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Effective: December 1, 2006 |
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23.30.10ar1 - LTCF, EW With Community Spouse (Archive) |
Archived: October 1, 2008 |
This section provides policy on when to begin or end use of an LTC income calculation for a client residing in a long-term care facility (LTCF) or receiving Elderly Waiver (EW) services and who has a community spouse.
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.
For more information on additional policy for client who have a community spouse see LTC/EW and Assets.
Begin the LTC Income Calculation for the LTC spouse for the month of one of the following:
l Admission to the LTCF or medical hospital.
l The receipt of 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.
Example:
Rita lives in the community with her husband Ralph. Rita receives AC services. On July 10 Rita applies for MA. Her case manager determines she is eligible for EW on July 18 and services under that program begin immediately.
Action:
Because Rita has a community spouse, redetermine eligibility beginning in July using a LTC income calculation.
Use a community income calculation when determining eligibility for months prior to the month of the LTC income calculation.
Example:
Paula is admitted to a LTCF on June 7. She applies for MA on June 9 and requests two months retroactive coverage. Her husband is not applying for coverage.
Action:
Paula’s certification period is April through September. Use a community income calculation for April and May. Because Paula has a community spouse, begin using an LTC income calculation in June, the month she enters the LTCF.
Calculate a shortened spenddown for the months prior to the start of the LTC income calculation if the client was on MA with a six-month spenddown.
Example:
Poppy was admitted to the hospital on February 27 after being injured in a car accident. She was then admitted to an LTCF on March 14 for an expected six month stay. Her husband continues to live in the community. She has been on MA for the past three months with a six-month spenddown. Her certification period is December through May.
Action:
Begin using a LTC income calculation for the month of February (the month she entered the facility). Calculate a shortened spenddown for the months of December and January. Adjust the spenddown according to shortened spenddown policy.
Update eligibility for a community spouse who is enrolled in a Minnesota Health Care Program (MHCP). The LTC spouse is no longer counted in the community spouse’s household size.
Note: See spenddowns for more information on when to make a change in the spenddown amount, satisfaction date and/or recipient amount.
l Six-month Spenddown:
Recalculate the entire certification period for a community spouse who is receiving MA with a six-month spenddown using the appropriate household size and deeming rules for each month.
Example:
Jordan and his wife, Kelsey, have been on MA for the past year and currently have a six-month spenddown. Their certification period is September through February. Jordan’s wife is admitted to an LTCF on November 23.
Action:
Begin the use of an LTC income calculation for Kelsey’s eligibility beginning in November and calculate a shortened spenddown for September and October.
Recalculate Jordan’s eligibility for the entire certification period. Use a household size of two for September and October and a household size of one beginning in November.
l Monthly Spenddown:
Recalculate a community spouse’s monthly MA spenddown eligibility for the months of the certification period the client’s spouse is using an LTC income calculation. Continue to use a monthly spenddown and the appropriate household size for the community spouse’s eligibility.
End the LTC Income Calculation for the month of one of the following:
l Discharge from the LTCF.
l End of EW services.
Redetermine eligibility for the remaining months of the certification period.
l Use a community income calculation for the months after the discharge month following standard household size and deeming policy.
l Use a monthly spenddown for the remainder of the certification period for clients 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:
Robin has resided in a LTCF for the past nine months. Her current certification period is June through November. She is discharged home on August 9 and will resume living with her spouse.
Action:
The LTC income calculation ends in August. Begin using a community income calculation for September through November.
Robin’s income is over the appropriate monthly income standard and has a spenddown. She does not have any anticipated medical expenses. The worker takes action on August 27.
Action:
Robin must use a monthly spenddown for the remainder of the certification period. Because Robin does not anticipate medical expenses she cannot meet her spenddown. Close Robin’s eligibility for October due to 10-day notice requirements. She will have MA eligibility for September without a spenddown.
Example:
Tobias has a received EW services for eight months. He lives with his wife Rachel who is not receiving MA. Tobias’ certification period is February through July. EW services end May 31 because Tobias is no longer at risk of placement.
Action:
Because Tobias has a community spouse, redetermine eligibility for June and July using a community income calculation with a household size of two, and following appropriate deeming rules. A monthly spenddown should be used if Tobias’ income is over the appropriate income standard. Close MA with 10-day notice if Tobias cannot meet a monthly spenddown.
Example:
Gerry lives in the community with her husband Sam. She is eligible for MA with a six-month spenddown. Sam does not receive MA. Gerry’s certification period is June through November. On August 1, Gerry begins receiving EW services.
Action:
Because Gerry has a community spouse, redetermine her eligibility using a LTC income calculation for August. Redetermine eligibility for June and July with a shortened spenddown.
Gerry’s EW services end in October.
Action:
Redetermine eligibility for November using a community income calculation. If Gerry has a spenddown it must be monthly.
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.