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Purpose: This section will assist in determining whether individuals are eligible for Assisted Living Facility (ALF) and Long Term Care (LTC) HCBS Waiver benefits.
Current Policy Effective Date: September 1, 2010
Date Last Reviewed: March 16, 2010
Previous Policy: October 1, 2009
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POL M1002A: DETERMINING ELIGIBILITY FOR ASSISTED LIVING FACILITY (ALF) AND LONG TERM CARE (LTC) HCBS WAIVER
1. Applicants Must Meet Basic Eligibility Factors
Refer to Section M600 for a description of all basic eligibility factors.
2. Applicants Must Meet Medical Necessity Requirement
Verification of medical necessity must be obtained by accessing the Provider Web Portal through
the LT101 tab located within ECOM.
Applicants meet the medical necessity requirement when the LT101 has any of the following:
· 13 or more points. Client may be served in a nursing facility, swing bed, HCBS-LTC or HCBS-ALF waiver.
· DOES NOT have 13 points, but placement remains medically necessary to maintain optimal functioning and maintain the continued safety and welfare of the client.
· No approved LT101, did not complete LT101 because the individual passed away within three working days of admission.
3. Applicants Must be Aged, Blind Or Disabled
Applicants must meet one of the following factors:
· Age – 65 or older.
· Blind – legally blind based on Social Security standards.
· Disabled – person who receives disability benefits from SSA, or is determined disabled by WDH.
4. Applicants Must Be Age 19 Or Older
5. Applicants Must Need Services For 30 Days Or More
6. SSI Eligibles Do Not Need To Submit Application
If the client becomes ineligible for SSI, an application will be required to determine continued eligibility under another coverage group.
7. Applicants Must Meet Income Requirements
Require the countable income to be within the maximum income standard. Refer to Medicaid Table 1A for the income standards. Refer to Section M901 to determine if income is countable.
8. Applicants Must Meet Resource Requirements
Require the countable resources to be within the maximum resource limit. Refer to Medicaid Table 7 for the resource standards. Refer to Section M801 to determine if resources are countable.
9. Services Withheld For Resource Transfers
Resources cannot be transferred for less than fair market value during the look-back period prior to application or when clients are receiving benefits.
Refer to Section M803 for information on transferred resources and Section M804 for information on transfer penalties.
10. Clients Must Have Approved Plan Of Care
11. Benefits Begin First Day of Month Plan Of Care Is Approved
Benefits begin the first day of the month the plan of care is approved by WDH.
12. Clients May Not Receive Retroactive Medicaid
Do not authorize retroactive Medicaid for clients unless they are found eligible under another coverage group allowing retroactive medical assistance.
13. Clients May Enter Nursing Homes
Clients entering nursing home must obtain a new LT101 if they have been in long term care or assisted living facilities for more than 60 days.
Clients entering a nursing home and remaining for 30 days must have their coverage changed to Nursing Home Care. Refer to Section M1001A for additional eligibility information.
Clients will not lose their Waiver slot when hospitalized or in a nursing home.
14. Clients Must Be Reviewed
Clients must be periodically reviewed every 12 months to determine continued eligibility. Refer to 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.
15. Clients May Lose Benefits
The case will close on the first day of the next month when any of the following occur:
· Client is discharged from the Assisted Living Facility (ALF) or Long Term Care (LTC) HCBS Waiver.
· Client does not complete a review.
· Client enters a public institution, excluding Unita Hall.
· Client dies.
· Client determined no longer eligible.
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Reference:
Defining Age, Blind, Disabled: 42 CFR 435 Subpart F
Income: 42 CFR 435 Subpart K
Resources: 42 CFR 435 Subpart L
Defining Group: 42 CFR 435.217
Social Security Act §1902(a)(10)(A)(ii)
Clarifying Information:
1. Clients May Also Receive Hospice Benefits.
Subtype must not be changed when receiving Hospice benefits in addition to Waiver benefits.
2. Clients Pay No Patient Contribution.
Clients do not pay a patient contribution. There will be a patient contribution after 30 days if an HCBS client transfers to a nursing home.
Training Link: Not available at this time.
Worker Responsibilities:
Indicating Waiver Eligibility For SSI Eligibles
1. Change subtype on MERE screen in EPICS. Refer to Medicaid Table 3.
Closing SSI Case And Opening Waiver Case
1. Close SSI case.
2. Request an EC-200 EqualityCare (Medicaid) Application from the client to establish eligibility.
3. Open new waiver case if still meeting financial requirements.
Determining Countable Income
1. Refer to Section M901 for information on countable income.
Determining Countable Resources
1. Refer to Section M800 for resource standards.
2. Refer to Section M801 to determine if resources are countable.
Calculating Resource Transfer Penalty
1. Refer to Sections M803 and Section M804 for information on resource transfers and related penalties.
Accessing LT101 To Determine Medical Necessity
1. Log into the Provider Web Portal Through ECOM
1A. Click the LT101 tab from ECOM (the Provider Welcome page will open).
