LTC and Spenddowns 10/15/2013 1. LTC and Spenddowns Agenda Lesson 1: 300% Test Lesson 2: Spenddown...

LTC and Spenddowns

10/15/2013

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LTC and SpenddownsAgenda

Lesson 1: 300% TestLesson 2: Spenddown to Institutional Care (Permanent and Temporary Stays) & Override PL for budgeting an Independent Living PILLesson 3: Budgeting Prior Medical Income for LTC and WH Lesson 4: Approving LTC for childrenLesson 5: PACE Program Start Date

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LTC and SpenddownsLesson 1: The 300% Test > Introduction

• 300% Test Policy

– The 300% Policy is an income test for individuals requesting long term care benefits. The test compares the consumer’s income to 300% of the SSI limit.

– The 300% test creates two available categories for coverage, 300% and Medically Needy.

– Let’s see how this test works in practice.

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LTC and Spenddowns

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The 300% Test

Background

A special income test for Medicaid coverage for long term care coverage [Nursing Facility, Home and Community Based Services (HCBS), Program of All-Inclusive Care for the Elderly (PACE), and Money Follows the Person (MFP)] is being implemented effective 11/01/2013. The special income limit is 300% of the SSI standard for a single person. That limit for 2013 is $2,130. This special income test does not apply to non-long term care medical programs.

If the individual’s countable income before deductions is not in excess of the limit, he/she is Medicaid eligible for long term care coverage. If the consumer’s income exceeds the limit, the individual is not Medicaid eligible for coverage, but may still be eligible under the Medically Needy (MN) program by meeting a spenddown.

Lesson 1: The 300% Test > Background

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The 300% Test

Application of this policy is a three step process.

1. 300% Test – The applicant’s countable income before deductions is applied against the special 300% income limit. If the income does not exceed the limit, the applicant is eligible for Medicaid coverage of his/her long term care services. The case is budgeted for long term care with the appropriate protected income limit and a one month base period. The patient liability/client obligation/participant obligation is determined using the post-eligibility treatment of income. Spousal impoverishment division of assets and income allocation provisions apply.

Example: A single nursing home applicant with countable income of $1,850/month applies for assistance. Since monthly income is less than $2,130, the applicant is eligible for Medicaid coverage (assuming otherwise eligible) using long term care budgeting and a one month base. If the applicant’s income exceeds the 300% income limit, proceed to step 2.

Lesson 1: The 300% Test > Step 1

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The 300% Test

2. Cost of Care Exceeds Obligation – If the applicant’s income fails the 300% test, eligibility must be determined under the Medically Needy (MN) program. The anticipated cost of care for the long term care services is measured against the monthly obligation. If the cost of care exceeds the obligation, the case is budgeted as Medically Needy (MN) with the appropriate long term care protected income limit and a one month base period. The obligation (spenddown) is determined using the post-eligibility treatment of income. Spousal impoverishment division of assets and income allocation provisions apply.

Example: A single applicant with countable income of $2,347/month applies for HCBS assistance. Since monthly income exceeds $2,130, the applicant is not eligible for Medicaid – coverage under Medically Needy (MN) is determined. The anticipated cost of HCBS services is $1,750/month and the monthly client obligation (spenddown) is $1,600 (using the HCBS PIL). Since the cost of care exceeds the spenddown, the case is Medically Needy (MN) using long term care budgeting with a one month base. If the cost of care does not exceed the obligation (spenddown), proceed to step 3.


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The 300% Test

3. Obligation Exceeds Cost of Care – If the applicant’s income fails the 300% test and his/her obligation exceeds the anticipated cost of care, the case is budgeted as Medically Needy (MN) with the independent living protected income limit and a six month base period. Post-eligibility treatment of income is not used. The spousal impoverishment provisions do not apply.

Example: A single applicant with countable income of $3,147/month applies for PACE coverage. Since monthly income exceeds $2,130, the applicant is not eligible for Medicaid – coverage under Medically Needy (MN) is determined. The anticipated cost of PACE services is $1,225/month and the monthly participant obligation is $2,400. Since the obligation (spenddown) exceeds the cost of care, the case is Medically Needy (MN) using independent living budgeting with a six month base.


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The 300% Test

Tools:

Worksheet – The W-4 (Financial Eligibility Determination Worksheet For Nursing Facility Cases) is being eliminated. A new worksheet (300% Special Income Test for Long Term Care Worksheet) has been developed.

