Long Term Care
DSHS Home Page
 
Search     for:
DSHS Home    Acronyms    Alerts    Screens    WAC Number Index    WCCC

Long Term Care


Revised June 19, 2014



Categorically Needy LTC – Family (K01)

 

Medically Needy LTC – Family (K95)

 

Medically Needy LTC – Family with spenddown (K99)

 

Categorically Needy LTC in a medical facility – SSI recipient (L01)

 

Categorically Needy LTC in a medical facility – SSI related (L02)

 

Categorically Needy LTC – SSI related undocumented alien (L04)

 

Categorically Needy waiver or Hospice services – SSI recipients (L21)

 

Categorically Needy waiver or Hospice services – SSI related (L22)

 

State Funded LTC – SSI Related for non-citizen Clients at Home or Alternate Living Facility (L24) 

 

Medically Needy LTC/Medically Needy Hospice in a medical facility – no spenddown (L95)

 

Medically Needy LTC in a medical facility – with spenddown (L99)

 

Personal Needs Allowance (PNA)

 

Case Specific Situations

Hospice (in Medical Chapter)

Medically Needy Residential Waiver (MNRW)

 


CATEGORICALLY NEEDY LTC - FAMILY (K01)

Who is eligible for K01 medical?

 

How long is the K01 certification period?

 

How do I screen K01 medical?

 

How do I process a pending K01 AU?

 


 

Who is eligible for K01 medical?

 

·         A child or adult who has met institutional status described in EAZ Manual – WAC 182-513-1320 Determining institutional status for long-term care (LTC) services and is:

 

o    Residing in a medical institution for a period of 30 days or longer; or

 

o    Is between 18-21 years old and resides in a psychiatric institution for 30 days or longer; or

 

o    Is a child age 17 or younger and resides in a psychiatric institution for 90 days or longer.

 

·         K01 medical coverage is for children and adults who do not meet aged, blind or disabled criteria and who are one of the following:

 

o    The parent of, or relative caring for, an eligible dependent child;

 

o    A dependent child age 18 or younger;

 

o    A pregnant woman;

 

o    An individual who is not a dependent or a parent, but who is under the age of 21 (or

    22 if already residing in the institution and the application is received prior to

    their 21st birthday).

 

·         For more information see the following EAZ Manual references:

 

o    WAC 182-505-0240 Washington Apple Health - Parents and caretaker relatives.

 

o    WAC 182-505-0210 Washington Apple Health - Eligibility for children.

 

o    WAC 182-513-1315 Eligibility for long-term care (institutional, home and community based (HCB) waiver, and hospice) services.

 

o    WAC 182-513-1320 Determining institutional status for long-term care (LTC) services.


NOTE:

Federally Qualified SSI related clients aged 18 and older, who meet the following should be opened on an L-track medical program:

 

·         Reside in an IMD

·         Applied for LTC prior to their 21st birthday

·         Meet all financial and non-financial eligibility rules


How long is the K01 certification period?

 

·         K01 is certified for 12 months.

 

·         Re-determine eligibility for other medical coverage if client loses institutional status during their certification period. Children under the age of 19 who lose institutional status remain continuously eligible for CN coverage for the balance of their certification.

 

How do I screen K01 medical?

 

·         To screen an K01 AU, take the following steps:

 

1.    Follow the instructions in Screening an Application.

 

o    If the applicant is a child, enter the child as the head of household.

 

o    On the Programs page, click the checkbox next to Long Term Care.

 

o    On the Finalize page, use the Specify Program option to select the K01 program.  

 

How do I process a pending K01 AU?

 

·         To process a pending K01 AU, take the following steps:

 

1.    From the AMEN screen, select Option O – Interview.

 

2.    On the PEND screen:

 

o    Enter a [Y] – Yes in the Beginning Processing for ALL pending AUs listed with Blank Intake Begin Date? field or enter [Y] – Yes in the S field for each individual AU to initiate the intake interview.

 

3.    On the ADDR screen:

 

o    Enter a [Y] in the Auth Rep/Payee field, if appropriate.

 

4.    On the STAT screen, complete the Finl Resp fields as follows:

 

o    [PN] – Applicant for the applicant.

 

o    [NM] – Non Members for any other household member(s).

 

5.    On the DEM1 screen:

 

o    Enter the [valid value for the clients living arrangement] in the Living Arngmt field. See <F1> Help.

 

o    Enter the [marital status] in the Marital Status field.

 

6.    On the INST screen:

 

o    In the Facility section:

 

¨        Enter the [type of facility] in the INST Type field. The facility type must be from the same subset as the living arrangement coded on the DEM1 screen.

 

¨        Enter the [provider number] in the Provider ID field if the provider is one of the following facility types: MD – Nursing Facility – Medicaid, ME – Nursing Facility – Medicare, or HC – Hospice Care Center.

 

¨        Enter the [first of the month the client was admitted] in the Entry Date field.

 

¨        Enter the [client’s level of care] in the Level Care field.

 

¨        Enter the [date payment to the facility should begin] in the Payment Auth Date field. This is the date the LTC services are approved and displays on the award letter.

 

¨        Enter the [facilities private daily rate] in the Private Rate field. Contact the facility for rate information.

 

¨        Enter the [facilities state daily rate] in the State Rate field. Press <F20> to access the MMEN for state rates for nursing facilities and hospice providers.


NOTE:

To find the most current state rate for nursing facilities, veteran facilities or hospice care centers go to the MMEN Vendor File Submenu and enter option D – Provider Name List.


7.    On the LTCX screen:

 

o    In the LTC Expenses / Deductions section:

 

¨        Enter any [qualified expenses or deductions] that can be used to reduce participation or excess resources in the Type and Amount field.

 

o    If the client has dependent family members, use the Family Member Allowance section to:

 

¨        Enter [C – for a dependent living with a community spouse or O – for dependent not living with a community spouse] in the Type field.

 

¨        Enter the [gross income amount] of the dependent in the Amount field. If the dependent does not have any income, leave the Amount field blank.

 

o    Enter a [Y] in the Force Name on Check Rule field, if the client wishes to use the name on the check rule.

 

8.    Enter [client resource information] on the RES1, RES2 and RES3 screens. For information on how to complete the resource screens see RES1 Resources 1 Screen in the Screen descriptions R thru S chapter.

 

o    See EAZ Manual – WAC 182-514-0245 Washington Apple Health - Resource eligibility for MAGI-based long-term care program.

 

9.    If the client has transferred an asset, complete the TRAN screen with the appropriate information. See <F1> and <F2> Help. For more information, see EAZ Manual – Transfer of an Asset.

 

10.    On the EARN screen:

 

o    Complete this screen if the client has earned income. See How do I complete the EARN screen? for additional information.

 

11.     On the UNER screen:

 

o    Enter the types and amounts of all unearned income. See How do I complete the fields on the UNER screen? for additional information.

 

o    Enter the income contributed to a child from the parents as [OC] – Other Countable in the Srce field.

 

¨        When the applicant is a dependent child, only the child’s own income (including child support received on the child’s behalf) and money contributed to the child is counted. See EAZ Manual – WAC 182-514-0240 Washington Apple Health -- General eligibility requirements for MAGI-based long-term care program.

 

12.     Complete the CSRA screen if the client has a community spouse.

 

13.     On the SHEL screen: see How do I code the SHEL screen when there is a community spouse?


NOTE:

If the LTC client has a community spouse, shelter expenses must be entered on the spouse’s SHEL screen in order to compute the excess shelter portion of the spousal maintenance allowance (and the shelter deduction for the spouse’s Basic Food, when applicable).


14.    After committing the interview data, follow the instructions in the Process Application Month chapter for all pending months.

 

15.     Once the pending months have been processed, follow the instructions in the Finalize Application chapter.


MEDICALLY NEEDY LTC - FAMILY - NO SPENDDOWN (K95)

Who is eligible to receive K95 medical?

 

How long is the K95 certification period?

 

How do I screen a K95 AU?

 

How do I process a pending K95 AU?

 


 

Who is eligible to receive K95 medical?

 

·         K95 medical is available only to children (20 years and younger).

 

·         K95 has the same non-financial eligibility requirements as K01. See EAZ Manual – WAC 182-514-0230 Washington Apple Health - MAGI-based long-term care program and EAZ Manual – WAC 182-519-0100 Eligibility for the medically needy program.

 

·         K01 trickles to K95 if the child is age 18 or younger and their income is over 200% FPL, but below the monthly state rate in the institution.

 

·         K01 trickles to K95 if the child is age 19 or 20 and their income is over the one-person TANF standard but below the monthly state rate in the institution.

 

How long is the K95 certification period?

