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Long Term Care, Alternate Care, Managed Care & Waiver Services

Revised April 21, 2008

Categorically Needy Home Services (C01) Categorically Needy Long Term Care SSI Recipients (L01) Family Long Term Care - Categorically Needy (K01) Family Long Term Care - Medically Needy (K95) Family Long Term Care - Spenddown (K99) Hospice (in Medical Chapter) Medically Needy Residential Waiver (MNRW)

Categorically Needy Home Services (C01) Who is eligible for C01? What programs does C01 cover? How long is the C01 certification period? How do I screen C01 medical? How do I process a pending C01 AU? How do I process a change when a client changes from one waiver program to another waiver program? How do I process a change when a client receiving COPES/waiver services at home is permanently admitted to an Alternate Living Facility? How do I add Hospice to a client receiving waiver services? How do I process a change when a client residing in an Alternate Living Facility enters a Hospice Care Center? How do I change from L-track to C01 when a client elects Hospice or returns home with COPES/waiver services? How do I process a change when a C01 client is permanently admitted to a Nursing Home? How do I close C01 for a client who is deceased? How is Personal Needs Allowance (PNA) determined? Where do I view split participation when there is a split cost of care?

Who is eligible for C01?   ·        A person who meets the criteria in the following WAC/EA-Z Manual sections may be eligible for C01 Medical:   EA-Z Manual WAC 388-513-1315 Eligibility for long-term care (institutional, wavier, and hospice) services.   EA-Z Manual WAC 388-503-0510 How a client is determined "related to" a categorical program. EA-Z Manual WAC 388-513-1350-Defining the maximum amount of resources allowed and determining resources availability for long term care cases. EA-Z Manual WAC 388-515-1505 Community Options Program Entry system (COPES) (2) for COPES cases. EA-Z Manual WAC 388-515-1510 DDD Waivers and Outward Bound Residential Alternatives (2) for DDD Waivers cases.

NOTE: For more information about Home and Community Services, see the Long Term Care Manual.  For more information about the Developmentally Disabled (DDD) Program Waiver, see http://intra.ddd.dshs.wa.gov/WaiverManual/index.shtml.

What programs does C01 cover?   ·        C01 medical provides categorically needy medical and waiver service coverage under these different programs:   Community Options Program Entry System (COPES) - a Medicaid-waiver program that provides an aged or disabled person, who has been assessed as needing nursing facility care, the option to remain at home or in an alternate living facility. See WAC 388-513-1301 Definitions related to long-term care (LTC) services. Division of Developmental Disabilities (DDD) waivers- services provided in the home and community to SSI related individuals who would otherwise require the services provided in an Intermediate Care Facility for the Mentally Retarded (ICF/MR).  See WAC 388-513-1301 Definitions related to long-term care (LTC) services. Hospice – providing a terminally ill client a variety of treatment alternatives that can be received at home, in a nursing facility or a Hospice care center.  See EA-Z Manual - MEDICAL ASSISTANCE PROGRAMS - HOSPICE. o       Program of All-inclusive Care for the Elderly (PACE) - a managed care service provided by contracted providers.  Clients receiving PACE services are identified on the MANC screen after ACES receives the MMIS interface with this information.  See EAZ Manual - Waiver Services - HCS CNP (COPES/New Freedom/PACE/MMIP and WMIP).

How long is the C01 certification period?   ·        C01 medical is certified for 12 months.

How do I screen C01 medical?   To screen a C01 AU, take the following steps:   1.      From the Welcome Back page in aces.online, click the Screen New Application link at the top of the page. The Applicant page displays in a new window.   2.      On the Applicant page:   Enter the applicant’s name in the Applicant Name field. Enter the applicant’s address under the Residential Address.  If the applicant has a mailing address, click the box next to Mailing Address same as above to remove the checkmark and enter the applicant’s mailing address. Click the AREP/Payee checkbox if an Authorized Representative is needed.  The case manager/social worker managing the service (HCS/AAA or DDD) must be indicated as an Authorized Representative. See Screening aces.online Add AREP.   Click the Next button. 3.      On the Address Validation page:   o       Take the necessary steps to complete the address validation process.  See Screening - Address Validation for additional information.   o        Click the Next button.   4.      On the Programs page:   o       Click the checkbox next to COPES/HCBS Waiver/DDD Waiver/Hospice    5.      Click the Next button, the Add Member – Search Criteria displays.   6.      Add all household members and complete the screening process.  For more information, see Screening – aces.online.

