Waiver Services - HCS MNP Medically needy in-home waiver (MNIW)
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Waiver Services - HCS MNP Medically needy in-home waiver (MNIW)


Revised May 13, 2013



Purpose: Describes the LTC Waiver MN program in a home setting. This program ends 3/31/2012. The MN and CN Home and Community Based Waivers authorized by Home and Community services has been combined effective 4/1/2012. See WAC 182-515-1505.

WAC 182-515-1550Medically needy in-home waiver (MNIW)

WAC 182-515-1550

WAC 182-515-1550

Effective January 1, 2013

WAC 182-515-1550 Medically needy in-home waiver (MNIW)

This section describes the financial eligibility requirements for waiver services under the medically needy in-home waiver (MNIW) and the rules used to determine a client's responsibility in the total cost of care.

  1. To be eligible for MNIW, a client must:
    1. Not meet financial eligibility for Medicaid personal care or the COPES program;
    2. Be eighteen years of age or older;
    3. Meet the SSI-related criteria described in WAC 182-512-0050;
    4. Require the level of care provided in a nursing facility as described in WAC 388-106-0355;
    5. In the absence of waiver services described in WAC 388-106-0500, continue to reside in a medical facility as defined in WAC 388-513-1301, or will likely be placed in one within the next thirty days;
    6. Have attained institutional status as described in WAC 388-513-1320;
    7. Have been determined to be in need of waiver services as described in WAC 388-106-0510;
    8. Be able to live at home with community support services and choose to remain at home;
    9. Not be subject to a penalty period of ineligibility for the transfer of an asset as described in WAC 388-513-1363, WAC 388-513-1364, and WAC388-513-1365; and
    10. Meet the resource and income requirements described in subsections (2) through (6) of this section.
  2. The department determines a client's nonexcluded resources under MNIW as described in WAC 388-513-1350.
  3. Nonexcluded resources, after disregarding excess resources described in subsection (4) of this section, must be at or below the resource standard described in WAC 388-513-1350 (1) and (2).
  4. In determining a client's resource eligibility, the department disregards excess resources above the standard described in subsection (3) of this section:
    1. In an amount equal to incurred medical expenses such as:
      1. Premiums, deductibles, and co-insurance/co-payment charges for health insurance and Medicare premiums;
      2. Necessary medical care recognized under state law, but not covered under the state's Medicaid plan; or
      3. Necessary medical care covered under the state's Medicaid plan.
    2. As long as the incurred medical expenses:
      1. Are not subject to third-party payment or reimbursement;
      2. Are not the result of medical and remedial care expenses that were incurred as the result of imposition of a transfer of asset penalty described in WAC 388-513-1363, 388-513-1364 and 388-513-1365;
      3. Have not been used to satisfy a previous spenddown liability;
      4. Have not previously been used to reduce excess resources;
      5. Have not been used to reduce client responsibility toward cost of care; and
      6. Are amounts for which the client remains liable.
  5. The department determines a client's countable income under MNIW in the following way:
    1. Considers income available described in WAC 388-513-1325 and WAC 388-513-1330 (1), (2), and (3);
    2. Excludes income described in WAC 388-513-1340;
    3. Disregards income described in WAC 388-513-1345;
    4. Deducts monthly health insurance premiums, except Medicare premiums, not used to reduce excess resources in subsection (4) of this section;
    5. Allows an income deduction for a nonapplying spouse, equal to the effective one-person medically needy income level (MNIL) less the nonapplying spouse's income, if the nonapplying spouse is living in the same home as the applying person.
  6. A client whose countable income exceeds the effective one-person MNIL  may become eligible for MNIW:
    1. When they have or expect to have medical expenses to offset their income which is over the effective one-person MNIL; and
    2. Subject to availability in WAC 388-106-0535.
  7. The portion of a client's countable income over the effective one-person MNIL  is called "excess income."
  8. A client who has or will have "excess income" is not eligible for MNIW until the client has medical expenses which are equal in amount to that excess income. This is the process of meeting "spenddown." The excess income from each of the months in the base period is added together to determine the total "spenddown" amount.
  9. The following medical expenses may be used to meet spenddown if not already used in subsection (4) of this section to disregard excess resources or to reduce countable income as described in subsection (5)(d) of this section:
    1. An amount equal to incurred medical expenses such as:
      1. Premiums, deductibles, and co-insurance/co-payment charges for health insurance and Medicare premiums;
      2. Necessary medical care recognized under state law, but not covered under the state's Medicaid plan; and
      3. Necessary medical care covered under the state's Medicaid plan.
    2. The cost of waiver services authorized during the base period.
    3. As long as the incurred medical expenses:
      1. Are not subject to third-party payment or reimbursement;
      2. Are not the result of medical and remedial care expenses that were incurred as the result of imposition of a transfer of asset penalty described in WAC 388-513-1363, 388-513-1364 and 388-513-1365.
      3. Have not been used to satisfy a previous spenddown liability;
      4. Have not been used to reduce client responsibility toward cost of care; and
      5. Are amounts for which the client remains liable.
  10. Eligibility for MNIW is effective the first full month the client has met spenddown.
  11. In cases where spenddown has been met, medical coverage and MNIW begin the day services are authorized.
  12. A client who meets the requirements for MNIW chooses a three or six month base period. The months must be consecutive calendar months.
  13. The client's income that remains after determining available income in WAC 388-513-1325 and WAC 388-513-1330 (1), (2), (3) and excluded income in WAC 388-513-1340 is paid towards the cost of care after deducting the following amounts in the order listed:
    1. An earned income deduction of the first sixty-five dollars plus one-half of the remaining earned income;
    2. Personal needs allowance (PNA) in an amount equal to the one-person Federal Poverty Level (FPL)  described in WAC 182-505-0100;
    3. Medicare and health insurance premiums not used to meet spenddown or reduce excess resources;
    4. Incurred medical expenses described in subsection (4) of this section not used to meet spenddown or reduce excess resources.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

