Applications For Medicaid and Long Term Care

1. Applications For Medicaid and Long Term Care July 20th 2011 Medicaid Policy Team Idaho Department of Health and Welfare

2. What We Will Cover • Pre-Application Readiness • Resource Assessment for Long Term Care • Application processing • Application Readiness • Timelines • Level of Care & Share of Cost • Factors that impact Timelines & Eligibility • Community Spouse • Excess Resources • Transfer of Resources • Continuing Eligibility • Negative Actions & Fair Hearings

3. Pre-Application Readiness –Resource Assessment • Is conducted one-time to determine the resources of married customers who require Long Term Care Services when the customer: • Has a spouse who is not seeking or receiving Long Term Care -AND- • Requires Long Term Care level services and is expected to continue services for 30 consecutive days,– OR –Received services in a Nursing Home for 30 consecutive days in the past. • Verifications of value and ownership of all combined resources need to be dated, as of: • The date of first entry into a nursing home, even it is in the past, or • The first day of requiring Waivered Level Services.

4. Resource Assessment & Application Federal Spousal Impoverishment (FSI) • Allows for a person to transfer some of his or her interest in resources to the spouse • Resource Transfer Allowance (RTA) The long term care spouse may also transfer the RTA to the community spouse without an asset transfer penalty • Marriage Settlement Agreement • Transfer countable resources out of LTC spouse’s name. Current Standards (7-1-2011; updated annually) Community Spouse Resource Allow Spousal Share Minimum $21,912.00 Maximum $109,560.00 Community Spouse Need Standard (monthly income) Minimum $1,838.75 Maximum $2,739.00 Community Spouse Shelter Standard $551.63

5. Filing an Application Paper Application • Download from Health and Welfare website • Fax to 1-866-434-8278 • Bring in to local office • Mail to: Self Reliance Programs, PO Box 83720, Boise, ID 83720-0026. Applying in Person • Applicant or authorized representative applies in person at Health & Welfare office, then signs a Statement of Facts. • Applications are effective as of the first day of the application month. However: • Eligibility and payment for Nursing Home services may not start before the date the Pre-Admission Screening and Resident Review (PASRR) is completed by the Nursing Home. • Retroactive eligibility for the three months prior to the application month will be assessed at customer request.

6. Application Processing Department Responsibilities • DHW must process within 45 days • 90 days allowed if a disability determination must be done • As of May 2011, average approval time for all Medicaid applications under 10 days • The Department uses available sources of information to verify as many factors of eligibility as possible • Social Security Administration • Wages • Immigration • Idaho Vital Records

7. To Get a Timely and Correct Decision Applicant and/or Representative Responsibilities • Apply promptly after medical event or loss of health insurance • Complete application form completely and clearly • Provide good contact information, with mailing address and phone number • Include name of authorized representative on application, if applicable • Ensure name, date of birth and SSN and Medicare Claim Number of applicant are correct • List all family members living with applicant • Allow 1-2 hours if planning to apply in person at a local office • Provide verifications along with application whenever possible (list on application form) • Respond to requests for verification as soon as possible within 10 days • Call if unsure of what documents are acceptable as verification

8. Eligibility Requirements Must qualify due to: • Age (65 or older) • Disability (per Social Security standards) • Family Status (child under 19, parent of needy child, or pregnant woman) Proof of disability shown by: • Receipt of SSDI or SSI • Determined disabled through Department’s referral to Disability Determination Services • Level of care determination required for long-term care services, which include nursing home and comparable care in another facility or home • Nurse Reviewer assesses need for long-term care in home if applicant indicates the services are needed • Nursing Facility completes PASRR to verify need for long term care in a Nursing Facility (payment not made for any days before PASRR completed & submitted)

9. Recipient Share of Cost for Care Waivered Services • Share of cost (SOC) for waiver services is calculated only on the cost of services for care.  SOC does not cover the cost for Rent, Utilities, and Food (RUF) or the Basic Allowance.  These allowances are part of the Personal Needs Allowance (PNA).  The PNA and other allowances are used when determining the amount of the SOC. HCBS Waivers - Personal Needs Allowance (PNA) NOT Responsible for Rent/Mortgage Responsible for Rent/Mortgage Marital Status PNA (1-1-09) PNA (1-1-09) Single 674 1,011 Married/Comm SP 1,011 1,011 Married/HCBS SP 674 (ea) 1,011 (ea) RUF- Rent Utilities and Food $584 Allowable Deductions $674 SSI Single Minus $90 $584 to Provider

