1 Department of Medical Assistance Services 1 1 Department of Medical Assistance Services Long-term Care Spring

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Department of Medical Assistance Services

1www.vita.virginia.govwww.dmas.virginia.gov 1


Long-term Care Spring Cleanup

BPRO Conference

Department of Medical Assistance ServicesApril 30, 2015

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Ready to Work? We’ll Cover:• Clean Sweep - Coverage of LTC services • Institutionalization for LTC purposes grime and grit• LTC Home equity requirement foaming bubbles• 300% SSI covered group smudges• Financial requirement odds and ends• Resource assessment dust bunnies• Transfer of assets cobwebs• MN spenddown cookie crumbs• MN in PACE spare change• DMAS-225 sticky fingers• Changes & case transfers cleansers• Neat and Tidy Questions www.vita.virginia.govwww.dmas.virginia.gov 2


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Clean Sweep - Coverage of LTC Services

• Available for all full-benefit groups.– Exception: AG recipients limited to ID, DD, DS waivers

• 300% SSI covered groups only for those who need LTC services and are not eligible in another full-benefit covered group.

• 300% SSI covered groups: – ABD in Medical Facility;– ABD Receiving Waiver Services; – ABD Hospice;– F&C in Medical Facility;– F&C Receiving Waiver Services;– F&C Hospice. M0320 and M0330

www.vita.virginia.govwww.dmas.virginia.gov 3


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Institutionalization for LTC Purposes Grime & Grit

• Individual has received 30 consecutive days of– care in medical institution (e.g. nursing facility), or- Medicaid CBC services, or- a combination of the two; or

• Individual has been screened and approved to receive LTC services and it is anticipated that he is likely to receive services for 30 or more consecutive days; or

• Individual has signed hospice election that has been in effect for 30 consecutive days.

M1410.010



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Preadmission screening not needed when individual:• is in NF at time of application;• received Medicaid LTC in one or more of preceding 12 months and

LTC was terminated for reason other than no longer meeting level of care;

• no longer in needs LTC, but is requesting assistance for a prior period of LTC;

• enters NF directly from EDCD waiver or PACE;• leaves NF and begins receiving EDCD waiver services or enters

PACE, and pre-admission screening was completed prior to the NF admission;

• enters NF from out-of-state; • enters NF from VA hospital;• has full benefit Medicaid coverage and was or is expected to be

admitted to NF for fewer than 30 days.M1420.400



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• Eligibility determination made based on best information available at time of evaluation.

• If it is known at the time of eligibility determination that the services were not or will not be received for 30 consecutive days, definition of institutionalized individual not met.

M1410.010



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Screened and

Approved in:

In a Facility?

Application Month

Processing Month

Month of Application/ongoing as

Institutionalized

Retroactive Determination as Institutionalized

(in a medical facility)

January no January January yes no

January no February February yes no

N/A yes January February yes yes

January no March April yes no

April no March Wheneverno, but yes for

Aprilno



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Institutionalization - MEDICAID WORKS Exception

Personal assistance is included in MEDICAID WORKS benefit package.• If enrollee only needs personal assistance, he is

not considered institutionalized.- No patient pay

• If enrollee needs any other LTC services, enrollee must meet all criteria for LTC:

- Preadmission screening- Resource assessment, if married- Asset transfer requirement- Patient pay.

M0330.400



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LTC Home Equity Requirement Foaming Bubbles

Applies to individuals in any covered group needing Medicaid payment for LTC.

• Individuals with equity value (tax assessed value minus encumbrances) in home property that exceeds limit are NOT eligible for Medicaid payment of long-term care services unless the home is occupied by– a spouse,– a dependent child under age 21 years, or– a blind or disabled child of any age.

• Limit applied based on date of application or request for LTC coverage and at each renewal – $552,000 for 2015.

