|
Purpose: This section will assist in determining whether an individual is eligible for the Adult or Children’s Developmental Disabilities HCBS Waiver.
Current Policy Effective Date: January 1, 2008
Date Last Reviewed: November 30, 2007
Previous Policy: July 1, 2006
|
POL M1002B1: Determining Eligibility for Adult Or children’s Developmental disabilities HCBS Waiver
1. Applicants Must Meet Basic Eligibility
Reference Section M600 for information on basic eligibility.
2. Applicants Must Meet Level of Care Requirement
Applicants must be approved for ICF/MR level of care indicated on the LT-MR-104.
3. Applicants Meet Disability Requirements
Applicants meeting the level of care requirement per the LT-MR-104 fulfill disability requirements.
4. DFS May Need Funding Letter
If plan of care date is filled in on the LT-MR-104, a slot is available.
If there is no plan of care date or if the plan of care date is “pending” on the LT-MR-104, require funding letter from the case manager. The funding letter verifies slot availability.
5. Children Defined as Birth Up to Age 21
6. At Age 21, Existing Clients Must Meet Adult Waiver Criteria
Clients are considered adults at age 21. Clients must be redetermined for ICF/MR level of care and slot availability indicated on the LT-MR-104. The intention is prevention of an eligibility gap when transitioning from children to adults.
7. SSI Eligibles Do Not Need to Submit Applications
If SSI is lost, an application will be required to redetermine eligibility.
8. Applicants Must Meet Income Requirements
Require the countable income to be within the maximum income standard per month. Reference Medicaid Table 1A to see income standards. Reference Section M901 to determine if income is countable.
9. Applicants Must Meet Resource Requirements
Require the countable resources to be within the maximum resource limit. Reference Medicaid Table 7 to see resource standards. Reference Section M801 to determine if resources are countable.
10. Some Services Withheld for Nonexempt Asset Transfers
Nonexempt resources cannot be transferred for less than fair market value during the look-back period prior to application or when clients are receiving benefits.
Reference Section M803 to determine if an resource transfer is exempt and Section M804 for information on related penalties.
11. Applicants May Have Eligibility for 12 Continuous Months
The eligibility continues for 12 months from the effective date of eligibility, or for 12 months from the last periodic review, for children under the age of 19.
12. Benefits Begin First Day of Month Using Plan of Care Date
13. Clients Must Be Reviewed
Clients must be periodically reviewed every 12 months to determine continued eligibility. Reference Section M1403 for information on reviewing eligibility.
A review is not required for SSI clients.
Clients must be reviewed for other Medicaid program eligibility before closing cases.
14. Clients May Lose Benefits
The case will close on the first day of the next month when any of the following occur:
· Client does not complete review.
· Client enters a public institution, excluding Uinta Hall.
· Client dies.
· Client determined no longer eligible.
|
Reference:
Defining Group: 42 CFR 435.217
Social Security Act §1902(a)(10)(A)(ii)(xv)
Social Security Act § 1902(e)(12)
Income: 42 CFR 435 Subpart K
Resources: 42 CFR 435 Subpart L
Clarifying Information:
1. Developmentally Disabled (DD) is defined as one who is experiencing significant sub-average physical/emotional/mental functioning as verified by a medical professional or the WDH.
2. SSI Eligibles Do Not Require Application.
3. New LT-MR-104 Must Be Received From the Case Manager When Client Turns 21.
4. New DFS100 Form Is Not Required When the Client Turns 21.
5. Clients Pay No Patient Contribution.
6. Clients under age 19, discharged from the Waiver, may have eligibility for the remainder of the 12 continuous months.
Training Link: Not available at this time.
Worker Responsibilities:
Determining Countable Income
1. Refer to Section M901 to determine if income is countable.
Determining Countable Assets
1. Refer to Section M800 for resource standards.
2. Refer to Section M801 to determine if resources are countable.
Calculating Nonexempt Resource Transfer Penalty
1. Refer to Sections M803 and M804 for information on transferring nonexempt resources and related penalties.
Determining Eligibility
1. Receive the LT-MR-104 from case manager to determine ICF/MR level of care and slot availability.
2. Authorize benefits beginning with first day of the month.
2A. Use plan of care date listed on form.
2B. Send approval notice to applicant and Case Manager Notification to case manager.
3. If plan of care date is pending or not filled in:
3A. Request a copy of the funding letter from case manager.
3B. Verify slot is available.
4. Receive a funding letter to indicate slot availability.
5. Send a pending notice (M304) to client and Case Manager Notification to case manager, which verifies financial eligibility.
6. Pend plan of care until approved.
7. Receive approval from DD Division.
8. Refer to Medicaid Table 3 to update subtype on MERE screen in EPICS.
9. Authorize case and send approval notice to client and Case Manager Notification to case manager.
Indicating Eligibility for SSI Eligibles
1. Receive LT-MR-104 with start date.
2. Change subtype on MERE screen in EPICS to appropriate subtype. Refer to Medicaid Table 3.
3. Authorize case and send approval notice to client and Case Manager Notification to case manager.
Determining Continued Eligibility if Client Loses SSI
1. Require application.
2. Determine continued eligibility.
3. Change subtype on MERE screen in EPICS. Refer to Medicaid Table 3.
Determining Eligibility for Applicant Without Funding Letter
1. Screen the application to see if the applicant meets eligibility under another Medicaid group.
2. Deny the applicant if not eligible.
Verifying Continued Eligibility For Existing Clients After Turning 21
1. Receive a new LT-MR-104.
2. Change subtype on MERE screen in EPICS. Refer to Medicaid Table 3.
Approving Adult Benefits
1. Enter program type “ME SS” on SEPA screen in EPICS.
2. For 300% CAP, enter subtype “ND” on MERE screen in EPICS.
3. For SSI Eligible, enter subtype “NI” on MERE screen in EPICS.
4. Authorize case on SSRM screen in EPICS, using appropriate code from Medicaid Table 3.
5. Send approval notice from Medicaid Table 16 to applicant and Case Manager Notification to case manager.
Approving Child Benefits
1. Enter program type “ME SS” on SEPA screen in EPICS.
2. For 300% CAP, enter subtype “DK” on MERE screen in EPICS.
3. For SSI Eligible, enter subtype “DC” on MERE screen in EPICS.
4. Authorize case on SSRM screen in EPICS, using appropriate code from Medicaid Table 3.
5. Send approval notice from Medicaid Table 16 to applicant and Case Manager Notification to case manager.
Denying Adult Benefits
1. Enter program type “ME SS” on SEPA screen in EPICS.
2. For 300% CAP, enter subtype “ND” on MERE screen in EPICS.
3. For SSI Eligible, enter subtype “NI” on MERE screen in EPICS.
4. Deny case on SSRM screen in EPICS, using appropriate code from Medicaid Table 15.
5. Send denial notice from Medicaid Table 16 to applicant and Case Manager Notification to case manager.
Denying Child Benefits
1. Enter program type “ME SS” on SEPA screen in EPICS.
2. For 300% CAP, enter subtype “DK” on MERE screen in EPICS.
3. For SSI Eligible, enter subtype “DC” on MERE screen in EPICS.
4. Deny case on SSRM screen in EPICS, using appropriate code from Medicaid Table 15.
5. Send denial notice from Medicaid Table 16 to applicant and Case Manager Notification to case manager.
Reviewing Cases
1. Refer to Section M1403 for information on reviewing cases.
Closing Cases
1. Close case on SSRM screen in EPICS for the appropriate benefit month, using appropriate code from Medicaid Table 15.
2. Send 10-Day closure notice from Medicaid Table 16 when an adverse action has occurred.
|