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EAZ
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Revised September 3, 2009 |
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Long-term care |
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Purpose: To explain a long-term care program called Roads to Community Living (RCL) for individuals who have been in a medical facility for six months or longer and are able to live in the community when RCL services are in place. |
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Clarifying Information What is RCL? RCL is a demonstration project funded by a five-year “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 institutional to community settings. Who is eligible for the RCL project? Individuals who:
How long are participants eligible for services?
More about financial eligibility during the demonstration period RCL participants remain eligible for Medicaid during the demonstration period regardless of any changes in financial circumstances, including:
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. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Worker Responsibilities You will be notified by an HCS or DDD case manager that a client has been discharged from the medical facility to the RCL program. HCS social workers use the DSHS 14-443 Financial/Social Service Communication. DDD case managers use the DSHS 15-345 CSO/DDD Communication. Enter the case manager's agency name and mailing address on the AREP screen in ACES so the case manager will receive copies of ACES letters. EXAMPLE: DDD Casemanager-RCL program with the agency address. Change the Medicaid program Most of the RCL clients will be receiving an institutional medical coverage group (L-track). For most cases, you will change the ACES medical coverage group to waiver eligibility using C01. Some clients may need coverage under a CNP General Assistance program or an HCS Medically Needy waiver program if income is more than the Special Income Level. Allow the new AU to certify for 12 months. Do not pull the certification back to match the end month of the previous AU. This is because of the guaranteed 365 days of Medicaid eligibility under this program. If the RCL client is an SSI recipient and will be receiving services in their own home you may open S01 instead of C01. 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. 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 General Assistance 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. 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. 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 388-515-1505 for HCS clients and 388-515-1510 for DDD 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 DDD Waiver in order to continue the case as a C01. In addition to the financial eligibility, functional criteria for the HCS or DDD 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 C01 program or eligible for a non institutional CN-P 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. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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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 DDD, redetermine Medicaid eligibility using non institutional Medicaid rules.
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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 (usually a C01, S01 or F06) and issue the Medical facility an award letter using the short stay screen. If the RCL client returns to a medical institution because the community placement did not work out and the placement is projected for over 30 days, the case will need to be changed back to the institutional program (L track for SSI related, K track for children).
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, the 365 day count starts over. 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.
Follow necessary supplemental accomodation (NSA) procedures. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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ACES Procedures There is no code for the RCL program in ACES. Use the same rules and coding as the C01 program.
On the AREP screen, indicate the address of the agency case managing the RCL program.
Indicate Casemanager:RCL program on the AREP screen with the address. See Long Term Care, Alternate Care and Waiver Services.
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Scope of the RCL Program The chart below is the projection of the number of clients that will enter the RCL program during the demonstration.
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