Case Specific Situations - LTC

Created on: 
Nov 08 2019

Online Processing

Mainframe Processing

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

What program do I open for a client in a hospital?

If the client does not meet institutional status to establish eligibility in the hospital, then users need to consider S02 (Categorically Needy SSI Related Medical) eligibility. However, there are certain situations when L-track medical would be to the client’s advantage. These cases need to be reviewed by policy if the worker is uncertain what program would be best for the client.

Online Processing

How do I process a change when a client changes from one setting or service to another?

To process a change when a client changes from one setting or service to another, take the following steps:

  1. On the Case Actions page in the Change of Circumstances section, select the month that the change occurred from the Benefit Month drop down menu and then click Start Changes.
  2. On the Facility page, complete the following fields:
  • Leave Date field - Enter the [date the client left the facility] if the client has discharged from a facility already coded on the Facility page.
  • If the client has entered another facility or Alternate Living Facility (ALF) add a new Facility page and complete the following fields:
    • Type field - Select the appropriate facility type from the drop down menu.
      • The facility type must be from the same subset as the living arrangement coded on the Client Details page.
    • ID field - Enter the [provider number] if required.
    • Entry Date field - Enter the [date the client entered the facility or ALF].
    • Level of Care field - Select the level of care from the drop down menu.
    • Payment Auth Date field - Enter the [date payment should begin]. This is the date services are approved and displays on the award letter.
Note: If the Payment Auth Date field is not completed the Assistance Unit (AU) may approve; however, the cost of care is not calculated.
  • Private Rate field - Enter the [facilities private daily rate]. Contact the facility for rate information.
  • State Rate field - Enter the [facilities state daily rate].
  1. On the Home and Community Based Services page, complete the following fields:
  • End Date field - Enter the [date the services ended] if the existing services have ended.
  • If new services have been approved, add a new Home and Community Based Services page and complete the following fields:
    • Type field - Select the new waiver service type from the drop down menu.
    • Provider ID field - Enter the [provider number] if required.
    • Start Date field - Enter the [date the new waiver service begins].
    • Approval Source field - Select the approval source from the drop down list.
    • Payment Auth Date field - Enter the [date payment is to begin].
Note: If the Payment Auth Date field is not completed the AU may approve; however, the cost of care is not calculated.
  • If the type is Hospice (H), complete the additional following fields:
    • Private Rate field - Enter the [provider’s private daily rate]. Call the facility to get the current private rate.
    • State Rate field - Enter the [provider’s state daily rate].
  1. From the Navigation tree, select Review.
  2. If there are no errors on the Review page, click Eligibility on the Navigation tree.
  3. On the Eligibility page, a Details link displays to the right of any AU that is currently active. Click the Details link.
  4. Review the Eligibility Details page for each AU. If all looks correct, click Confirm Benefits.
  5. Click Commit Changes on the Eligibility page.

To process the change for the months after the change took place, take the following steps:

  1. On the Case Actions page in the Change of Circumstances section, click Start Changes.
  2. On the Facility page, complete the following fields:
  • If the client has discharged from a facility or ALF already on the Facility page, delete the page containing the old facility information.
  • If the client has entered a new facility, add a new Facility page. For more information on how to add a new page, see How do I add details?
  • On the Facility page, complete the following fields:
    • Type field - Select the type of facility from the drop down list. The facility type must be from the same subset as the living arrangement coded on the Client Details page.
    • ID field - Enter the [provider number] if required.
    • Entry Date field - Enter the [date the client entered the facility or ALF]. This can be the same date as the leave date from a prior facility.
    • Level of Care field - Select the level of care from the drop down list.
    • Payment Auth Date field - Enter the [date payment should begin]. This is the date services are approved and displays on the award letter.
Note: If the Payment Auth Date field is not completed the AU may approve; however, the cost of care is not calculated.
  • Private Rate field - Enter the [facilities private daily rate]. Contact the facility for rate information.
  • State Rate field - Enter the [facilities state daily rate].
  1. On the Home and Community Based Services page, complete the following fields:
  • If existing services have ended that are already coded on the Home and Community Based Services, delete the page to remove the old information.
  • If new services have been approved, complete the following fields:
    • Type field - Select the appropriate waiver service type from the drop down list.
    • Provider ID field - Enter the [provider number] if required.
    • Start Date field - Enter the [date the new waiver service begins].
    • Approval Source field - Select the approval source from the drop down list.
    • Payment Auth Date field - Enter the [date payment is to begin].
Note: If the Payment Auth Date field is not completed the AU may approve; however, the cost of care is not calculated.
  • If the type is Hospice (H), complete the following fields:
    • Private Rate field - Enter the [provider’s private daily rate]. Call the facility to get the current private rate.
    • State Rate field - Enter the [provider’s state daily rate].
  1. From the Navigation tree, select Review.
  2. If there are no errors on the Review page, click Eligibility on the Navigation tree.
  3. On the Eligibility page, a Details link displays to the right of any AU that is currently active. Click the Details link.
  4. Review the Eligibility Details page for each AU. If all looks correct, click Confirm Benefits.
  5. Click Commit Changes on the Eligibility page.