Medically Needy in-home Waiver (MNIW)

The rules in this section are used for individuals that have gross income higher than the Medicaid SIL.  These individuals live in a home setting.

The Medicaid SIL is 300% of the federal benefit rate (FBR).

For individuals with gross income under the Medicaid SIL, determine eligibility using the HCS CN Waiver (COPES) rules.

 

MNIW Database

Active participants and clients on the waiting list are tracked on the MNRW/MNIW database.  (This data base is available only to DSHS staff at: http://adsaweb/mnwaiver/default2.htm).

Financial services staff will input the client data into the database after the client has been determined functionally and financially eligible for MNRW/MNIW services.

Financial services staff will enter a termination code  MNRW/MNIW database when MNIW services are closed.

Use S02 Medical Coverage Group when screening into ACES.

The MNIW/MNRW calculator on the data base does the eligibility calculation for MNIW.  In ACES the work around program is a S02 for this program.  More information on ACES coding is at the end of this clarifying page.


Resource and income eligibility



Resources:

  • Single client    $2000
  • Married client $3000

We can't use Community Spouse rules to there is no community spouse resource standard.  Resource rules follow SSI related standard for MN.

Excess Resources:

  • Clients cannot participate excess resources toward their cost of care.
  • If a client has resources over the standard, use the following to disregard some or all of the excess: (WAC 182-513-1350)
    • Premiums, deductibles, co-pays.
    • Necessary medicare care recognized by state law and not covered by medicaid.
    • Necessary medical care covered by medicaid.
    • Not subject to third party payment or reimbursement
    • Not been used for previous spenddown.
    • Not been previously used to reduce excess resources
    • Not incurred during a transfer of asset period of ineligibility
    • Not been used to reduce client responsibility towards cost of care
    • Client remains liable for the amounts.

Transfers

Income:

  • Countable income must be at or below the monthly cost of care.
    • If above, the client must meet the remaining spenddown with other incurred medical costs.
  • Cost of care is the total of anticipated monthly waiver services authorized plus prorated one-time costs.

Countable Income

  • See excluded income WAC 182-513-1340.
  • MN Disregards:
    • $20 general disregard (don't use to determine client responsibility toward cost of care in post eligibility).
    • 65 and 1/2 earned income deduction.
    • Monthly health insurance premium (not Medicare)
    • MNIL

Spousal Deeming

  • If a married client lives with their spouse
  • And the spouse's income is less than the MNIL
  • Deem income from the client to the spouse up to the MNIL
  • ONLY deem from the client to the spouse
  • NEVER deem from the spouse to the client
  • Never deem to or from a spouse when one is an SSI client
  • Subtract the spouse's income from the MNIL
  • The difference is the amount to allocate from the client

 


NOTE:

For MNIW, the Medically Needy Income Level (MNIL) is used in initial eligibility.  The Federal Poverty Level (FPL) is used as the personal needs allowance (PNA) in determining the cost of care.

The department matched the PNA used for the CN Waiver (COPES) and is state funding the difference between the federal allowance MNIL and the FPL

For this reason, it is important to remember the MNIL is the standard used in initial eligibility for MNIW.


Calculating the cost of care

Calculating the cost of care:

  • Use the total monthly cost of waiver services
  • prorate one-time waiver service costs by the number of months in the base period.
  • Add together the monthly cost and the prorated one-time cost.

Comparison income to costs:

  • Compare the countable income to the calculated cost of waiver services
  • If income is at or below the cost, client is eligible without meeting a further spenddown.
  • If income is above the cost, client will still have a spenddown to meet.

Excess Income

  • If income exceeds the cost of waiver services, client will need to meet the remaining spenddown with other incurred medical expenses.
  • Use the same criteria for non-institutional MN medical (S99).

