210-RICR-50-00-1
210-RICR-50-00-1. Medicaid Long-Term Services and Supports Overview and Eligibility Pathways (version Adoption, 07/15/2018 to 12/29/2022)
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1.1 Overview
The provisions set forth
herein pertain to the scope of Medicaid long-term services and
supports (LTSS) and the various pathways for initial and continuing
eligibility.
1.2 Legal Authority
A. This Chapter of rules
related to Medicaid LTSS is promulgated pursuant to federal
authorities as follows:
1. Federal Law: Title XIX of
the U.S. Social Security Act 42
U.S.C. §§ 1396a , 1115, 1902, 1903, 1905, 1915; 1396k ;
1413(b)(1)(A) of the Affordable
Care Act.
2. Federal Regulations: 42
C.F.R. §§ 431,435, 440, and 441 .
3. The Medicaid State Plan and
the Title XIX, Section 1115 (a) Demonstration Waiver (11-W-00242/1),
effective through December 31, 2018.
B. Additionally, legal
authority related to LTSS is derived from R.I.
Gen. Laws, Chapter 40-8 and §§ 40-8.6 to 40-8.13 .
1.3 Definitions
A. For the purposes of LTSS
Medicaid, the following definitions apply:
1. “Department of Behavioral
Healthcare, Developmental Disabilities, and Hospitals" or
"BHDDH” means the state agency established under the
provisions of R.I. Gen. Laws Chapter 40.1-1 whose duty it is to serve
as the State’s mental health authority and establish and promulgate
the overall plans, policies, objectives, and priorities for State
programs for adults with intellectual and developmental disabilities
as well mental illness and substance abuse education, prevention and
treatment.
2. “Department of Human
Services" or "DHS” means the State agency established
under the provisions of R.I. Gen. Laws Chapter 40-1 that is empowered
to administer certain human services. The DHS has been delegated the
authority through an interagency service agreement with the Executive
Office of Health and Human Services (EOHHS), the Medicaid Single
State Agency, to determine Medicaid eligibility in accordance with
applicable State and federal laws, rules and regulations.
3. “Developmental
disability” means, for the purposes of the RI Department of
Behavioral Healthcare, Developmental Disabilities and Hospitals, a
condition that affects a person, eighteen (18) years or older, who is
either an intellectually developmentally disabled adult or a person
with a severe, chronic disability that:
a. Is attributable to a mental
or physical impairment or combination of mental and physical
impairments;
b. Manifests before the person
attains age twenty-two (22);
c. Is likely to continue
indefinitely;
d. Results in substantial
functional limitations in three (3) or more of the following areas of
major life activity:
(1) Personal care
(2) Communication
(3) Mobility
(4) Learning
(5) Self-direction
(6) Capacity for independent
living
(7) Economic self-sufficiency;
and
(8) Reflects the person's need
for a combination and sequence of special, interdisciplinary, or
generic care, treatment or other services which are life-long or of
extended duration and are individually planned and coordinated.
4. "Eligibility date"
means the first day of the month in which a person is eligible for
Medicaid LTSS. It is based on the month the application or, for
existing beneficiaries, the request for LTSS is made and is otherwise
unrelated to the date a person entered an institution or began
receiving LTSS, regardless of payer. The eligibility date does not
include periods of retroactive eligibility.
5. “Executive Office of
Health and Human Services" or "EOHHS” means the state
agency established in 2006 under the provisions of R.I. Gen. Laws
Chapter 42-7.2 within the executive branch of state government which
serves as the principal agency for managing the Departments of
Children, Youth, and Families (DCYF); Health (RIDOH); Human Services
(DHS); and Behavioral Healthcare, Developmental Disabilities, and
Hospitals (BHDDH).
6. “Financial eligibility”
means the set of factors used to determine whether a person is
entitled to receive services based upon income and/or resource
requirements, as well as limitations related to the transfer of
assets, which includes both liquid resources and real property, prior
to the application for Medicaid LTSS.
7. “Functional disability”
means any long-term limitation resulting from an illness, health
condition, or impairment that affects a person’s ability to perform
certain activities of daily living without substantial assistance or
supervision.
8. “Home and Community-Based
Services" or "HCBS” means any Medicaid LTSS State Plan or
Section 1115 waiver-authorized services available to beneficiaries at
home or in a community-based setting.
9. “Institution” or
"Health institution" means a State-licensed health facility
that provides health and/or social services and supports on an
in-patient basis. For the purposes of this rule, the term means
long-term care hospitals and treatment facilities (LTH), intermediate
care facilities for persons with intellectual disabilities (ICF/ID),
and nursing facilities (NF).
10. “Integrated Health Care
Coverage Groups” or "IHCC" means any Medicaid coverage
group consisting of adults who are eligible based on receipt of
Supplemental Security Income (SSI), SSI protected status, the SSI
income methodology and a related characteristic (age or disability),
or as a result of participation in another federal or State program,
such as the Breast and Cervical Cancer Program. This group includes
beneficiaries eligible for community Medicaid (non-long-term care),
Medicaid-funded LTSS and the Medicare Premium Payment Program (MPPP).
11. “Integrated Health and
Human Services Eligibility System" or "IES” means the
state's eligibility system that enables applicants, through a single
application, to be considered for multiple health and human service
programs simultaneously.
12. “Intermediate Care
Facility for Persons with Intellectual/Developmental Disabilities"
or "ICF/ID” means a State-licensed health care facility that
provides long-term services and supports to persons with intellectual
/developmental disabilities.
