Overview (Long Term Care)

Revised September 5, 2008

Purpose: To give an overview of long term care (LTC) services for those in medical institutions or receiving DDD Waiver, HCS Waiver or Hospice services This section also gives an overview of "non-institutional" Medicaid services such as Medicaid Personal Care (MPC)

What is an institutional Medicaid program and what is long term care services?

The term "institutional" Medicaid means institutional medicaid rules are used in eligibility.

In ACES the institutional Medicaid programs are under the L, C and K track programs.

Long-term care (LTC) programs provide services for the elderly and disabled in need of institutional care. Some clients who receive LTC services are able to continue living in their home or in an alternate living facility (ALF).

Home and community-based services, provided under a Medicaid waiver granted by the federal government, enable them to live in a residential setting outside of a nursing or other medical facility or in their own home. Such services are referred to as waiver services.

Others require institutional services that can be provided only in a medical facility.

Some clients receive hospice services in addition to or instead of services in their home or a medical facility.

All clients approved for DDD or HCS Waiver services, Hospice services or in a medical institution 30 days or more have attained institutional status and are considered to be institutionalized as described in Medicaid law and the regulations used to implement these programs.

The department must determine a client's eligibility for LTC services according to both functional and financial requirements. A department-designated social worker establishes functional eligibility; some of their responsibilities are described in this category. A financial services specialist (FSS) uses the rules and procedures described in this category to establish a client's financial eligibility and participation in the cost of care. The amount of income and resources a client must contribute to the cost of care for services received is established in what is called the post-eligibility determination.

Home & Community Services (HCS) and Division of Developmental Disabilities (DDD) can authorize Medicaid Personal Care (MPC) for clients eligible to receive a non institutional CN Medicaid program and assessed to be eligible for MPC.

MPC clients are not considered institutionalized. The financial eligibility for MPC is eligibility for a "non-institutional CN Medicaid program. A chart in the MPC section gives more information.

This category also describes the rules and procedures used to determine a client's eligibility for non-institutional medical assistance provided in an ALF. Some clients require the assistance provided in such ALF , but do not require the additional services provided under an program. The financial standards used to determine eligibility for non-institutional medical assistance in an ALF are based on the department-contracted rate and the private rate of the facility in which the client lives.

When determining eligibility and the cost of care for LTC services, program policy requires an allocation of income and resources from the institutionalized spouse to the community spouse. For purposes of these allocations, the distinction is made throughout this category between an institutionalized spouse, who is applying for or receiving LTC services, and a community spouse, who is not, when eligibility and participation in the cost of care for these services is determined. The Medicare Catastrophic Care Act in 1988 began the spousal allocation process used to discourage the impoverishment of a spouse due to the need for LTC services by their husband or wife. That law and those that have extended and/or amended it are referred to as spousal impoverishment legislation.

The rules used to determine eligibility and participation costs for waiver services are similar to those for institutional services, but there are important differences. These differences, in addition to those related to hospice services, are discussed when the rules that describe them are covered in this section.

A client may be eligible for both medical assistance and institutional services, or be eligible for one but not the other.

See long-term care medical standards and personal needs allowance chart for current institutional standards.

Responsibilities and program administration

1. Community Services Offices (CSO) financial service specialist (FSS) staff determine financial eligibility for the following long-term care (LTC) clients:

Division of developmental disabilities (DDD) clients receiving LTC, DDD Waiver or MPC services paid for by DDD. (unless the DDD individual is married and spouse is on HCS services with no children on medical or cash, see HCS responsibility below).
DDD LTC medical institutions are:
- Residential Habilititation Centers (RHC)
  - Fircrest School
  - Frances Haddon Morgan Center
  - Lakeland Village
  - Rainier School
  - Yakima Valley School
- Intermediate Care Facilities for the Mentally Retarded (ICF/MR)
  - Barclay Group Home
  - Chelsea
  - Brookhaven
  - Bedford
  - Camelot Group Home
  - Carlton

Mental health clients receiving LTC services paid for by Mental Health / Regional Support Network (MH/RSN). (Includes medical institutions Eastern and Western State Hospital).

Drug and Alcohol Substance Abuse (DASA) clients receiving LTC services paid for by DASA

Households receiving temporary assistance for needy families (TANF) or state family assistance (SFA) (including children's medical only unless active with 076 MEDS) financial or medical benefits that include an LTC client.
Clients active on Medical in the CSO and entering a medical/nursing facility facility for a short stay (under 30 days).
Institutional children or family medical.
Hospice services if client is not on an HCS Waiver program or MPC authorized by HCS.
- Hospice eligibility is handled by a CSO central unit 132.
- This includes Hospice elections in a nursing home or hospice care center.
- Hospice services are paid by Health and Recovery Service Administration (HRSA)

2. Home and community services (HCS) FSS staff determine financial eligibility for all other LTC clients who receive the following services from HCS:

