SSI Related Non-institutional Alternate Living Facility
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SSI Related Non-institutional Alternate Living Facility


Revised June 23, 2014



Categorically Needy Alternate Living Facility (G03) Non-Institutional SSI Related

 

Medically Needy Alternative Living Facility no spenddown (G95) Non-Institutional SSI Related

 

Medically Needy Alternative Living Facility with spenddown (G99) Non-Institutional SSI Related

 


Categorically Needy Alternate Living Facility (G03) Non-Institutional SSI Related

Who is eligible to receive G03 medical?

 

How long is the G03 certification period?

 

How do I screen G03 medical?

 

How do I process a pending G03 AU?


 

Who is eligible to receive G03 medical?

 

·         A person who resides in Alternate Living Facility (ALF) and meets the requirements in the following EAZ Manual sections may be eligible for G03:

 

·         Non-Institutional SSI related clients living in an adult family home or boarding home (G03).

 

·         See Non Institutional Medicaid – Examples for additional information.

 

How long is the G03 certification period?

 

·         G03 is certified for 12 months.

 

·         See WAC 182-504-0015 Washington Apple Health - Certification periods for categorically needy (CN) programs.

 

How do I screen G03 medical?

 

1.    From the Welcome Back page in aces.online, click the Screen New Application link at the top of the page. The Applicant page displays in a new window.

 

2.    On the Applicant page, enter the head of household’s Name, Residential and Mailing Addresses.  Continue with the screening process until you reach the Programs page.

 

3.    On the Programs page:

 

o    Select Alternate Care in the Programs section.

 

4.    Continue with the screening process until you reach the Finalize page.

 

5.    On the Finalize page:

 

o    Select Medical Assistance (MA). Coverage Group (G03) CN Alternate Living Facility.

 

o    Enter the Application Date.

 

o    Click Commit.  

 

How do I process a pending G03 AU?

 

·         To process a pending G03 AU, take the following steps: 

 

1.    Select AMEN screen, Option O - Interview in the selection field.

 

2.    On the ADDR screen:

 

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

 

o    If client is receiving Medicaid Personal Care (MPC) services, code the address of the case manager on the AREP screen.

 

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

 

o    [PN] – Applicant for the applicant and an applying spouse (only if the spouse resides in the same room at the ALF).

 

o    [SP] – Ineligible Spouse for the non-applying spouse (only if the spouse resides in the same room at the ALF).

 

4.    On the DEM1 screen:

 

o    In the living arrangement field, enter [the appropriate valid value for the type of ALF the client is living in]. See <F1> Help.

 

o    Enter [the applicant’s marital status] in the Marital Status field. See <F1> Help.

 

5.    On the DEM2 screen:

 

o    If the client is receiving Medicare Part A or Part B, enter a [Y] in the Entitled Medicare field and press <F22> to complete the TPL1 screen. See How do I process a pending S03 AU? Step 5.

 

o    If the client does not meet aged criteria, enter applicant’s disability information in the Dis/Incap Type field. See <F1> help.

 

o    Enter the applicant’s Vet Status. See <F1> help.

 

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 ALF subset. See <F1> help.

 

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

 

    Enter [L] – Alternate Living Facility (ALF) in the Level Care field.

 

    Enter the [payment authorization date] in the Payment Auth Date field. This entry is only necessary if approving payment to an ALF for Medicaid Personal Care (MPC).

 

    Enter the [private daily rate of the facility] in the Private Rate field.

 

    Enter the [state daily rate of the facility] in the State field.

 

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.

 

7.    On the MEDX screen:

 

·          If the client pays for health care insurance:

 

o    Enter the [HP] – Recurring Health Insurance Premium (FA or MA Only) or [RP] - Reimbursed Health Insurance Premium (MA Only) in the Typ field.

 

o    Enter the [end date to match the certification period end date] in the End Date field.

 

o    Enter [the amount of the recurring expense] in the Amt field.

 

o    Enter [the appropriate valid value] in the V field.  See <F1> Help.

 

o    Enter [the amount of the non-recurring expense that is paid by a third party] If part of the expense is paid by a third party, in the TPL Amt field.

 

o    Enter [the name of the medical provider/pharmacy] in the Provider Name field.

 

8.    Follow the steps outlined in Process Application Months and Finalize Application chapters.

 

·         If the client’s income is below the Medicaid SIL and the facility’s state rate X 31 days plus the GA PNA, the client will be eligible for G03 CN coverage.

 

·         If the client’s income is above the SIL, the AU will trickle to G95/G99.

