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Effective: December 1, 2006 |
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23ar1 - Long-Term Care (LTC) and Elderly Waiver (EW) (Archive) |
Archived: October 1, 2008 |
Eligibility rules for clients living in a Long-Term Care Facility (LTCF) or receiving Elderly Waiver (EW) services can be very different than for clients living in the community who are not receiving EW services.
To be eligible for MA LTC coverage a person must:
l Have a Long-Term Care Consultation (LTCC) screening.
l Be a resident of an LTCF.
An LTCF includes the following placements:
l A nursing facility.
l An intermediate care facility for persons with mental retardation or related conditions (ICF/MR).
l A medical hospital.
l An MA-covered bed in a Regional Treatment Center (RTC).
An LTCF does not include placements in non-Medicaid facilities such as the Veteran’s Administration facilities. These clients are considered community residents.
The Elderly Waiver (EW) provides MA funding for home and community-based services for people age 65 and older who would otherwise need nursing facility care. For more specific information on EW including cost sharing, the Special Income Standard and how to coordinate EW and Alternative Care (AC) to avoid overlap, see Elderly Waiver.
To receive EW services a person must meet all of the following conditions:
l Have a Long-Term Care Consultation (LTCC) screening.
l Require a nursing facility level of care.
l Be able to remain in the community rather than a nursing facility.
l Chooses community care.
l The cost to MA for the community-based services must cost less than institutional care.
l Be MA eligible.
Home and community-based services include:
l Adult day care.
l Respite care.
l Homemaker services.
l Adult foster care (other than room and board costs).
l Extended home health.
l Case management.
l Equipment and supplies not covered by MA, Medicare, or the client. The equipment and supplies must help keep the client out of a nursing facility.
l Companion services.
l Extended personal care.
l Home-delivered meals.
l Caregiver training and education.
l Assisted living.
l Residential care.
l Extended transportation.
l Chore services.
There are several forms that are used solely for LTC. They include:
l Long-Term Care/County Communication Form (DHS-3050).
This form enables counties to request a DHS-1503 from a facility, the dates of admit or discharge, and if Medicare payments were received. It also enables counties to notify LTC facilities of changes in eligibility including effective dates and LTC spenddown amount changes.
l The Physician Certification Form (DHS-1503).
This form provides information regarding the clients LTC stay including information about the length of stay, whether a Long-Term Care Consultation was completed, and diagnosis.
l The New Applicant Request for Payment of Long-Term Care Services (DHS-4803).
This form is used for both LTC and EW clients. See Application Forms for more information.
l The Request for Payment of LTC Services (DHS-3543).
This form is used for both LTC and EW clients. See Application Forms for more information.
This chapter provides information on:
l Determining the Community Spouse.
Whether or not a client has a spouse, and if that spouse is in placement, receiving EW services or in the community, determines what type of income calculation will be used to determine the LTC or EW client’s eligibility
l The Long-Term Care Consultation (LTCC).
Provides information about what an LTCC is, when it is required and the repercussions of not having one.
l Choosing the Appropriate Income Calculation.
LTC/EW clients have several income calculation options. This section lists when to use an LTC income calculation and when to use a community income calculation.
l Beginning or Ending the LTC Income Calculation.
There are specific requirements for when to begin or end using the LTC Income Calculation based on whether or not a client has a community spouse and whether the client receives LTC, EW or SIS-EW.
Household size for LTC/EW clients is always one. This section provides more information on when to use the household size and what to use it for.
l The LTC Income Calculation.
The LTC Income Calculation uses different disregards, deductions and allocations from other types of income calculations.
l Long-Term Care Spenddowns and Waiver Obligations.
There are several different types of cost sharing obligations for clients who use a LTC income calculation. This section provides detailed information on those cost sharing obligations.
LTC and EW have additional asset policy to follow.
Clients who have made an improper transfer of income or assets are ineligible for payment of LTC services for the months of the penalty.