Roads to Community Living (RCL)
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Roads to Community Living (RCL)


Revised September 10, 2014


Long-term care


Purpose: To explain a long-term care program called Roads to Community Living (RCL) for individuals who have been in a medical facility and may be able to live in the community if the additional services offered under RCL are provided. These services are provided either when the individual is in a medical institution or after they have been discharged.

Clarifying Information

What is RCL?

RCL is a statewide, demonstration project funded by a “Money Follows the Person” grant. The grant was received by Washington State from the federal Centers for Medicare and Medicaid Services (CMS). The purpose of the RCL demonstration project is to investigate what services and supports will successfully help people with complex, long-term care needs transition from an institution to a community setting.

 

Services and supports from the RCL demonstration project that have proven successful are being used to help shape recommended changes to Washington State’s long-term care system. This will result in more people with complex long-term care needs being able to remain independent or transition from institutional into community settings in Washington State.

Who is eligible for the RCL project?

 

Individuals eligible for RCL are:

 

  • People of any age with a continuous, qualified stay of 3 months or longer in a qualified institutional setting (hospital, nursing home, ICF-ID)*; OR
  • Individuals in a psychiatric hospital with a continuous stay of 3 months or longer who are under the age of 22, or 65 and older.

AND each of the following:

  • Receiving Medicaid-paid inpatient services immediately prior to discharge [including most of the ACES N group, also known as MAGI (see exceptions below)];
  • Interested in moving to a qualified community setting (home, apartment, licensed residential setting with 4 or less unrelated individuals);
  • On the day of discharge to begin the demonstration year, RCL participants must be functionally and financially eligible for, but are not required to receive, waiver or state plan services.

 

Individuals who are not eligible for RCL are:

  • Individuals who are solely receiving Aged, Blind or Disabled (ABD) cash assistance.
  • Individuals in the N21 and N25 alien emergency medical group (AEM).
 

How long are participants eligible for RCL services?

  • Participants are entitled to continued medical coverage through the end of the month of the 365 days following their discharge date.  This is called continuous medical eligibility.
  • The clock on demonstration period services stops if a participant needs to be re-institutionalized for greater than 30 days.  The social worker/case manager will inform the financial worker of the new 365 day period if it has changed. 
  • Participants are not to be re-assessed for financial Medicaid eligibility until the end of their 365 day demonstration period.
  • In order to received Medicaid beyond the 365 period, a participant must be determined eligible to receive medical by the financial worker.

More about Medicaid eligibility during the demonstration period

RCL participants remain eligible for Medicaid during the demonstration period regardless of any changes in financial circumstances, including:

  • Acquisition of resources or income above program standards
  • Transfers of assets

Financial eligibility will be reviewed at the end of the demonstration period.  Clients must meet eligibility requirements for a medical/long-term care program at that time to continue to receive them after the 365 day period. 


Clarifying Information

You will be notified by an HCS or DDA case manager that a client has been discharged from the medical facility to the RCL program on all Classic Medicaid programs. 

HCS social workers use the DSHS 14-443 Financial/Social Service Communication via barcode.

DDA case managers use the DSHS 15-345 CSO/DDA Communication.

Change the Medicaid program

Most of the RCL clients will be receiving an institutional medical under L02.  For most cases, you will change the ACES medical coverage group to waiver eligibility under L22 (L21 for an SSI recipient).

Once the case has changed from L02 to L22, initiate a review to extend the medical for 12 months.  If the RCL client is an SSI recipient use the L21 in ACES and code as if it is a COPES client. The case manager will not know until the end of the demonstration period if the client will need waiver services or if care needs can be met with Medicaid Personal Care  (MPC) services.  

The case manager/social worker will notify financial if there has been a change in the 365 days by submitting a 14-443 with a new ending date. 

What if the RCL client initially declines personal care services upon discharge?

The case manager/social worker will notify financial if the client has initially declined services upon discharge based on LTC chapter 29.  Financial will add freeform text to the ACES award letter:   If you choose to receive ongoing RCL services through your 365 day period, the amounts listed as total responsibility toward the cost of care will be your contribution to your provider. (Up to the cost of the actual services).   

Provide continuous eligibility throughout the demonstration period

A change in financial circumstances that would ordinarily cause closure of the Medicaid assistance unit does not affect Medicaid eligibility for RCL clients. This only applies to Medicaid eligibility. The continuous eligibility guarantee does not apply to cash, food, or Medicare Savings programs.

