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GRH and Health Care

GRH and Health Care. MA, GAMC and Waivers. Automatic Eligibility. Receiving GRH payment MA—must have MA basis MA with waiver Eligible for MA payment of LTC services EW exception: Must do EW calculation GAMC—no MA basis May or may not receive GA grant. MA Spenddown.

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GRH and Health Care

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  1. GRH and Health Care MA, GAMC and Waivers

  2. Automatic Eligibility • Receiving GRH payment • MA—must have MA basis • MA with waiver • Eligible for MA payment of LTC services • EW exception: Must do EW calculation • GAMC—no MA basis • May or may not receive GA grant

  3. MA Spenddown • Income over $867 (100% FPG) • Spend down to $650 (75% FPG) • What bills can be used? • Medicare premiums paid by enrollee • Remedial Care • Waiver services • What can’t be used? • GRH room and board costs

  4. Remedial Care • Special deduction for GRH • Fixed amount updated twice yearly • Allowed for anyone in a facility where county has a GRH agreement • Applied against spenddown, or • Deducted from income (EW)

  5. Spenddown Example 1 • Client age 34, single, residing in rate 1 GRH facility (cost $776) • Eligible for CADI waiver • Receives RSDI of $1070 • Pays Medicare Part B premium of $96 Eligible for GRH? No. $1070 - $20 general deduction and $96 ($84 + $12) PN > $776 What is his spenddown?

  6. Example 1 Calculation • Income exceeds $867 • $1070 – 650 = $420 spenddown Can he meet his spenddown? • H bill (Medicare) $96 • P bill (remedial care) $210 • $420- 306 = $113 spenddown balance (MMIS recipient amount) • Met with R bill (CADI services)

  7. Spenddown Example 2 • Client age 50, single, residing in a board and lodge with $1183 GRH rate • Receives RSDI of $1571 • Not yet Medicare eligible • Gets TCM services costing $286 • Not eligible for GRH grant • What is his spenddown?

  8. Example 2 Calculation • Income exceeds $867 • $1571 - $650 = $921 spenddown • Can he meet his spenddown? • P bill (remedial care) $210 • $921 - $210 = $711 spenddown balance (MMIS recipient amount) • R bill (TCM) $286 • $711- 286 = $425 remaining balance • Not enough bills at this time—can’t meet spenddown

  9. EW Eligibility • Income under the SIS? Compute waiver obligation • Income over the SIS? No community spouse: Spenddown Community spouse: LTC budget

  10. Example 3: SIS-EW • Single client resides in GRH with assisted living • Receives RSDI and pension of $1816 • Pays Medicare Part B of $96 • Has $15 Part D copays (initial month) • Not eligible for GRH grant Does she have a waiver obligation?

  11. Example 3 Calculation • Income is less than SIS of $1911 • Income deductions: • Medicare premium $96 • Maintenance needs allowance $860 • Remedial care $210 • Copays $15 (initial month only) • $1816 – 1181 = $635 waiver obligation

  12. Example 4: SIS-EW and GRH • Single client resides in adult foster care • GRH rate 1 ($776) • Receives RSDI of $850 • QMB pays Medicare Is there a waiver obligation?

  13. GRH $850 RSDI 20 general 830 96 personal needs 734 $776 GRH rate -734 42 GRH grant SIS-EW $850 RSDI -860 maintenance needs 0 waiver obligation Example 4 Calculation

  14. Example 5: Income Above SIS • Single client resides in assisted living • Receives RSDI and VA of $2075 • Pays Medicare Part B of $96 Waiver obligation? Spenddown?

  15. Example 5 Calculation • Income exceeds SIS of $1911 • $2075-650=$1425 spenddown • H bill $96 (Medicare) • P bill $210 (remedial care) • Spenddown balance $1119 • Must meet with waiver services and other bills

  16. Example 6: SIS-EW with Community Spouse • Wife resides in GRH with assisted living • Receives RSDI and pension of $1816 • Pays Medicare Part B of $96 • Husband resides in their home • Calculated spousal allocation $800 Does she have a waiver obligation?

  17. Example 6 Calculation • Income less than SIS • Income deductions: • Medicare premium $96 • Maintenance needs allowance $860 $1816 – 956 = $860 available to allocate • Calculated allocation $800 • Remedial care $210 No waiver obligation

  18. Example 7: Income Over SIS with Community Spouse • Husband resides in assisted living • Receives RSDI and VA of $2075 • Pays Medicare Part B of $96 • Wife resides in independent apartment • Calculated spousal allocation $800 What is the spenddown amount?

  19. Example 7 Calculation • Use LTC calculation • Income deductions -$96 Medicare premium -$84 personal needs -$800 spousal allocation -$210 remedial care • $2075 – 1190 = $885 spenddown

  20. Example 8: Both Spouses on EW and in GRH • Couple resides in apartment and both receive assisted living services through EW • Husband receives $2000 RSDI and pension • Wife receives $1200 RSDI • Both pay Medicare Part B of $96 Spenddown? Waiver obligation?

  21. Husband Income exceeds SIS $2000 650 1350 spenddown H bill $96 (Medicare) P bill $210 (remedial) $1044 spenddown bal. Wife Income under SIS $1200 96 Medicare 860 Maint. Needs 210 remedial care $ 34 waiver obligation Example 8 Calculation

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