M1460.150



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LTC Covered Group Hierarchy Smudges

Under Age 18• Title IV-E or SSI• Individual under 21• 300% SSI - no resource test• MN – resource test

F&C Over Age 18• Individual Under 21• LIFC• Pregnant Woman• 300% SSI – resource test• MN – if Pregnant Woman –

resource test

ABD• SSI• Protected• 80% FPL - resource test• Medicaid Works – evaluated

for LTC only when CBC service(s) other than personal assistance requested

• 300% SSI - resource test• MN - resource test

M1460.200



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What’s So Special About the 300% SSI Group?

• Gross income counted with no disregards• No deeming of spousal or parental income• Certain types of income are only counted for

this group. Examples:– Infrequent or irregular income– Grants, scholarships– Relocation assistance– Disaster assistance

M1460.611



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300% SSI Covered Group Resource Limits

• ABD = $2,000 (use M1480 for married institutionalized individual with community spouse)

• F&C parent, pregnant woman, individual under 21 = $1,000

• Child under 18 has NO resource test.

M1460



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Children in LTC• MAGI methodology does not allow for an institutionalized child living with

parents to be in his own MAGI household. – Evaluate children under age 18 years for eligibility in the F&C 300% SSI

covered group. – Child is an assistance unit of one; parental/spousal income not deemed

available. – No resource test for child under age 18 in 300% SSI group, regardless of

marital status.

• Child turning age 18 no longer meets definition for 300% covered group and will need referral for disability determination unless he is eligible in Child Under Age 19 covered group (under MAGI methodology).

• Individual age 18-21 in nursing facility or ICF-ID should be evaluated for eligibility in CN and MN Individual Under Age 21 covered groups. – If not eligible, refer for a disability determination.

M1460.220



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Resource Odds and EndsDoes Medicaid policy require verification of excluded resources such as cars, homes, burial plots, etc.?

• Not for one car or burial plots, but if more than one car or a burial plan, rather than plots are reported, must be verified.

• Home property needs to evaluated and may need to be verified since exclusion not identical for all covered groups.

• Do not request information that is not required and do not deny for failure to provide information that is not required. M0130.200



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Resource Odds and Ends

Is verification of termination of financial account required if individual declares he no longer has bank account that is listed in his record?

• EW needs to ask individual what happened to the resource.

• May need to be evaluated as an uncompensated transfer of assets.– Verification could be needed to determine that transfer

was compensated.

M1450



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Life insurance

• Chart attached to policy can be used to verify cash value as long as – Individual’s actual age (i.e. not an age range)

is listed.– Policy does not earn dividends.

M1130.300



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Home property exclusion – NF patient’s spouse who was living in home died. Patient has been in NF for more than six months. Which, if any, real property exclusions apply?

• SSI (including Protected) and 300% SSI - six-month home exclusion does NOT apply since patient has already been in NF for at least six months (M1460.530).

• 80% FPL – intent to return home exclusion may apply (chapter S11, Appendix 2).

• Other real property exclusions may apply if ALL criteria for exclusion are met:– Reasonable but Unsuccessful Efforts to Sell (M1130.140)– Property Essential to Self-support (S1130.500 - S1130.510).www.vita.virginia.govwww.dmas.virginia.gov 17


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Resource Assessment Dust Bunnies

Screened and

Approved in:

In a Facility?

Application Month

Resource Assessment Month

Processing Month

Month of Application/ongoing as

Institutionalized

Retroactive Determination

as Institutionalized

(in a medical facility)

January no January January January yes no

January no February February February yes no

N/A yes Januaryfirst continuous

period of institutionalization

February yes yes

January no March March April yes no

April no March April Wheneverno, but yes for

Aprilno



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Intent to transfer - protected period

• Allows IS time to legally transfer some or all of his resources to CS. • After initial eligibility determination, IS who has resources in his name

which exceed resource limit has Medicaid resource eligibility "protected" for 90 days if following criteria are met: – resources in CS’s name < PRA at time of application, – amount of resources that may be transferred to bring CS’s

resources up to the PRA will reduce IS’s resources to no more than $2,000, and

– IS has indicated in writing his intent to transfer resources to CS on “Intent to Transfer Assets to A Community Spouse” form or other

statement. M1480.240



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Intent to transfer

• 90-day protected period not applicable when: – IS not eligible for Medicaid;

– IS previously established Medicaid eligibility as an IS, had a protected period of eligibility, became ineligible, and reapplies for Medicaid; or

– At time of application, CS owns resources equal to or exceeding

PRA.