How do I code the Shelter Expenses page when there is a community spouse?

For a Long-Term Care client with a Community Spouse, shelter expenses must be entered on the Community Spouse’s Shelter Expenses page to be used in the community spousal allowance/excess shelter calculation.

The excess shelter allocation is the amount in excess of the appropriate standard. For additional information, see Apple Health eligibility manual - WAC 182-513-1380 Determining a person's financial participation in the cost of care for long-term care (LTC) services.

ACES uses the four-person Standard Utility Allowance (SUA) in this computation. If utilities are included in the rent, mortgage, maintenance fees or condo fees, deduct that amount of the four-person SUA from these expenses so it is not allowed twice.

What do I do if the client’s Supplemental Security Income (SSI) stops and the system cannot auto-determine a client's Categorically Needy eligibility?

If the State Data Exchange (SDX) interface indicates a client is no longer SSI eligible the following occurs:

  • On the Unearned Income page, ACES updates the client’s income type SSI Benefits (SI) to $0 and the L01 (Categorically Needy LTC in a Medical Facility - SSI Recipient) or L51 (SSI Non-Institutional CN CFC or MPC) Assistance Unit (AU) remains active.
  • Alert 248 - SSI TERMINATED, REDETERMINE MEDICAL ELIGIBILITY is generated for the worker of record.
  • ACES generates Letter 022-05 (Redetermination for Medical at SSI Termination) with Form 14-078 (Eligibility Review) attached.
  • If the ER Received field on the Case Actions page is not updated with Yes (Y) within 60 days from the date the eligibility review was sent, the AU is automatically terminated with Reason Code 235 - Review not complete.
  • Once the SSI income is removed from the Unearned Income page, the AU trickles from L01 to L02 (Categorically Needy LTC in a Medical Facility - SSI Related) medical.

When a client’s SSI benefits are terminated, re-determine the client’s medical eligibility for other programs (such as L02 if the client is still residing in a medical institution) following the processes outlined in the Apple Health eligibility manual - WAC 182-504-0120 Washington apple health - Effective dates of changes.

When should I use the Facility page?

The Facility page should be used when:

  • A client is admitted to a medical facility for over 29 days; or
  • When a client is admitted to a medical facility and does not return to the same setting.
EXAMPLE: Client resides in a Nursing Facility (NF), and has a medical condition requiring hospitalization. The client discharges from the NF and enters the hospital. After two weeks, the client enters a new NF. This situation should be coded on a Facility page because the client had discharged from the NF.
EXAMPLE: Client resides in an Assisted Living Facility (ALF), and has a medical condition that requires a stay in a NF or hospital for over 29 consecutive days. The Client then returns to the same ALF. This situation should be coded on a Facility page.
EXAMPLE: Client resides in an ALF, and enters a NF. After two weeks the client discharges from the NF and enters a different ALF. This situation should be coded on a Facility page.

How do I close a Long Term Care (LTC) medical program for a client who is deceased?

