Consolidating the Home and Community Based (HCB) Medically Needy (MN) Waivers into the COPES Waiver effective 4/1/2012
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Consolidating the Home and Community Based (HCB) Medically Needy (MN) Waivers into the COPES Waiver effective 4/1/2012


Revised May 13, 2013


HCB Waivers authorized by Home and Community Services (HCS)


Purpose: Effective 4/1/2012, the Medically Needy Income Waiver (MNIW) and Medically Needy Residential Waiver (MNRW) has been combined into the COPES Categorically Needy (CN) Waiver. This section describes the initial eligibility for those with gross income over the Medicaid Special Income Level (SIL) 300% of the FBR

Consolidating the MN Waivers into the COPES Waiver


  • MNRW and MNIW end 3/31/2012
  • Active MN Waiver cases will be transitioned to COPES in April 2012
  • Single clients with income above the SIL or married clients with 1/2 of the community income above the SIL can be considered for COPES using the new rules found in WAC 182-515-1508 (4) They will receive CN medical
  • These clients will be eligible for MSP/S03 once the L22/COPES assistance unit (AU) is opened.

Not all HCS CN programs are called COPES. Here is the complete list of programs using the 388-515-1505 eligibility rules

This section contains the following HCB CN services:

  1. Community options program (COPES)  This includes HCB CN services for those in new eligibility group 3 (those with income over the Medicaid SIL)

  2. New Freedom consumer directed services  (New Freedom)

  3. Program of all-inclusive care for the elderly  (PACE)

  4. Washington Medicaid integration partnership (WMIP)

  5. Roads To Community Living (RCL)

ACES program L21 (SSI recipients) and L22 (SSI related) is used for all the programs indicated above. 


New Income Calculation effective 4/1/2012


  • A new COPES income calculation will be used for former MN Waiver clients to determine initial income eligibility
  • All other existing COPES eligibility rules apply to clients who are eligible under these new rules found in WAC 182-515-1508 (4)  

CN Waiver eligibility (COPES) effective 4/1/2012



Resources

Use existing institutional medical resource rules for all individuals receiving COPES, including those who were formerly eligible under the Medically Needy Waivers.

Initial Income Eligibility

Individuals are income eligible for COPES in one of the following three ways:

Group 1 (existing group):

  • SSI recipients who are functionally eligible
  • SSI related individuals who are otherwise eligible for S02
  • No changes have been made to eligibility for individuals who become eligible for CN waivers under this group. 
  • Group 2 (existing group):
  • SSI related individuals with income in their own name that is at or below the Special Income Level (SIL )
  • SSI related individuals who are married with a community spouse and 1/2 of their community income is at or below the SIL
  • No changes have been made to eligibility for individuals who become eligible for CN waivers under this group

Group 3 (new group - former MN Waiver recipients):

  • SSI related individuals with income in their own name above the SIL and if married with a community spouse 1/2 of the community income is above the SIL   
  • Net income (as described below) is at or below the MNIL  

Group 3 Net Income Calculation:

  • Reduce the client's gross income by:
    • Exclusions in WAC 182-513-1340
    • Disregards in WAC 182-513-1345
      • $20
      • $65 and 1/2 earned income
    • The cost of care standard which is based on the monthly state average nursing facility rate
    • Monthly private health insurance premiums (no Medicare).  If paid other than monthly, prorate the expense into a monthly amount
    • Outstanding medical bills prorated into a monthly amount over the 12-month certification period.
  • If the results is no greater than the MNIL, they are income eligible for COPES and can be opened on L22 (and receive CN medical)

 


CN Waiver Participation

Group 1 (existing group):

  • SSI recipients who are functionally eligible
  • SSI related individuals who are otherwise eligible for S02
  • No participation toward CN Waiver services
  • Contribute toward room and board up to the room and board standard

Group 2 (existing group):

  • SSI related individuals with income in their own name that is at or below the Special Income Level (SIL )
  • SSI related individuals who are married with a community spouse and 1/2 of their community income is at or below the SIL  .
  • Pay participation based on the existing COPES rules

Group 3 (new group-former MN Waiver recipients):

  • SSI related individuals with income in their own name above the SIL and if married with a community spouse 1/2 of the community income is above the SIL Net income (as described below) is at or below the MNIL.
  • Participation is calculated in the same wa y for this group as it is for those who are in Group 2
  • Allow spousal allocations and dependent allocations
  • Room and board is calculated in the same way for this group as it is for those who are in Group 2.