 

·         K95 medical is certified for 12 months.

 

How do I screen a K95 AU?

 

·         K95 AUs are initially screened into ACES as a K01 AU, following the instructions in How do I screen a K01 AU?

 

How do I process a pending K95 AU?

 

·         While pending, the AU is still a K01 and is processed following the steps in How do I process a pending K01 AU?

 

·         The K01 AU trickles to K95 during finalize, if appropriate, based on eligibility, living arrangement and coding on the INST.

 


MEDICALLY NEEDY LTC-FAMILY-WITH SPENDDOWN (K99)

Who is eligible to receive K99 medical?

 

How long is the K99 certification period?

 

How do I screen a K99 AU?

 

How do I process a pending K99 AU?

 


 

Who is eligible to receive K99 medical?

 

·         K99 medical is available only to children (20 years and younger).

 

·         K99 has the same non-financial eligibility requirements as K01. See EAZ Manual – WAC 182-514-0230 Washington Apple Health - MAGI-based long-term care program and EAZ Manual – WAC 182-519-0100 Eligibility for the medically needy program.

 

·         K01 trickles to K99 if the child’s (18 years and younger) income exceeds the state rate, but remains under the private rate.

 

How long is the K99 certification period?

 

·         ACES defaults to a six-month base period, which can be shortened to three-months by following the instructions in Spenddown – How do I set up a spenddown AU and base period?

 

·         Retroactive medical is three-months immediately prior to the month of application, if the client was in the institution in the retroactive period.

 

How do I screen K99 medical?

 

·         K99 medical is initially screened into ACES as a K01 AU, following the instructions in How do I screen a K01 AU?

 

How do I process a pending K99 AU?

 

·         While pending, the AU is still a K01 and is processed following the steps in How do I process a pending K01 AU?

 

·         The K01 AU trickles to K99 during finalize, if appropriate, based on eligibility, living arrangement and coding on the INST.

 

·         See How do I enter medical expenses? for instructions on entering medical expenses for a K99 AU.

 


CATEGORICALLY NEEDY LTC IN A MEDICAL FACILITY - SSI RECIPIENT (L01)

Who is eligible for L01 medical?

 

How long is the L01 certification period?

 

How do I screen L01 medical?

 

How do I process a pending L01 AU?

 

How does ACES issue cash to active L01 AUs?

 


 

Who is eligible for L01 medical?

 

·         A person who receives federal cash benefits under the Supplemental Security Income (SSI) program who also meets the eligibility and institutional criteria as defined in EAZ Manual Long-Term Care chapter may be eligible for L01 medical. See EAZ Manual – WAC 182-513-1301 through WAC 182-513-1455.

 

How long is the L01 certification period?

 

·         L01 medical has no review end date and is certified for as long as the client is eligible for both SSI and institutional Long-Term Care (LTC) services.

 

How do I screen L01 medical?

 

·         To screen an L01 AU, take the following steps:

 

1.    Follow the instructions in Screening a Client.

 

o    On the Programs page, click the checkbox next to Long Term Care.

 

o    In the Program Determination Criteria section, click the checkbox next to SSI Eligible.

 

How do I process a pending L01 AU?

 

·         To process a pending L01 AU, follow the steps in How do I process a pending L02 AU?

 

How does ACES issue cash to active L01 AUs?

 

·         When SSA determines an SSI only recipient’s stay in a medical facility will exceed three months, the SSI cash payment is reduced to $30 a month. When this occurs, ACES issues a cash supplement to bring the client’s income up to the Personal Needs Allowance (PNA) standards. See EAZ Manual – WAC 388-478-0040 Payment Standard for persons in a medical institution.

 

·         When a cash benefit is issued from an L01 AU, the program type is set to M – SSI MIL Client/Aged with Cash Payment, N – Blind with Cash Payment or O – Disabled with Cash Payment and the benefit amount displays in the CPI field on MAFI.

 

 


CATEGORICALLY NEEDY LTC IN A MEDICAL FACILITY - SSI RELATED (L02)

Who is eligible for L02 medical?

 

How long is the L02 certification period?

 

How do I screen L02 medical?

 

How do I process a pending L02 AU?

 


 

Who is eligible for L02 medical?

 

·         Clients who meet the eligibility criteria described in EAZ Manual - WAC 182-513-1315 Eligibility for long-term care (institutional, home and community based (HCB) waiver, and hospice) services.

 

·         See Categorically Needy Waiver or Hospice Services - SSI Related (L22) section.

 

How long is the L02 certification period?

 

·         L02 is certified for 12 months.

 

How do I screen L02 medical?

 

·         To screen an L02 AU, take the following steps:

 

1.    Follow the instructions in Screening a Client.

 

o    On the Programs page, click the checkmark next to Long Term Care.

 

How do I process a pending L02 AU?

 

·         To process a pending L02 AU, take the following steps:

 

1.    From the AMEN screen, select Option O – Interview.

 

2.    On the PEND screen:

 

o    Enter a [Y] – Yes in the Beginning Processing for ALL pending Aus listed with Blank Intake Begin Date? field or enter [Y] – Yes in the S field for each individual AU to initiate the intake interview.

 

3.    On the ADDR screen:

 

o    Enter a [Y] in the Auth Rep/Payee field, if appropriate.

 

4.    On the STAT screen, complete the Finl Resp fields as follows:

 

o    [PN] – Applicant for the applicant.

 

o    [SP] – Ineligible Spouse/Non-Applying Spouse for the applicants’ spouse.


NOTE:

The dependents are coded on the LTCX screen under the Family Member Allowance section. This allows the correct post-eligibility allowance calculation for the dependents. A dependent is a child, sibling or parent the individual is claiming to the IRS as a dependent.


5.    On the DEM1 screen:

 

o    Enter the [valid value for the clients living arrangement] in the Living Arngmt field. See <F1> Help.

 

o    Enter the [marital status] in the Marital Status field.


NOTE:

The marital status of both the applicant and spouse must be coded as S- Legally Separated, P – Separated, A – Married Living Apart or M – Married for the system to recognize the couple as married. This information is needed for the system to determine if the spouse is a “community spouse” or an “institutional spouse” and correctly calculate the spousal allocation.


6.    On the DEM2 screen:

 

o    If the applicant is receiving Medicare Part A or Part B, enter a [Y] in the Entitled Medicare field.

 

o    Complete the TPL1 screens. See TPL – Third Party Liability Screens – Coding.

 

¨        If the client is 65 or older, the Disability / Incapacity field can be left blank.

 

7.    On the INST screen:

 

o    If the client lives in an alternative living or medical facility, use the Facility section to:

 

¨        Enter the [type of facility] in the INST Type field. The facility type must be from the same subset as the living arrangement coded on the DEM1 screen.

 

¨        Enter the [provider number] in the Provider ID field if the provider is one of the following facility types: MD – Nursing Facility – Medicaid, ME – Nursing Facility – Medicare, SN – VA Nursing Facility or HC – Hospice Care Center.

 

¨        Enter the [date client entered the facility] in the Entry Date field.

 

¨        Enter the [client’s level of care] in the Level Care field.

 

¨        Enter the [date payment to the facility should begin] in the Payment Auth Date field. This is the date the LTC services are approved and displays on the award letter.

 

¨        Enter the [facilities private daily rate] in the Private Rate field. Contact the facility for rate information.

 

¨        Enter the [facilities state daily rate] in the State Rate field. Press <F20> to access the MMEN for state rates for providers.

 

·         For non-medical facilities, use the rate provided by the Home & Community Services (HCS), Division of Developmental Disabilities (DDD), or HCS Social Worker (SW) / Community Nurse Consultant (CNC) case manager.

 

o    In the Home Community Based Service section, enter the following information if the client receives waiver or hospice services:

 

¨        Enter the [appropriate waiver or service type] in the HCBS Type field.

 

¨        Enter the [provider ID number] when using HCBS type [H] – Hospice in the Provider ID field. To find the provider’s ID number press <F20> to go to the MMEN and enter option [A] – Vendor Name List. See Vendor Payment – Inquire on a Vendor Number.

 

¨        Enter the [date the waiver service begins] in the Start Date field.

 

¨        Enter the [approval source code] in the Approval Source field.

 

¨        Enter the [date payment is to begin] in the Payment Auth Date field. This is the date the LTC services are approved and displays on the award letter.

 

¨        If the HCBS type is [H] – Hospice:

 

·         Enter the [provider’s private daily rate] in the Private Rate field. Call the facility to get the current private rate.

 

·         Enter the [provider’s state daily rate] in the State Rate field. Access the State Rate from the MMEN.


NOTE:

To find the most current state rate for nursing facilities, veteran facilities or hospice care centers go to the MMEN Vender File Submenu and enter option D – Provider Name List.


