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Effective: December 1, 2006 |
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03.40.15ar1 - Mental Retardation and Related Conditions (MR/RC) (Archive) |
Archived: December 1, 2007 |
Certain people with mental retardation and related conditions (MR/RC) who are eligible for Medical Assistance (MA) may be eligible for additional home and community-based services if they:
l Use a disabled basis of eligibility for MA.
l Require a 24-hour plan of care.
l Choose to participate in the waiver program as an alternative to receiving care in an Intermediate Care Facility for the Mentally Retarded (ICF-MR).
There is no age limit for the MR/RC waiver.
Eligibility factors are listed below with any information that is unique for this group. Links to standard program guidelines are included as well.
Citizenship/Immigration Status.
Insurance and Benefit Recovery.
Relationship to Other Groups/Bases.
Other Groups/Bases to Consider.
Application Process (standard guidelines)
Follow standard MA guidelines.
The earliest possible begin date of MA without deeming parental or spousal income is the first day of the month in which waiver services begin.
Renewals (standard guidelines)
Follow standard MA guidelines.
The county case manager determines that the person has a diagnosis of mental retardation or a related condition and requires 24-hour care. MR/RC does not require that the person be certified disabled by the Social Security Administration (SSA) or State Medical Review Team (SMRT). The case manager’s waiver determination takes the place of the MA disability certification.
Note: This includes people who receive MA for Employed Persons with Disabilities (MA-EPD) concurrently with MR/RC.
Social Security Number (standard guidelines)
Follow standard MA guidelines.
Follow standard MA guidelines.
Residency (standard guidelines)
Follow standard MA guidelines.
MR/RC enrollees who are not eligible for the Medicare Savings Programs are not eligible for payment or reimbursement of Medicare premiums unless they also receive MA-EPD.
Note: MA-EPD enrollees must have income under 200% FPG to qualify for payment or reimbursement of Medicare premiums.
Household Composition (standard guidelines)
Determine whether the person is eligible for MA based on income and assets.
l The county agency must request written approval from DHS to disregard parental income and assets of waiver applicants under age 21 who live with their parents. If parental income makes the child ineligible or results in a spenddown, submit the "Request to Suspend Medical Assistance Deeming Rules" to DHS.
Note: Submit a separate request for DHS approval for each applicant child.
l Do not request a deeming suspension if the child is MA-eligible without regard to parental income due to receipt of Supplemental Security Income (SSI) or adoption assistance, or if total household income is below the MA standard for the household size.
n If the parents report income orally or on the HCAPP that is less than the MA standard for the household size, request verification and determine eligibility based on household income.
n If the parents report income orally or on the HCAPP that would result in a spenddown, do not request verification. Do not send a denial notice. Submit the request to suspend deeming based on the parents’ statement.
l Request a suspension of deeming for TEFRA children who transfer to the MR/RC waiver. Children cannot receive TEFRA and MR/RC at the same time.
l If the child is ages 18, 19, or 20, advise the client to apply for SSI.
n Do not deem parental income if the child meets all conditions for the waiver, since this determination takes the place of an SSA or SMRT determination. MA does not deem the income of the parents of disabled children ages 18 through 20.
n Do not submit the Request to Suspend Medical Assistance Deeming Rules.
l For married applicants, request suspension of deeming of spousal income (and assets for applicants age 21 and over). Note on the form that you are requesting suspension of spousal, rather than parental, deeming.
l If DHS grants the suspension of deeming rules or no suspension is needed, determine MA eligibility using a household size of one. Stop counting the parents’ (or spouse’s) income effective the first of the month waiver services begin.
l If the MA case is closed, the county agency must request a new deeming waiver from DHS if the family reapplies.
If the person is requesting retroactive MA for months before MR/RC services begin, follow standard MA household size and deeming guidelines for the retroactive months.
If eligibility for the Medicare Savings Programs is also being determined, follow the household size and deeming guidelines of the Medicare Savings Program for that program's eligibility.
Eligibility Method (standard guidelines)
Use Method B for assets and income.
Asset limit is $3000 (household size of one), except for:
l Children under 21, who have no asset limit.
l Adults who are concurrently eligible for MA-EPD; then follow the MA-EPD asset guidelines.
Note: When eligibility for a Medicare Savings Programs is also being determined, follow that program’s asset guidelines for the Medicare Savings Program eligibility.
MR/RC applicants and enrollees may transfer assets to their spouses without penalty. Asset transfers to others may be improper, and result in a period during which the client is still eligible for MA, but ineligible for MR/RC waiver services.
Income Guidelines (standard guidelines)
Income standard is 100% FPG.
Exception: If concurrently eligible for MA-EPD, there is no separate income limit. Follow MA-EPD income guidelines.
Exclude child support and RSDI payments received by or on behalf of children under age 18.
Follow standard MA guidelines.
Spenddowns/Premiums (standard guidelines)
If income is greater than 100% FPG, the person must spend down to 75% FPG. Use a monthly spenddown. Treat the cost of waiver services as a medical bill incurred on the first of the month. The MR/RC enrollee is responsible for payment of the spenddown amount.
Exception: If the person is concurrently eligible for MA-EPD, follow MA-EPD rules to determine the premium amount.
Covered Services (standard guidelines)
MR/RC funds the following services in addition to the standard MA services:
l Day training and habilitation services, including supported employment.
l Supported living services for children.
l Supported living services for adults.
l Respite care.
l Homemaker services.
l Environmental modification.
l Case management.
l In home family supports.
l Adult day care.
l Extended personal care attendant services after regular MA coverage is exhausted.
l Personal support.
l Assistive technology.
l Caregiver and consumer training, education, and community supports.
l Chore services.
l Specialist services.
l 24-hour emergency assistance.
MR/RC services are not available during a period of hospitalization or residence in an ICF-MR.
Service Delivery (standard guidelines)
Enrollees age 65 or older must enroll in managed care if they live in managed care counties.
The average statewide cost to MA for MR/RC services must be less than the cost of providing the care in institutional settings. DHS makes this determination by averaging the cost of services for all eligible people. This cost requirement does not apply to each individual who receives MR/RC services.
Note: If the child receives adoption assistance, either note that on the referral form or notify the DHS Parental Fee unit by other means. Parents of children who receive adoption assistance are not liable for parental fees.
Refer MR/RC enrollees under age 18 to DHS to determine and collect parental fees.
Note: If the child receives adoption assistance, either note that on the referral form or notify the DHS Parental Fee unit by other means. Parents of children who receive adoption assistance are not liable for parental fees.
Follow standard MA guidelines.
MR/RC enrollees who apply for Medicare Savings Programs must meet all requirements for those programs. Refer to the guidelines noted earlier in this section.
Not applicable.