13. “Katie Beckett
eligibility” means an eligibility category that allows certain
children under age 19 who have long-term disabilities or complex
medical needs who require an institutional level of care to obtain
the Medicaid long-term services they need at home. With Katie Beckett
eligibility, only the child’s income and resources are considered
when determining eligibility.
14. “Long-term services and
supports" or "LTSS" means a spectrum of services
covered by the Medicaid program for persons with clinical and
functional impairments and/or chronic illness or diseases that
require the level of care typically provided in a health care
institution. Medicaid LTSS includes skilled or custodial nursing
facility care, therapeutic day services, and personal care as well as
various home and community-based services. Medicaid beneficiaries
eligible for LTSS are also provided with primary care essential
benefits. The scope of these services and supports and the choice of
settings is determined by a comprehensive assessment of each person's
unique care needs.
15. “LTSS living
arrangement” means the institutional or home or community-based
setting where a Medicaid LTSS beneficiary resides while receiving
Medicaid LTSS.
16. “LTSS specialist”
means a State agency representative responsible for conducting
assessments, determining eligibility for LTSS, authorizing services,
and/or providing assistance to people in navigating the Medicaid LTSS
system.
17. “Medicaid Affordable
Care Coverage Groups” or "MACC" means a classification of
persons eligible to receive Medicaid who are subject to the Modified
Adjusted Gross Income or "MAGI" standard for determining
income eligibility as outlined in the Medicaid Code of Administrative
Rules, "Health Coverage for Children, Families, and Adults"
(See Part 30-00-5 of this Title).
18. “MAGI standard” means
the method for evaluating Medicaid income eligibility using the
modified adjusted gross income (MAGI) standard established under the
ACA. Persons who are or would be income-eligible for the ACA
expansion for adults may obtain Medicaid LTSS if they meet the
applicable clinical/functional eligibility criteria, are under age
sixty-five (65), and are not eligible for or enrolled in Medicare.
19. "Medicaid Single
State Agency" means the state agency authorized under state law,
Title XIX of the U.S. Social Security Act (42 U.S.C. § 1396a et
seq .) and the Medicaid State Plan as the entity legally
responsible for the program / fiscal management and administration of
the Medicaid program. The EOHHS is the designated single state agency
in Rhode Island.
20. “Needs-based criteria”
means the basis for determining clinical/functional eligibility for
Medicaid LTSS. The LTSS needs-based criteria encompass medical,
social, functional, and behavioral factors, and the availability of
family support and financial resources.
21. “Preadmission Screening
and Resident Review" or "PASRR” means the process
required by federal law that evaluates and ensures individuals who
have a serious mental illness (SMI) and/or intellectual disability
are not inappropriately placed in nursing facilities for long-term
care. PASRR requires that those applicants for a Medicaid-certified
nursing facility are evaluated for appropriateness.
22. “Primary care essential
benefits” means non-LTSS Medicaid health coverage, and includes an
array of acute, subacute, and specialty essential benefits, as
identified under the Medicaid State Plan, provided by licensed health
professionals. These essential benefits include, but are not limited
to: health promotion, disease prevention, health maintenance,
counseling, patient education, various specialty services and
diagnosis and treatment of acute and chronic medical and behavioral
health illnesses and conditions in a variety of health care settings
such as office visits, inpatient, home care, and day care.
1.4 Types of LTSS
A. Under the terms of Title
XIX of the U.S. Social Security Act of 1964, Medicaid LTSS in an
institutional-setting is a State Plan service available to all
otherwise eligible Medicaid beneficiaries and new applicants,
providing they meet certain eligibility factors.
B. “Institution” is the
term used in Title XIX to refer to a hospital (H), an intermediate
care facility for persons with intellectual/developmental
disabilities (ICF/ID), and a nursing facility (NF). These
institutions are licensed in Rhode Island by the Department of Health
(RIDOH) as health care facilities under Chapter 23-17 of the R.I.
Gen. Laws. Although the term "institution" is not accurate
in a licensure sense, under federal regulations at 42 C.F.R. §
440.40, the eligibility criteria for Medicaid LTSS remain tied to
these institutional settings and vary in accordance with types of
services each typically provides and the needs of the population(s)
they serve. As these services are now also available to beneficiaries
in a home and community-based setting, the Medicaid LTSS rules apply
across settings, as follows:
1. Medicaid LTSS in Health
Care Institutions - Persons who meet the applicable eligibility
requirements may access LTSS in the following State-licensed health
care institutions/facilities -
a. Nursing Facilities (NF). A
person is eligible to access Medicaid LTSS in a NF when it is
determined, based on a comprehensive assessment, that he or she has
the highest need for a NF level of care.
b. Intermediate Care Facility
for persons with Intellectual/Developmental Disabilities (ICF/ID). To
qualify, a person must meet the applicable statutory standards set
forth in § 40.1-22-6 pertaining to developmental disabilities and:
(1) have the level of need for
LTSS typically provided in an ICF-ID; or
(2) would require an ICF/ID
level of care if were not for LTSS provided in a home or community
based setting. As the State's Section 1115 waiver provides the
authority for the home and community-based LTSS provided to members
of this population with developmental disabilities, the BHDDH is
required to provide services in the least restrictive setting
appropriate to a person's level of care needs.
c. Long-term Hospital (LTH) -
A person must meet the needs-based criteria for long-term services in
a hospital setting established by BHDDH and/or the EOHHS. Medicaid
LTSS may also be available to children in State custody or with
special health care needs receiving services in residential treatment
facilities and hospitals if they meet the applicable level of care
requirements.