How do I process a pending C01 AU?   To process a pending C01 AU take the following steps:   1.      From the AMEN, select Option O – Interview.    2.      On the STAT screen, complete the Finl Resp fields as follows:   [PN] – Applicant for the applicant.   [NM] – Non-member for any other household members.  3.      On the DEM1 screen:   In the Living Arrangement field, enter the [appropriate valid value based on the client’s situation].  See <F1> Help.

NOTE: ACES will deny C01 for Hospice clients residing in an Alternate Living Facility (ALF). For more information, see EA-Z Manual Medical Assistance Programs - Hospice.

In the Marital Status field, enter the [appropriate valid value]. See <F1> Help.

NOTE: Coding in the Marital Status field may be used to determine the Personal Needs Allowance (PNA) allowed when determining the client’s participation amount.

EXAMPLE When the applicant with living arrangement [AH] – At Home lives at a separate residence from the spouse, code the Marital Status field as [A] – Married Living Apart to give the Federal Poverty Level (FPL) as the PNA. See WAC 388-513-1380 Determine a client's financial participation in the cost of care for long-term care (LTC) services. For HCS CN Waiver (COPES), see WAC 388-515-1505. For DDD Waivers, see WAC 388-515-1510.

4.          On the INST screen complete the appropriate section(s) based on client's circumstances: o       In the Facility section: ¨      If the client does not live at home, enter the [appropriate valid value] in the [INST type] field.  See <F1> Help.   ¨      Enter the [Provider ID number] in the Provider ID field if appropriate.  If the client is receiving Hospice in a Nursing Facility, enter the provider number and rate for the Nursing Facility and the provider number and rate for the Hospice provider.  To find the provider’s ID number press <F20> to go to the MMEN (Vendor Files Submenu) and enter option [A] – Vendor Name List. See Vendor Payment - Inquire on a Vendor Number.

NOTE: Provider numbers are not required for Alternate Living Facilities (ALF), Hospitals, Residential Habitation Centers (RHC) or Institutions for Mentally diseased (IMD).

¨      Enter the [date the client entered the facility] in the Entry Date field.   ¨      Enter the [client’s level of care] in the Level Care field.  See <F1> Help. This mandatory field should match the facility type.  For example, if the Level of Care Code is [L] – Alternate Living Facility (ALF), then the Type Code should be [FH] – Adult Family Home.    ¨      Enter the [date the payment to the facility is to begin] In the Payment Auth Date field.  This is the date the LTC services are approved and displays on the award letter.

NOTE: An entry in the Payment Auth Date field is optional.  However, if the field is blank, LTC services cannot begin

¨      Enter the [facility’s private daily rate] in the Private Rate field. Call the facility to get the current private rate.   ¨      Enter the [facility’s state daily rate] in the State Rate field.  Access the State Rate from the MMEN.   o       In the Home Community Based Service section: ¨      Enter the [appropriate waiver service type] in the HCBS Type field.    ¨      If the HCBS type is [H] – Hospice, enter the [Provider ID number] in the Provider ID field. To find the provider’s ID number press <F20> to go to the MMEN and enter option [A] – Vendor Name List.  See Vendor Payment - Inquire on a Vendor Number.    ¨      Enter the [date the waiver service begins] in the Start Date field.   ¨      Enter the [approval source code] in the Approval Source field.   ¨      Enter the [date payment is to begin] In the Payment Auth Date field.  This is the date the LTC services are approved and displays on the award letter.    ¨      If the HCBS type is [H] – Hospice:   ¨      Enter the [provider’s private daily rate] in the Private Rate field. Call the facility to get the current private rate.   ¨      Enter the [provider’s state daily rate] in the State Rate field.  Access the State Rate from the MMEN.    5.   If the client has expenses or deductions that can be used to reduce participation, excess resources, or Room and Board costs, complete the LTCX screen with the appropriate information.  See <F1> and <F2> Help.   6.   On the RES1, RES2, and RES3 screens, enter client resource information.  See EA-Z Manual WAC 388-513-1350 Defining the maximum amount of resources allowed and determining resources availability for long-term care (LTC) services.   7.   On the EARN screen:   o       Complete this screen if the client has earned income.  See <F1> and <F2> Help.    o       Enter a [Y] in the Sep Prpty field if the applicant and spouse are both receiving LTC services.  This applies the “Name on the Check Rule.” See EAZ Manual WAC 388-513-1330 LTC Available Income.   8.   On the UNER screen:   o       Enter the appropriate types and amounts of the applicant’s unearned income. See <F1> and <F2> Help.   o       Enter a [Y] in the Sep Prpty field if the applicant and spouse are both receiving LTC services.  This applies the “Name on the Check Rule.” See EAZ Manual WAC 388-513-1330 LTC Available Income.     9.  On the LTCD screen:   o       Enter the appropriate types and amounts of the deemor’s income and resources.  See <F1> and <F2> Help.   o       Enter a [Y] in the Sep Prpty field if the applicant and spouse are both receiving LTC services.  This applies the “Name on the Check Rule.” See EAZ Manual WAC 388-513-1330 LTC Available Income.