M1480.240www.vita.virginia.govwww.dmas.virginia.gov 20


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• If IS does not transfer resources to CS within 90-day period, all of IS’s resources will be counted available to IS when the protected period ends.

• If IS loses eligibility after 90-day protected period is over, and then reapplies for Medicaid, – he CANNOT have resource eligibility protected again, and – PRA is NOT subtracted from his resources

M1480.240



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• If completed “Intent to Transfer Assets” form is not returned by time application is processed, no protected period of eligibility may be established.

• All resources in IS’s name must be counted in his eligibility determination beginning with month following initial eligibility determination period.

• If eligible, enroll IS for a closed period of coverage beginning with retroactive period and ending with last day of the month of initial eligibility period. M1480.240



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Resource assessment claim of undue hardship

• Must be in writing.

• When both spouses have exhausted all avenues to obtain resource value for FOM– If DMAS determines undue hardship exists, spousal resource

standard used.

• When separated spouse cannot be located or refuses to cooperate– If DMAS determines undue hardship exists, individual is evaluated

as though there is no CS.

• If DMAS determines undue hardship does not exist, payment for LTC services must be denied for failure to verify resources held at beginning of institutionalization.



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Claim of undue hardship – separated spouse • Applicant must:

– make attempts to locate estranged spouse– provide physician’s statement if medical

condition prevents participation in process– provide identifying information about

estranged spouse and length of separation• must be separated at least 36 continuous months, or • have extraordinary circumstances (continued)



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Claim of undue hardship (continued) • EW must send DMAS Eligibility Section:

– Form or cover sheet with applicant’s identifying information and length of time separated, as well as documentation of client and EW’s attempts to locate and obtain information.

• EW must not use on-line systems to locate separated spouse.• DMAS determines undue hardship:

– exists• EW will receive Affidavit and Assignment forms to be signed by

applicant and notarized (if not already provided) – does not exist

• EW will be advised to deny Medicaid payment for LTC services for failure to verify resources held at beginning of institutionalization

M1480.225



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Resource Assessment Dust BunniesNew optional cover sheet and request form for Resource Assessment Undue Hardship Request; provide to applicant with Affidavit and Assignment forms



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Transfer of Assets Cobwebs

Annuities purchased/owned by institutionalized individual – uncompensated asset transfer or resource?

• If annuity is revocable, assignable or there is any other condition under which individual can access funds in annuity (other than periodic payments), annuity is countable resource regardless of whether or not other criteria in M1450.520 are met.



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Transfer of Assets CobwebsThese types of annuities owned by institutionalized individual do not impact asset transfer:

• Annuity is described in one of the following subsections of section 408 of the Internal Revenue Service (IRS) Code: – IRA, – accounts established by employers and certain associations of

employees, – simple retirement accounts, or

• Annuity is a simplified employee pension (within the meaning of section 408(k) of the IRS Code; or a Roth IRA.

M1450.520



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Transfer of Assets CobwebsAnnuities purchased/owned by institutionalized individual – uncompensated asset transfer or resource?

• Annuity is considered a compensated transfer if it

– is irrevocable and non-assignable;– is actuarially sound

term of annuity equals individual’s estimated life expectancy

lifetime annuity not actuarially sound because term is open-ended;

– provides for equal payments with no deferral and no balloon payments; and

– names the Commonwealth as the remainder beneficiary in for at least the total amount of medical assistance paid on behalf of the institutionalized individual



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Annuities purchased/owned by CS • Only requirement to be considered

compensated transfer of assets is that Commonwealth be named primary beneficiary for at least total amount of medical assistance paid on behalf of IS.

• annuity cannot be settled while IS is alive. M1450.520



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Sale of real property – Are the cost of repairs needed to sell real property considered compensated transfers of assets?

