Purpose: This section will assist in determining eligibility for the Acquired Brain Injury HCBS Waiver.
Current Policy Effective Date: January 1, 2008
Date Last Reviewed: November 30, 2007
Previous Policy: July 1, 2007
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POL M1002B2: Determining eligibility for Acquired Brain Injury HCBS Waiver
1. Applicants Must Meet Basic Eligibility
Reference Section M600 for information on basic eligibility factors.
2. Applicants Must Meet Level of Care Requirement
Applicants must be approved for the ICF/MR level of care indicated on the LT-ABI-105.
3. Applicants Meet Disability Requirements
Applicants meeting the level of care requirement per the LT-ABI-105 fulfill disability requirements.
4. DFS May Need Funding Letter
If plan of care date is filled in on the LT-ABI-105, a slot is available.
If there is no plan of care date or if the plan of care date is “pending” on the LT-ABI-105, require a funding letter from the case manager. The funding letter verifies slot availability.
5. Applicants Must Be Age 21 Through 64
6. SSI Eligibles Do Not Need to Submit Application
If SSI is lost, an application will be required to redetermine eligibility.
7. 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.
8. Applicants Must Meet Resource Requirements
Require the countable resources to be within the maximum asset limit. Reference Medicaid Table 7 to see resource standards. Reference Section M801 to determine if resources are countable.
9. Some Services Withheld for Nonexempt Resource 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 to Section M804 for information on related penalties.
10. Benefits Begin First Day of Month Using Plan of Care Approval Date
11. 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.
12. Clients May Lose Benefits
The case will close on the first day of the next month when any of the following occur:
· Client dies.
· Client determined no longer eligible.
· Client does not complete review.
· Client enters a public institution, excluding Uinta Hall.
· Client turns 65.
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Reference:
Define Group: 42 CFR 435.217
42 CFR 435 Subpart F
Income: 42 CFR 435 Subpart K
Assets: 42 CFR 435 Subpart L
Clarifying Information:
1. SSI Eligibles Do Not Require an Application.
2. Client Pays No Patient Contribution.
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 to see asset standards.
2. Refer to Section M801 to determine if assets are countable.
Calculating Nonexempt Asset Transfer Penalty
1. Refer to Sections M803 and M804 for information on exempt assets and related penalties.
Determining Eligibility
1. Receive the LT-ABI-105 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. Refer to medical subtype Medicaid Table 3 to update MERE screen in EPICS.
8. Authorize case and send approval notice to client and Case Manager Notification to case manager.
Indicating Eligibility for SSI Eligibles
1. Receive LT-ABI-105 with start date.
2. Change MERE screen in EPICS to appropriate subtype using appropriate code from 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 using appropriate code from 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.
Approving Benefits
1. Enter program type “ME SS” on SEPA screen in EPICS.
2. Enter subtype “BI” on MERE screen in EPICS.
3. Authorize case on SSRM screen in EPICS, using appropriate code from Medicaid Table 3.
4. Send approval notice from Medicaid Table 16 to applicant and Case Manager Notification to case manager.
Denying Benefits
1. Enter program type “ME SS” on SEPA screen in EPICS.
2. Enter subtype “BI” on MERE screen in EPICS.
3. Deny case on SSRM screen in EPICS, using appropriate code from Medicaid Table 15.
4. 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.