2. Medicaid Home and
Community-based (HCBS) LTSS - The State’s Section 1115
demonstration waiver authorizes Medicaid LTSS when provided in a home
and offers an array of community-based settings as an alternative to
care in one of the three principal covered health care institutions
(NF, ICF/ID, or LTH). Access to these services enables beneficiaries
to optimize their health and retain their independence while delaying
or diverting the need for care in a more restrictive health care
institutional setting.
a. Scope of HCBS Coverage.
Medicaid HCBS includes both core and specialized services and
supports authorized under the State Plan or Section 1115
demonstration that address each individual beneficiary's unique
long-term functional and clinical needs. The array of HCBS may vary
depending on the beneficiary’s needs and the institutional level of
care required.
b. Limitations. Room and board
are NOT covered for HCBS by Medicaid.
1.5 Applicability
The provisions set forth
herein apply to any person seeking Medicaid LTSS coverage, including
those who are uninsured, receiving non-LTSS Medicaid under Part 3 of
Chapter 40 of this Title or MCAR 1305, “Eligibility Requirements”,
or have third-party forms of coverage through Medicare or a
commercial insurer.
1.6 Scope of LTSS Coverage
A. Upon being determined
eligible for Medicaid LTSS, a beneficiary is entitled to Medicaid
State Plan and Section 1115 waiver services across the care
continuum. Subchapters 05 and 10 of this Chapter identify the LTSS
covered services and the various Medicaid LTSS programs that serve
beneficiaries with specific types of health needs, including the
following:
1. Primary care essential
benefits. All LTSS Medicaid beneficiaries are entitled to receive the
primary care essential health benefits available to beneficiaries in
the MACC and IHCC groups, covered under the Medicaid State Plan and
Section 1115 demonstration waiver, including primary and preventive
care as well as acute and subacute services. If a beneficiary has
third-party insurance, such as Medicare or commercial insurance that
does not provide the full scope of Medicaid benefits, Medicaid
provides wrap-around coverage for any Medicaid services that are
unavailable.
2. Institutional and home and
community-based care. Medicaid LTSS beneficiaries are eligible for
the full scope of LTSS covered by the Medicaid State Plan and Section
1115 waiver. As the State uses needs-based criteria to determine the
scope of services a beneficiary is authorized to receive, Medicaid
LTSS coverage varies along with a beneficiary’s functional capacity
and acuity needs, social environment, access to family and other
third party supports, and personal choices. The range of Medicaid
LTSS extends from 24/7 comprehensive care in a health institution to
a limited package of services in a community-based setting, to one, a
few, or a bundle of home and community core and ancillary services in
the home.
B. Medicaid beneficiaries who
are receiving primary care essential benefits through a managed care
plan or fee-for-service through a MACC group MAGI pathway pursuant to
Part 30-00-2 of this Title (ACA Expansion Adults) or a IHCC group SSI
(Supplemental Security Income or SSI eligible and SSI-protected
status and Elders and Adults with Disabilities or EAD) pathway in
accordance with Part 40-00-1 of this Title may be eligible for
Medicaid LTSS preventive (see § 40-05-1.8 of this Title) or full
benefits if they meet certain clinical/functional and financial
eligibility criteria. The State uses information known about the
beneficiary when determining eligibility for LTSS for current
Medicaid beneficiaries to the full extent feasible. The additional
information required, as out-lined below, may be provided by
completing the applicable sections of the DHS-2 form, or designated
supplemental form, or by updating an on-line account as appropriate:
Basis
of Eligibility
Supplemental
Information Required from Existing Beneficiaries Seeking LTSS
Preventive
LTSS Clinical/function
(See
Part 40-05-1 of this Title)
Functional/clinical
Level
of Need (See Part 5 of this Subchapter)
Financial
Eligibility - Allocation of resources and transfer of assets
-Part 40-00-3 of this Title and Part 6 of this Subchapter)
Post-eligibility
Treatment of Income (See Part 8 of this Subchapter)
1.SSI
Documentation
from health provider
Documentation
from health provider
Limited
to current information on spouse and dependents as related to
spousal impoverishment and transfer of assets
Applies
- information related to allowances including income and
expenses of spouse and dependents
2.
EAD
Documentation
from health provider
Documentation
from health provider
Limited
to 60 months pre-application of information on spouse and
dependents as related to spousal impoverishment and transfer of
assets
Applies
- information related to allowances income and expenses of spouse
and dependents
3.
ACA Expansion Adults
Not
applicable
Documentation
from health provider
Limited
60 months of pre-application information on resources of self,
spouse and dependents as related to transfer of assets only
Not
applicable
1.7 Qualifying for Medicaid LTSS
A. Under Title XIX, the
federal Medicaid law, an applicant for LTSS must be either a current
beneficiary or possess an income, clinical/functional, or age-related
characteristic related to a MAGI eligible or SSI population AND have
an established need to qualify to apply. With the enactment of the
federal Affordable Care Act of 2010, federal law requires that
Medicare, commercial health insurers, and group health plans provide
as part of the primary care essential benefit package up to thirty
(30) days of subacute and rehabilitative care for persons who have
had an acute care incident requiring services in a health
institution. Medicaid is also required to provide this benefit.