NOTE: When information is entered on the LTCD screen, users receive Edit 1585 - GO TO THE "SHEL" SCREEN TO ENTER COMMUNITY SHELTER EXPENSES. For L01, the SHEL screen does not need to be coded. Users can <F4> past this edit.

After committing the interview data, follow the instructions in the Process Application Month chapter for all pending months. After all pending months have been processed, follow the instructions in the Finalize Application chapter to complete the C01 eligibility determination.

NOTE: C01 will trickle to C95/C99 for Hospice clients who reside in a medical institution and have income over the Special Income Level (SIL). C01 will deny for Hospice clients with income over the (SIL) who reside at home or in an (ALF). Edit 2228 - REVIEW CLIENT'S LIVING SITUATION - RESCREEN APPROPRIATE MEDICAL will be generated and workers should review the case for other medical programs. For more information, see EA-Z Manual Long Term Care Medically Needy and EAZ Manual Medical Assistance Programs - Hospice Clarifying Information.

How do I process a change when a client changes from one waiver program to another waiver program? To process the change for the month in which the change occurred, take the following steps: 1. From the AMEN, access the active C01 AU via Option R - Interim / Hist Change and enter the [month of the change] in the Benefit Month field.   2. On the ADDR screen, update the address if appropriate.   3. On the AREP screen, make any needed changes.   4. On the INST screen in the Home Community Based Service section:   o     Enter the [date the services ended] in the End Date field for the existing service.   o     Enter the [new waiver service type] in the HCBS Type field on the next line. See <F1> Help.   o     Enter the [Provider ID number] in the Provider ID field if the HCBS type is H (Hospice). To find the provider's ID number press <F20> to go to the MMEN and enter option [A] – Vendor Name List. See Vendor Payment - Inquire on a Vendor Number.   o       Enter the [date the new waiver service begins] in the Start Date field.   o       Enter the [approval source code] in the Approval Source field.  See <F1> Help.    o       Enter the [date payment is to begin] In the Payment Auth Date field.    o       If the HCBS type is [H] – Hospice:   ¨      Enter the [provider’s private daily rate] in the Private Rate field. Call the facility to get the current private rate.   ¨      Enter the [provider’s state daily rate] in the State Rate field.  Access the State Rate from the MMEN.   5.      Commit the data.     To process the change for the months following the change month(s), take the following steps:   1.      From the AMEN access the active C01 AU via Option R - Interim/Hist Change and enter the [month of the change] in the Benefit Month field.   2.      On the ADDR screen, update the address if appropriate.   3.      On the AREP screen, make any needed changes.   4.      On the INST screen, in the Home Community Based Service section:   o    Enter [Y] – Yes in the Delete field to remove the old HCBS information.   o       Enter the [new waiver service type] in the HCBS Type field on the next line. See <F1> Help.   o       Enter the [new Provider ID number] in the Provider ID field if the HCBS type is [H] – Hospice. To find the provider's ID number press <F20> to go to the MMEN and enter option [A] – Vendor Name List. See Vendor Payment - Inquire on a Vendor Number.   o       Enter the [date the new waiver service begins] in the Start Date field.   o       Enter the [HCBS Approval Source] in the Apprvl Source field. See <F1> Help.   o       Enter the [date payment is to begin] In the Payment Auth Date field.   o       If the HCBS type is H – Hospice:   ¨      Enter the [provider’s private daily rate] in the Private Rate field.  Call the facility to get the current private rate.   ¨      Enter the [provider’s state daily rate] in the State Rate field.  Access the State Rate from the MMEN  <F20>.   5.      Commit the data.   6.      Repeat the above steps for each month after the change month through the ongoing month.

