Medi-Cal Handbook State Waiver Programs and Limited ... · State Waiver Programs and Limited Services ... under the age 21 who have full scope Medi-Cal eligibility. ... parental/spousal

Medi-Cal Handbook page 42-1State Waiver Programs and Limited Services

42. State Waiver Programs and Limited Services

42.1 Waiver Programs (Proc. 19-D]

42.1.1 Background

The Social Security Act [Section 1915(c)] permits states to request waivers of otherwise applicable federal law in order to provide health care services to allow clients to remain at home or in the community rather than be in an institutionalized setting. The goal is that the client will experience an enhanced and enriched quality of life if allowed to return home or to the community.

The Department of Health Services (DHS) currently has six such waivers in effect:

• Department of Developmental Services Home and Community-Based Services (DDS-HCBS) Waiver

• Medi-Cal In-Home Operations (IHO) Waiver• In-Home Medical Care Services (IHMC) Waiver• Acquire Immune Deficiency Syndrome (AIDS) Waiver• Multipurpose Senior Service Program (MSSP) Waiver

42.1.2 Overview

To qualify for services under a waiver program, the applicant must be Medi-Cal eligible AND must also be medically certified by the designated responsible agency. The responsible agency usually completes the “medical certification” prior to referring the individual to the county to apply for Medi-Cal. Occasionally, the medical certification is not completed until after Medi-Cal eligibility is determined.

Medi-Cal eligibility is determined at a county level by Eligibility Workers for the following three waiver programs. “Institutional Deeming” (LTC spousal impoverishment rules) apply as if the client were institutionalized when determining Medi-Cal eligibility for the:

• DDS-HCBS Waiver• Medi-Cal IHO Waiver• MSSP Waiver.

Update # 07-02 Revised: 07/24/13

page 42-2 Medi-Cal HandbookState Waiver Programs and Limited Services

“Regular” Medi-Cal eligibility rules apply when determining Medi-Cal eligibility for the following waiver programs administered by DHS:

• IHMC Waiver• AIDS Waiver.

42.1.3 DHS In-Home Operations (IHO)

The DHS In-Home Operations (IHO) oversees the development and implementation of home nursing programs. The IHO authorizes medically necessary long-term shift nursing services in the home for Medi-Cal clients who are eligible for the Early and Periodic, Screening, Diagnosis and Treatment (EPSDT) and/or one of the three federal waiver programs (Medi-Cal IHO Waiver, IHMC, and AIDS Waivers).

These home nursing services are authorized as an alternative for individuals who would otherwise qualify for care in nursing facilities recognized by Medi-Cal. The request of these nursing services is done through the IHO by the Medi-Cal provider.

42.1.4 Early and Periodic, Screening, Diagnosis and Treatment (EPSDT) Program

EPSDT is a Medi-Cal program under the responsibility of the IHO for individuals under the age 21 who have full scope Medi-Cal eligibility. This benefit allows for periodic screenings to determine health care needs. Based upon the identified health care need, diagnostic and treatment services are provided. This program also allows for the provision of shift nursing services in the home of these individuals.

42.1.5 Personal Care Services Program (PCSP)

The Personal Care Services Program (PCSP) is a component of the In-Home Supportive Services (IHSS) program. Unlike IHSS, PCSP does not allow a parent of a minor child or spouse to be the care provider.

Clients who are receiving benefits under either of the Model-NF and DDS-HCBS Waivers that disregard parental and spousal income and property and who are not eligible for IHSS services only because that program does not disregard parental and spousal income, are eligible for the PCSP.

Revised: 07/24/13 Update # 07-02


PCSP provides the following services:

• Assistance to ambulate (walk around)• Bathing, oral hygiene, dressing, and grooming• Care and assistance with prosthetic devices• Bowel, bladder and menstrual care• Repositioning, range of motion exercises and transfers• Feeding and assurance of adequate fluid intake• Respiration and Paramedical services• Assistance with self-administration of medications• Ancillary services (e.g., meal preparation, laundry, shopping and domestic

services).

42.2 Department of Developmental Services - Home and Community-Based (DDS-HCBS) Waiver

42.2.1 Background

The Department of Developmental Services - Home and Community-Based Services (DDS-HCBS) Waiver Program was implemented in 1982. It was designed to serve developmentally disabled persons who remain in their communities and homes rather than in an institutional setting.

At the program's onset, a developmentally disabled person was required to meet all the regular Medi-Cal eligibility requirements. Effective 10/1/93, eligibility requirements for the DDS-HCBS program were amended to allow for “INSTITUTIONAL DEEMING” which includes:

• The waiving of parental/spousal deeming of income and property prior to determining Medi-Cal eligibility, and

• The application of spousal impoverishment provisions as if the client were institutionalized.