Qualifying Income Trust (QIT) – A qualifying Income Trust (QIT), also known as a Miller Trust, is an instrument used in some states to comply with the special 300% income limit when an individual’s income exceeds the limit. Some, or all, of the individual’s income is transferred to the trust each month. Only the amount of income not transferred to the trust is then counted against the income limit.

Use of a QIT is not valid in states with a Medically (MN) program. Since Kansas offers a Medically Needy (MN) program, a QIT is not valid in the state. The full amount of income received by the individual is countable.

Lesson 1: The 300% Test > Tools

LTC and Spenddowns

• The 300% test is used to determine if a consumer’s income is within 300% of the SSI limit.

• This test is used to determine the eligibility aid code for long term care applicants/recipients.

• LTC Consumers meeting the 300% criteria will have an aid code that begins with 300 (ex. 300/XX/N/N)

• LTC Consumers not meeting the 300% criteria but whose income does not exceed the cost of care are approved as Medically Needy with an aid code beginning MDN.

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Lesson 1: The 300% Test > Summary

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LTC and SpenddownsLesson 2: Spenddown to Institutional Care > Introduction

• Spenddown to Institutional Care—Permanent and Temporary Stays– One month budgeting for all Institutional Care

(Temporary and Permanent)

• Override Patient Liability to budget an Independent Living PIL for Admission/Discharge/Temporary Stay Months– Using the $475.00 PIL for Admission, Discharge,

and Temporary months

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New Rules!

Current Policy:

Independent living base periods are established for 6 months (3 months for prior period). Those base periods may be shortened for various reasons, including the commencement of long term care services. Currently, a temporary stay in an institution does not break an existing base period. Also, the existing base ends the month after the month of institutionalization for long term care stays. In addition, the month of discharge from an institution after a long term stay establishes a new base period beginning with the month of discharge.

Lesson 2: Spenddown to Institutional Care > Current Policy

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New Rules!

New Policy:

It is the new policy to break an existing independent living base period anytime a recipient becomes institutionalized. The months of institutionalization (whether short term or long term stay) will be budgeted with a one month base period. The admission and discharge months are budgeted with the independent living PIL, except where there is a community spouse. Where there is a community spouse, all institutional months would be budgeted with the institutional PIL. An obligation for each institutional month would be created and sent to the MMIS. No need to send spenddown information for any institutional month (except General Hospital).

NICE!

Lesson 2: Spenddown to Institutional Care > Proposed Policy

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Outcomes:

1) Institutionalized individuals without a community spouse (other than those in a general hospital) shall always be budgeted as long term care with a one month base period. The only difference is whether the stay is short or long term. Short term stays are budgeted with independent living PIL, long term with institutional PIL. The admission and discharge months shall always be budgeted with independent living PIL.

2) Institutionalized individuals with a community spouse shall always be budgeted as long term care with a one month base and institutional PIL for all months beginning with the month of entry into the facility.

3) Institutional cases that fail both the 300% special income test and the cost of care test will be budgeted as independent living with a 6 month base period. That policy is not affected by the proposed change.

Lesson 2: Spenddown to Institutional Care > Outcomes

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First, Add a new Requested Medical Type effective the first month of the LTC budgeting.

Lesson 2: Spenddown to Institutional Care > KEES Process

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Lesson 2: Spenddown to Institutional Care > Override PL

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Example 1:

Lesson 2: Spenddown to Institutional Care > Examples

Institutional short term stay of 01/06/2014 thru 03/17/2014 for a single individual with existing independent living base period of 11/01/2013 thru 04/30/2014. Individual passes both the 300% and cost of care tests.

Existing independent living base period before institutionalization 11/2013 12/2013 01/2014 02/2014 03/2014 04/2014 05/2014 06/2014 07/2014 08/2014 09/2014 $950 $950 $965 $965 $965 $965 $475 $475 $475 $475 $475 $475 $455 $455 $470 $470 $470 $470 Total spenddown for the base period 11/01/2013 thru 04/30/2014 is $2,790

Revised spenddown(s) after institutionalization 11/2013 12/2013 01/2014 02/2014 03/2013 04/2014 05/2014 06/2014 07/2014 08/2014 09/2014 $950 $950 $965 $965 $965 $965 $965 $965 $965 $965 $965 $475 $475 $475 $475 $475 $475 $475 $475 $475 $475 $475 $455 $455 $470 $470 $470 $470 $470 $470 $470 $470 $470 The existing spenddown base period is shortened to 11/01/ 2013 thru 12/31/2013 with a new spenddown of $910. A one month base for 01/2014, 02/2014 and 03/2014 is established with a patient liability of $470 for each month based on an independent living PIL of $475. A new six month base period is established 04/01/2014 thru 09/01/2014 with a spenddown of $2,820.

