State-funded long-term care program for non citizens

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Revised May 10, 2012

Purpose:

NOTE:

Effective 11/1/2009 there is no nursing home coverage under the AEM program. The legislature gave limited funding for a state funded long-term care program to cover services that were being authorized under AEM prior to 11/1/2009.

Effective 5/14/2011, the legislature directed ADSA to move individuals to a residential setting if appropriate. The WAC has been changed to allow for either nursing facility or residential setting under this program.

WAC 388-438-0125 describes the state-funded long-term care program. New admissions into nursing facilities or residential settings under the state-funded long-term care program must be pre-approved by David Armes, Home & Community Services Headquarters. If David Armes is unavailable contact Lori Rolley, Home & Community Services Headquarters.

This program has limited slots for coverage based on legislative funding

Medical Assistance EAZ manual material with WAC on AEM

Always consider the possibility of Aged Blind Disabled (ABD) cash or Medical Care Services (MCS)

Other programs should always be considered before considering the 45 slot state-funded long-term care program.

Many legally admitted non-citizens who are in a five year medicaid bar or other eligible non-federally qualified status can be considered for the ABD cash program. MCS should be considered for legally admitted non-citizens who do not qualify for ABD cash.

Disability Lifeline program ends 10/31/2011. Individuals who are aged/blind/disabled may continue to receive benefits under the ABD cash program starting 11/1/2011. State funded medical care services (MCS) program is described in WAC 182-508-0005 and will be filed by an emergency 11/1/2011.

ABD cash is described in WAC 388-400-0060 and will be filed as an emergency 11/1/2011.

For nursing facility coverage under ABD cash or MCS the individual must meet income and resource criteria and be assessed as nursing facility level of care (NFLOC) by an HCS social worker.

An active G01 (MCS) does not require a pre-approval by HCS HQ prior to nursing facility admission.

A G01 admission into a nursing facility may require a pre-approval through the managed care program Community Health Plan of Washington by the nursing facility.

G01 in residential setting. (MCS).

Clarifying Information

New applications

Notify the social worker immediately when processing an application if the client will only qualify for the state-funded long-term care program that needs pre-approval by David Armes, HCS HQ.

The client who meets financial and categorical eligibility requirements may request and receive state funded long-term care services if the following are met:

The client has received a determination of nursing facility level of care (NFLOC) by an HCS social worker. ;
Headquarters staff at Home & Community Services (HCS) have pre-approved the admission for payment under the state-funded nursing facility program.
Local HCS staff will coordinate with HCS HQ for a pre-approval.

NOTE:

ADSA/HCS Headquarters will consider placement in a home setting for the state-funded 45 slot long term care service program. This setting is not described in WAC 388-438-0125 but will be approved as an ETR if there is an available slot, the individual meets financial eligibility under WAC 388-515-1505 and the placement is appropriate.

Long-term care services under State Funds for non citizens

Aging and Disability Services Administration has a limited amount of state funding available for non citizens who have been denied or terminated from AEM coverage and are in need of long-term care services outside of a hospital. These non citizens are not eligible for the ABD cash or MCS program

IMPORTANT

The state funded program is not supported by ACES. An L04 is used in ACES for nursing facility cases. An S07 is used for LTC services pre-approved by HCS HQ in a residential setting.

ADSA/HCS headquarters must track each case using the state funds to pay for long-term care services under this program.

ADSA/HCS headquarters staff must contact HCA in order to ensure CN payment is flagged for individuals approved for this program.

For state funded nursing home denials and terminations contact David Armes, Financial Policy Manager at ADSA headquarters via e mail.

The following must be reported to David Armes:

New admits. Include the date and facility.
Discharges. Include the date and circumstances.
Any closures. Include the date and circumstances.
If a state funded client's medical condition causes re-hospitalization, re-refer to the AEM hospital specialty team at CSD for consideration of federal coverage under the AEM program. Notify David Armes of this referral and if AEM approval is received for the hospitalization.
If a client in a residential setting and a change of income. S07 is used as a workaround. The calculation is done off line and instructions on a case by case basis will be needed. Contact HCS HQ policy staff for assistance.

Specialty Hospital Unit for AEM coverage

Most admissions into the state-funded long-term care program start out in a hospital. These applications are completed by a specialty hospital unit at the CSO. This unit refers to MPA/HCA medical consultant for possible AEM coverage in the hospital.

Prior to admission into a NF, a prior approval by ADSA is needed. Even if there is an approval of AEM in the hospital, AEM does not cover NF admissions.

Once an AEM Hospital case has been approved a NF slot by ADSA HQ, HCS financial staff will transfer the case into HCS for maintenance and tracking.

A client receiving services under the state funded long-term care program may have a health event that would require hospitalization. The federal AEM program must be considered for any hospitalization. HCS financial staff must coordinate with the CSD AEM Hospital specialty unit so a referral to the MPA medical consultant can be made. Contact Nhan Thai, Supervisor of the AEM Hospital Unit.

Notify David Armes, HCS Headquarters of any hospitalization so a slot can be held for a discharge to a nursing facility or residential setting.

EXAMPLE

Joe Smith is approved through 10/31/2009 under the federal AEM program. The federal AEM program for nursing home ended on 10/31/2009. Effective 11/1/2009, this client was grandfathered into the state-funded nursing facility program as Mr. Smith is still in need of nursing home care. The coverage group in ACES remahttp://cm.ssv.wa.gov/iw-cc/command/iw.formspub.previewins a L04.

EXAMPLE

Jane Smith has been in a hospital for six months. All options for alternative settings have been explored by the hospital. She must either remain in the hospital indefinitely or be placed in a nursing home.

She is assessed by the HCS social worker and meets NFLOC. The HCS office handling the assessment contacts HCS headquarters for an available slot under the state-funded long-term care program. Once headquarters approves a slot and the client is financially and resource eligible eligible, an L04 is opened in ACES. The nursing home will be able to admit Jane and bill under the state-funded nursing facility program.

EXAMPLE

Jayna Smith is a legally admitted alien in the 5 year bar. Jayna is exempt from sponsored deeming because she has no income. (income less than 130% of the FPL).

Jayna has been hospitalized and is in need of nursing home care due to a stroke. She has been assessed by the HCS SW and meets NFLOC.

Jayna can be opened on disability lifeline unemployable (DL-U). There is no need to refer for the state-funded funded nursing home program. DL-U covers nursing facility coverage.

DL placements do not need a pre-approval by HCS HQ. See managed care section for instructions on the DL-U program and nursing facility admissions.

If this individual is a candidate for DL-X, submit a packet to the SSI facilitator.

EXAMPLE

John Doe has been hospitalized and is in need of LTC. Mr. Doe's needs can be met in an adult family home setting. Mr. Doe is financially eligible for the S07 program and there has been a pre-approval from HCS HQ. Any new admissions into the state-funded long-term care program must be served in a residential setting unless the person's needs cannot be met except in a nursing facility.

ACES instructions

L04 is used for state funded long-term care nursing facility admissions.

S07 is used for state funded residential admissions as a workaround.

Eligibility for residential settings is the same as the COPES program. The determination of room and board and participation would follow the calculation described in WAC 388-515-1509. Award letters and change notices would need to be hand generated.

Notify David Armes or Lori Rolley when an individual is being considered for the state funded LTC program in a residential setting and has income. Work around instructions will be needed based on the individual's income.

ACES Instructions-Alien Medical

Notify David Armes, HCS HQ of any admission, discharge, closure, or hospitalization under this program so MPA can be notified of the CN coverage needed.