• If individual paid fair market value for cost of repairs while he owned home, asset transfer is compensated.

• If individual allowed a deduction from purchase price of property, the sale must be evaluated as an uncompensated asset transfer.

M1450.610



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Imposing penalty period – When does it begin?• Individual must be otherwise eligible for

Medicaid payment of LTC except for imposition of penalty period– Must be resource eligible– If not in NF, must

• be eligible for Medicaid in full-benefit covered group other than 300% SSI, or

• meet spenddown, or• be admitted to NF. M1450.630



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• Penalty period = amount of uncompensated transfer ÷ average monthly private nursing facility rate at time of transfer.

• Effective January 1, 2015, rate for northern Virginia localities = $8,367– Alexandria, Arlington, Fairfax, Fairfax County, Falls

Church, Manassas, Manassas Park, Prince William County and now Loudoun County

• Rate remains unchanged for all other localities = $5,933 M1450.630



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Transfer of Assets CobwebsUndue hardship

• May exist when the imposition of a transfer of assets penalty period would deprive the individual of medical care such that the individual’s health or life would be endangered or he would be deprived of food, clothing, shelter, or other necessities of life.

• Individual or authorized representative may request undue hardship evaluation.

• NF may act on behalf of individual to submit request; NF must have written authorization from the individual or authorized representative.

M1450.700



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Claim of undue hardship

• Individual must meet all Medicaid eligibility requirements and be subject to a penalty period.

• Cannot be made on a denied or closed Medicaid case (e.g. due to individual’s death or discharge from LTC).

• Cannot be made when the penalty period has already expired.

• Cannot be used to dispute the value of a resource.



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Transfer of Assets CobwebsClaim of undue hardship - all documentation listed below must be sent when claim submitted to DMAS:

• reason(s) for transfer; • attempts made to recover asset, including legal actions and results of attempts;

• notice of pending discharge from facility or discharge from CBC services due to denial or cancellation of Medicaid payment for these services;

• physician’s statement that inability to receive nursing facility or CBC services would result in individual’s inability to obtain life-sustaining medical care;

• documentation that individual would not be able to obtain, food, clothing or shelter;

• list of all assets owned and verification of their value at time of transfer if individual claims he did not transfer resources to become Medicaid eligible; and

• documents such as deeds or wills, if ownership of real property is an issue.



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Transfer of Assets CobwebsClaim of undue hardship

• If DMAS unable to approve undue hardship request because sufficient supporting documentation was not provided at time claim was submitted, claim must be denied.– Appeal rights apply.

• Once claim is denied, no further decision related to same

asset transfer will be made by DMAS, should individual again request/reapply for Medicaid coverage of LTC services.

M1450.700



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MN Spenddown Cookie Crumbs

Spenddown deductions• Verification of a covered service as medically

necessary can be by whatever authorization is required for Medicaid to cover the service – e.g. licensed mental health professional for

behavioral health services • Appliances that can be used for other

purposes (refrigerators, whole house generators) are not allowable spenddown expenses. M1340.500



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MN Spenddown Cookie Crumbs

MN facility patients on spenddown -• New RUG code amount replaces facility per

diem rate.• RUG amounts based on individual’s care

needs--vary by individual and facility and subject to change at any time.

• EW must obtain RUG code amount for patient each time spenddown must be calculated.This means monthly if individual’s spenddown liability exceeds monthly Medicaid rate.

M1460.100



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MN Spenddown Cookie CrumbsPatient pay for MN facility patients - spenddown liability less than or equal to Medicaid rate

• Daily RUG code amount used to determine monthly Medicaid rate for calculation of spenddown liability.

• Medicaid must not pay any of patient’s spenddown liability to provider. In order to prevent any Medicaid payment of spenddown liability, spenddown liability is added to available income for patient pay.– exception made when there is CS.

• Eligible for Medicaid effective first day of the month, based on the projected Medicaid rate for the month.



