remaining months of the certification period.
l Use a community income calculation for the month of discharge and after.
l Use a monthly spenddown for the remainder of the certification period if the client is determined to have a spenddown.
Note: If the client cannot meet a monthly spenddown, close eligibility with 10-day notice. This may give the client an additional month of eligibility without a spenddown.
Example:
Bertha has lived in an LTCF for nine months and does not have a community spouse. Her current certification period is June through November. She is discharged home on August 9.
Action:
The LTC income calculation ends in July. Begin using a community income calculation for August through November.
Bertha’s income is over the appropriate monthly income standard and has a spenddown. She does not have any anticipated medical expenses.
Action:
Bertha must use a monthly spenddown for the remainder of the certification period. Because Bertha does not anticipate medical expenses she cannot meet her spenddown. Close Bertha’s eligibility for September. Bertha will have MA eligibility for August without a spenddown.
When an LTCF or EW client dies, continue the LTC income calculation through the month of death whether or not there is a spouse.
It is very important to enter the exact date of death in the system. Claims may be rejected if dates on medical claims and the system date of death do not match.