If an RCL client is receiving Medicaid and ABD cash (G02 medical coverage group), the cash benefit is not protected. If a change causes ineligibility for cash, close the G02 assistance unit and open an SSI-related medical assistance unit through the 365 period. 

If a change occurs that may cause ineligibility, advise the client and the case manager that the change may affect eligibility when the eligibility review is completed after the demonstration period.

Are there any exceptions to continuous eligibility? 

Yes.  the only exceptions are:

  • Moving out of state
  • incarceration for 30 days or more
  • death

What if there is mail return?

If mail is returned, see if a forwarding address is provided.

  • If one is provided, update the address.  No further action is necessary
  • If one is not provided, attempt to call the client via the phone number or inquiring with the case manager as to the current address. 
  • If the financial worker is still unable to determine where the client is, terminate the medical for loss of contact/whereabouts unknown. Advance notice is not necessary.
  • If the client provides an updated Washington address at any time during the original 365 day period, the assistance unit is reinstated from the month of termination through the end of the original 365 day certification period.  A new application is not necessary. 

Determine the client's cost of care

Depending on the client’s income amount, clients receiving RCL services may have to participate toward the cost of room and board and personal care in an alternate living facility  (ALF) or for personal care costs in their own homes. Rules for determining the amount the client is responsible for are in WAC’s 182-515-1505 for HCS clients and 182-515-1510 for DDA clients

What happens at the end of the 365 day period?

For non-SSI clients an eligibility review will be sent to the client and/or the client's representative for the annual review.  After the 365 day period, a redetermination must be made.  The client must meet income and resource eligibility under the HCS or DDA  Waiver in order to continue the case as a L22.

In addition to the financial eligibility,  functional criteria for the HCS or DDA Waiver must be met.   This must be confirmed by the current case manager.

Coordination with the agency case managing the service is important.  If the client is no longer eligible under financial rules for the L22 program or eligible for a non institutional CN Medicaid program, the financial worker will need to notify the case manager to close services on day 366 or as soon as possible once the review is completed.  During the redetermination period, keep the Medicaid open even if it goes beyond 365 days unless we know the client is not eligible for any other Medicaid program. 

If the client is eligible for a non institutional categorically needy Medicaid program, Medicaid personal care  (MPC) can be considered.

What if the client is on the MAGI program in the medical facility?

MAGI clients with the exception of N21 and N25 are eligible for RCL services.  DSHS financial workers are unable to issue RCL letters or make any changes on a MAGI cases as these cases are maintained by the Health Benefit Exchange/Health Care Authority (HCA).


EXAMPLE

RCL clients can start receiving services prior to the discharge from the medical institution.  An example of this is a person who assists the client, (called a Community Choice Guide),  to find housing before they are discharge. Upon discharge, the client may choose not to have personal care services during the 365 days. The social worker/case manager will inform the financial worker that the client is discharged under RCL and is declining ongoing services. 

The financial worker will change the program from L01/L02/L95 to L21/L22 and issue an award letter.  The financial worker will note in the the freeform text of the ACES letter:  If you choose to receive ongoing RCL services through your 365 day period, the amounts listed as total responsibility toward the cost of care will be your contribution to your provider. (Up to the cost of the actual services).   


The agency authorizing services will communicate to the financial worker by the 365th day.

This communication should include what services if any will be authorized beyond the 365th day. (either MPC or Waiver services).

For MPC, a client would need to be eligible for a non institutional Medicaid program. 

If services are not authorized by HCS or DDA, redetermine Medicaid eligibility  using non institutional Medicaid rules. 