Both existing beneficiaries and new applicants must have established
a continuing need for LTSS -- that is, for an institutional level of
care -- to qualify for Medicaid LTSS once the thirty (30) days of
essential benefit coverage is exhausted. This need in previous RI
Medicaid rules was referred to as “considered institutionalized”
for the purposes of determining Medicaid LTSS eligibility as
indicated below:
1. Existing beneficiaries -
Under the Medicaid State Plan, all Medicaid beneficiaries are
eligible for up to thirty (30) days of LTSS coverage in addition to
the required thirty-day essential benefit period of acute and
subacute care in a health care institution as part of their non-LTSS
primary essential benefit coverage. A separate determination of
eligibility or change in service delivery is not required for this
period of coverage. Therefore, an existing beneficiary may qualify to
apply for Medicaid LTSS without a change in eligibility or service
delivery options if they have received the required period of
continuous coverage is provided in this manner or, if seeking LTSS in
the home and community-based setting, they require or are receiving
at least one Medicaid covered LTSS benefit to address a functional
need that otherwise would require care in an institutional setting.
The Medicaid MCOs and DHS eligibility specialists are available to
provide assistance to existing beneficiaries during this period.
2. New applicants - New
Applicants are considered to have such a need if they have met one of
the following:
a. Received the level of
services typically provided in a NF, ICF-ID, or LTH setting for at
least thirty (30) consecutive days and are expected to have a
continued need for such services or have:
(1) Obtained acute care
services in a hospital or similar health facility for at least thirty
(30) consecutive days and are seeking LTSS;
(2) Received Medicaid
preventive level services while residing at home or in a
community-based care setting for at least thirty (30) consecutive
days;
(3) Been determined to have
needs that require the level of services typically provided in a
health care institution for at least thirty (30) consecutive days or
would require such services were those in the home and
community-based setting not provided.
b. Received or required at
least one Medicaid covered LTSS benefit at home or in a
community-based setting to address a functional/clinical need that
would otherwise necessitate the type of LTSS typically provided in a
health institution.
1.8 Eligibility Determination
Process
A. There is a multiphase
process for determining eligibility and authorization for Medicaid
LTSS that includes the following steps:
1. Information, Referral,
Options Counseling - Prior to initiating the application process
and/or at any step during the eligibility determination sequence,
applicants and/or their family members or authorized representatives
may seek information, referral and/or options counseling to assist
them in navigating the LTSS system. Part 4 of this Subchapter sets
forth role of this service.
2. Person-centered Planning --
Upon making application for LTSS, the person-centered planning
process must begin for anyone seeking HCBS. The process is available,
at the applicant's option, for LTSS in a health care institution as
well. Person-centered planning is an individualized approach to
planning that places the applicant at the center of decision-making
thereby enabling him or her to direct his/her own services and
supports in accordance with his/her own desires, goals and
preferences, with impartial assistance and supported decision-making
when helpful. Accordingly, the person-centered planning is an
on-going process that continues through the eligibility determination
process through to the authorization of services and thereafter. In
accordance with 45 C.F.R. § 441.301(c)(1), the State must ensure
that throughout this process, the applicant has sufficient and
necessary information in a form he/she can understand to make
informed choices and direct the planning process to the maximum
extent possible. See Part 4 of this Subchapter for specific
provisions.
3. Eligibility Determination
Factors - To gain access to LTSS, the information provided by
applicants is evaluated across the eligibility factors identified
below, though not necessarily in a specific order:
a. General eligibility
factors. All persons seeking initial or continuing Medicaid LTSS must
meet the general requirements for the program related to residency,
citizenship and immigration status, and social security numbers and
the like. The application form must be completed and signed along
with the authorizations necessary to conduct electronic data matches
to verify income and resources; and to request personal health
information to assess and review clinical/functional level of need.
General eligibility factors for MACC MAGI-based LTSS eligibility are
located in § 30-00-1.5(C) of this Title and for SSI-based LTSS
eligibility in Part 5 of this Subchapter. Existing beneficiaries
seeking LTSS must only update general eligibility information if
there have been changes since the point of their last renewal.
b. Clinical/functional
eligibility factors. An assessment of clinical and functional needs
serves as the basis for a level of care determination and is
conducted for all persons seeking Medicaid LTSS, without regard to
eligibility pathway. This assessment is based on needs-based criteria
that evaluate clinical, functional, social and behavioral needs as
well as environmental factors. A Medicaid Assessment and Review Team
(MART) determination of disability status is not required unless the
applicant is seeking LTSS coverage while working through the Sherlock
Plan or unless the applicant has been deemed to have a disability by
the Social Security Administration. The responsibilities for
assessing need vary for each institutional level of care as follows:
(1) Nursing Facility. The
State established clinical and functional disability criteria under
the Section 1115 waiver which assess the scope of a beneficiary’s
need for a NF level of care. The EOHHS is responsible for assessing
the level of need of persons seeking Medicaid coverage of LTSS
typically provided in a NF and long-term hospital care, including
home and community-based alternatives. As indicated in Part 5 of this
Subchapter, the scope of a person's clinical/functional need for a NF
level of care (high or highest) affects the type of LTSS available to
the person and thus the choice of setting (institutional and/or
HCBS).
(2) Intermediate care
facilities for persons with intellectual disabilities. The BHDDH uses
needs-based criteria to evaluate clinical/functional eligibility for
the ICF/ID level of care that incorporate the requirements set forth
in State law (R.I. Gen. Laws § 40.1-22-6), the scope of services and
supports required, and the impact of familial, social, and
environmental factors that affect the choice of setting.
(3) Long-term Hospital Care.
