Applications-Client is not otherwise eligible for a non-institutional CNP program

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Revised May 18, 2012

Purpose: Clients who have income over the Medically Needy Income Level (MNIL), resources exceed SSI related standard, client has a community spouse, client resides in a medical facility (nursing home/hospice care center), or is not otherwise eligible for non institutional Categorically Needy (CN).

Applications-Client is not otherwise eligible for a non-institutional CNP program.

In ACES, screen in a L22 medical coverage group.If the hospice election date is within 90 days of the application date, consider retro coverage under the L22 program back to the election date as long as the client is income and resource eligible in each of the prior months and is related to the L22 program.

1. How is the client related to a L22 program?

Refer to 388-515-1505 Financial Eligibility Requirements for long- term care services under COPES when L22/Hospice rules are used to determine eligibility and the client is not residing in a medical institution. For those residing in a medical institution, follow the rules in WAC 388-513-1315. A client must be Aged, Blind or Disabled to be eligible for this program. Follow regular office procedures to request a Non-Grant Medical Assistance (NGMA) determination from DDDS if no disability has been established.

2. Household Composition-who do I include in the AU?

Indicate the spouse as a spouse on the STAT screen using the SP code. Indicate the spouse's income, resources on their own screens. The shelter costs are indicated on the spouse's shelter screen.

Indicate the dependents in the HH as NM on the STAT. Code the LTCX screen with the number of dependents and their income and whether they are residing with the community spouse.

Do not indicate dependents on STAT if they are not in the HH. Do indicate these dependents on the LTCX screen.

See ACES PROCEDURES

3. Resources-What should I know?

Resource standards for the L22/Hospice program follow institutional SSI related rules. Do not deny applications when resource limits exceed $2000 for a single client or $3000 for a married client. Refer to WAC 388-513-1350 for more information on resource eligibility for institutional programs.

See LTC income and resource standards chart

EXAMPLE

A married couple one applying for hospice. Their combined available resources total $35,000. In this example, the community spouse* is allowed the Spousal Resource Transfer Maximum under institutional Medicaid rules. (Effective July 1, 2009, this limit is $48,639 plus $2000 for the institutionalized client.

*A community spouse is a person who does not receive institutional, waiver or hospice services and who is legally married to an institutionalized client.

List all assets owned by the client including their primary residence. Remember, this client may be subject to estate recovery.

A client may reduce their excess resources in the month of application by any unpaid medical expenses for which they are liable. This can include health insurance, Medicare premiums, deduction and co-insurance charges and any necessary medical care recognized under state law, but not covered under the state's Medicaid plan. See WAC 388-513-1350

The amount of excess resources is limited to the amounts indicated in WAC 388-513-1350

The L95 and L99 MN program for Hospice is only used in Medical Institutions such as nursing facilities or Hospice Care Centers. There is no MN Hospice program under the L95 and L99 outside of a medical institution.

EXAMPLE

Single client applies for medical and has elected hospice services. Gross income is $1,800 (Under the SIL ). He has $4000 in his savings account but you verified he has an unpaid hospital bill of $2000. If the client is liable for the bill in the month of application, he will be resource eligible. A client who is receiving hospice services in a nursing facility may also apply excess resources towards the cost of their care.

EXAMPLE

Single client applies for medical and has elected hospice services in a nursing facility. He has income of $500 per month but has $5000 in available resources. Client would be resource ineligible for most Medicaid programs. If the hospice cost of care* exceeds the excess resources plus the monthly income, the client would be eligible under the L22 program. The excess resources are applied towards the client share of the cost of care (participation). See subsection 5 below for more information on participation.

*Cost of care is determined by the daily rate of the medical institution and multiplying by the number of days.

For nursing facilities, it is based on 95% of the customary room and board rate plus the hospice rate (both are indicated on the INST screen).

For Hospice Care Centers, it is based on the Hospice Care Center daily rate x the number of days

EXAMPLE

Single client applies for medical and has elected hospice services at home. He has $1800 per month income (under the SIL ). He has $4000 in resources. His cost of care will be $2100 per month but he has no outstanding medical bills. We would deny the Hospice medicaid because his resources exceed the medicaid standard of $2000. We cannot project the cost of care outside a medical institution to reduce resources. WAC reference is 388-513-1350.

Married clients do have a higher resource standard when using institutional hospice rules. The hospice applicant is allowed $2,000 in resources; in addition, their community spouse is allowed the state spousal resource standard. The 7/1/2009 $48,639 This standard may every other year.

Once a client has been determined resource eligible for hospice and has a community spouse, the client has until the end of the month of the first regular eligibility review to transfer any excess resources owned in their name into the name of their community spouse. Set a tickler for 1 month prior to the eligibility review to check this. Send a DSHS 50-04 Resource Transfer letter for Married Clients.

4. Income

The CN income limit for the L22 Hospice program is higher than the MNIL for in home and uses the SIL (special income level) as the eligibility standard.

This makes this program more beneficial for clients whose income is higher and who would only qualify for MN coverage or MN with a spend-down under the SSI related medical (S) programs.

The financial eligibility rules used for in home hospice when using the L22 program are in WAC 388-515-1505. Follow these rules when Hospice clients have income under the SIL and live outside a medical institution.

Client keeps income up to 100% of the federal poverty level (FPL) as a personal needs allowance (PNA ) when single and living at home.
Client keeps income up to the MNIL as a PNA when married with a community spouse and living at home
Spouse's income is not counted when determining how much the client must pay each month toward hospice care (this is also called participation). The institutional spouse's income may be allocated to the community spouse.
Dependent children can be allowed allocations from the Hospice applicant's income. This is coded on the LTCX screen in ACES (under family member exemptions). Indicate:
- "C" if the dependent lives in the same household as the community spouse.
- "O" if the dependent does not live in the same household as the community spouse.
- The child's income separately for each child.

The financial eligibility rules used for Hospice in a nursing facility are in WAC 388-513-1315.

The rules to determine participation for an individual that has elected hospice in a nursing facility are in WAC 388-513-1380.

See: Long Term Care income and resource standard chart

5. Participation

Long Term Care (LTC) has two parts-initial eligibility (is the person financially eligible?) and post eligibility commonly known as participation (how much does the client have to contribute towards the cost of their care?).

When there is participation involved, hospice agencies must be given an award letter showing the amount they need to collect. We must also return the DSHS/Medicaid Hospice Notification form to the Hospice Agency indicating the participation and an award letter will follow.

6. ACES Coding

ACES coding instructions for Hospice.

Use the F1 and F2 help for additional information on the screens.

Community Spouse Resource Evaluation (CSRA ) screen will come up on all cases with a community spouse. The date the client entered the nursing home or elected hospice services is indicated.

Additional ACES links that may help in coding LTC cases:

ACES instructions for LTC.
ACES coding instructions how do I process a change when a client changes from a Waiver program to Hospice. Note: Indicate both Hospice and HCB Waiver on the INST screen when client is receiving both services.