How do I process a change when a client receiving COPES/waiver services at-home is permanently admitted to an Alternate Living Facility? To process the month in which the change occurred, take the following steps:   1.      From the AMEN, select Option R - Interim/Hist Change for the C01 AU for the month of change.    2.      On theADDR screen, update the address if appropriate.   3.      On the AREP screen, make any needed changes   4.      On the DEM1 screen, enter the [appropriate valid value] in the Living Arngmt field.  See <F1> Help.   5.      On the INST screen in the Facility section:   Enter the [appropriate valid value] in the [INST type] field.  See <F1> Help.   Press <F4>  and bypass Edit 1734 UNLESS FIELD IS ENTERED, AU/CLIENT MAY FAIL ELIGIBILITY as Provider numbers are not required for ALF, Hospital, IMR or IMD.    Enter the [date the client entered the facility] in the Entry Date field.   Enter the [client’s level of care] in the Level Care field.  See <F1> Help.   Enter the [date payment is to begin] In the Payment Auth Date field.  This is the date the LTC services are approved and displays on the award letter.   Enter the [facility’s private daily rate] in the Private Rate field. Call the facility to get the current private rate.   Enter the [facility’s state daily rate] in the State Rate field.  Access the State Rate from the MMEN Vendor Files Submenu <F20>.  6.      On the LTCX screen:             Enter [UP] – Prior Cost of Care for In Home Svcs - (One Month Expense) in the LTC Expenses/Deductions Type field.   Enter the [amount] in the amount field.   Enter the [appropriate code] in the V field.  See <F1> Help. 7.     Call DONE and commit the data.

NOTE: For the month of change, the MAFI screen displays the amount client owes for in-home services. The LTCP screen shows participation assigned to in-home services in the first column and the amount owing the ALF in the second column.

8.   Repeat steps 1 through 5, call DONE and commit the data for each month after the leave month through the ongoing month.

How do I add Hospice to a client receiving waiver services?   1.      From the AMEN, access the active C01 AU via Option R – Interim/Hist change for each month the services need to be added.   2.      On the ADDR screen, update the address.   3.      On the AREP screen, add the Hospice agency.  Keep the Waiver service case manager/social worker on the AREP screen as the Waiver service is priority.    4.      On the DEM1 screen, only if the client has entered aHospice Care Center, enter [HC] - Hospice Care Center in the Living Arrngmt field.

NOTE: If a client residing in an (ALF) enters aHospice Care Center, see How do I process a change when a client in an Alternate Living Facility enters a Hospice Care Center?

5.   On the INST screen:   o       Enter the required Hospice information in the facility section if the client now resides in aHospice Care Center.  See <F1> and <F2> Help.    o       Enter the required Hospice information in the HCBS section if the client resides at home.  See <F1> and <F2> Help.    6.   Call DONE and commit the data.

How do I process a change when a client in an Alternate Living Facility enters a Hospice Care Center?   1.      From the AMEN, access the active C01 AU via Option R - Interim / Hist Change for the month of change.   2.      On the ADDR screen, update the address.   3.      On the AREP screen, make any needed changes.   4.      On the DEM1 screen,   Enter [HC] Hospice Care in the Living Arngmt field.  5.      On the INST screen in the Facilities section:   Enter the [date the client left the ALF] in the Leave field. Enter [NM] - Leaving-Going to a Medical Facility - with/without Hospice in the NAC field. Enter [HC] –Hospice Care Center in the [INST type] field on the next line.  Enter the [Provider ID number] in the Provider ID field.  To find the provider’s ID number press <F16> to go to the MMEN (Vendor Files Submenu) and enter option [A] – Vendor Name List.  See Vendor Payment - Inquire on a Vendor Number.  Enter the [date the client entered the facility] in the Entry Date field. Enter [O] - Hospice in the Level Care field.  See <F1> Help. Enter the [date payment is to begin] In the Payment Auth Date field.  This is the date the LTC services are approved and displays on the award letter.  Enter the [facility’s private daily rate] in the Private Rate field. Call the facility to get the current private rate. Enter the [facility’s state daily rate] in the State Rate field.  Access the State Rate from the Vendor Files Submenu.  6.      Call DONE and commit the data.   7.      From the AMEN, select Option R - Interim / Hist Change for each subsequent month.    8.      On the ADDR screen, update the address.   9.      On the AREP screen, make any needed changes   10. On the DEM1 screen, enter [HC] Hospice Care in the Living Arngmt field.    11. On the INST screen, Follow the same steps as #5 except enter [Y] - Delete History Change in the Del Ind field to delete the ALF information.   12. Call DONE and commit the data.