Each agency serving beneficiaries who may require Medicaid LTSS in a
hospital setting is authorized under the State’s 1115 waiver to
tailor the clinical/functional criteria to meet their population’s
general and unique needs within the parameters of applicable federal
regulations and laws. This applies to persons seeking services
through the EOHHS Habilitation Program that were authorized prior to
establishment of the Section 1115 demonstration in 2009 under the
State’s § 1915(c) Habilitation Waiver and the various programs
administered by the BHDDH. EOHHS determines clinical/functional
eligibility for applicants seeking an LTH level of care through the
Medicaid Habilitation program and certain persons referred by the
BHDDH for admission to the State's Eleanor Slater Hospital.
(4) Children with Special
Health Care Needs. Children with disabilities and/or serious chronic
and disabling conditions may require a NF, ICF/ID or LTH level of
care at home or in an institutional-setting. The process for
assessing level of need for children who are eligible based on the
MAGI, SSI or custody of the State's Department of Children, Youth and
Families (DCYF) is conducted by multiple entities under the auspices
of the early, periodic, screening, detection and treatment (EPSDT) in
Part 30-00-1 of this Title. The designated unit of EOHHS determines
clinical/functional eligibility for children who do not qualify for
coverage through one of these pathways and are seeking coverage of
LTSS in a home setting in accordance with the provisions located in
Part 10-3 of this Chapter. Continuing eligibility for current
beneficiaries is based on the method used to determine initial
eligibility and, if no basis for coverage is found, across the
remaining pathways.
c. Financial Eligibility
Factors. LTSS eligibility specialists in the Department of Human
Services (DHS) are responsible for determining financial eligibility
through the IES and related systems. The financial requirements
pertain to an array of factors including the calculation of countable
income and resources using the MAGI or SSI method and the allocation
of resources and transfer of asset requirements that are unique to
the determination of LTSS eligibility. Both of the following apply to
new and existing beneficiaries seeking LTSS without regard to basis
of eligibility and are explained in greater detail in Part 6 of this
Subchapter.
(1) Allocation of resources
with spouses/dependents. The evaluation and allocation of resources
at the point the need for LTSS is established and/or at the time of
application is required for LTSS applicants who have spouses. This
process, referred to as the Community (Non-LTSS) Spouse Resource
Allowance (SRA), allocates the joint resources of couples in
accordance with federal standards to ensure a sufficient amount is
protected for the non-LTSS spouse's needs -- that is, unavailable to
pay for the costs of care for the LTSS applicant/beneficiary. The
allocation of resources at this state of the eligibility process is
distinct from that which occurs when determining the amount of income
a beneficiary must pay toward the cost of care in the
“post-eligibility” treatment of income. LTSS MAGI beneficiaries
are subject to allocation of resource requirements but are exempt
from the post-eligibility treatment process.
(2) Transfer of assets.
The determination of financial eligibility for Medicaid LTSS requires
that the State review whether an applicant made a "disqualifying"
transfer of assets - liquid resources and real property -- in the
sixty (60) month period before the need for LTSS was established. A
transfer is deemed to be disqualifying if the asset was conveyed for
less than fair market value. Under federal law, such a transfer is
presumed to have been made to reduce assets for the expressed purpose
of gaining Medicaid LTSS eligibility. The State is required to impose
a penalty period, during which Medicaid coverage for LTSS is
unavailable, that is equal to the amount of the disqualifying
transfer divided by the average cost of care at the private pay rate.
B. Once eligibility has been
determined, payment for Medicaid LTSS becomes available only after
the following inter-related steps are completed:
1. Service Plan -- Development
of a service plan ensures that a beneficiary is or will be able to
attain the full scope of services required to meet his or her needs
in the choice of LTSS living arrangement. Towards this end, LTSS
specialists from across the EOHHS agencies and their community
partners and contractual agents consider the results of the
clinical/functional needs-based assessment, more intensive
evaluations, as appropriate, and/or the consensus decisions made in
the person-centered planning process for HCBS or the results of the
PASRR for nursing facility care to help ensure that every beneficiary
receives the right services, at the right time, and in the most
appropriate setting.
2. Post-Eligibility Treatment
of Income (PETI) -- Under the State’s Section 1115 waiver, all
non-MAGI eligible LTSS beneficiaries are subject to the PETI process.
PETI is the basis for calculating a beneficiary's liability to pay
toward the cost of care. During this process, income is evaluated a
second time, federal spousal impoverishment requirements are applied,
if appropriate, and additional deductions from income are taken for
personal needs, non-covered health care costs like insurance
premiums, and other allowable expenses. PETI varies somewhat
depending on the type of Medicaid LTSS -- in a health institution or
HCBS -- selected by a beneficiary and the requirements of his/her
service plan. Accordingly, the development of the service plan and
the beneficiary's health care priorities and preferences established
in the person-centered planning process are important factors that
must be considered when calculating beneficiary liability. The PETI
process is set forth in detail in Part 8 of this Subchapter.
3. Authorization of Payment
for LTSS - Authorization of Medicaid LTSS is required before a
payment is made for coverage provided to a beneficiary. This process
entails a complex set of transactions in which information about the
scope of services approved and/or utilized and the beneficiary's
liability are transmitted from the IES to the State's Medicaid claims
system (Medicaid Management Information System or “MMIS”). Once
these transactions are completed, payment is authorized to an LTSS
provider dating back to the eligibility date -- the first day of the
month in which the application was filed -- and prospectively unless
retroactive eligibility has been approved.