8.    On the LTCX screen:

 

o    In the LTC Expenses / Deductions section:

 

¨        Enter any [qualified expenses or deductions] that can be used to reduce participation or excess resources in the Type and Amount field.


NOTE:

Expense type RP – PREDICTABLE ONGOING EXPENSE - Added to Facility Rate for MN Initial Elig Cal is not a deduction. This amount is added to the facility rate and used as the “recurring medical expenses” when calculating the income limit in initial eligibility for MN medical for Group (3) clients who have gross income above the SIL and net countable below the MNIL.


o    In the Housing Maintenance Allowance section, enter the following information if a client in a medical facility has an approved housing maintenance allowance/MIIE.

 

¨        Enter the [housing maintenance amount] authorized by HCS or DDD social services in the Amount field.

 

·         The maximum amount used in the post-eligibility calculation is the one-person MNIL.

 

¨        Enter a [Y-Yes or N- No] in the Approved field.

 

¨        Enter the [beginning month & year] in the Begin Month field.

 

·         This allowance is for six months, starting with the month entered in this field.

 

o    In the Family Member Allowance section, enter the following information if the client has a dependent(s).

 

¨        Enter [C – for a dependent living with a community spouse or O – for other Dependents not living with a community spouse] in the Type field.

 

¨        Enter the [gross income amount] of the dependent in the Amount field.

       If the dependent does not have any income, leave the Amount field blank.

 

o    Enter a [Y] in the Force Name on Check Rule field, if the client wishes to use the

     name on the check rule.


NOTE:

In situations where there is an institutional spouse and both are receiving services, the worker may choose to force the name on the check rule; however, the system requires that they force the rule on both clients LTCX screens.


o    Enter a [Y] in the Waive Spousal Allocation field, if the client wishes to waive the spousal portion of the maximum spousal/family allowance.

 

o    In the Room & Board Exceptions section, enter the following information if the client has an approved R&B exception:

 

¨        Enter the [R&B exception type code] in the Type field.

 

¨        Enter the [amount of the exception] in the Amount field.

 

·         The exception allowed in the post-eligibility calculation cannot exceed the maximum R&B liability amount.

 

¨        Enter the [R&B exception verification code] in the V field.

 

¨        Enter the [month & year the exception ends] in the End Month field.

 

9.    Enter [client resource information] on the RES1, RES2 and RES3 screens. For information on how to complete the resource screens see RES1 Resources 1 Screen in the Screen descriptions R thru S chapter.

 

o    See EAZ Manual – WAC 182-513-1350 Defining the resource standard and determining resource eligilibility for long-term care (LTC) services.

 

10.    If the client has transferred an asset, complete the TRAN screen with the appropriate information. See <F1> and <F2> Help. For more information, see EAZ Manual – Transfer of an Asset.

 

11.    On the EARN screen:

 

o    Complete this screen if the client has earned income. See How do I complete the EARN screen? for additional information.

 

12.     On the UNER screen:

 

o    Enter the types and amounts of all unearned income. See How do I complete the fields on the UNER screen? for additional information.


NOTE:

When a spousal maintenance or dependent allowance is used to reduce participation of a LTC client, the amount of that allowance must be counted as income to the spouse or dependent if he/she applies for services. Code this income on the UNER screen as [AH] – Budget in MA only AUs (not Cash or Food) for medical or [AN] – Budget in MA, Cash and Food AUs for Cash, Food or Medical.


13.    Complete the CSRA screen if the client has a community spouse. See <F2> Help

 

14.     On the SHEL screen:

 

o    For more information about this screen and how to update this screen, see <F2>

    Help and SHEL – Shelter Expenses Screen in the Interview chapter.


NOTE:

If the LTC client has a community spouse, shelter expenses must be entered on the spouse’s SHEL screen in order to compute the excess shelter portion of the spousal maintenance allowance (and the shelter deduction for the spouse’s Basic Food, when applicable).


15.    After committing the interview data, follow the instructions in the Process Application Month chapter for all pending months.

 

16.     Once the pending months have been processed, follow the instructions in the Finalize Application chapter.

 

 


CATEGORICALLY NEEDY UNDOCUMENTED ALIEN LTC - SSI RELATED (L04)

Who is eligible for L04 medical?

 

How long is the L04 certification period?

 

How do I screen L04 medical?

 

How do I process a pending L04 AU?

 


 

Who is eligible for L04 medical?

 

·         Non-citizen clients in a nursing facility who are pre-approved by HCS and meet the eligibility requirements described in EAZ Manual – WAC 182-507-0125 State-funded long-term care services program  and EAZ Manual State-funded long-term care program for non citizens.

 

·         Non-citizen clients in a hospital approved by Medical Purchasing Administration (MPA). L04 is only considered if the client is not eligible for S07 – Non-Citizen CN SSI Related, but would be eligible under institutional rules.

 

·         See EAZ Manual – WAC 182-513-1315 Eligibility for long-term care (institutional, home and community based (HCB) waiver, and hospice) services and meet the criteria described in WAC 182-507-0110 Washington Apple Health - Alien medical programs. See clarifying information for processing requirements by the Centralized Medical Unit (CMU).

 


NOTE:

All other medical programs must be considered before using the L04 program.


How long is the L04 certification period?

 

·         L04 medical is certified for 12 months

 

How do I screen L04 medical?

 

·         An L04 AU is initially screened as a L02 following the instructions in Screening – How do I screen an application for a client?

 

·         The L02 AU will trickle to a L04 during finalize, if appropriate, based on eligibility, living arrangement and coding on the INST and ALAS screen.

 

 

How do I process a pending L04 AU?

 

·         To process a pending L04 AU, take the following steps:

 

1.    From the AMEN, select Option O – Interview.

 

2.    On the PEND screen:

 

o    Enter a [Y] – Yes in the Beginning Processing for ALL pending Aus listed with Blank Intake Begin Date? field or enter [Y] – Yes in the S field for each individual AU to initiate the intake interview.

 

3.    On the ADDR screen:

 

o    Enter a [Y] in the Auth Rep/Payee field, if appropriate.

 

4.    On the STAT screen, complete the Finl Resp fields as follows:

 

o    [PN] – Applicant for the applicant.

 

o    [SP] – Ineligible Spouse/Non-Applying Spouse for the applicants’ spouse.


NOTE:

The dependents are coded on LTCX screen under the Family Member Allowance section. This allows the correct post-eligibility allowance calculation for the dependent. A dependent is a child, sibling or parent the individual is claiming to the IRS as a dependent.


5.    On the DEM1 screen:

 

o    Enter the [NF – Nursing Facility or HS – Hospital] in the Living Arngmt field.

 

o    Enter the [marital status] in the Marital Status field.


NOTE:

The marital status of both the applicant and spouse must be coded as S- Legally Separated, P – Separated, A – Married Living Apart or M – Married for the system to recognize the couple as married. This information is needed for the system to determine if the spouse is a “community spouse” or an “institutional spouse” and correctly calculate the spousal allocation.


6.    On the DEM2 screen:

 

o    Enter the [appropriate code] for the non-citizen applicant in the citizenship field. See <F1> Help and <F2> Help.

 

o    Enter the applicant’s disability information in the Disability / Incapacity fields.

 

¨        If the client is 65 or older, the Disability / Incapacity field can be left blank.

 

7.    On the INST screen:

 

o    In the Facility section:

 

¨        Enter [MD – Nursing Facility – Medicaid or HS - Hospital] in the INST Type field. The facility type must be from the same subset as the living arrangement coded on the DEM1 screen.

 

¨        Enter the [provider number] in the Provider ID field if the provider is a MD – Nursing Facility – Medicaid or HC – Hospice Care Center.

 

¨        Enter the [date client entered the facility] in the Entry Date field.

 

¨        Enter the [client’s level of care] in the Level Care field.

 

¨        Enter the [date payment to the facility should begin] in the Payment Auth Date field. This is the date the LTC services are approved and displays on the award letter.

 

¨        Enter the [facilities private daily rate] in the Private Rate field. Contact the facility for rate information.

 

¨        Enter the [facilities state daily rate] in the State Rate field. Press <F20> to access the MMEN for state rates for providers.

 

8.    On the ALAS screen for the applicant:

 

o   Enter the applicant’s citizenship / alien status information. For instructions on completing the ALAS screen, see Screening Descriptions – ALAS – Aliens, Students and PII screen.

 

o   Enter [A – ADSA HEADQUATERS APPROVED] in the [Alien Medical Approval Source] field. 

 

9.    On the LTCX screen:

 

o    In the LTC Expenses / Deductions section:

 

¨        Enter any [qualified expenses or deductions] that can be used to reduce participation or excess resources in the Type and Amount field.