1C. Enter your User ID and Password on Provider Welcome page.
1Ci) Click on the “Log In” button (the ACS Wyoming Medicaid Home Page will open).
1D. Select the LT101 Inquiry link on the left hand side of the ACS Wyoming Medicaid Home Page (the
LT101 Inquiry page will open).
1E. Conduct the client search by entering one of the following:
1Ei) EqualityCare ID or
1Eii) Combination of Name, Date of Birth and Gender or
1Eiii) Combination of Name and Social Security Number or
1Eiv) Combination of Date of Birth and Social Security Number.
1F. Click on the “Reset” button to reset your search criteria or the “Submit” button to submit the
inquiry (the LT101 Inquiry Results screen will open) or
1Fi) Message may appear that there are no LT101 records found (double check your
Inquiry information and resubmit your search if needed).
1G. Select the button corresponding to the Placement Summary you want to view.
1Gi) Click the “Submit” button(the Assessment of Medical Necessity for Long Term care web page
Will open).
1H. The Medical Necessity for Long Term Care web page contains the following information:
1Hi) Client Name, Address, Phone Number, DOB, SSN, Medicaid Number.
1Hii) Date of Referral, Date of Review.
1Hiii) Name of Facility, Admit date.
1Hiv) Expected to remain in medical institution for 30 consecutive days (shows yes or no).
1Hv) Placement summary.
1. Has 13 or more points. Client may be served either in a nursing facility or swing bed OR
on either HCBS-LTC or ALF waiver.
2. DOES NOT have 13 points, but placement remains medically necessary to maintain
optimal functioning and maintain the continued safety and welfare of the client.
3. DOES NOT have 13 points, and DOES NOT meet the medical necessity criteria for Long Term Care.
1Hvi) Score.
1Hvii) Case Manager/Care Coordinator or Project Out Transition Specialist.
1Hviii) Public Health Office, County Number.
1Hix) At the bottom of this page, you are given the options to either go “Back” to the Inquiry
Results page, “Print”, Or conduct a “New Search”.
1Hx) Print this screen as verification of medical necessity for the case file.
Determining Disability For Applicants Not Receiving Social Security Disability
1. Provide applicant or client with the EC-300 EqualityCare (Medicaid) Disability Determination Application and instructions.
2. Direct the applicant or client to forward the completed packet and previous 12 months of medical records to WDH in the enclosed self addressed postage paid envelope at the following address:
EqualityCare/Medicaid
Attn: Eligibility Unit
6101 Yellowstone Road, Suite 210
Cheyenne, WY 82002
3. If applicant or client brings the EC-300 and medical records to the DFS Office:
2A. Mail, Fax or email a scanned copy of the EC-300 and medical records directly to the Eligibility Unit
2B. Do not keep a copy of the EC-300 or medical records.
4. Send email to the Eligibility Unit with the name, and case number of the applicant.
5. Receive an approval or denial of the disability determination from WDH.
4A. WDH will provide a disability determination renewal date on all approvals
4B. Require a new disability determination on a client who is not receiving benefits from SSA, based on the above
renewal date provided by WDH.
Determining Eligibility
1. Obtain LT101 from the Provider Web Portal.
2. Send a pending notice (M302) to client and a Case Manager Notification to the case manager.
3. Pend case until plan of care approved or denied and slot is available.
4. Receive notification from WDH that slot is available and plan of care is approved or denied.
5. Obtain new LT101, if 60 days have passed since initial application.
6. Re-verify financial eligibility, if 60 days have passed since initial application.
7. If approved, authorize benefits beginning with first day of the plan of care month.
8. If not approved, deny case.
Approving ALF Benefits
1. Enter program type “ME SS” on SEPA screen in EPICS.
2. If the client is SSI, enter subtype “RL” on MERE screen in EPICS.
3. If the client is 300% CAP, enter subtype “R3” 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.
6. Send Case Manager Notification to the case manager.
Approving LTC Benefits
1. Enter program type “ME SS” on SEPA screen in EPICS.
2. If the client is SSI, enter subtype “NE” on MERE screen in EPICS.
3. If the client is 300% CAP, enter subtype “NA” 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.
6. Send Case Manager Notification to the case manager.
Denying ALF Benefits
1. Enter program type “ME SS” on SEPA screen in EPICS.
2. If the client is SSI, enter subtype “RL” on MERE screen in EPICS.
3. If the client is 300% CAP, enter subtype “R3” 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.
6. Send Case Manager Notification to the case manager.
Denying LTC Benefits
1. Enter program type “ME SS” on SEPA screen in EPICS.
2. If the client is SSI, enter subtype “NE” on MERE screen in EPICS.
3. If the client is 300% CAP, enter subtype “NA” 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.
6. Send Case Manager Notification to the case manager.
Reviewing Cases
1. Refer to Section M1403 for information on reviewing cases.
2. Send Case Manager Notification to the case manager.
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.
3. Send Case Manager Notification to the case manager. |