Third-party Resources

  • Third-party resources are assigned toward the provider payment along with participation and room and board
  • This is the same for all groups
  • There are no changes to how third-party resources are applied
  • See Long-term care insurance and third-party resources  for additional information

Medicare Savings Program QMB (S03) Eligibility

  • COPES clients receiving Medicare are eligible for QMB (S03) including those who are eligible under Group 3 starting in 4/1/2012. 
  • S03 can be opened once the L22 is open.  The effective date is the first of the following month all eligibility factors are received.
  • See Medicare and Long-term care for additional information including open effective dates for MSP programs.

Medicare Part D Co-Pays Waived for individuals receiving HCB Waivers (COPES)

  • Medicare Part D recipients receiving COPES services are not subject to Medicare D co-payments
  • Once open on L22, the case will be sent to CMS by Provider One
  • CMS will notify the Part D provider (PDP) that the individual is on COPES and is not subject to Part D co-pays.
  • See Medicare and Long-term care for additional information

Copes income eligibility groups

 Eligibility Group  Description  At home payment obligation  ALF payment obligation
 Group 1

 Otherwise eligible for non institutional CN medical

  • S01-SSI client
  • S02-SSI related CN client
  • S08-SSI related CN HWD working disabled client
 No participation  Room and board only. 

(HWD pays monthly premium to OFR plus room and board)
 Group 2

Single:  Income no greater than the SIL

Married:  1/2 Community Income no greater than the SIL

 Participation  Participation and Room & Board
 Group 3

 Single:  Income greater than the SIL

Married:  1/2 community income greater than the SIL

 Participation  Participation and Room & Board

Health Insurance Premiums and Outstanding Medical Expenses (Group 3)

Participation Deduction Only

  • If a health insurance premium or old medical expense is not needed to make the person eligible under the 4/1/2012 (group 3) income eligibility rules, code the expenses on the LTCX as you normally do for COPES to reduce participation.

Both Initial Eligibility and a Participation Deduction

  • If the health insurance or old medical expense is needed in order for a person to be eligible under the 4/2012 (Group 3) income rules the expense will be coded on LTCX twice.  Once to be used for initial income and once for participation.
    • For initial eligibility:
      • Code the monthly health insurance premium on LTCX as expense type RP (prorate it to a monthly amount if paid other than monthly)
      • Manually prorate the old medical expense and code the prorated amo0unt on LTCX as expense type RP
    • For participation:
      • In addition, code the health insurance premium and old medical expense as you normally do on LTCX to reduce participation.

 


EXAMPLE

Client has non-excluded, unearned income of $6500 per month, health insurance of $110 per month and an outstanding hospital bill of $600.  In order to be eligible both the health insurance and the old medical bill must be used for the initial eligibility calculation.  Divide the old medical bill by 12.  $600 divided 12 = $50.

Expense type RP - Initial eligibility

  • Code the $110 monthly health insurance as expense type RP on LTCX
  • Code $50 as expense type RP on LTCX

Participation

  • Code the $110 monthly health insurance as expense OH on LTCX
  • Code $600 as expense type UO on LTCX for the initial month of eligibility (or whatever portion can be allowed until the entire amount has been used as a participation deduction).


Spousal Impoverishment and New Openings for new Group 3

  • Spousal impoverishment rules apply for new openings on or after 4/1/2012
  • Follow the regular procedures for verifying and coding resources
  • Verify and code the community spouse's income in ACES on the EARN 02 and UNER 02
  • Verify and code the community spouse's shelter costs in ACES on SHEL 02
  • Verify and code the couple's resources on the appropriate RES screens
  • Verify and code the community spouse's shelter costs in ACES on SHEL 02

Resource eligibility issues



Per WAC 182-513-1350, resource eligibility is on the first moment of the first day of the month. 

Some individuals in new group 3, may have income under the statewide average nursing facility rate, but over the actual cost of care for the facility they are currently residing in.

For these individuals, it is important to explain to the client and their authorized representatives:

  1. They never pay more than the actual cost of care
  2. Any excess available income after paying the actual cost of care is considered a countable resource as of the first day of the following month. 

Additional information on the consolidation of MN Waivers into the HCS CN (COPES) Waiver

Consolidation of Medically Needy Long-term care programs into COPES

Questions and Answers on the COPES program

Modification Date: May 13, 2013