 

o    In the Housing Maintenance Allowance section, enter the following information if a client in a medical facility has an approved housing maintenance allowance/MIIE.

 

¨        Enter the [housing maintenance amount] authorized by HCS or DDD social services in the Amount field.

 

·         The maximum amount used in the post-eligibility calculation is the one-person MNIL.

 

¨        Enter a [Y-Yes or N- No] in the Approved field.

 

¨        Enter the [beginning month & year] in the Begin Month field.

 

·         This allowance is for six months, starting with the month entered in this field.

 

o    In the Family Member Allowance section, enter the following information if the client has a dependent(s).

 

¨        Enter [C – for a dependent living with a community spouse or O – for other Dependents not living with a community spouse] in the Type field.

 

¨        Enter the [gross income amount] of the dependent in the Amount field. If the dependent does not have any income, leave the Amount field blank.

 

o    Enter a [Y] in the Force Name on Check Rule field, if the client wishes to use the name on the check rule.


NOTE:

In situations where there is an institutional spouse and both are receiving services, the worker may choose to force the name on the check rule; however, the system requires that they force the rule on both clients LTCX screens.


o    Enter a [Y] in the Waive Spousal Allocation field, if the client wishes to waive the spousal portion of the maximum spousal/family allowance.

 

10.    Enter [client resource information] on the RES1, RES2 and RES3 screens. For information on how to complete the resource screens see RES1 Resources 1 Screen in the Screen Descriptions R thru S  chapter.

 

o    See EAZ Manual – WAC 182-513-1350 Defining the resource standard and determining resource eligibility for long-term care (LTC) services.

 

11.    If the client has transferred an asset, complete the TRAN screen with the appropriate information. See <F1> and <F2> Help. For more information, see EAZ Manual – Transfer of an Asset.

 

12.    On the EARN screen:

 

o    Complete this screen if the client has earned income. See How do I complete the EARN screen? for additional information.

 

13.     On the UNER screen:

 

o    Enter the types and amounts of all unearned income. See How do I complete the fields on the UNER screen? for additional information.


NOTE:

When a spousal maintenance or dependent allowance is used to reduce participation of a LTC client, the amount of that allowance must be counted as income to the spouse or dependent if he/she applies for services. Code this income on the UNER screen as [AH] – Budget in MA only AUs (not Cash or Food) for medical or [AN] – Budget in MA, Cash and Food AUs for Cash, Food or Medical.


14.    Complete the CSRA screen if the client has a community spouse.

 

15.     On the SHEL screen, see How do I code the SHEL screen when there is a community spouse?

 

o    For more information about this screen, see <F2> Help and SHEL – Shelter Expenses Screen in the Interview chapter.


NOTE:

If the LTC client has a community spouse, shelter expenses must be entered on the spouse’s SHEL screen in order to compute the excess shelter portion of the spousal maintenance allowance (and the shelter deduction for the spouse’s Basic Food, when applicable).


16.    After committing the interview data, follow the instructions in the Process Application Month chapter for all pending months.

 

17.     Once the pending months have been processed, follow the instructions in the Finalize Application chapter.

 

 


CATEGORICALLY NEEDY WAIVER OR HOSPICE SERVICES - SSI RECIPIENTS (L21)

Who is eligible for L21 medical?

 

How long is the L21 certification period?

 

How do I screen L21 medical?

 

How do I process a pending L21 AU?

 

What programs does L21 cover?

 


 

Who is eligible for L21 medical?

 

·         A person with SSI income who meets the criteria in the following EAZ Manual sections may be eligible for L21 medical:

 

o    EAZ Manual – WAC 182-513-1315 Eligibility for long-term care (institutional, home and community based (HCB) waiver, and hospice) services.

 

o    EAZ Manual – WAC 182-505-0510 Washington Apple Health - Program Summary.

 

o    EAZ Manual – WAC 182-513-1350 Defining the resource standard and determining resource eligibility for long-term care (LTC) services.

 

o    EAZ Manual – WAC 182-515-1505 Long-term care home and community based services and hospice.

 

o    EAZ Manual – WAC 182-515-1510 Division of developmental disabilities (DDD) home and community services waivers.


NOTE:

For more information about Home and Community Services (HCS), see the Long Term Care chapter. For more information about Developmentally Disabled (DDD) waiver services, see EAZ Manual – Waiver Services – CNP DDD Waivers.


How long is the L21 certification period?

 

·         L21 medical has no review end date and is certified for as long as the client is eligible for both SSI and waiver service coverage.

 

How do I screen L21 medical?

 

·         To screen an L21 AU, take the following steps:

 

1.    Follow the instructions in Screening a Client.

 

o    On the Programs page, click the checkbox next to COPES/HCBS Waiver/DDD Waiver/Hospice.

 

o    In the Program Determination Criteria section, click the checkbox next to SSI Eligible.

 

o    If ONLY the COPES/HCBS Waiver/DDD Waiver/Hospice box is checked on the Programs page in screening, the AU will initially start as a L22.

 

How do I process a pending L21 AU?

 

·         To process a pending L21 AU, follow the steps in How do I process a pending L02 AU?

 

o    If a client is living in an assisted living facility, adult family home, or in a medical facility on hospice it is necessary to complete the Facility and the Home Community Based Services sections on the INST screen.

 

What programs does L21 cover?

 

·         L21 medical provides categorically needy medical, and coverage for waiver services and hospice care for clients receiving SSI income under these different programs:

 

o    Community Options Program Entry System (COPES) – a Medicaid-waiver program that provides an aged or disabled person, who has been assessed as needing nursing facility care, the option to remain at home or in an alternative living facility. See EAZ Manual – WAC 182-513-1301 Definitions related to long-term care (LTC) services.

 

o    Division of Developmental Disabilities (DDD) waivers – services provided in the home and community to SSI related individuals who would otherwise require the services provided in an Intermediate Care Facility for the Mentally Retarded (ICF/MR). See EAZ Manual – WAC 182-513-1301 Definitions related to long-term care (LTC) services.

 

o    Hospice – provides a terminally ill client a variety of treatment alternatives that can be received at home, in a nursing facility or a Hospice care center. See EAZ Manual – Medical Assistance Programs – Hospice.

 

o    Programs of All-inclusive Care for the Elderly (PACE) – is a managed care service provided by contracted providers. Clients receiving PACE services are identified on the MANC screen after ACES receives the ProviderOne interface file. For more information, see What information is received from ProviderOne to ACES?

 


CATEGORICALLY NEEDY WAIVER OR HOSPICE SERVICES - SSI RELATED (L22)

Who is eligible to receive L22 medical?

 

What income criteria are used to determine COPES Waiver eligibility under the L22 coverage group?

 

How long is the L22 certification period?

 

How do I screen L22 medical?

 

How do I process a pending L22 AU?

 


 

Who is eligible to receive L22 medical?

 

·         A person who is SSI related who meets the criteria in the following EAZ Manual sections may be eligible for L22 medical:

 

o    EAZ Manual – WAC 182-513-1315 Eligibility for long-term care (institutional, home and community based (HCB) waiver, and hospice) services.

 

o    EAZ Manual – WAC 182-503-0510 Washington Apple Health - Program summary. 

 

o    EAZ Manual – WAC 182-513-1350 Defining the resource standard and determining resource eligibility for long-term care (LTC) services.

 

o    EAZ Manual – WAC 182-515-1505 Long-term care home and community based services and hospice.

 

o    EAZ Manual – WAC 182-515-1510 Division of developmental disabilities (DDD) home and community based services waivers.

 

o    HCB Services (COPES, New Freedom, WMIP, Pace) Overview.

 

o    Long-Term Care Home and Community Based Services and Hospice (CN).

 

What income criteria are used to determine COPES Waiver eligibility under the L22 coverage group?

 

·         Effective 4/01/2012 the L22 HCS CN Waiver-SSI related program was expanded to add eligibility for COPES Waiver services for individuals with gross income over the Medicaid SIL, but whose net countable income  is below the MNIL.

 

·         Individuals may be determined eligible for COPES Waiver when meeting one of the following criteria:

 

o    Group (1): Clients who would be otherwise eligible for SSI-related CN medical and have net countable income below the CNIL when SSI-related income rules are used.

 

o    Group (2): Clients who have net countable income above the CNIL and gross income below the SIL.

 

o    Group (3): Clients who have gross income above the SIL and net countable below the MNIL when the income rules for the COPES Waiver expansion are applied.

 

·         The CN Waiver Qualification field listed on the Eligibility Results page in ACES 3G will indicate which rule was used to establish a client's CN Waiver eligibility.