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MN Spenddown Cookie CrumbsPatient pay for MN facility patients with spenddown liability greater than Medicaid rate & all MN CBC patients

• Patient not eligible for Medicaid until he incurs medical expenses that meet spenddown liability within month. Determinations are made monthly, retrospectively, after the month has passed and expenses have actually been incurred. – If spenddown happens to be met before end of month, EW can enroll for that

month.

• Individual’s resources and income must be verified each month before determining if spenddown has been met.

• Because spenddown determination is completed after month and expenses are not projected, spenddown liability is not added to remaining income for patient pay.

M1470.620 and M1470.630www.vita.virginia.govwww.dmas.virginia.gov 41


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MN in PACE Spare Change

Patient pay for MN PACE patients

• PACE has capitated monthly rate, available from PACE provider, that is due and payable on first day of month. When MN individual is in PACE, amount of allowed PACE expenses is rate that is due as of first day of each month.

• Medicare Part D premiums are included in monthly PACE rate. Medicare Part D premium cannot be used to meet spenddown and must be subtracted from monthly PACE rate when determining if spenddown has been met or as deduction from patient pay.

• Patient’s spenddown liability and PACE monthly rate (minus the Medicare Part D premium) establish whether spenddown eligibility determination can be projected or must be determined retrospectively.

M1470.640



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MN in PACE Spare ChangePatient pay for MN PACE patients

• If MN patient’s spenddown liability is less than or equal to monthly PACE rate (minus the Medicare Part D premium), individual is eligible for Medicaid. As long as individual’s spenddown liability and PACE monthly rate do not change, individual is enrolled in ongoing coverage effective first day of month in which spenddown is initially met. – Enough of individual’s income must be preserved to allow for personal maintenance allowance;

spenddown liability is not subtracted from gross income nor added to the available income for patient pay.

– Subtract the allowances listed in M1470.400 from gross monthly income, as applicable. Compare remaining income for patient pay to monthly PACE rate (minus the Medicare Part D premium) for month. Patient pay is lesser of the two amounts.

• If MN patient’s spenddown liability exceeds monthly PACE rate (minus the Medicare Part D premium), he is not eligible for Medicaid until he actually incurs medical expenses that meet spenddown liability within month. Monthly medical expenses are determined retrospectively; they cannot be projected for the spenddown budget period. Patient pay is calculated same way it is for CBC.

M1470.640



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DMAS-225 Sticky Fingers

• Form is not being eliminated.

• Don’t show patient pay calculation or include the patient pay amount on form.

• When penalty period is applied, only the date range of the penalty may be provided.



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Multiple ProvidersWhich provider receives the DMAS-225?• Only one original DMAS-225 is sent to one provider (retain copy)• For hospice services patients, send form to hospice provider• For facility patients, send form to nursing facility• For PACE or adult day health care patients, send form to PACE or adult day

health care provider• For Medicaid CBC patients, send form to:

– personal care provider, for agency-directed EDCD personal care services and other services. If patient receives both personal care and adult day health care, send the DMAS-225 to personal care provider

– service facilitator, for consumer-directed EDCD services– case manager, for any enrollee with case management services:

• case manager at the Community Services Board, for the ID/MR and DS waivers• case manager (support coordinator), for the DD Waiver,• case manager at DMAS, for the Tech Waiver, to:

Department of Medical Assistance ServicesDivision of LTC, Waiver Unit,

600 E. Broad Street,

Richmond, Virginia 23219



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Changes and Case Transfers Cleansers

Transferring LTC cases - Which LDSS is responsible for case?

• Community living arrangements do not include medical facilities, ALFs or group homes with four or more beds.

• When individual is admitted to NF or ALF from community living arrangement, case is not transferred, but remains with LDSS in locality where individual last lived outside of institution.

• When individual is discharged from NF or ALF to community living arrangement, case responsibility belongs to locality where individual resides.

M1520.500



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Need More Information? • Cindy Olson

(804) [email protected]

• Karen Packer(804) [email protected]

• Kelly Pauley(804) [email protected]

• Susan Hart(804) [email protected]



mailto:[email protected]




Documents

1 Department of Medical Assistance Services 1 1 Department of Medical Assistance Services Long-term Care Spring