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Effective: November 1, 2011 |
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23ar8 - MA Payment of Long-Term Care (LTC) Services (Archive) |
Archived: December 1, 2011 |
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, a combination LTC/medical spenddown, or a waiver obligation.
Eligibility Requirements for MA Payment of 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/DD).
l services covered by home and community-based waiver programs (CAC, CADI, DD, EW, and BI).
Eligibility Requirements for MA Payment of LTC Services
People who request MA payment of LTC services must meet the following specific eligibility requirements in order for MA to pay for those services. The eligibility requirements apply regardless of the length of stay in a facility.
1. Meet all MA applicable eligibility requirements, 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.
2. Need an institutional level of care. 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:
residing in a long-term care facility (LTCF), he or she must have either received a Pre-Admission Screening (PAS) 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.
requesting services through the CAC, CADI, BI, or EW waiver programs, the person must have received a Long-Term Care Consultation (LTCC) 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.
requesting services through the Developmental Disabilities (DD) waiver, the person must have a Full Team Developmental Disabilities (DD) Screening. 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/DD), 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 within the applicable home equity limit 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.
Exception: MA adults without children do not have an asset test and are not subject to transfer penalties.
Process requests for MA payment of LTC services as soon as possible but no later than the maximum time allowed. See Processing Periods for more information.
Follow standard MA processing periods for people who request MA payment of LTC services when applying for MA. Do not deny an incomplete application at the end of the processing period if the applicant is cooperating with providing information.
For current MA enrollees who request MA payment of LTC services, process the request for MA payment of LTC services as soon as possible since claims for LTC services will not be paid until the enrollee is determined eligible for MA payment of LTC services.
If the enrollee is requesting services because of a move to an LTCF, approve eligibility back to the date the enrollee moved into the LTCF or the date that all eligibility requirements for MA payment of LTC services were met, whichever is later.
If the enrollee is requesting services through a home and community-based services waiver program, approve eligibility no earlier than the date of the LTCC or the date the enrollee meets all eligibility requirements for MA payment of LTC services, whichever is later. Coordinate the begin date with the lead agency case manager.
You must notify people who request MA payment of LTC services of the results of the eligibility determination. If the results of the eligibility determination do not result in a MAXIS system notice, are not included in a MAXIS system notice, or cannot be added to the MAXIS system notice, send the ”Notice of Action for Medical Assistance (MA) Payment of Long-Term Care Services” (DHS-4915).
When adding worker comments to a MAXIS system notice, use the wording, including legal citations, listed on the Notice of Action for Medical Assistance (MA) Payment of Long-Term Care Services (DHS-4915).
Send a ”Lead Agency Case Manager/Worker Communication Form” (DHS-5181) to the lead agency case manager or a ”Long-Term Care - County Communication Form” (DHS-3050) to the LTCF when payment of LTC services is approved, denied, or closed.
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.
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.