 

 

How long is the L22 certification period?

 

·         L22 is certified for 12 months.

 

How do I screen L22 medical?

 

·         To screen an L22 AU, take the following steps:

 

1.    Follow the instructions in Screening a Client.

 

o    On the Programs page, click the checkbox next to COPES/HCBS Waiver/DDD Waiver/Hospice.

 

How do I process a pending L22 AU?

 

·         To process a pending L22 AU, follow the steps in How do I process a pending L02 AU?

 

o    If a client is living in an assisted living facility, adult family home, or in a medical facility on hospice it is necessary to complete the Facility and the Home Community Based Service sections on the INST screen.

 

 

 

 


STATE FUNDED LTC - SSI RELATED FOR NON-CITIZEN CLIENTS AT HOME OR ALTERNATE LIVING FACILITY (L24)

Who is eligible for L24 medical?

 

How long is the L24 certification period?

 

How do I screen L24 medical?

 

How do I process a pending L24 AU?

 


 

Who is eligible for L24 medical?

 

·         Non-citizen clients at home or in an Alternate Living Facility (ALF) who are pre-approved by ADSA  and meet the eligibility requirements described in EAZ Manual – WAC 182-513-1315 Eligibility for long-term care (institutional, home and community based (HCB) waiver, and hospice) services and meet the criteria described in WAC 182-507-0110 Washington Apple Health - Alien medical programs.

 

How long is the L24 certification period?

 

·         L24 medical is certified for 12 months

 

How do I screen L24 Medical?

 

1.    An L24 AU is initially screened as a L22 following the instructions in Screening a Client.

 

o   On the Programs page, click the checkbox next to COPES/HCBS Waiver/DDD Waiver/Hospice.

 

o   On the Finalize page, select the L22 AU.  The L22 AU will trickle to a L24 during finalize, if appropriate, based on eligibility, living arrangement and coding on the INST and ALAS screen.

 

How do I process a pending L24 AU?

 

·         To process the pending L22 AU, follow the steps in How do I process a pending L02 AU?

 

o   On the INST screen in the Home Community Based Service section, enter:

 

¨        [W – WA Waiver] in the HCBS Type field.

 

¨        [HC - Home & Community Services (HCS)] in the Approval Source field.

 

o   On the ALAS screen, enter

 

     ¨    [A – ADSA Approved] in the Alien Medical Approval Source field.

 


MEDICALLY NEEDY LTC/MEDICALLY NEEDY HOSPICE IN A MEDICAL FACILITY - NO SPENDDOWN (L95)

Who is eligible for L95 medical?

 

How long is the L95 certification period?

 

How do I screen L95 medical?

 

How do I process a pending L95 AU?

 

 


 

Who is eligible for L95 medical?

 

·         SSI related clients who reside in a medical institution, including clients who receive hospice services, and have non-excluded income over the Special Income Level (SIL) and less than the facility’s department contracted rate. For more information see EAZ Manual – WAC 182-513-1395 Determining eligibility for institutional or hospice services for individuals living in a medical institution under the medically needy (MN) program.

 

·         Children, who are blind or disabled, reside in a medical institution and have non-excluded income over the categorically needy (CN) standard for the children’s medical program and less than the facility’s department contracted rate.

 

o    For more information see EAZ Manual – WAC 182-513-1395 Determining eligibility for institutional or hospice services for individuals living in a medical institution under the medically needy (MN) program.

 

How long is the L95 certification period?

 

·         L95 medical is certified for 12 months.

 

How do I screen L95 medical?

 

·         An L95 is initially screened as an L02 following the instructions in How do I screen L02 medical?

 

o    If the COPES/HCBS Waiver/DDD Waiver/Hospice box is checked on the Programs page in screening, the AU will initially start as a L22.

 

·         The L02/L22 AU will trickle to L95 during Finalize, if appropriate, based on the income, living arrangements and INST screen coding.

 

How do I process a pending L95 AU?

 

·         While pending, the AU remains a L02/L22 and is processed following the steps in How do I process a pending L02 AU?

 

·         If the AU exceeds the income standard for L95, it will trickle to spenddown. See Medically Needy LTC in a medical facility – with spenddown (L99).

 

·         A HOSPICE indicator displays on the ELIG and STAT screen when hospice is the priority program for the AU.

 

 


MEDICALLY NEEDY LTC/MEDICALLY NEEDY HOSPICE IN A MEDICAL FACILITY - WITH SPENDDOWN (L99)

Who is eligible to receive L99?

 

How long is the L99 certification period?

 

How do I screen L99?

 

How do I process a pending L99 AU?

 

How do I enter spenddown medical expenses for an L99 AU in M status?

 

How do I initiate an Eligibility Review on an L99 AU?

 


 

Who is eligible to receive L99?

 

·         Clients who meet the criteria described in EAZ Manual – WAC 182-513-1395 Determining eligibility for institutional or hospice services for individuals living in a medical institution under the medically needy (MN) program.

 

How long is the L99 certification period?

 

·         The default certification/base period for L99 is 6 months, which can be shortened to 3 months following the instructions in Spenddown – How do I set up a spenddown AU base period?

 

·         Under certain conditions, the base period can be set to a period other than 3 or 6 months. See EAZ Manual – WAC 182-519-0110 Spenddown of excess income for the medically needy program for these conditions.

 

How do I screen L99?

 

·         An L99 is initially screened as an L02 following the instructions in How do I screen L02 medical?

 

o    If the COPES/HCBS Waiver/DDD Waiver/Hospice box is checked on the Programs page in screening, the AU will initially start as a L22.

 

·         The L02/L22 AU will trickle to L99 during Finalize, if appropriate, based on the income, living arrangements and INST screen coding.

 

How do I process a pending L99 AU?

 

·         While pending, the AU is still a L02/L22 and is processed following the steps in How do I process a pending L02 AU?

 

·         If the AU exceeds the income standard for L02, it will trickle to L99 in [M] – MA Spenddown. See Medically Needy LTC in a medical facility – with spenddown (L99).

 

·         For additional information on the spenddown process, see EAZ Manual – WAC 182-519-0110 Spenddown of excess income for the medically needy program.

 

·         A HOSPICE indicator displays on the ELIG and STAT screen when hospice is the priority program for the AU.

 

How do I enter spenddown medical expenses for an L99 AU in M status?

 

·         To enter medical expenses to meet the client’s spenddown liability on an L99 AU in [M] – MA Spenddown status, follow the instructions in Spenddown – How do I enter medical expenses?

 

How do I initiate an Eligibility Review on an L99 AU?

 

·         Eligibility reviews can be initiated on L99 AUs in [A] – Active status. If the AU is in [M] – MA Spenddown status, an eligibility review can be initiated when the ongoing month is the month after the current base period end month.

 

·         Complete the eligibility review on an active L99 AU following the instructions in the Eligibility Review/Recertification Process chapter.

 

 


PERSONAL NEEDS ALLOWANCE (PNA)

What is a personal needs allowance (PNA)?

 

How is personal needs allowance determined (PNA)?

 


What is a personal needs allowance (PNA)?

 

·         This is the standard amount of income that an institutional client is allowed to keep to use for housing, clothing, personal items and other incidentals. This allowance is sometimes referred to as Clothing and Personal Incidentals (CPI). For more information see EAZ Manual – WAC 182-513-1380 Determining a client’s financial participation in the cost of care for long-term care (LTC) services.

 

·         The PNA is deducted from the client’s countable income when determining their cost-of-care responsibility.

 

How is personal needs allowance determined (PNA)?

 

·         A client’s (PNA) is calculated based on the clients living arrangement, authorized services and marital status. For more information see EAZ Manual – Long-Term Care Personal Needs Allowance (PNA) charts.

 

·         When a client is in multiple settings during the month, the PNA used in the cost-of-care calculation will be the highest PNA the client was eligible for at any point during the month.

 

 


CASE SPECIFIC SITUATIONS

How do I process a change when a client changes from one setting or service to another?

 

How do I process a change when a client changes from one L-track medical coverage group (L02) to a non-institutional medical coverage group on MPC services?

 

How do I add hospice services to a client receiving LTC services?

 

How do I add an Authorized Representative to an AU?

 

How do I code the SHEL screen when there is a community spouse?

 

What do I do if the client’s SSI income stops?

 

When should I use the STAY screen?

 

When should I use the INST screen?

 

What program do I open for a client in a hospital?

 

How do I close an LTC medical program for a client who is deceased?

 

How do I code the non-applying spouse’s demographic, income and resource information?

 

How do I code the spousal allocation when a community spouse or dependent is applying for non-institutional medical or food assistance?

 

How do I code a legal dependent on a LTC AU?