Nursing facility (NF) care.
- New applications for nursing facility care.
- Active Medicaid clients when NF care is 30 days or longer. (Exception to this is when the case is an active TANF, family or children related medical program).
HCS Waiver services both in home or in an alternate living facility. This includes:
Roads to Community Living (RCL) authorized by HCS.
Medicaid Personal Care (MPC) services authorized by HCS.
Grandfathered Chore services authorized by HCS.
Food stamp eligibility (associated with LTC services) when the non-LTC clients in the household do not receive TANF or childrens/family financial or medical benefits.
General Assistance (GA) for clients receiving services authorized by HCS.
Married couple, one individual is on HCS services (MPC or HCS Waiver) the other spouse is on active DDD services (MPC or DDD Waiver), no children on TANF/family or children related cash or medical.
Family. One parent is on HCS services. Community spouse is not on services or medical. Child is active SSI. (No family member is on active TANF/family or children related medical).
Family. One parent is on HCS services. Community spouse is not on services or medical. Child in the household not on active TANF/family or children related medical. (on mother's health insurance, not interested in Medicaid for child).

Rule of thumb: If there is active TANF/family/children related case attached, the case is retained by the CSO unless the active case is with the MEDS unit.

LTC case shared case with the MEDS unit (076) unit:

· The only time cases are shared on an ongoing basis is when HCS shares a case unit with the MEDS unit. (See case records). The MEDS unit maintains the assistance unit active with their office. The HCS unit maintains the assistance unit receiving HCS services.

Client active on COPES through HCS and applies for Basic Health Plus (BH-P) medical assistance or Children's Health Insurance Program through MEDS for the children. HCS will maintain the COPES case and MEDS will maintain the children's medical.

Client's child is active on children's medical program through MEDS. A parent applies for COPES or nursing home services. The application for the COPES and/or nursing facility services would be handled by HCS if there is no active program with the local CSO.

Client active on COPES through HCS and applies for pregnancy medical for their spouse through the MEDS unit.

Client active on S07/Alien medical with the CSO. Children are active on F08 Non citizen children's medical through MEDS. Client gets pre approval for Nursing Facility admission through coordination between H.R.S.A and HCS under the nursing facility AEM program. Client is expected to remain in the nursing home for 90 days. HCS will request S07 file from the CSO for program change to L04. F08 case remains with MEDS.

EXAMPLE

A client active on S30 Breast and Cervical Cancer Medicaid through the MEDS unit can receive MPC services through HCS if found functionally eligible. Active S30 cases on MPC would remain with the MEDS unit. The MEDS unit would need to notify HCS/AAA when a S30 Medicaid case is closed. If a client on S30 needs Waiver services or has a nursing facility admit over 30 days, an application must be submitted to determine long-term care eligibility through HCS as these services are not provided through the Breast and Cervical Cancer program. These cases take coordination between the MEDS unit and HCS.

Financial staff determines financial eligibility by comparing the client's income, resources, and circumstances to program requirements.

The HCS social worker (SW), Area Agency on Aging (AAA) casemanager, DDD case manager (CM), or the Veterans Affairs registered nurse (VARN) determines functional eligibility according to the particular program and place of residence and authorizes the services that are appropriate for the plan of care. Both financial and functional eligibility must be established concurrently. Coordination between financial and social service staff is required to process applications and provide services.

Financial staff determine eligibility for non-institutional medical assistance at the same time they determine eligibility for institutional, waiver, or hospice services.

NOTE:

The agency case-managing Waiver, MPC or RSN (mental health) services must receive a copy of the Medicaid notices. Indicate the authorizing agency address on the AREP screen for the Medical Assistance Unit (AU). Most services paid are dependent on Medicaid eligibility. The agency case-managing the service must get notice if a case is terminated or if participation changes.

Application for Nursing Facility Care

Department-designated social services staff:
1. Ensure that the client has made a financial application.
2. Assess the client’s functional eligibility for institutional care by completing the comprehensive assessment (CA).
3. Screen all clients to determine potential for and/or interest in home and community-based services.
4. Determine if the client is likely to attain institutional status as described in WAC 388-513-1320.
5. Notify the facility when the client doesn’t appear to meet the need for NF care.
6. Determine if there is potential for relocation and what level of intervention would be required following the procedures outlined in nursing facility case management.
7. Provide financial services staff with the following information:
  - Date of NF admission, or date of CA request, whichever is later.
  - If the client is likely to attain institutional status (projected in a medical facility 30 days or more).
  - The amount of housing maintenance exemption, if appropriate.
  - Authorize NF placements.
  - Arrange transfers and relocations.
  - Authorize discharge allowances.
  - Help the client with discharge planning.
Financial services staff:
1. Refer the client to the SW for a CA, if the client contacts the FSS first, and document the date the client first requested NF care.
2. Determine the client’s financial eligibility for LTC services and non-institutional medical assistance.
3. Authorize payment for NF care if the client is both functionally and financially eligible. Institutional services are approved effective the date of:

Request for CA or date of financial request for benefits, whichever is earlier, or

Financial eligibility for institutional services or date of NF placement, if later than the above dates.
Notify the SW when the request for services is received and ensure that the SW receives a copy of the initial approval/denial notice.

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