Worker Responsibilities

  1. Open the RCL client on one of the follow classic medical programs in ACES using COPES coding on the ACES Institution (INST) screen.  For DDA authorization use the DDA Waiver coding on the ACES Institution (INST) screen.   A review form is not needed to complete any of these actions:
    1. L21 for SSI recipients. 
    2. HCS clients:  L22 for SSI related individuals.  Initiate a review in ACES to set up the 365-day Medicaid period. Be sure the review end-date is the last day of the month in which the 365th day falls. You may need to “pull back” the review end date
    3. DDA clients: L22 for SSI related individuals with income no greater than the special income level (SIL). Initiate a review in ACES to set up the 365-day Medicaid period. Be sure the review end-date is the last day of the month in which the 365th day falls. You may need to “pull back” the review end date. 
    4. S99 for SSI related individuals with income greater than the SIL, who are on DDA services. Screen an S02 medical program into ACES. Ensure that the case trickles to an S99. Use the calculated spenddown amount as a non-covered medical expense in ACES online. Call the medical expense, “RCL Processing Expense”. Ensure the program moves into “A – active” status. At the end of the first six months, initiate a review and certify the S99 for the remainder of the 365-day period using the calculated spenddown amount as a non-covered medical expense in ACES online. Be sure the review end-date is the last day of the month in which the 365th day falls.
    5. Clients active on an N track (MAGI) program through the Health Benefit Exchange (HBE) with the exception of N21 and N25 are eligible for RCL services.  These clients remain on the N track program during their RCL period.  Financial workers are unable to extend MAGI review dates for N track cases.  Financial workers do not have access to a case maintained by the HBE. 
  2. Send an award letter outlining the dates for the 365-day period (the certification period) and client participation. If the client has declined personal care services note in the Freeform Text field that if the client chooses to receive ongoing RCL services, the amounts listed will be their contribution to their provider. 
  3. The financial record remains with HCS during the 365-day Medicaid period unless:
    1. Active on an N track (MAGI) program with the HBE.
    2. Active on an L track (L21 or L22 program) and on DDA services.  These cases are managed by the DDA LTC specialty unit. 

 


NOTE:

 

At the end of the 365-day period, determine eligibility for ongoing medical. Consult with the case manager regarding switching to MPC, COPES or other waiver services. If the client is not eligible to receive MPC or other waiver services, determine eligibility for a non-institutional medical program and send active or spenddown pending cases to the CSO.  Notify the social worker or case manager if not eligible for MPC or HCB Waiver services. 


What happens if a client receiving RCL returns to a Medical institution during the 365 period?

If the RCL client returns to a medical institution for a short stay  (under 30 days), treat the case like any other short stay.  Keep the case active on the current Medicaid program active in the community  and issue the Medical facility an award letter using the short stay screen.

If the RCL client returns to a medical institution and the placement is projected for over 30 days, the case will need to be changed back to the institutional program (L02, L95  track for SSI related, K track for children). 

  • Make sure the eligibility review is pulled back in ACES to reflect the month that is one year later than the last review was completed.
  • If it has been over a year since a review has been completed, do the program change and pull the eligibility review to the last review while a redetermination is being made. 
    • Send a new eligibility review for completion
    • Set a barcode tickler to check the status. 
    • Keep the Medicaid case open while doing a redetermination of eligibility. 
  • Once a client is no longer in the RCL program, they must meet the income and resource eligibility for institutional medical. 

It is possible that a client will be re-enrolled in the RCL program again as part of discharge planning.  If a client is placed back into the community under the RCL program, they are re-enrolled in RCL for what remains of their 365 days.  If the original 365 day end date has been changed, the social worker or case manager will notify the financial worker. 

Can clients who have previously completed their 365 day demonstration project re-enroll in RCL?  If so, how?

Yes, clients who are re-institutionalized after their 365 day demonstration period is over may be re-enrolled in RCL if the need is clearly stated and the new plan of care has been reviewed.  The purpose of re-enrollment planning is to ensure that a thorough look is taken at why the original plan did not result in long term successful community placement, and to outline how the new plan addresses the identified gaps.

If the client has been subsequently re-institutionalized for at least 90 consecutive qualified days, he/she may be re-enrolled in RCL for another 365 day demonstration period using the following process.  All processes outlined above apply for the 2nd enrollment.

How can the financial worker tell if it is an RCL case? 

Because there is not a specific code for RCL in ACES, documentation is the only way to identify an RCL case in ACES and the ECR.   On the Client Tab in the ECR, document the client is on RCL.  This is the only method currently of flagging the case that it is RCL.

  • Indicate in the narrative and behind the INST screen "Roads to Community Living RCL" client
  • For DDA clients, indicate on the AREP screen Case manager-RCL program with the case manager's address.
  • Create a note in the barcode electronic record.  In the ECR select the first tab (under the client ID number).  This will take you to a screen where you can add notes to the case.  This note will always pop up whenever the worker goes into the ECR to review the case.  Indicate:   Roads to Community Living (RCL) case.

Follow necessary supplemental accommodation  (NSA) procedures.


ACES Procedures

There is no code for the RCL program in ACES.

For SSI related clients use the same rules and coding as the L22 program. 

For SSI clients at home in residential settings, use the same rules and coding as the L21 program.

  •  If service is authorized by HCS, code as a COPES case in ACES.
  • If service is authorized by DDA, code as a DDA Waiver in ACES.

See Long Term Care, Alternate Care and Waiver Services.   

Modification Date: September 10, 2014