Eligibility and Enrollment

ASAPs shall establish administrative procedures for carrying out the following determinations and functions: (1) Eligibility. An Applicant shall be eligible for Home Care Program Services if the Applicant is an Elder who meets the following eligibility criteria: the application requirements of 651 CMR 3.04(2); the age and residency requirements set forth in 651 CMR 3.04(3); the financial eligibility requirements set forth in 651 CMR 3.04(4); and the Functional Impairment Level, determination of need and Service Priority Matrix requirements set forth in 651 CMR 3.04(5). (a) Implications of MassHealth Frail Elder Home and Community Based Waiver Enrollment. 1. MassHealth members who meet Home Care Program eligibility criteria under 651 CMR 3.04 shall be eligible to receive Home Care Program Services provided that such services are determined to be non-duplicative with other MassHealth services. 2. MassHealth members shall be ineligible for Home Care Program Services if enrolled in an all-inclusive MassHealth program. (2) Application for the Home Care Program. (a) The ASAP shall afford any individual the opportunity to apply for the Home Care Program and shall inform each Applicant about the eligibility requirements and his or her rights and obligations under the program. (b) A determination of eligibility shall be made on all applications determined to be emergency cases within one business day after the date of referral. For purposes of 651 CMR 3.04(2)(b), “emergency cases” shall mean any situation that may place an elder at risk of nursing home placement due to such circumstances as an imminent or unexpected return to the community from a hospital or other facility. (c) The ASAP shall contact an Applicant within three business days after the date the referral is received to commence the intake process. (d) Within five business days after the referral is received, the ASAP shall complete an initial LTC Assessment for the purpose of determining eligibility and assessing the needs of the Applicant in accordance with 651 CMR 3.04(1) through (5). (e) If the Applicant is hospitalized or institutionalized, the initial assessment may be conducted prior to discharge. The Applicant's home environment and his or her ability to function in that setting will be assessed at the first home visit following discharge. (f) If the Applicant is unable or unwilling to have an initial LTC Assessment conducted within five days from the date the referral is received, the ASAP shall make reasonable efforts to conduct the assessment within a reasonable time period and shall document the reason for the delay. (g) An application for services shall be documented in the manner prescribed by Elder Affairs and in compliance with Documentation Standards. The Applicant or his or her Designated Representative shall sign and date an Applicant consent and disclosure form, certifying that the information is correct to the best of his or her knowledge. (h) At the time of application, the Applicant shall be notified in writing of his/her right to appeal a decision by the ASAP in accordance with 651 CMR 3.04(6)(c). (i) Within eight business days of the initial LTC assessment, the ASAP must determine the Applicant's eligibility for Home Care Program Services; provide a written notification to the Applicant regarding eligibility; and develop and initiate the appropriate service(s). (j) Appropriate Home Care Program Services shall be provided to an Applicant who is determined to be eligible pursuant to the requirements set forth in 651 CMR 3.04 in accordance with a Home Care Service Plan which is to be developed pursuant to 651 CMR 3.05. (k) Notwithstanding the requirements for the application for and the provision of Home Care Program Services, if the ASAP determines that there is an immediate need for services, services may be implemented prior to the determination of eligibility if it is reasonable to expect the Applicant will be eligible for Home Care Program Services pursuant to the requirements of 651 CMR 3.04. (3) Age and Residency. (a) Age. An Applicant or Consumer must be 60 years of age or older, or younger than 60 years old with a physician's documented diagnosis of Alzheimer's Disease, a related disorder, or other dementia must meet the eligibility criteria set forth in 651 CMR 3.04(4) and (5). (b) Residency. An Applicant or Consumer must reside in Massachusetts. Home Care Program Services shall not be provided to individuals residing in the following settings: a hospital, clinic, or infirmary; a convalescent home, rest home, nursing facility or charitable home for the aged or other facility licensed under M.G.L. c. 111, § 71; state hospitals or facilities licensed under M.G.L. c. 19, § 7 and c. 19B, §§ 7 and 15; or Assisted Living Residences. (4) Financial Eligibility. (a) An Applicant must meet the appropriate financial eligibility criteria set forth in the Financial Eligibility Guidelines issued by Elder Affairs. (b) The Financial Eligibility Guidelines based on annual gross income by Family size shall be increased to