San Andreas Regional Center (SARC) completes the DDS-HCBS waiver medical certification and then forwards the information to the Assistance Application Center (AAC) for a Medi-Cal eligibility determination.



Benefits

The DDS-HCBS Waiver Program allows for enhanced medical services for certain developmentally disabled persons who live at home or in the community instead of in an intermediate care facility.

The major differences between “regular” Medi-Cal and DDS-HCBS Waiver Medi-Cal include the following provisions:

• Spousal impoverishment rules apply as if the applicant were institutionalized. The DDS-HCBS applicant may transfer property to the spouse according to CSRA rules.

• If the client is a child, parental income and property are not considered even though the child lives in the home.

• If the client is an adult, spousal impoverishment rules apply.

• A second vehicle is exempt if the vehicle has been modified to accommodate the physical handicap(s) or medical needs of the client. Verification must be by the physician’s written statement of necessity.

• A separate MFBU is established for an individual who qualifies for Medi-Cal under the DDS-HCBS Waiver Program. If other family members wish to be aided, the client is treated similar to those on PA (e.g., the client may be used to link other family members although the client is not in the family’s MFBU).

• Persons certified under the DDS-HCBS Waiver Program may receive additional services offered through other funding sources to enhance Medi-Cal, such as skilled nursing at home, home health services, specialized medical equipment and supplies, chore service, etc.

Requirements

An applicant for this program must meet all of the following criteria:

• Has been certified for the DDS-HCBS Waiver Program based on his/her medical, social and developmental care needs by San Andreas Regional Center (SARC).

• Is ineligible for “regular” Medi-Cal or has a Share of Cost (SOC) when parental/spousal income and resources are considered.



• Meets all Medi-Cal requirements, however, parental/spousal income and resources are not considered and spousal impoverishment provisions may be applied.

• Is eligible for full scope Medi-Cal. (e.g., A person only eligible for restricted 58 Medi-Cal or a person residing in a nursing home under the State-only Aid Code of 53 is not eligible for the DDS-HCBS Waiver Program.)

• Must have Medi-Cal linkage. A DDSD referral is required when no other linkage exists, the client requests it, or it is beneficial to the client.

Reminder:The EW must use the most beneficial FULL scope Medi-Cal program to determine eligibility that is applicable to the client (e.g., ABD, MN, MI, or FPL). Eligibility is based on the DDS-HCBS Waiver client’s own income and property, including amounts remaining after spousal impoverishment rules are applied.

Example:A child under 19 who has a SOC in the MN or MI program or excess property may be eligible under the appropriate FPL program which disregards property using a family size of one. The client would then be reported to MEDS using the appropriate waiver Aid Code.

• A DDSD referral is not required unless:

• Eligibility is based on Medi-Cal requiring that the client be disabled,• The client has no other basis for linkage, or• There would be an advantage if the client were disabled (e.g., income

deductions available only to the disabled). This determination of disability may be advantageous when a child becomes an adult.

• May or may not have a SOC when the DDS-HCBS Waiver rules are applied.

Note:If the client is eligible for zero share of cost Medi-Cal when the income and resources of his/her parents or spouse are considered, there is no need for the special waiver program criteria. The EW must establish “regular” Medi-Cal.



42.2.2 Medi-Cal Eligibility

Application Referrals

San Andreas Regional Center (SARC) will identify potentially eligible persons for the DDS-HCBS Waiver Program. SARC will then evaluate the client for certification under the Waiver Program based on medical, social and developmental care needs. Only clients who have successfully completed the certification process are referred to the county for a Medi-Cal eligibility determination.

A “Department of Developmental Services Waiver Referral” (DHS 7096) is mailed directly to the Assistance Application Center (AAC). The referrals are for disabled children under 18 years of age and who are living with their parents. The purpose of the referral is to give the child the advantage of being in a separate FBU with only their own separate income and property budgeted.

• If the child is receiving Medi-Cal but has a share-of-cost (SOC), the continuing Supervisor and Eligibility Worker are notified to set up a SARC FBU for the child.

• If the child is not currently receiving Medi-Cal, AAC initiates an application for the child by mailing a letter and an application packet to the parent to complete.

Note:These children are usually approved for SSI when they reach 18 years of age and parental financial responsibility ends.

Referrals may be made for:

• An application (intake) when the applicant has no current Medi-Cal record.

• A reevaluation of eligibility when the DDS-HCBS applicant has an active Medi-Cal record with a SOC.

“Public Agency” Representative

As a “public agency”, SARC may apply for Medi-Cal on behalf of an incompetent person when there are no family or friends to assist them.

Written authorization is not necessary for a “public agency representative” to apply for Medi-Cal on behalf of incompetent individuals.

