MA Payment of Long-Term Care (LTC) Services (Archive)

People who request MA payment of LTC services must meet specific eligibility requirements before MA can pay for their LTC services. People who meet the eligibility requirements for MA payment of LTC services may be obligated to contribute income toward the cost of the LTC services they receive. The amount of income that a person is obligated to contribute to the cost of LTC services is based on either an LTC income calculation or a community income calculation. From these calculations it is determined if a person has an LTC spenddown, a medical spenddown The difference between a client’s net countable income and the appropriate FPG standard as calculated in a community income calculation. A client must have incurred medical expenses in an amount equal to or greater than the medical spenddown to become eligible for MA Medical expenses include reasonable and necessary medical expenses, services provided through a home and community-based waiver program, LTCF costs, and Medicare and other health insurance premiums., a combination LTC/medical spenddown The difference between a client’s long-term care (LTC) spenddown and the cost of the client’s LTC or Elderly Waiver (EW) services. A client must have incurred medical expenses, in addition to the cost of LTC or EW services, in an amount equal to or greater than the combination LTC/medical spenddown to become eligible for MA., or a waiver obligation The amount of income over the maintenance needs allowance that people eligible for SIS-EW must contribute toward the monthly cost of waiver services..

What are LTC Services?

Eligibility Requirements for MA Payment of LTC Services.

Chapter Overview.

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What are LTC Services?

LTC services include:

l  skilled nursing facility (SNF) care.

l  nursing facility care in an inpatient medical hospital.

l  intermediate care facility care (ICF, ICF/MR).

l  services covered by home and community-based waiver programs (CAC, CADI, DD, EW, and TBI).  

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Eligibility Requirements for MA Payment of LTC Services

People who request request MA payment of LTC services must meet the following specific eligibility requirements in order for MA to pay for those services.  

1. Meet all MA eligibility requirements, such as having countable assets within the asset limit, cooperating with third party liability requirements and documenting citizenship.

Note:  Refer to Asset Assessments for special asset rules that apply to the treatment of assets of a married couple when one spouse resides in an LTCF or requests home and community-based services through the EW program and has a community spouse A person who does not reside in a long-term care facility (LTCF) or receive services through a waiver program (EW, CAC, CADI, DD or BI) who is married to a long-term care (LTC) spouse. A community spouse may receive Medical Assistance (MA) or services through the Alternative Care (AC) program..

2. Need an institutional level of care A level of care that is equivalent of what would be received in a nursing facility, a hospital, or an intermediate care facility for the developmentally disabled (known as an ICF/MR).. Documentation of an institutional level of care depends on the client’s living arrangement or the home and community-based services waiver program that is being requested. If the person is:

n  residing in a long-term care facility (LTCF), he or she must have either received a Pre-Admission Screening (PAS) A screening to assess a person’s need for a nursing facility level of care required for all people entering a certified nursing facility, hospital "swing" bed, or a certified boarding care facility. or been determined to be exempt from the preadmission screening. An institutional level of care requirement has been met when a Physician’s Certification (DHS-1503) indicates that a screening has been completed or that a screening is not required.

n  requesting services through the CAC, CADI, TBI, or EW waiver programs, the person must have received a Long-Term Care Consultation (LTCC) A program to help people make decisions about long-term care and prevent inappropriate nursing home or boarding care placement. within the past 60 calendar days that demonstrates the person requires an institutional level of care and is anticipated to begin these services within the next 30 days. This information is indicated on the Lead Agency Case Manager/Worker Communication form (DHS-5181).

Note:  Make a referral to the county’s LTCC team upon receipt of a Minnesota Health Care Programs Application for Payment of Long-Term Care Services (DHS-3531) or a Minnesota Health Care Programs Request for Payment of Long-Term Care Services (DHS-3543) if the DHS-5181 has not yet been received.

n requesting services through the Developmental Disabilities (DD) waiver, the person must have a Full Team Developmental Disabilities (DD) Screening Evaluation of the level of care needed by a person who is assessed as being at risk of placement in an intermediate care facility for the developmentally disabled (ICF/MR), nursing facility, or is requesting residential, training and habilitation, or family support services.. Screening teams are convened to evaluate the level of care needed by a person with a developmental disability diagnosis when an assessment indicates the person is at risk of placement in an Intermediate Care Facility for the Developmentally Disabled (ICF/MR), nursing facility, or is requesting services in the areas of residential, training and habilitation, or family support. The full team DD screening takes the place of the LTCC. This information is indicated on the Lead Agency Case Manager/Worker Communication form (DHS-5181).

3. Have home equity of $500,000 or less unless an exception applies.

4. Name DHS a preferred remainder beneficiary of certain annuities owned by the person or the person’s spouse.

5. Not be subject to a transfer penalty.

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Chapter 23 Overview

l  Long-Term Care Consultation (LTCC).

Includes information on what an LTCC is, LTCC referrals and functions, and waiver program, Alternative Care (AC) and preadmission screening verifications.

l  Determining Which Income Calculation to Use.

Provides information to determine if a community income calculation or an LTC income calculation is used to calculate how much income a person must contribute toward the cost of LTC services. An explanation of the Special Income Standard (SIS) for the EW program is also discussed.

l  LTC Income Calculation.

Provides information to determine when to begin or end the LTC income calculation, what income is counted and what deductions are allowed in the LTC income calculation, and how to calculate community spouse and family allocations.

l  LTC Spenddowns and Waiver Obligations.

Provides information about LTC spenddowns, combination LTC/Medical spenddowns, and waiver obligations.

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