incorporate the percentage increase of the Cost of Living (COLA) announced by the U.S. Bureau of Labor Statistics and adopted by the U.S. Social Security Administration for Social Security and Supplemental Security Income (SSI) effective each st January 1 . Elder Affairs may, in its discretion, not more than once per year, on the first of a month and with at least 30 days advance public notice, amend the Financial Eligibility Guidelines to change the Home Care Program voluntary suggested co-payment schedule. The Financial Eligibility Guidelines shall be made available as a public record by Elder Affairs. (c) Information and Referral Services, Protective Services Casework (as defined in 651 CMR 5.02: Definitions for Consumers who are deemed to be suffering from Abuse in accordance with M.G.L c. 19A, §§ 14 through 26), and Emergency Shelter are provided without regard to income. (d) Protective Services clients in need of Home Care Program Services shall be subject to Financial Eligibility and Cost Sharing eligibility criteria for the Home Care Program. However, the ASAP may provide Home Care Program Services to these elders regardless of income and/or payment of a co-payment if the ASAP determines that discussion of financial eligibility and/or payment of fees would have an adverse effect on the provision of Protective Services. This determination shall be in compliance with procedures issued by Elder Affairs. (e) Annual Gross Income. For purposes of determining financial eligibility, annual gross income means the annual rate of income received by an individual or Family from the following sources: 1. Wages or salary; 2. Net income from self-employment; 3. Social Security pensions and survivor's benefits; 4. Disability insurance income; 5. Capital gains, taxable or tax free dividends, taxable or tax free interest income, proceeds from estates or trust disbursements, and royalties; 6. Net rental income and net income from roomers and boarders (gross rental income, less expenses received from a person other than a spouse or child residing in the home); 7. Public assistance and welfare payments; 8. Pensions and annuities; 9. Unemployment compensation and worker's compensation; 10. Alimony and child support; 11. Federal Veteran's pension; 12. Railroad Retirement benefits; 13. Business income; 14. IRA distributions; 15. Lump sum payments; 16. Other income; provided that reverse mortgage loan proceeds (pursuant to M.G.L. c. 19A, § 36), and war reparations income shall not be considered income. (f) Income from an Asset. Income from any asset jointly owned by two or more persons is presumed to be distributed in equal shares unless a different distribution of income is verified. If the Consumer or Applicant claims less than the proportional share, he or she shall verify the amount owned with one or more of the following documents: title; purchase contract; documentation of ownership for joint bank accounts; certificate of ownership; financial institution records; other documentation that indicates ownership; or a notarized affidavit signed by all owners of the asset attesting to the distribution of ownership. When such a partial ownership is verified, the income shall be attributed to the Consumer or Applicant in proportion to the ownership interest. (g) Verification. The Applicant's/Consumer's signed declaration that the financial information provided is true, to the best of his or her knowledge and belief shall ordinarily constitute the basis for income verification. Such declaration shall include the amount of gross monthly income, the source(s) of such income and the type of income. The Applicant's or Consumer's statements will be sufficient to establish his or her eligibility, provided that the information is complete and consistent. If the ASAP determines that the declaration appears insufficient, supportive evidence shall be requested. If the Applicant/Consumer refuses to make a full declaration, or refuses to supply evidence needed, the application for the Home Care Program shall be denied. This denial shall be subject to the right to appeal. (h) Determination and Redetermination of Financial Eligibility. 1. Redetermination of financial eligibility shall take place annually. If the ASAP is aware of an income change, other than cost of living allowance increases in Social Security benefits), the financial redetermination shall take place as soon as possible, or at the next scheduled home visit. An interim (between annual redeterminations) financial redetermination shall not be done solely due to a cost of living increase in Social Security benefits. 2. If the living arrangements of a Family changes for longer than three months, a redetermination must be carried out. If one spouse leaves the home for longer than three months, the spouse remaining at home shall be re-determined on the basis of a one-person Family. (5) Functional Impairment Level Assessment and Service Priority. (a) A Long Term Care Assessment shall be completed to determine eligibility for the Home Care Program. Such assessment shall be in accordance with forms and procedures as required by Elder Affairs. Initial assessments for Applicants shall entail at least one home visit. (b) Functional Impairment Levels (FIL). A FIL shall be determined for each Applicant or Consumer based on his or her inability to perform Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs). The status of the Consumer shall be reviewed at each reassessment and the Functional Impairment Level changed if appropriate. 