 


Base Periods

  • Use a 3 or 6-month base period.
  • If a client's countable income is less than the expected monthly cost of waiver services, use a 6-month base period.
  • If the only reason the client is eligible is because of a pro-rated one-time cost or outstanding medical bills, use a 3-month base period.

Participation

  • Clients must participate toward the cost of their care

Be Aware:

  • Clients may pay participation to multiple providers
  • Financial services advises the client of the total amount of participation for the month.
  • Social Services must adjust SSPS.

Participation

Deduct the following from gross non-excluded income:

  • 65 1/2 earned income deduction
  • PNA (using the FPL)
  • Health insurance premiums, including Medicare part B and D not used to reduce resources or meet spenddown.
  • Incurred medical expenses not used to meet spenddown
  • Income deemed to spouse

Do not allow the $20 general disregard.


MNIW and ETRs

An approved ETR is needed to allow any other expense.  Refer the ETR request to the HCS Regional designee.

Examples of non-allowed expenses:

  • Guardianship fees
  • Child support
  • Mandatory income taxes

ACES Award Letter

  • ACES does not automatically generate a LTC award letter
  • Manually generate a 002-17 Approval for LTC medical benefits letter
  • Do not use a COPES letter

MNIW and Excess Spenddown

  • If income exceeds the cost of waiver services, the client is not eligible for MNIW until they meet the remaining spenddown.
  • Inform the client they are not eligible for the MNIW program until they have met spenddown
  • Inform the SW that the client must meet a spenddown before services can be authorized
  • Medicaid for MNIW with spenddown cannot be opened until services are opened
  • The opening date of MN with spenddown is the date the MNIW services were authorized
  • Advise the SW/CM when a client has met a spenddown and when the base period will end.
  • When service authorization is received, open the MNIW program through end of the base period.
  • Manually generate ACES letter.  Approval for LTC Medical benefits 0002-17
  • Clearly document ACES NARR which bills were used to meet spenddown

NOTE:

MNIW clients are not QMB eligible

  • Not automatically eligible like COPES clients
  • Income is too high
  • Do not screen in a S03
  • State-paid buy-in occurs beginning month 3 for active S99 clients including MNIW

MN Waiver Data base

  • MNRW and MNIW shares the same database
  • FSS inputs active MNIW clients into database
  • Headquarters will monitor the active list and advise field when active slots are filled
  • Headquarters will notify field when all slots are filled

MN Waiver Calculator

  • Trial Eligibility Calculator
    • Does not save entered data
    • Used to determine eligibility during the pre-authorization process
  • Permanent eligibility calculator
    • Saves 3 months of client eligibility data
    • Is part of the data entry screens for the MN Waiver database
  • The MN Waiver calculator is available to ADSA staff only at

MNIW, Spenddown and ACES

ACES Medical Coverage group S99 is used as a work around for the MNIW program

  • Screen in for a S02-ACES will trickle to a S99
  • INST-Use HCB Waiver type C and date services begin.
    • In remarks indicate MNIW case
    • INST does not come up automatically in the screen flow.  You must remember to "call up" that screen.
  • LTCX-Code the deductions we normally indicate on the LTCX screen for post eligibility as a reference.
    • Deductions on the LTCX screen is not part of the calculation for a S99 series. We put the deductions as a reference only. 
    • Make sure health insurance deduction (not medicare) is indicated on the MEDX screen too.  Health insurance premiums are indicated on the MEDX for S series.
    • LTCX does not come up automatically in the screen flow.  You must remember to "call up" that screen.
  • When bills are provided that meet spenddown:
    • Complete AMEN, option T Spenddown Medical Expense Update (SDME)
    • Add expenses provided by the client as you would for any S99.
  • Meeting Excess Spenddown
    • Medicaid for MNIW with spenddown cannot be opened until services are opened.
    • The opening date for MN with spenddown is the date the MNIW services were authorized.
  • More about meeting excess spenddown
    • When clients provide bills advise the case manager when a client has met a spenddown and when base period will end.
    • When service authorization is received, open MNIW program through the end of the base period.
    • Manually generate ACES letter
      • Approval for LTC medical benefits-0002-17
      • Indicate you have been approved for Medically Needy in-home service (MNIW).  Make sure the ending date of the base period is indicated on the letter.
    • Clearly document ACES narrative which bills were used to meet spenddown.

ACES coding-Screening in Married Clients

  • Married client, spouse's income is under the MNIL:
    • Use Fin Resp code of SP
    • ACES will use a $3000 resource standard as a couple and deem client's income to the spouse up to the MNIL (taking into account the spouse's income).
  • Married client, spouse's income at or above the MNIL:
    • Use Fin Resp code of NM
    • ACES will use a $3000 resource standard as a couple. 
Modification Date: May 13, 2013