 

How do I view the participation amounts when it is split between multiple providers?

 


 

How do I process a change when a client changes from one setting or service to another?

 

·         To process a change when a client changes from one setting or service to another, take the following steps:

 

1.    From the AMEN, select Option R – Interim / Hist Change.

 

o    Enter the [month of the change] in the Benefit Month field.

 

2.    On the ADDR screen,

 

o    Update the address if appropriate.

 

3.    On the AREP screen:

 

o    Update the Authorized Representative information as appropriate.

 

4.    On the DEM1 screen:

 

o    Update the living arrangement if appropriate.

 

5.    On the INST screen:

 

o    In the Facility section, if the client has discharged from a facility already on the INST:

 

¨        Enter the [date the client left the facility or ALF] in the Leave Date field.

 

o    If the client has entered another facility or ALF, take the following steps:

 

¨        Enter the [type of facility] in the INST Type field. The facility type must be from the same subset as the living arrangement coded on the DEM1 screen.

 

¨        Enter the [provider number] in the Provider ID field if the provider is one of the following facility types: MD – Nursing Facility – Medicaid, ME – Nursing Facility – Medicare, or HC – Hospice Care Center.

 

¨        Enter the [date the client enter the facility or ALF] in the Entry Date field.

 

¨        Enter the [level of care] in the Level Care field.

 

¨        Enter the [date payment should begin] in the Payment Auth Date field. This is the date services are approved and displays on the award letter.

 

¨        Enter the [facilities private daily rate] in the Private Rate field. Contact the facility for rate information.

 

¨        Enter the [facilities state daily rate] in the State Rate field. Press <F20> to access the MMEN for state rates for providers.

 

·         In the Home Community Based Service section, if the existing services have ended:

 

o    Enter the [date the services ended] in the End Date field.

 

o    Enter the [new waiver service type] in the HCBS Type field on the next line. If new services have been approved.

 

o    Enter the [provider number] in the Provider ID field if the HCBS type is H – Hospice. To find the provider’s ID number press <F20> to go to the MMEN. Enter option [A] – Vendor Name List. See Vendor Payment – How do I inquire on a vendor?

 

o    Enter the [date the new waiver service begins] in the Start Date field.

 

o    Enter the [approval source code] in the Approval Source field.

 

o    Enter the [date payment is to begin] in the Payment Auth Date field.

 

o    If the HCBS type is [H] – Hospice:

 

¨        Enter the [provider’s private daily rate] in the Private Rate field. Call the facility to get the current private rate.

 

o    Enter the [provider’s state daily rate] in the State Rate field. To find the provider’s state rate press <F20> to go to the MMEN. Enter option [A] – Vendor Name List. See Vendor Payment – How do I inquire on a vendor?

 

6.    Call DONE and commit the data.

 

·         To process the change for the months after the change took place, take the following steps:

 

7.    From the AMEN, select Option R – Interim / Hist Change.

 

o    Enter the [month after the change] in the Benefit Month field.

 

8.    On the ADDR screen:

 

o    Update the address if appropriate.

 

9.    On the AREP screen:

 

o    Update the Authorized Representative information as appropriate.

 

10. On the INST screen, in the Facility section, if the client has discharged from a facility or ALF already on the INST:

 

o    Enter a [Y] – Yes in the Delete field to remove the old facility information.

 

¨        Enter the [type of facility] in the INST Type field. The facility type must be from the same subset as the living arrangement coded on the DEM1 screen.

 

o    If the client has entered a new facility:

 

¨        Enter the [provider number] in the Provider ID field if the provider is one of the following facility types: MD – Nursing Facility – Medicaid, ME – Nursing Facility – Medicare, or HC – Hospice Care Center.

 

¨        Enter the [date the client enter the facility or ALF] in the Entry Date field.

 

·         This can be the same date as the leave date from a prior facility.

 

¨        Enter the [level of care] in the Level Care field.

 

¨        Enter the [date payment should begin] in the Payment Auth Date field. This is the date services are approved and displays on the award letter.

 

¨        Enter the [facilities private daily rate] in the Private Rate field. Contact the facility for rate information.

 

¨        Enter the [facilities state daily rate] in the State Rate field. Press <F20> to access the MMEN for state rates for providers.

 

·         In the Home Community Based Service section, if existing services have ended that are already coded on the INST:

 

o    Enter the [Y] – Yes in the Delete field to remove the old HCBS information.

 

¨        If new services have been approved.

 

o    Enter the [new waiver service type] in the HCBS Type field on the next line.

 

o    Enter the [provider number] in the Provider ID field if the HCBS type is [H] – Hospice. To find the provider’s ID number press <F20> to go to the MMEN. Enter option [A] – Vendor Name List. See Vendor Payment – How do I inquire on a vendor?

 

o    Enter the [date the new waiver service begins] in the Start Date field.

 

o    Enter the [HCBS approval source code] in the Apprvl Source field.

 

o    Enter the [date payment is to begin] in the Payment Auth Date field.

 

o    If the HCBS type is [H] – Hospice:

 

¨        Enter the [provider’s private daily rate] in the Private Rate field. Call the facility to get the current private rate.

 

¨        Enter the [provider’s state daily rate] in the State Rate field. To find the provider’s state rate press <F20> to go to the MMEN. Enter option [A] – Vendor Name List. See Vendor Payment – How do I inquire on a vendor?

 

11. Call DONE and commit the data.

 

12. Repeat the above steps for each month after the change month through the ongoing month.

 

 

How do I process a change when a client changes from one L-track medical coverage group (L02) to a non-institutional medical coverage group on MPC services?

 


NOTE:

These are the steps needed to process non-institutional clients residing in an ALF on MPC services.

 

These steps also work for processing a change from a non-institutional medical coverage group on MPC (G02, G03, S01, S02, S08) to LTC medical coverage group.  


·         To process a change when a client discharges from a NF - Nursing Facility to an AF - Alternate Living Facility on MPC services, take the following steps:

 

1.    Add a program from the existing active L02 AU. Follow the instructions in Add a Program.

 

o    On the Programs page, click the check box next to Long Term Care.

 

o    On the Finalize page, use the Specify Program option to select the appropriate Medical Coverage Group.

 

o    The Application Date should be the date the client was discharged from the NF.

 

·         To initiate and complete the interview on the pending AU, take the following steps:

 

1.    From the AMEN screen, select Option O – Interview.

 

2.    On the PEND screen:

 

o    Enter a [Y] – Yes in the Beginning Processing for ALL pending AUs listed with Blank Intake Begin Date? to initiate the intake interview.

 

3.    Update the ADDR as appropriate.

 

4.    On the STAT screen, complete the Finl Resp fields as follows:

 

o    [PN] – Applicant for the applicant.

 

5.    On the AREP screen:

 

o    Update the Authorized Representative information as appropriate.

 

6.    On the DEM1  screen:

 

o    Update the living arrangement from NF - Nursing Facility to the appropriate living arrangement.

 

7.     On the INST  screen:

 

o    In the Facility section, since client has discharged from a nursing facility:

 

¨        Enter a [Y] - Yes in the Delete field to remove the prior Facility information. (Do not delete the prior Facility in the month the change occurred.)

 

¨        Enter the [type of facility] in the INST Type field. The facility type must be from the same subset as the living arrangement coded on the DEM1 screen.

 

o    Entered the new Facility:

 

¨        Enter the [date the client enter the ALF] in the Entry Date field.

 

·         This should be the same date as the leave date from the prior facility.

 

  • Enter the [level of care] in the Level Care field.

 

¨        Enter the [date payment should begin] in the Payment Auth Date field. This is the date services are approved and displays on the award letter.

 

¨        Enter the [facilities private daily rate] in the Private Rate field. Contact the facility for rate information.

 

¨        Enter the [facilities state daily rate] in the State Rate field. Press <F20> to access the MMEN for state rates for providers.

 

o    In the Home Community Based Service section:


NOTE:

This section needs to be completed for individuals approved for Medicaid Personal Care (MPC) by HCS or DDD.


¨        Enter the [M – Medicaid Personal Care (MPC)] in the HCBS Type field.

 

¨        Enter the [date the waiver service begins] in the Start Date field.

 

¨        Enter the [approval source code] in the Approval Source field.

 

¨        Enter the [date payment is to begin] In the Payment Auth Date field.  This is the date the MPC services are approved and displays on the approval letter.

 

8.    Call DONE and commit the data. (The existing L02 will deny with Reason Code 201 - Living Arrangement - Cash/Medical Assistance.)

 

·         After committing the interview data, follow the instructions in the Process Application Month chapter for the pending AU.  

o   In the month the change occurred DO NOT delete the prior Facility, instead add the Leave Date (this allows the prior facility to be paid).