1. The FIL is determined by counting the number of ADL and IADL impairments based on the assessment. 2. The Functional Impairment Levels (FIL) are: FIL 1: four-seven ADL Impairments; FIL 2: two-three ADL Impairments; FIL 3: one ADL Impairment and any number of IADL impairments; or six or more IADL Impairments; and FIL 4: no ADL impairments and four-five IADL Impairments. (c) Long Term Care Assessment for Home Care Program Services. An Applicant's need for Home Care Program services shall be determined using the LTC Assessment. After determining that the Applicant or Consumer has a qualifying FIL, the ASAP shall determine the extent of need for Home Care Program Services. The assessment shall also determine a Caregiver's need for Respite Care Services. The ASAP shall determine whether an Applicant or Consumer should be expected to be maintained at home considering current problems, Unmet Needs and expected availability of other resources including formal services and informal supports. If the possible services authorized and/or arranged for are deemed inappropriate to maintain an Applicant or Consumer safely in his or her home, the ASAP may not provide purchased services, but must provide assistance in securing the appropriate needed services, following the appropriate appeals, if any, pursuant to 651 CMR 3.04(6)(c). (d) Service Priority. Priority of service is determined according to the FIL and Unmet Needs. The following list identifies eight service categories in order of priority: 1-C: FIL 1 with one or more Critical Unmet Need(s); 2-C: FIL 2 with one or more Critical Unmet Need(s); 3-C: FIL 3 with one or more Critical Unmet Need(s); 4-C: FIL 4 with one or more Critical Unmet Need(s); 1-NC: FIL 1 with Non-critical Unmet Needs; 2-NC: FIL 2 with Non-critical Unmet Needs; 3-NC: FIL 3 with Non-critical Unmet Needs; and 4-NC: FIL 4 with Non-critical Unmet Needs. (e) To qualify for Home Care Services, an Applicant's initial FIL and Service Priority must be either 1-C, 2-C or 3-C according to the list included in 651 CMR 3.04(5)(d). A Consumer's ongoing FIL and Service Priority must be determined to be either 1-C, 2-C, 3-C or 4-C, or 1-NC, 2-NC, 3-NC, or 4-NC to remain eligible to receive Home Care Services. (f) Consumers whose Caregivers are in need of Respite Care Services must be categorized under the appropriate FIL and be determined to have one or more Critical Unmet Needs. (g) Exceptions. An Applicant or Consumer who meets the eligibility criteria set forth in 651 CMR 3.00, but is not within a Service Priority standard identified in 651 CMR 3.04(5)(e), may qualify for an exception when he or she meets one or more of the following criteria. 1. Elders who are at risk of being unable to remain in the community due to a variety of factors, including, but not limited to substance use disorders, cognitive, emotional, or mental health problems, or cultural and/or linguistic barriers. 2. Protective Services. Elders who are receiving or are eligible to receive Protective Services as defined in 651 CMR 3.02 shall be eligible for Home Care Program Services. 3. Congregate Housing. Consumers residing in a Congregate Housing Facility. 4. Waiver Consumers. Consumers who are eligible for the Frail Elder Home and Community Based Waiver Program. (6) Notification of Eligibility. (a) The ASAP shall give written notice to each Applicant after a decision is made as to whether such individual is eligible for Home Care Program Services. Such notification shall include a statement of his or her suggested monthly voluntary co-payment or a statement of his or her cost sharing co-payment, if applicable. (b) If the Applicant has been found ineligible for the Home Care Program, the notice of ineligibility shall contain a statement of reasons supporting the finding of ineligibility, a reference to applicable regulations, and an explanation of the Applicant's right to request an appeal pursuant to the 801 CMR 1.00: Standard Adjudicatory Rules of Practice and Procedure and 651 CMR 1.00: Adjudicatory Rules of Practice and Procedures. (c) Right to Appeal. 1. An Applicant/Consumer shall be informed in writing of his or her right to request a Review of an ASAP's decision to deny an application for Home Care Program Service. 2. The Applicant or Consumer shall also be informed in writing of his or her right to Appeal a Review decision to Elder Affairs' Hearings Officer as specified in 651 CMR 1.07: Initiation of Appeal of a Review Decision. The Appeal shall be conducted in accordance with 801 CMR 1.00: Standard Adjudicatory Rules of Practice and Procedure and 651 CMR 1.00: Adjudicatory Rules of Practice and Procedures.