1.9 Eligibility Pathways
A. The eligibility pathways
available to persons seeking Medicaid LTSS have different
requirements all of which are automatically taken into account when
application information is processed. As indicated below, the process
for determining eligibility and the sequence may vary for members of
a particular population depending on the pathways available.
1. SSI and SSI-related Groups
- SSI recipients and members of certain SSI-related groups are
automatically eligibility for Medicaid based on a determination by
SSA as indicated in Part 40-00-3 of this Title. Federal regulations
at 42 C.F.R. § 435.603(j) specifically exclude Medicaid
determinations of eligibility for members of this group, including
for LTSS, using the MAGI standard except in instances in which an SSI
recipient no longer meets disability criteria and loses cash
assistance on this basis. Special provisions also apply to Medicaid
LTSS beneficiaries who are receiving SSI and are expected to need
LTSS coverage for ninety (90) days or less. Accordingly, access to
LTSS proceeds as follows:
a. Eligibility Criteria.
Medicaid beneficiaries who are SSI-eligible and need LTSS are subject
to the clinical/functional eligibility factors required for an
institutional level of care set forth in Part 05-1 of this Chapter as
well as the financial eligibility requirements related to the
transfer of assets. The resource limit is set at $2,000.
b. Special Conditions.
Re-evaluation of income and resources is not required unless current
eligibility is based on different Medicaid group size (couple v.
individual) or there is a change in income or resources resulting
from need for or use of LTSS. In addition:
(1) SSI recipients who have §
1619(b) status, as indicated in § 40-05-1.5.4 of this Title, remain
eligible for two (2) months of continuing SSI cash assistance if
admitted to an LTH, such as Eleanor Slater Hospital or an equivalent
HCBS setting; and
(2) SSI recipients who obtain
Medicaid LTSS for a period not expected to exceed ninety (90) days
may continue to receive SSI cash assistance during this time to
maintain a community residence. Such income is excluded in the
financial eligibility determination sequence, including the
post-eligibility treatment of income.
c. Determination Process. SSI
recipients are not subject to a MAGI determination and a
re-evaluation of income/resource eligibility using the SSI method is
not required when applying for LTSS. Although a review of
functional/clinical eligibility is conducted, a full assessment of
level of care needs may be waived for certain populations based on
their type of disability as indicated in Part 5 of this Subchapter.
All other steps in the eligibility determination process apply to the
extent that the special rules applicable to the treatment of SSI
income allow, as indicated in Part 40-00-3 of this Title.
d. Retroactive Coverage.
Retroactive coverage is available for any allowable non-Medicaid
covered LTSS expenses in the ninety (90) day period prior to the
eligibility date in circumstances in which the applicant for LTSS was
not enrolled in Medicaid at that time.
2. Adults 19 to 64 - All
persons seeking initial or continuing eligibility for Medicaid LTSS
in this age group are evaluated across several pathways unless they
are currently eligible for Medicaid.
a. Eligibility Criteria.
Applicants are subject to the general and functional/clinical
eligibility requirements. Not all financial eligibility factors such
as resource limits apply, as indicated. The financial eligibility
requirements vary across pathways; if a beneficiary is determined
ineligible in the current category (existing beneficiaries) or a
pathway of choice (new applicants), the IES automatically evaluates
whether eligibility through another pathway exists up to and
including the medically needy pathway. The process generally proceeds
as follows:
(1) MACC Group for
MAGI-eligible Adults: Income limit -133% of the FPL; No resource
limit.
(2) IHCC non-SSI eligible
Adults with Disabilities in Community Medicaid: Income limit - 100%
of the FPL; Resource Limit - $4,000. Applies to new applicants and
existing beneficiaries.
(3) Special Income/HCBS:
Income limit - 300% of the SSI standard; Resource Limit - $4,000.
New applicants only.
(4) Medically Needy: Income
limit - Cost of Care; Resource Limit - $4,000. New applicants
only
b. Special Conditions. Several
eligibility pathways have special conditions that target or exclude
certain populations:
(1) MACC Group for
MAGI-eligible Adults: Pathway is closed to persons who are 65 and
older or who are eligible for or enrolled in Medicare. In addition to
the exemption from a resource limit, PETI rules do not apply and, as
a result, beneficiaries in this group do not have to pay a portion of
income toward the cost of care. Spousal impoverishment protections,
guaranteed through the SSI method, are also unavailable through this
pathway.
(2) IHCC non-SSI adults with
disabilities in Community Medicaid: Current beneficiaries may request
to be assessed for an LTSS level of care and provide only the
information related to financial eligibility factors to evaluate the
transfer of assets, the allocation of resources between
spouses/dependents, and beneficiary liability in accordance with Part
8 of this Subchapter. Existing beneficiaries seeking Medicaid LTSS
under the Sherlock Plan must apply pursuant to the requirements set
forth in Part 40-15-1 of this Title.
(3) Special Income: Pathway
for new applicants with income above the Community Medicaid limit (up
to 300 percent of the SSI benefit rate) and adults with disabilities
in the IHCC medically needy group who are seeking care in a health
institution such as a hospital or nursing facility.
(4) HCBS: Reserved for persons
seeking Medicaid LTSS in the HCBS setting who would, absent these
services, have the "high" or "highest" need for
an institutional level of care. Generally, these are new applicants
for Medicaid.
(5) Medically Needy: Countable
income must be below the average cost of care in the applicable
institutional setting, as set forth in Part 40-05-2 of this Title.