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Example 2:


Institutional long term stay begins 02/14/2014 for a single individual with an existing independent living base period of 09/01/2013 thru 02/28/2014. Individual passes both the 300% test and cost of care tests.

Existing independent living base period before institutionalization 09/2013 10/2013 11/2013 12/2013 01/2014 02/2014 03/2014 04/2014 05/2014 $1105 $1105 $1105 $1105 $1122 $1122 $475 $475 $475 $475 $475 $475 $610 $610 $610 $610 $627 $627 Total spenddown for the base period 09/01/2013 thru 02/28/2014 is $3,694

Revised spenddown(s) after institutionalization 09/2013 10/2013 11/2013 12/2013 01/2014 02/2014 03/2014 04/2014 05/2014 $1105 $1105 $1105 $1105 $1122 $1122 $1122 $475 $475 $475 $475 $475 $475 $62 $610 $610 $610 $610 $627 $627 $1060 The existing spenddown base period is shortened to 09/012013 thru 01/31/2014 with a new spenddown of $3067. A one month base for 02/2014 is established with a patient liability of $627 based on an independent living PIL of $475. One month bases continue beginning 03/2014 with a patient liability of $1060 based on an institutional PIL of $62.

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Example 3:


Single applicant files an application for institutional long term care on 11/15/2013 and requests prior medical assistance. Institutionalization began on 10/07/2013. Individual passes both the 300% and cost of care tests.

Base periods based on a new application with request for prior medical assistance 08/2013 09/2013 10/2013 11/2013 12/2013 01/2014 02/2014 03/2014 04/2014 05/2014 $1210 $1210 $1210 $1210 $475 $475 $475 $62 $715 $715 $715 $1148 There is a two month prior medical base period of 08/01/2013 thru 09/30/2013 with a spenddown of $1430 based on an independent living PIL of $475. A one month base for 10/2013 is established with a patient liability of $715 based on an independent living PIL of $475. One month bases continue beginning 11/2013 with a patient liability of $1148 based on an institutional PIL of $62.

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Example 4:


Single applicant files an application for medical assistance on 01/31/2014 with no request for prior medical assistance. The applicant entered a rehabilitation hospital for a long term stay on 01/11/2014.

Base period based on a new application for a long term hospital stay 01/2014 02/2014 $895 $895 $475 $62 $400 $833 There is a one month base period for 01/2014 with a spenddown of $400 based on an independent living PIL of $475. One month bases continue beginning 02/2014 with a spenddown of $833 based on an institutional PIL of $62.

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Example 5:


Single applicant files an application for institutional short term care on 2/11/2014 with no request for prior medical assistance. The applicant entered the facility on 02/02/2014. The application is processed and approved on 03/21/2014. On 04/10/2014 the agency is notified the recipient is still in the facility and will remain there indefinitely. Base periods based on a new application for short term institutional care 02/2014 03/2014 04/2014 05/2014 06/2014 07/2014 08/2014 09/2014 10/2014 11/2014 12/2014 01/2015 $785 $475 $290 There is a one base period beginning 02/2014 and continuing with a patient liability of $290 based on an independent living PIL of $475. Revised patient liability after it is reported that the institutional stay is long term 02/2014 03/2014 04/2014 05/2014 $785 $785 $785 $785 $475 $475 $475 $62 $290 $290 $290 $723 There is a one month base period for each month of 02/2013 thru 04/2014 with a patient liability of $290 based on an independent living PIL of $475. A one month base for 05/2014 on forward is established with a patient liability of $723 based on an institutional PIL of $62.

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Example 6:


A single long term care institutional recipient reports being discharged from the facility on 12/23/2013 to independent living.

Existing base periods and patient obligations 12/2013 01/2014 02/2014 03/2014 04/2014 05/2014 06/2014 07/2014 08/2014 09/2014 $1325 $62 $1263

There is an on-going one month base period with a patient liability of $1263 based on an institutional PIL of $62.

Revised base periods and patient liability based on a discharge for the facility to independent living 12/2013 01/2014 02/2014 03/2014 04/2014 05/2014 06/2014 07/2014 08/2014 09/2014 $1325 $1345 $1345 $1345 $1345 $1345 $1345 $475 $475 $475 $475 $475 $475 $475 $830 $850 $850 $850 $850 $850 $850 The month of 12/2013 is re-budgeted with a patient liability of $830 based on an independent living PIL of $475. A new six month base period of 01/2014 thru 06/2014 is established with a spenddown of $5100 based on an independent living PIL of $475.