How do I change from L-track to C01 when a client elects Hospice or returns home with COPES/waiver services?    1.      From the Assistance Unit>>Summary page in aces.online, add C01 program by following the steps in add a program.  See Screening – aces.online.    2.      On the AMEN, access the case in Option O - Interview for the ongoing month.   3.      On the PEND screen, select the C01 to begin processing the pending AU.   4.      On the ADDR screen, update the address if appropriate.     5.      On the AREP screen, update as appropriate.   6.      On the STAT screen for the C01, update the required fields.   7.      On the STAT screen for the L-track AU, enter Reason Code 587 Already Eligible for program in Different AU – For Administrative use Only.   8.      On the DEM1 screen, update the living arrangements if appropriate.   9.      On the INST screen:   Enter [Y] – Yes in theDel Ind field to delete existing Facility information.  If the client is in an ALF or receiving hospice services in a medical facility, enter the new facility information on the next line. Enter the new HCBS information. 10. If the client has expenses or deductions that can be used to reduce participation, excess resources, or Room and Board costs, complete the LTCX screen with the appropriate information.  See <F1> and <F2> Help.   11. On the MISC screen, update the required fields.   12. Call DONE and commit the data. The L-track AU will close with Reason Code 587 Already Eligible for program in Different AU – For Administrative use Only.

NOTE: If there is a related Medicare Savings Program (MSP) AU that closes due to income, reinstate the MSP AU once the program change has been completed.  The MSP AU will spawn to the highest coverage group the client is eligible to receive.

13.      On the AMEN, select Option P – Processing.     14.      On the APP1 screen, enter [Y] – Yes in the Sel field to indicate the benefit month you wish to process.    15.      When processing the month in which the change occurred, take the following steps:   On the INST screen: ¨      Enter the date the client left the facility or elected hospice in the Leave Date field.      ¨      Enter the Next Arrangement Code (NAC) to indicate the client’s new service setting.  See <F1> and <F2> Help.    ¨      If the client is receiving Hospice care in a medical facility, add the new facility information.  If the client has not changed facilities, enter the date the client elected hospice in the Entry Date field.    ¨      Add the new HCBS information.   16.      Call DONE and commit the data.  The L-track AU will close with the appropriate reason code.    17.      When processing months following the month in which the change occurred, take the following steps:   On the STAT  screen for the L-track AU, enter Reason Code 587 Already Eligible for Program in Different AU - For Administrative Use Only. On the INST screen: ¨      Enter [Y] – Yes in theDel Ind field to delete existing Facility information.    ¨      If the client is receiving Hospice care in a medical facility, add the new facility information. If the client has not changed facilities, enter the date the client elected hospice in the Entry Date field.   ¨      Enter the new HCBS information.   Call DONE and commit the data.  The L-track AU will close Reason Code 587 Already Eligible for Program in Different AU - For Administrative Use Only. 18.      After all pending months have been processed, access the C01 AU in Option Q - Finalize Application .

How do I process a change when a C01 client is permanently admitted to a Nursing Facility?

NOTE: Hospice clients who enter a nursing facility remain on C01.  See EAZ Manual Medical Assistance Programs Hospice - ADSA Programs.

When a C01 client is permanently admitted to a nursing facility, you will need to close the C01 and process an L02.

How do I close C01 for a client who is deceased?   Take the following steps to process all months, beginning with the month the client died through the ongoing month:   1.      From the AMEN, select Option R - Interim / Hist Change and enter the [month you want to process] in the Benefit Month field.       2.      On the DEM2 screen:   o       Enter the [date the client died] in the Death Date field.    o       Enter the [state where the client died] in the Death State field.  See <F1> Help.   3.      On the INST screen:   o       If the client was receiving services in an ALF or Medical facility:   ¨      When processing the month the client died, enter the [date the client died] in the Facility Leave Date field   ¨      Enter [NM] - Leaving-Going to a Home Setting - NO Waiver or Hospice Services in the NAC field.  This prevents ACES from giving the client a discharge allowance.   ¨      Do not enter an end date in the HCBS end date field as this will cause the AU to close incorrectly for Reason Code 281 – Waiver Not Approved.   4.      Call DONE and commit the data.

How is Personal Needs Allowance (PNA) determined?   ·        Clients are allowed the highest personal needs allowance (PNA) in a given month based on living arrangement, authorized service and marital status. For more information, see EA-Z Manual Long Term Care Participation.   ·        Long term care PNA standards: Long Term Care Medical Standards-Personal Needs Allowance (PNA) Charts.

EXAMPLE If a client resided at home the first day of the month and went into a nursing home the same day, allow the in home PNA because the client resided in a home setting at least 1 minute during that given month.

EXAMPLE If a client went from a nursing home to an adult family home on COPES services the first day of the month, allow the COPES ALF PNA as it is the highest allowed.

EXAMPLE Following Example 2, if the client was then discharged home on COPES from the ALF on the last day of the month, the benefit would be recalculated allowing the COPES in home PNA..

Where do I view split participation when there is a split cost of care?   ·        The MAFI screen displays the LTCP indicator next to the Total Payment field.  Workers can access the LTCP screen by pressing <F16> on MAFI.