Special income deductions also apply.
c. Determination Process. The
principal distinction in the determination process aside from the
difference in eligibility criteria is the method for evaluating
income - MAGI v. SSI - as indicated below:
(1) New Applicants for
Medicaid -- When applying for Medicaid LTSS, all new applicants who
are under age sixty-five (65) and are neither enrolled in or eligible
for Medicare are evaluated first to determine whether eligibility
using the MAGI method for the MACC group for adults exists. Transfer
of asset requirements are applied and an applicant must provide any
information about liquid resources and real property necessary to
complete that step in the eligibility process. If a new applicant
under age 65 is found ineligible for the MAGI-based MACC group
coverage, or is requesting retroactive coverage, the SSI method is
used to determine financial eligibility and all steps in the LTSS
determination process, including PETI apply.
(2) Current Medicaid
Beneficiaries -- Current Medicaid beneficiaries who are seeking LTSS
remain within the eligibility category that serves as the basis for
their existing eligibility and are only referred as appropriate if
LTSS eligibility in this category would be denied due to the
supplemental information provided when seeking LTSS. Adults with
disabilities who are receiving non-LTSS Community Medicaid under
Chapter 40 of this Title are referred for a determination of
clinical/functional eligibility, in the same manner as those who are
SSI-eligible, while the required financial eligibility factors unique
to LTSS are reviewed. All beneficiaries can initiate the LTSS
eligibility determination by contacting a DHS LTSS eligibility
specialist and completing the applicable sections of the integrated
health and human services application form, or an alternative form
designated for this purpose, or updating their accounts in the IES
Consumer Portal.
d. Retroactive Coverage.
Retroactive coverage for up to ninety (90) days is available for LTSS
applicants in this population who are determined eligible using the
SSI method. Under the terms of the State's Section 1115 demonstration
waiver, all MAGI-eligible MACC groups, including the ACA expansion
adults, do not have access to retroactive coverage unless eligible as
a pregnant woman under the terms and conditions of the State’s
Section 1115 waiver.
3. Elders 65 and older - The
eligibility pathways for persons sixty-five (65) years of age and
older vary somewhat when compared to those available for persons
between 19 and 64 as specified above. The chief distinction is that
members of this population are not evaluated for MAGI-based
eligibility even if they are the parents/caretakers of a Medicaid
eligible child. Differences in criteria by pathway are as follows:
a. Eligibility Criteria. All
persons seeking Medicaid LTSS are evaluated using the SSI method
through to the authorization of services; MAGI-based eligibility is
not permitted under applicable federal law. Although the income
requirements vary, the resource limit is $4,000 for an individual
applicant across pathways:
(1) IHCC non-SSI eligible
elders in Community Medicaid: Income limit - 100% of the FPL;
Resource Limit - $4,000.
(2) Special Income/HCBS:
Income limit - 300% of the SSI standard; Resource Limit - $4,000
(3) Medically Needy: Income
limit - Cost of Care; Resource Limit - $4,000
b. Special Conditions. The
special conditions for adults with disabilities whose eligibility is
determined using the SSI method also apply to elders.
c. Determination Process. The
principal distinction in the determination process for members of
this population is also a function of whether a person is a new
applicant or current Medicaid beneficiary.
(1) New Applicants for
Medicaid -- When applying for Medicaid LTSS, all new applicants who
are sixty-five (65) year of age and older are subject to a full
financial eligibility review using the SSI method as well a
determination of clinical/functional eligibility and all the steps in
the LTSS determination process, including PETI apply.
(2) Current Medicaid
Beneficiaries -- Current Medicaid beneficiaries who are sixty-five
(65) and older and eligible and receiving non-LTSS MACC Medicaid as a
parent/caretaker under Chapter 30 of this Title are referred for both
a full financial eligibility review using the SSI method, which
requires that they provide additional information related to their
own and joint spousal resources, and functional/clinical eligibility
review. Current beneficiaries eligible for non-LTSS Community
Medicaid under Chapter 40 of this Title are referred for a
determination of clinical/functional eligibility, in the same manner
as those who are SSI-eligible, while the required financial
eligibility factors unique to LTSS are reviewed. All beneficiaries
can initiate the LTSS eligibility determination by contacting a DHS
LTSS eligibility specialist and completing the applicable sections of
the integrated health and human services application form, or an
alternative form designated for this purpose, or updating their
accounts in the IES Consumer Portal.
d. Retroactive Coverage.
Retroactive coverage is available for a period of up to ninety (90)
day for LTSS applicants evaluated on the basis of the SSI method.
Accordingly, all elders are eligible for retroactive coverage.
4. Children up to Age 19 -
Children requiring LTSS are generally evaluated for MACC group
eligibility and provided the services and supports they need under
the authorities included in the Medicaid State Plan without requiring
a separate determination of eligibility. As indicated in Part 10-3 of
this Chapter, there is also a separate eligibility pathway known as
Katie Beckett (KB), which was established by Congress for children
with serious illnesses and/or disabilities who are receiving care at
home and, as a result, would otherwise be ineligible for Medicaid.
These children would most likely be eligible if they were receiving
care in an institution. The KB pathway, which is named after the
young woman who inspired its creation by Congress, applies the SSI
institutional rules to provide Medicaid coverage available to these
otherwise ineligible children by deeming their parents’ income as
unavailable to them. Accordingly, children eligible through the KB
pathway receive the full scope of Medicaid State Plan and Section
1115 waiver services, including Early, Periodic, Screening, Detection
and Treatment (EPSDT), provided to children with severe chronic
diseases and/or disabling impairments who qualify in the MACC group
pathway based on MAGI pursuant to Part 10-3 of this Chapter. The
eligibility pathways differ as follows:
a. Eligibility Criteria. All
children seeking initial or continuing eligibility for Medicaid LTSS
coverage must meet the general requirements for eligibility.