LTC and Spenddowns

• Consumers that have either a temporary or a permanent stay in a long term care facility will always have a one month base period.

• Depending on if the month is an Admission month, a Discharge month, or part of a Temporary stay, the consumer can retain the $475.00 Protected Income Limit.

• Whether or not the consumer has met or not met the 6 month spenddown does not impact how the temporary stay is budgeted.

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Lesson 2: Spenddown to Institutional Care > Summary

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LTC and SpenddownsLesson 3: Budgeting Prior Medical > Introduction

Budgeting Prior Medical Income for LTC and WH

KEES rules are written to always look for actual income in Prior Medical months when processing LTC and WH Requested Medical Types. KEES uses the information in the Average Calculator to determine what income was ‘actually’ received in a month.

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If the consumer is requesting prior month benefits for Long Term Care (LTC), actual income amounts for each prior month requested must be entered into the Average Calculator for benefits to be calculated correctly.

The Average Calculator is used to capture any actual amounts of income received in prior medical months for the Working Healthy and Long Term Care programs. In order for EDBC rules to view and calculate an actual income amount for these programs, the actual income from the prior medical months must be recorded in the Average Calculator. EDBC will count $0.00 income for a prior medical month for these programs if there is no information in the Average Calculator.

Let’s see what this would look like in KEES.

Lesson 3: Budgeting Prior Medical > Introduction

LTC and Spenddowns

• If the case has Prior Medical months for LTC or WH consumers, enter the income information in the Average Calculator in addition to the Reported Amount field. EDBC rules use the information listed in the Average Calculator to determine the actual income for the month.

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Lesson 3: Budgeting Prior Medical > Summary

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LTC and Spenddowns

• Approving LTC for children– Children requiring HCBS, PRTF, state

psychiatric hospital, and general hospital require a Medical Condition in KEES for an EDBC approval

– Workers processing LTC cases for children need to create an Active Medical Condition for any children requiring approval

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Lesson 4: Approving LTC for Children > Introduction

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Users need a special process to approve LTC children in KEES.

This means users need to create an Active Medical Condition record for any children needing a LTC approval for PRTF (Permanent Stay), HCBS, or other institutional stay.

On the Medical Condition List page, add an Active Medical Condition with a Medical Condition Type of DDS Disabled. When the KEES EDBC rules run, eligibility is determined for a Medically Needy Disabled program type.

In the future, children will be given a specific Active Medical Condition of LTC Child to use for this process. Since children do not need a disability determination for medical coverage.

NOTE: EES will no longer be processing LTC for PPS children. Also, this process does NOT apply to a temporary stay or PPS programs. LTC for PPS children is processed under PPS Medical Aid Codes.

Lesson 4: Approving LTC for Children > Process

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LTC and SpenddownsLesson 4: Approving LTC for Children > Process

Begin Date the record with the first day of the first month of LTC coverage.

LTC and Spenddowns

• To receive an approval for HCBS and Institutional Care children need to have an “Active” Medical Condition record in KEES.

• Currently this record needs to be set as DDS Disabled.

• At a future date, an Active Medical Condition of LTC Child will be added.

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Lesson 4: Approving LTC for Children > Summary

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LTC and Spenddowns

• PACE Program Start Date– Previously, the PACE start date has

always been tied to enrollment date.

– Now, the PACE start will be tied to the processing date.

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Lesson 5: PACE Program Start Date > Introduction

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PACE Program Start Date

The current start date for PACE coverage is dependent on the date the PACE entity notifies the Kansas Department for Children and Families (DCF) that the applicant has enrolled in the program. Depending on when the notification is received, PACE coverage begins either the first day of the next month, or the first day of the month after.

Although eligibility staff have been given direction as to the optimum time in which to complete processing of the application/request for coverage, the start date of coverage always begins according to when notification of enrollment was received, regardless of when the case is actually processed. This process has resulted in some unintended outcomes, including the commencement of PACE services before actual coverage is ever approved.

To mitigate the risk to both customer and provider an alternate process has been developed.

Lesson 5: PACE Program Start Date > Background

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While eligibility staff shall continue to be encouraged to process a PACE application/request as soon as possible to ensure needed services may begin without undue delay, the start date shall no longer be tied to the date enrollment notification is received from the PACE entity. Effective 11/01/2013, the start date for PACE coverage shall be the first day of the month after the month of approval.

The PACE entity shall continue to be responsible for notifying eligibility staff of the enrollment date. Once notification is received, assuming the applicant is otherwise eligible coverage shall be approved beginning with the first day of the month after the case is worked.