10. Nursing Facility Recipient Share for Cost of Care • Patient liability is the participant's income counted toward the cost of long-term care. Patient liability starts the first full calendar month the patient lives in long-term care. Note:A “full calendar month” includes the 1st and last day of the month.  Patient liability begins the month the participant is in the nursing home a “full calendar month”.  Patient liability continues through any month the participant is in the nursing home on the first day of the month.  If the participant is discharged to the hospital then readmitted to the nursing home, it is considered a continuous stay.   EXAMPLE 1: Participant is admitted to the Nursing Home 8-26-05 and is released 9-15- 05.  There is no patient liability calculated. EXAMPLE 2: Participant is admitted to the Nursing Home 8-26-05 and is released 10- 10-05.  There is patient liability calculated for September and October.

11. Income Deductions for Long Term Care Deductions are subtracted in the order listed. Remaining income is patient share of cost. • AABD Income Exclusions. • Aid & Attendance and UME Allowances.VA Aid and Attendance allowance and Unusual Medical Expense (UME) unless the veteran lives in a state operated veterans' home. • SSI Payment Two (2) Months.SSI payment for a participant entitled to receive SSI at his at-home rate for up to two (2) months, while temporarily in a long-term care facility. • AABD Payment.AABD payments for up to three (3) months in long-term care. • First Ninety Dollars ($90) of VA Pension.in a private long term care facility or State Veterans Nursing Home. • Personal Needs. Forty dollars ($40) for the participant’s personal needs. If a veteran or spouse in a private long term care facility or State Veterans Nursing Home, the first ninety dollars ($90) of the VA pension substitutes for the forty dollar ($40) personal needs.

12. Income Deductions from Long Term Care cont. • Employed and Sheltered Workshop Activity Personal Needs. • Home Maintenance deduction.If the participant had an independent living situation, before his admission for long-term care. His physician must certify in writing the participant is likely to return home within six (6) months. • Maintenance Need.A maintenance need deduction for tax dependent family member, living in the long-term care participant's home. • Medicare and Health Insurance Premiums. • Mandatory Income Taxes. • Guardian & Trust FeesThe total deduction for guardian and trust fees must not exceed twenty-five dollars ($25) monthly • Impairment Related Work Expenses. • Income Garnished for Child Support (but not for spousal support).

13. Deductions From Income When There is a Community Spouse or Family • Community Spouse Allowance • Is established by determining the Community Spouse Need Standard, • Community Spouse Need Standard, and • Deducting allowable expenses from Applicant’s income • Family Member Allowance • Deduct Aid To Families with Dependent Children (AFDC) payment standard for family size

14. Assets • Limit is $2000 for disabled/aged singles and $3000 for disabled/aged couples • Bank accounts and cash • Stocks, bonds and mutual funds • Real property (home is excluded as a resource) • Vehicles • Mortgages and promissory notes

15. Asset Transfers Part of the application process includes determining if the applicant has transferred resources prior to the application date without receiving adequate consideration, or fair market value. The Look-back Period for Resource Transfers is 5 years • Aid to the Aged, Blind and Disabled (AABD) participants are subject to a period of ineligibility if they transfer resources for less than fair market value • Exception: If the Total countable resources in the transfer month were less than $2000.00, it is not considered a resource transfer. What is a Resource Transfer? • Giving money to family • Transferring homes to family members • Selling homes for less than fair market value • Not establishing a notarized personal care services contract when a family member has been receiving payment for care given for the applicant • Income paid to a Miller trust and not used for patient liability

16. Allowable Transfers of Assets • Home transferred to a spouse or disabled adult child. • Home transferred to a sibling if the sibling has an equity interest in the home and has resided there for a year. • Home transferred to a child who has resided in the home for two years and provided care to the participant. • There must be a notarized agreement executed between participant and the child, at the time the child begins to care for the parent, that the care will be provided. • The family may be asked for a physician to certify in writing that Nursing Facility type care was provided by the child for the entire period.