Financial and clinical requirements vary depending on pathway.
Eligibility standards by pathway are set at:
(1) MACC group for children:
Family income limit - 261% FPL; no resource limit.
(2) Katie Beckett: Child
income limit - Special income limit for LTSS - federal benefit
rate; resource limit - $4,000; no income or resource deeming.
b. Special Conditions. The
special conditions apply only to the KB eligibility pathway. To be
eligible, the child must have a disabling impairment and needs
requiring the level of care typically provided in a health
institution (NF, ICF-ID, LTH) and live at home. A cost-effectiveness
test applies; that is, the cost of care at home must be at or below
cost of care provided in a health care institution. The child must be
otherwise ineligible for Medicaid based on family income,
c. Determination Process. The
eligibility system considers all children seeking Medicaid
eligibility in the MACC group for children first, in accordance with
the income limits set in Part 30-00-1 of this Title and the MAGI
eligibility process in Part 30-00-5 of this Title.
d. Retroactive Coverage.
Retroactive coverage is available for KB eligible beneficiaries, but
is unavailable for MACC group eligible beneficiaries, including
children with special needs.
1.10 Expedited Eligibility
A. Expedited eligibility is a
special process authorized under the State's Section 1115
demonstration for adults age nineteen (19) and over seeking LTSS in a
home and community-based setting. The purpose of this special process
is to provide a limited package of HCBS for no more than ninety (90)
days to applicants who meet the need for LTSS in a home or
community-based setting as specified in § 1.7(A)(2)(b) of this Part
and prefer to remain in or transition to a home or community-based
setting for a health institution while a full determination of
eligibility is being made.
1. Eligibility criteria -- To
be considered for expedited eligibility, new applicants must submit a
full and completed application for Medicaid LTSS and self-attest to
meeting the Medicaid LTSS general and financial eligibility
requirements for their appropriate coverage group -- that is, elder,
adult with disability, MACC group adult and so forth. Existing
beneficiaries must notify an LTSS eligibility specialist and provide
any supplemental information required to initiate an expedited
eligibility review. The need for LTSS must be established in
accordance with applicable functional/clinical criteria established
by EOHHS by a licensed treating physician or appropriately qualified
health practitioner or provider.
2. Applicable circumstances --
Expedited eligibility is the default eligibility for new applicants
and existing non-LTSS Medicaid beneficiaries who meet the
requirements set forth in this Part in the following circumstances:
a. Discharge from a hospital.
Discharge must be to a home or community-based setting from a
hospital or ancillary health institution after an acute care
admission.
b. Discharge from a from a
short-term health institution stay Discharge or transition to a home
and community-based setting from a nursing facility or subacute care
facility for a short-term stay or skilled rehabilitation if the
services provided are not covered as a Medicaid LTSS benefit and, as
such, Medicaid reimbursement for the stay is not required.
c. Expanded need. A person
seeking LTSS eligibility who is receiving preventive level services
authorized by EOHHS in accordance with Part 40-05-1 of this Title and
has expanded needs or is determined by a treating health practitioner
to have the need for in-home assistance to supplement skilled
homecare or hospice services currently in place; or to extend to the
period after skilled services have ended.
B. Expedited eligibility
benefits are limited to maximum of: twenty (20) hours weekly of
personal care/homemaker services; three (3) days weekly of adult day
services; and/or limited skilled nursing services based upon level of
need. Upon approval of Medicaid LTSS, the beneficiary qualifies to
receive full coverage. The following also apply:
1. Limited duration -- The
expedited eligibility benefit package is available for up to ninety
(90) days or until the eligibility decision is rendered, whichever
comes first.
2. Exemptions -- There is no
PETI conducted in conjunction with expedited eligibility and, as a
consequence, no required contribution toward the cost of care during
the ninety (90) coverage period. Retroactive eligibility is not
available, though costs incurred and unpaid for Medicaid covered
services prior to the LTSS application filing date are considered
when determining eligibility for full coverage.
3. Restrictions -- Under the
terms of the State's Section 1115 demonstration waiver, expedited
eligibility is not available for LTSS in a health institution
setting.
1.11 Roles and Responsibilities
A. Persons seeking LTSS
Medicaid eligibility must meet the general requirements that apply
program-wide related to residency, citizenship, and cooperation,
among others.
1. Agency responsibilities -
The EOHHS is responsible for determining Medicaid LTSS eligibility,
authorizing services, the appropriate level of care planning and
service coordination, as dictated by setting, and enrollment in
service delivery option of choice. Under the terms of interagency
agreements, the DHS and BHDDH have been authorized to determine all
or some aspects of LTSS eligibility as an agent of the EOHHS.
2. Applicant Responsibilities
-- Beneficiaries determined eligible through this pathway must
provide accurate and timely information and the consent necessary for
EOHHS, or its agent(s), to obtain the health care information
required for the clinical eligibility determination.
1.12 Severability
If any provision in any
section of this rule or the application thereof to any person or
circumstances is held invalid, its invalidity does not affect other
provisions or applications of the rule which can be given effect
without the invalid provision or application, and to this end the
provisions of this rule are declared to be severable.