Lesson 5: PACE Program Start Date > PACE Start Date

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Example 1: The PACE entity notifies DCF on 08/22/2013 that the applicant has been enrolled in the program. The application is processed and approved for coverage on 09/23/2013 with a start date of 10/01/2013 (first day of the month after the month processed/approved).

Example 2: The PACE entity notifies DCF on 11/05/2013 that the applicant has been enrolled in the program. The application is processed and approved on 11/08/2013 with a start date of 12/01/2013 (the first day of the month after the month processed/approved). Even though notification and approval both occur in the same month, coverage doesn’t begin until the next month.

Lesson 5: PACE Program Start Date > Examples

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Example 3: The PACE entity enrolls a consumer on 10/15/2013 and immediately begins providing services. DCF receives the application and notification services have started on 10/15/2013. The application is processed and approved on 10/29/2013 with a start date of 11/01/2013 (first day of the month after the month processed/approved). Even though the PACE entity has already began providing services, there is no coverage for those services provided prior to 11/01/2013.

Example 4: The PACE entity notifies DCF on 09/04/2013 that the applicant has been enrolled in the program. The PACE entity begins providing services effective 10/01/2013 assuming coverage will be approved commencing with that date. An application is never received or an application is received, but coverage is denied for excess resources. Since eligibility was never approved, there is no coverage for any of the PACE services provided.

Lesson 5: PACE Program Start Date > Examples

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Exceptions

There is no PACE coverage for months prior to the month after the month the application is processed and approved. However, in rare instances, eligibility staff may contact the Kansas Department for Aging and Disability Services (KDADS) PACE Program Manager for authorization to begin coverage prior to the month after the month approved. If an exception is granted, PACE coverage is effective the month authorized by the Program Manager.

No exception shall be processed by eligibility staff until authorized by the Program Manager. Documentation of the decision to apply an earlier state date must be included in the case file. Issuance of assistance without prior approval shall result in an overpayment subject to recovery.

Lesson 5: PACE Program Start Date > Exceptions

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Example 1: The individual files an application on 11/01/2013 and PACE notifies DCF of enrollment on 11/05/2013. DCF processes and approves coverage on 12/27/2013. PACE coverage should commence effective 01/01/2014 (the first day of the month after the month processed/approved), but the worker feels bad that the application is untimely and approves coverage effective 12/01/2013. Since retroactive coverage cannot be granted without an exception approved by the PACE Program Manager, approval for 12/2013 is considered an overpayment.

Example 2: DCF received a PACE application on 09/30/2013 and is ready to process on 10/03/2013. Eligibility will be effective 11/01/2013. The worker is aware that the applicant is in immediate need of services, and before fully processing the application, sends an exception request to the PACE Program Manager to begin coverage effective 10/01/2013. The PACE Program Manager grants the exception and the worker processes/approves coverage effective 10/01/2013.

Lesson 5: PACE Program Start Date > Exception Examples

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Example 3: When an application is processed, the worker fails to follow correct policy and approves coverage one month too soon. Realizing the mistake the next day, the worker sends an exception request to the PACE Program Manager to cover the month approved in error. The Program Manager denies the request. The incorrect approval month is considered an overpayment. Note: An exception request sent after the case has already been processed and approved shall be denied. There is no retroactive coverage without prior approval. An exception will not be granted to cover a processing error.

Lesson 5: PACE Program Start Date > Exception Examples

LTC and Spenddowns

• PACE Program Start Date– Effective 11/1/2013, the PACE start will be

tied to the processing date.– PACE is approved the month following the

month the application is processed.– The PACE program manager can allow

exceptions the case of immediate need, however, the request must be sent prior to any approval.

– Any PACE months issued prior to the month following the month of processing will be considered an overpayment for the consumer.

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Lesson 5: PACE Program Start Date > Summary

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LTC and SpenddownsWrap up

The 300% Test

Spenddown to Institutional Care (Permanent and Temporary Stays)

Budgeting Prior Medical Income for LTC and WH

Approving LTC for children


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• A recording of this webinar is available at http://www.kancare.ks.gov/kees/ in the next 24-hours.

• Send additional questions to [email protected]. Please note the webinar title in your email.

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Webinar Recording and Questions

LTC and Spendowns

http://www.kancare.ks.gov/kees/



mailto:[email protected]

LTC and Spenddowns 10/15/2013 1. LTC and Spenddowns Agenda Lesson 1: 300% Test Lesson 2: Spenddown...

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