 

·         Once the pending months have been processed, follow the instructions in the Finalize Application chapter. (The approval date for the G03 will be for the ongoing month.)


EXAMPLE

Michael resides in a Nursing Facility (NF) active on L02, and is discharged on 07/03/14 to an Alternate Living Facility (ALF) on Medicaid Personal Care (MPC) services.

 

On 07/30/14 the worker completes an Add a Program for G03 with an application date of 07/03/14. 

 

During Finalize the L02 remains active in the month the change occurred (July 2014), and historically closes in the ongoing month (August 2014), however, the AU will close historically with a paid thru date based on 10 day advanced notice, unless advanced notice is waived for the subsequent  months.

 

The G03 will deny for Reason Code 245 – No Eligible Household Member for all months the L02 was active. The approval date for the G03 will be for the ongoing month, if appropriate.


How do I add hospice services to a client receiving LTC services?

 

1.    From the AMEN, select Option R – Interim/Hist Change.

 

o    Enter the [AUID or CLID] in the AUID or Client ID field.

 

o    Enter the [month and year] the client elected hospice in the Benefit Month (MM YY) field.

 

2.    On the ADDR screen:

 

o    Enter a [Y] – Yes in the Auth Rep/Payee field.

 

3.    On the AREP screen:

 

o    Enter the [appropriate authorized representative] in the Rep Type field.

 

o    Enter the [hospice agency name] in the Corp Name field; or the [AREP Name] in the F Name MI L Name fields.

 

¨        If the client is receiving waiver services do not remove the (HCS/AAA or DDD) case manager from the AREP screen as the waiver service is the priority program.

 

o    Enter the [representative’s name] in the appropriate address fields.

 

4.    On the DEM1 screen:

 

o    Enter [HC] – Hospice Care Center in the Liv Arng field, only If the client has entered a Hospice Care Center.

 

5.    On the INST screen, in the Facility section:

 

¨        Enter the [type of facility] in the INST Type field. The facility type must be from the same subset as the living arrangement coded on the DEM1 screen.

 

¨        Enter the [provider number] in the Provider ID field if the provider is one of the following facility types: MD – Nursing Facility – Medicaid, ME – Nursing Facility – Medicare, HS – Hospital, IM – Institution for Mentally Diseased or HC – Hospice Care Center.

 

·         Hospitals and Institutions for Mentally Diseased do not have provider numbers.

 

¨        Enter the [date the client elected hospice] in the Entry Date field.

 

¨        Enter the [O - Hospice] in the Level Care field.

 

¨        Enter the [date payment to the facility should begin] in the Payment Auth Date field. This is the date the hospice was elected and services are approved and displays on the award letter.

 

¨        Enter the [facilities private daily rate] in the Private Rate field. Contact the facility for rate information.

 

¨        Enter the [facilities state daily rate] in the State Rate field. Press <F20> to access the MMEN for state rates for providers.

 

6.    On the INST screen, in the Home Community Based Service section:

 

o    Enter the [Y] – Yes in the Delete field to remove the old HCBS information.

 

o    Enter the [H- Hospice] in the HCBS Type field on the next line.

 

o    Enter the [provider number] in the Provider ID field. To find the provider’s ID number press <F20> to go to the MMEN. Enter option [A] – Vendor Name List. See Vendor Payment – How do I inquire on a vendor?

 

o    Enter the [date the client elected hospice] in the Start Date field.

 

o    Enter the [HCBS approval source code] in the Apprvl Source field.

 

o    Enter the [date payment is to begin] in the Payment Auth Date field.

 

o    Enter the [provider’s private daily rate] in the Private Rate field. Call the facility to get the current private rate.

 

o    Enter the [provider’s state daily rate] in the State Rate field. To find the provider’s state rate press <F20> to go to the MMEN. Enter option [A] – Vendor Name List. See Vendor Payment – How do I inquire on a vendor?

 

7.    Call DONE and commit the data.

 

How do I add an authorized representative to an AU?

 

·         To add an authorized representative to an AU, see How do I add an authorized representative to an AU?

 

How do I code the SHEL screen when there is a community spouse?

 

·         For a Long-Term Care client with a Community Spouse, shelter expenses must be entered on the Community Spouse’s SHEL screen to be used in the community spousal allowance/excess shelter calculation.

 

·         The excess shelter allocation is the amount in excess of the appropriate standard.  See EA-Z Manual WAC 182-513-1380 Determining a client’s financial participation in the cost of care for long-term care (LTC) services for additional information.

 

·         ACES uses the four-person Standard Utility Allowance (SUA) in this computation.  If utilities are included in the rent, mortgage, maintenance fees or condo fees, deduct that amount of the four-person SUA from these expenses so it will not be allowed twice.  

 

What do I do if the client’s SSI income stops?

 

·         If the SDX interface indicates a client is no longer SSI eligible the following occurs:

 

·         On the UNER screen, ACES updates the client’s income type SI to $0 and the L01 AU remains active.

 

·         Alert 248: SSI TERMINATED, REDETERMINE MEDICAL ELIGIBILITY generates for the worker of record.

 

·         Generates Letter 022-05 (Redetermination for Medical at SSI Termination) with an Eligibility Review form 14-078.

 

·         If the review indicator on the MISC screen is not updated with a Y within 60 days from the date the eligibility review was sent AUTO terminates the AU with Reason Code 235 – Review not complete.

 

·         Once the SSI income is removed from the UNER screen the AU trickles from L01 to L02.

 

·         When a client’s SSI benefits are terminated, re-determine the client’s medical eligibility for other programs (such as L02 if the client is still residing in a medical institution) following the processes outlined in the Medical Re-Determination chapter.

 

When should I use the STAY screen?

 

·         Short stay data can only be entered for:

 

o    Active medical recipients.

 

o    After the short stay has ended.

 

o    In a historical month.

 

o    Stays in a medical institution or for hospice services.

 

o    Client returns to their original setting when the short stay ends.


EXAMPLE

Client resides in an Adult Family Home (ALH) and is admitted to a nursing home for two weeks. The client returns back to the same AFH. This situation should be coded on the STAY screen.


EXAMPLE

Client resides at home and is active on an S02 AU. Client admits to a nursing home for three weeks. The client returns home. This situation should be coded on the STAY screen.


EXAMPLE

Client resides in a nursing facility, and has a medical condition requiring hospitalization. The client discharges from the nursing facility and enters the hospital. After two weeks, the client enters a new nursing facility. This situation should be coded on the INST screen because the client entered a different nursing facility.


EXAMPLE

Client resides in an Assisted Living Facility (ALF), and has a medical condition that requires a stay in a Nursing Facility or Hospital for over 29 consecutive days. Client then returns to the same ALF. This situation should be coded on the INST screen.


·         For more information regarding short stays, see the Short Stay chapter.

 

When should I use the INST screen?

 

·         The INST screen should be used when a client is admitted to a medical facility for over 29 days.

 

·         The client admits to a medical facility and does not return to the same setting.


EXAMPLE

Client resides in a nursing facility, and has a medical condition requiring hospitalization. The client discharges from the nursing facility and enters the hospital. After two weeks, the client enters a new nursing facility. This situation should be coded on the INST screen because the client had discharged from the nursing facility.


EXAMPLE

Client resides in an Assisted Living Facility (ALF), and has a medical condition that requires a stay in a Nursing Facility or Hospital for over 29 consecutive days. Client then returns to the same ALF. This situation should be coded on the INST screen.


EXAMPLE

Client resides in an Assisted Living Facility (ALF), and enters a nursing facility. After two weeks the client discharges from the nursing facility and enters a different ALF. This situation should be coded on the INST screen.


What program do I open for a client in a hospital?

 

·         If the client does not meet institutional status to establish eligibility in the hospital, then users need to look at SSI Related medical (S02). However, there are certain situations when an L-track medical would be to the client’s advantage.

 

·         These cases need to be reviewed by policy if the worker is uncertain what program would be best for the client.

 

How do I close an LTC medical program for a client who is deceased?

 

1.    From the AMEN, select Option R – Interim/Hist Change starting with the month the client passed away.

 

2.    On the DEM2 screen:

 

o    Enter the [date of death] in the Death Date field.

 

o     Enter the [death state] in the Death State field.

 

3.    Call DONE, verify AU is closing for Reason Code 244 – Death and commit the data.

 

4.    From the AMEN, select Option R – Interim/Hist Change for each month after the client passed away.

 

5.    On the DEM2 screen:

 

o    Enter the [date of death] in the Death Date field.

 

o     Enter the [death state] in the Death State field.