 

·         If the client’s income is below the SSI-related CNIL, Edit 2286 – CLIENT APPEARS ELIGIBLE FOR S02. SCREEN IN S02 AND CLOSE G03 generates on the  ELIG screen.


Medically Needy Alternative Living Facility No Spenddown (G95) Non-Institutional SSI Related

Who is eligible for G95 medical?

 

How long is the G95 certification period?

 

How do I screen in a G95 AU?

 

How do I process G95 medical?

 

What do I do when a client changes from a non-institutional program to an institutional program?

 


 

Who is eligible for G95 medical?

 

·         Clients who reside in department-contracted residential facilities and meet the criteria in WAC 182-513-1305 Determining eligibility for SSI-related non-institutional medical assistance in an alternate living facility (ALF) may be eligible for G95.

 

·         See Non Institutional Medicaid – Examples for additional information.


How long is the G95 certification period?

 

·         The G95 medical program is certified for 12 months.

 

How do I screen in a G95 AU?

 

·         A G95 AU is initially screened as a G03 following the instructions in How do I screen a G03 AU?

 

·         The G03 AU will trickle to G95 during finalize, if appropriate, based on income, living arrangements and INST screen coding. See WAC 182-513-1305 Determining eligibility for SSI-related non-institutional medical assistance in an alternate living facility (ALF).

 

How do I process G95 Medical?

 

·         While pending, the AU is G03 and is processed following: See How do I process a pending G03 AU? 

 

·         The AU will trickle to G95 in finalize, if appropriate, if the client’s income is higher than either the SIL or the ALF state rate (on INST) X 31 days plus the GA PNA, but below the ALF private rate (on INST) X 31 days plus GA PNA.

 

What do I do when a client changes from a non-institutional program to an institutional program?

 

·         Close the G95/G99 AU with a 500 level reason code.

 

·         Screen in a new AU appropriate to the clients living arrangement.

 

·         If the client resides in at home, or in an Assisted Living Facility (ALF) or receives Hospice services see How do I screen a C01 medical?

 

·         If the client is a recipient of Supplemental Security Income (SSI) and meets the eligibility and institutional criteria as defined in the EAZ Manual – Long Term Care chapter then see How do I screen L01 medical?

 

·         If the client resides in a medical facility and meets the eligibility and institutional criteria as defined in the EAZ Manual – Long Term Care chapter then see How do I screen L02 medical?


Medically Needy Alternative Living Facility With Spenddown (G99) Non-Institutional SSI Related

Who is eligible for G99 medical?

 

How long is the G99 certification period?

 

How do I screen in a G99 AU?

 

How do I process G99 medical?

 

When do G99 benefits begin?

 

How do I authorize spenddown for an AU in M status?

 

How do I enter spenddown medical expenses for a G99 AU in M status?

 


Who is eligible for G99 medical?

 

·            Clients who reside in department-contracted residential facilities and meet the criteria in  WAC 182-513-1305 Determining eligibility for SSI-related non-institutional medical assistance in an alternate living facility (ALF) may be eligible for G99.


How long is the G99 certification period?

 

·            Aces defaults to a six-month review and base period.  The base period may be changed to a three-month certification.See SPENDDOWN – PROCESSING chapter.

 

How do I screen in a G99 AU?

 

·            A G99 AU is initially screened as a G03 following the instructions in see How do I screen a G03 medical? 

 

·            The G03 AU will trickle to G99 during finalize, if appropriate, when the AUs countable income exceeds the private rate based on a thirty-one day month plus the GA PNA.

 

How do I process a G99 medical?

 

·         While pending, the AU is G03 and is processed following: See How do I process a pending G03 AU?

 

·         The G03 AU will trickle to G99 in M – Pending Spenddown status during finalize, when the AUs countable income exceeds the Assisted Living Facility (ALF) private rate x 31 days plus the GA PNA.

 

·         See EAZ Manual Spenddown for additional information on the spenddown process.

 

When do G99 benefits begin?

 

·          Medical coverage begins the date the spenddown is met.

 

How do I authorize spenddown for an AU in M status?

 

·            To authorize spenddown on a G99 AU in M status, follow the instructions in Spenddown Processing – Update and Confirm Spenddown Information.

 

How do I enter spenddown medical expenses for a G99 AU in M status?

 

·            To enter medical expenses to meet the client’s spenddown liability on a G99 AU in M status, follow the instructions in Spenddown – Enter Spenddown Medical Expenses.

Modification Date: June 23, 2014