17. Asset Transfer Penalty • Restricted Coverage- Not eligible for long-term care • Penalty Period- Divide the value of the asset transfer by the private nursing home rate (Currently $6484)= months not eligible for LTC • Daily transfer rate is $213 • Long-term care will begin the day after the penalty ends • Non-LTC Medicaid will cover the full month • Penalty for a person receiving services under the HCBS waiver is ineligibility • A person is not eligible for services until they have been institutionalized AND the penalty period has expired • Long Term Care will prorate and begin the day after the penalty expiration • Non-Long Term Care Medicaid will cover the full month once the expiration of the Penalty has occurred.

18. Ending an Asset Transfer Penalty • When all assets that were transferred for less than fair market value have been returned to the participant • The asset was transferred because the participant was the victim of fraud, misrepresentation or coercion. To consider the transfer to be the result of fraud steps must be taken to recover the assets and recovery rights assigned to the State. When a Hardship waiver may be granted • Individual proves not able to pay for Long Term Care • Individual makes reasonable efforts to recover transferred asset • Individual did not knowingly transfer asset • Individual assigns rights to recover asset to the State of Idaho

19. What is Income for Medicaid? Income includes, but is not limited to: • Wages and self-employment • Social Security benefits • Other government benefits, such as unemployment insurance • Dividends • Retirement or pension income • Inheritance or gifts

20. Income Limits • Aged or Disabled, single: $707 monthly • Aged or Disabled, couple: $1011 monthly • Long-Term Care, single: $2022 monthly • Long-Term Care, couple: $4044 monthly • Low-income parents: approximately 22% of Federal Poverty Limit (FPL) - $382 for family of 4 • Pregnant woman: 133% of FPL - $2478 for family of 4 • Children: Up to 185% of FPL - $3446 for family of 4

21. Workers With Disabilities For the Aged & Disabled: • $20 disregard from unearned income • $65 plus 50% disregarded from earned income • Couples budgeting • Must be between 16 and 65 years old • Must be working or self-employed • Earnings must be at least 15% of total income • Income must be at or below 500% of poverty ($4538 single; $6130 couple) • May be required to pay monthly premium

22. Continued Eligibility • Once approved for Medicaid, individuals are re-evaluated annually to determine if they continue to meet eligibility. • Medicaid recipients must report changes in their circumstances, in addition to the annual redetermination. • Re-evaluation notices and forms are sent out 45 days in advance; Participants must respond promptly with all required documents to avoid a break in coverage. • Long Term Care Residents must report changes in income, change to a different living arrangement or when they return home.

23. Reasons for Denial or Closure of Medicaid • Failure to provide information • Categorical ineligibility (Isn’t a member of a qualified covered group) • Can appeal with Social Security Administration if SSI was denied. • If DHW sent for disability determination, can request a second determination if new medical information is available. • Financial ineligibility (income and/or resources exceed limits) • Applicant can provide more recent verifications. • Can call DHW to find out the amount being counted for each source of income or each resource. • If verifications are not provided within 10 days, a notice of denial will be sent • Applicant still has up to 45 days from application date to provide. • Denial will be reversed if information is turned in within the 45 days and the person is eligible.

24. Fair Hearings- When a Participant Disagrees with the Department • The Hearing Officer, a neutral party, will conduct the hearing held on the appeal. • The applicant and DHW present “their side,” plus any applicable exhibits. • Hearing Officer determines whether DHW acted in accordance with Idaho’s Medicaid rules and any applicable federal guidance. • Applicant is entitled have to legal representation present (at own expense), plus any witnesses. • Hearings usually held telephonically. • Medicaid applicants have up to 30 days after date of denial to appeal decision. • Appeal form is mailed out with all notices of denial or termination of benefits. • Medicaid recipients also have 30 days to appeal and may request continuation of Medicaid while awaiting hearing on appeal (must request before Medicaid ends). • Hearing Officer issues preliminary decision. • Applicant has up to 14 days to request review of decision if he/she disagrees; after that, the decision becomes final. • DHW’s Administrative Procedures Section reviews request and determines whether to affirm, modify or reverse Hearing Officer’s decision.

25. Questions!