 

6.    On the INST screen:

 

o    Enter a [Y] in the Del Ind field and press <F4> to delete the institutional information.

 

How do I code the non-applying spouse’s demographic, income and resource information?

 

·         To correctly calculate eligibility for a LTC AU and the spousal/dependent allocation amount, the following data is required:

 

o    The Financial Responsibility code must be entered as SP – Ineligible Spouse.

 

o    The living arrangement must be completed on the DEM1 screen.

 

o    The marital status of both the recipient and spouse on the DEM1 screen must be one of the following:

 

¨        S – Legally Separated

 

¨        P – Separated

 

¨        A – Married Living Apart

 

¨        M – Married Living with Spouse

 

o    Information regarding he spouse’s resources and income must be entered into the system using the standard client based screens such as DEM1, UNER, EARN, SHEL and the resource screens. 

 

How do I code the spousal allocation when a community spouse or dependent is applying for non-institutional medical or food assistance?

 

·         To code the spousal allocation for a community spouse or dependent applying for non-institutional medical or food assistance, take the following steps:

 

1.    On the UNER screen:

 

o    Enter [AH – Budget in MA only AUs (not Cash or Food) for medical] or [AN – Budget in MA, Cash and Food AUs for Cash, Food or Medical] in the Srce field. 

 

o    Enter [AM – Anticipated Monthly] in the Inc Mthd field.

 

o    Enter [MO – Monthly] in the Freq field.

 

o    Enter the [amount of the allocation] in the Amt field.

 

How do I code a legal dependent on a LTC AU?

 

·         To code a legal dependent on a LTC AU, take the following steps:

 

1.    On the LTCX screen:

 

o    In the Family Member Allowance section:

 

¨        Enter [C – for a dependent living with a community spouse or O – for dependent not living with a community spouse] in the Type field.

 

¨        Enter the [gross income amount] of the dependent in the Amount field. If the dependent does not have any income, leave the Amount field blank.

 

How do I view the participation amounts when it is split between multiple providers?

 

·         The MAFI screen displays the LTCP indicator next to the Total Payment field.  Workers can access the LTCP screen by pressing <F16> on MAFI.

 

·         The LTCP screen is an inquiry only screen and can be called up from any other data collection screen.  It only displays when there is a split participation amount for that benefit month.

 

·         The LTCP screen displays:

 

o    The gross Post-Eligibility (PETI) income amount used to calculate the client’s cost-of-care responsibility.

 

o    The income processing rule used to determine the gross income amount used in the eligibility calculation.

 

¨        “Name on the Check Rule” or “Community Income Rule”.

 

o    The assignment section displays up to four service or facility/provider types to which the cost-of-care for the month may be assigned. The first occurrence is a duplicate of the provider or service whose information is displayed on the MAFI screen.

 

o    The cost-of-care for each provider when the client's cost of care for a single month is split between multiple services/providers.  For example, when a client moves from one facility to another.

 

o    The discharge date is the facility discharge date or service end date when the client received care from more than one service or setting during the month.

 

·         The STAY screen displays when a medical client is institutionalized or elects Hospice for a short period of time.  Use the STAY screen to access the SSCC screen that displays the amount the client owes the provider for a specified Short Stay.  The SSCC screen is accessible only from the STAY screen.

 

 


Medically Needy Residential Waiver (MNRW)

This section Invalid effective 3/31/12. For processing benefit month 4/01/12 forward See Categorically Needy Waiver or Hospice Services-SSI Related L22 section.

Screen MNRW cases into ACES as medical coverage group G03. When coded correctly, ACES will trickle to a G95 (MN without spenddown) or a G99 (MN with spenddown).

ACES uses the amount listed in the Private Rate field on the INST screen for G95 and G99 to calculate MN eligibility.

ACES uses the amount in the State Rate field on the INST screen for G03 (CN medical) as long as the countable income is below the SIL.

Currently, ACES is allowing the $20 disregard when comparing the income to the SIL. This is incorrect per policy. If a client’s gross non-excluded income is above the SIL, then the client is not G03 (CN) eligible. As a processing alternative, reducing the amount in the state rate field should allow this case to trickle G95 or G99, as appropriate, provided the amount coded in the private rate field is correct.

MN without spenddown (G95)

  1. Manually calculate eligibility or use the calculations from the MNRW Web site.

  2. Code the (INST) screen as follows:

    1. Type:  Use the appropriate facility type for the clients MNRW Residential living arrangement. See F1 for help.

    2. Entry Date: Code the date the client was admitted to the residential facility.

    3. Level of Care:  Code this field with “L”

    4. LTC Auth Payment Date:  Code the effective date of services the Social Services worker uses to begin payment for to the provider MNRW services

    5. Private Rate Field:  Code $100, unless the actual rate is higher due to an ETR.

    6. State Rate Field: Code the residential facilities actual daily rate authorized by the Social Services Worker (the rate used to determine eligibility) unless ACES remains G03. If so, you will need to lower this rate to an amount that will allow ACES to trickle to G95 or G99

    7. HCB Waiver Type and Date:  Code in “C” and the date the Social Services worker begins payment for to the provider MNRW services according to the Financial/Social Service Communication form 14-443.

    8. Remarks:  Clearly document all actions, including eligibility calculations and processing alternatives.


NOTE: ACES Letters for G95 and G95 cases do not issue an institutional award letter. Workers must manually generate an ACES letter:
  1. Approval for LTC Medical Benefits - 002-17

  2. Do not use COPES letter.


MN with spenddown G99
  1. Manually calculate eligibility or use the calculations from the MNRW Web site.

  2. Code the (INST) screen as follows:

    1. Type:  Use the appropriate facility type for the clients MNRW Residential living arrangement. See <F1> for help.

    2. Entry Date:  Code the date the client was admitted to the residential facility.

    3. Level of Care: Code this field with “L”

    4. LTC Auth Payment Date:  Code the effective date of services the Social Services worker uses to begin payment for to the provider MNRW services

    5. Private Rate Field:  Code the residential facilities actual daily rate authorized by the Social Services Worker (the rate used to determine eligibility).

    6. State Rate Field:  Code the residential facilities actual daily rate authorized by the Social Services Worker (the rate used to determine eligibility) unlessACES remains G03. If so, you will need to lower this rate to an amount that will allow ACES to trickle to G95 or G99

    7. HCB Waiver:  Code in “C” and the date the Social Services worker begins payment for to the provider MNRW services according to the Financial/Social Service Communication form 14-443.

    8. Remarks:  Clearly document all actions, including eligibility calculations and processing alternatives.

  3. Currently, ACES is not programmed to correctly calculate MNRW spenddown. Workers must manually compute the spenddown for the base period using the MNRW Web Calculator.

  4. Clearly document the ACES (NARR) what the manually calculated spenddown amount is and how it was computed. This will be your only record of the correct spenddown amount.

  5. Complete ACES (AMEN) Option V, Spenddown Authorization.

  6. Use the manually computed spenddown amount the base period and issue an ACES letter MN Spenddown - 020-01.

    1. When active slots are available:

      HCS can authorize a maximum of 600 participants on MNRW services during any waiver year, running from May to April. When a client is one of the 600 participants, they are using an active slot. When active slots are available, include freeform text in the MN Spenddown - 020-01 letter that explains the client is not eligible for the MNRW program until the spenddown is met.

    2. When no active slots are available and there is a wait list:

      If there are 600 participants on MNRW services, then there is no active slot available for a client. The client must go onto a wait list until an active client leave the program and an active slot becomes available. When there are no active slots available and a client must go onto the wait list, include freeform text in the MN Spenddown - 020-01 letter that explains that there are no active slots on the MNRW program and that the client must meet spenddown before he or she is considered eligible and can be placed on the wait list or receive MNRW services.

Meeting Spenddown

When the client provides bills that meet the manually calculated MNRW spenddown for the base period, first determine if there are active slots available.

  1. When active slots are available and client is authorized for MNRW services:

    1. Complete(AMEN), Option T Spenddown Medical Expense Update.

    2. Enter <a medical expense> that is equal to the ACES spenddown amount on the(AMEN), Option T, on the(SDME) screen.

    3. Complete(AMEN), Option V, Spenddown Authorization

    4. Manually generate the additional letter Approval for LTC Medical Benefits - 0002-17.

    5. Clearly document the ACES NARR which bills were used to meet spenddown

  2. When no active slots are available and there is a wait list:

    1. Deny MNRW

    2. Include freeform text that explains that there are no active slots for the MNRW program and that the client will be placed on a wait list.

    3. Clearly document the ACES NARR which bills were used to meet spenddown.

    4. Consider other medical programs.

    5. Clearly document your decision in the ACES NARR.

Modification Date: June 19, 2014