To close a LTC medical program for a client who is deceased, complete the following steps:

  1. From the Case Actions page in the Change of Circumstances section, select the month the client passed away from the Benefit Month drop down menu and click Start Changes.
  2. On the Client Details page, complete the following fields:
  • Death Date field - Enter the [date of death].
  • Death State field - Select the state where the client passed away from the drop down menu.
  1. On the Facility page, complete the following field:
  • Leave Date field - Enter the [date of death].
  1. On the Home and Community Based Services page, complete the following field:
  • End Date field - Enter the [date of death].
  1. On the Eligibility page click the Details link. This takes you to the Eligibility Details page.
  2. On the Eligibility Details page, verify the benefit information then click the Confirm Benefits button.
  3. On the Eligibility page, click the Commit Changes button. 
  • The Assistance Unit (AU) remains active for the month the client passed away.
  1. From the Case Actions page in the Change of Circumstances section, select each month after the client passed away from the Benefit Month drop down menu and update the following on the Client Details page:
  • Death Date field - Enter the [date of death].
  • Death State field - Select the state where the client passed away from the drop down menu.
  1. Delete the Facility and Home and Community Based Services pages. For more information on how to delete a page, see How do I delete entered details?
  2. Commit the changes on the Eligibility page.The AU closes with Reason Code 244 - Death and the paid through date is the date of death.

How do I code the non-applying spouse’s demographic, income and resource information?

To correctly calculate eligibility for a Long Term Care (LTC) Assistance Unit (AU) and the spousal/dependent allocation amount, the following data is required:

  • The Financial Responsibility code must be entered as Ineligible Spouse (SP) on the AU Details page.
  • The living arrangement must be completed on the Client Details page.
  • The marital status of both the recipient and spouse on the Client Details page must be one of the following:
    • Legally Separated (S).
    • Separated (P).
    • Married Living Apart (A).
    • Married (M).

Information regarding the spouse’s resources and income must be entered using the standard client based screens such as the Client DetailsUnearned IncomeEarned Income, Shelter Expenses and Resources pages.

How do I code a legal dependent on a Long Term Care (LTC) Assistance Unit (AU)?

To code a legal dependent on an LTC AU, complete the following fields on the Dependent/Child Income and Allowance page: 

  • Type field - Use the drop down menu to select one of the following:
    • Dependent child living with Community Spouse (C) - an applicant/recipient's natural or adopted child who is living in the household with the Community Spouse (CS).
    • Dependent not living with Community Spouse (O) - any dependent (child or otherwise) not living with a CS.
    • Other Dependent living with Community Spouse (D) - dependents other than the applicant/recipient's natural or adopted child.
  • Amount field: Enter the gross income amount of the dependent.
Note: Leave the Amount field blank if the dependent does not have any income.

How do I view the participation amounts when they are split between multiple providers?

When participation is split between multiple providers, the participation amounts for each provider can be viewed on the Eligibility Details page in the Post Eligibility section.

The Post Eligibility section displays:

  • The gross income amount used to calculate the client’s cost of care responsibility.
  • The assignment section displays the service or facility/provider types to which the cost of care for the month may be assigned.
  • The cost of care for each provider when the client's cost of care for a single month is split between multiple services/providers.
  • The discharge date is the facility discharge date or service end date when the client received care from more than one service or setting during the month.

In ACES.online, the split participation can be viewed on the Medical Eligibility page in the Split Cost of Care section.

Mainframe Processing 

How do I view the participation amounts when they are split between multiple providers?

The participation amounts can be viewed on the LTCP screen when it is split between multiple providers.

The MAFI screen displays the LTCP indicator next to the Total Payment field and it can be accessed by pressing <F16> on the MAFI screen.

The LTCP screen is an inquiry only screen and can be accessed from any other data collection screen. For more information, see How do I fast-path to a specific screen?

The LTCP screen displays:

  • The gross Post Eligibility (PETI) income amount used to calculate the client’s cost of care responsibility.
  • The income processing rule used to determine the gross income amount used in the eligibility calculation.
    • N - "Name on Check" rule or
    • C - "Community Income" rule.
  • The assignment section displays up to four service or facility/provider types to which the cost of care for the month may be assigned. The first occurrence is a duplicate of the provider or service whose information is displayed on the MAFI screen.
  • The cost of care for each provider when the client's cost of care for a single month is split between multiple services/providers.
  • The discharge date is the facility discharge date or service end date when the client received care from more than one service or setting during the month.

The STAY screen displays when a medical client is institutionalized or elects Hospice for a short period of time. Use the STAY screen to access the SSCC screen that displays the amount the client owes the provider for a specified Short Stay. The SSCC screen is accessible only from the STAY screen.

 

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.