Note:Parents must apply for Medi-Cal for their children if they are living together.



MFBU Determination

An individual who qualifies for Medi-Cal under the DDS-HCBS Waiver program is placed in his/her own MFBU.

IF... THEN...

There are multiple persons in the same household applying for these waivers,

Each person is in his/her own MFBU.

Other family members are applying for or are receiving regular Medi-Cal,

The DDS-HCBS or Model-NF Waiver person should be treated similar to public assistance (PA) persons (e.g., They are not in the MFBU with other family members, however, they may be used to link other family members).

The DDS-HCBS Waiver clients are treated as a PA recipient in the MFBU of other family members.

DDS-HCBS Aid Codes

The following Aid Codes are used for the DDS-HCBS Waiver cases:

Aid Code Description

6V DDS-HCBS Waiver (No SOC)

6W DDS-HCBS Waiver (SOC)

Reporting Responsibilities

The client/caretaker relative must report all changes within 10 days.

Budgeting Methodology

Budget methodology for a DDS-HCBS case is determined by linkage.

• If the recipient is disabled (determined disabled by SP-DDSD or in receipt of disability based RSDI), then ABD income deductions are used.

• If the recipient is eligible for Medi-Cal based on AFDC-MN/MI linkage, then AFDC-MN/MI budget methodology is used.



Note:The same Aid Code is used whether the recipient has been determined disabled or not. The EW must flag the case to ensure that the correct budget methodology is used.

Retro Medi-Cal

DDS-HCBS regulations may be applied retroactively if the DDS-HCBS Waiver individual has outstanding medical bills from the 3 month period prior to application and the applicant requests it.

42.2.3 Procedure

DDS-HCBS Determination For a New Applicant

The following procedures are followed when determining Medi-Cal under the DDS-HCBS waiver program:

STEP WHO ACTION

1. SARC Initiates an application by mailing a “Department of Developmental Services Waiver Referral” (DHS 7096) to the Assistance Application Center (AAC).

2. DDS-HCBS Contact Person at AAC

Receives DHS 7096.

Ensures a SAWS 1 and SC 41 are completed.

Mails MC 210, MC 219 and MC 13 (for noncitizens and second adult) to the representative for completion.

NOTE: The date AAC receives the referral form is to be used as the application date.

Assigns application as follows:

If there is: Then:

An open case record, Refers application to the current worker's supervisor.

No open case record, Refers to I.D. and assigns to AAC intake.

3. EW Receives application/referral and determines who is the representative for the case. Schedules face-to-face interview, if needed.



DDS-HCBS Determination for a Currently Eligible Medi-Cal Recipient

The following procedures are followed when a Department of Developmental Services Waiver Referral (DHS 7096) is received by a continuing EW:

4. EW Determines Medi-Cal eligibility under the DDS-HCBS Waiver program.

• Regular Medi-Cal criteria must be met (i.e., linkage, residency, cooperation, etc.), except parental/spousal income and property are waived and spousal impoverishment apply.

NOTE: If other family members receive Medi-Cal, the DDS-HCBS individual is treated as a Public Assistance (PA) recipient.

5. EW Determines linkage and submits a DDSD packet, if applicable.

If Applicant: Then a DDSD Referral is:

Receives Social Security due to own disability,

Not required since disability has already been established.

Is an MI Adult and has not been determined disabled (There are no DHS 7096 referrals on clients over age 18),

Required. Case will remain in DE-D pending status until DDSD decision is received.

Is an otherwise eligible child (under age 21),

Recommended, but not required.* Issue Medi-Cal using Aid Code 6V or 6W.

• Set up a case alert for DDSD follow-up.

• Use AFDC-MN/MI budgeting until DDSD decision is received.

• Revise budgets as needed when DDSD decision is received.

*Note: When a DDS-HCBS child enters LTC, the DDS-HCBS provisions no longer apply. He/She may only remain in his/her own MFBU if he/she has been determined “disabled.”

STEP WHO ACTION

1. EW Supervisor

Receives the DHS 7096. Establishes a control system and assigns to current EW.

2. EW Receives the DHS 7096 and determines who is the case representative.

NOTE: A new Application for Medi-Cal (MC 210) is only needed if the annual RD is due.

STEP WHO ACTION



Notices of Action (NOAs)

Approval, denial and/or discontinuance NOA is issued and send as follows:

• The original to the applicant, and• A copy to SARC.

Referring Agency

San Andreas Regional Center (SARC)

300 Orchard City Drive, Suite 170 Campbell, CA 95008-0002 Attn: Teria Tetz-hall, QMRP Phone: (408) 341-3425, Fax: (408) 379-1130

Release of Information

For DDS-HCBS applicants/recipients only, a release of information is not required to share ongoing eligibility information with San Andreas Regional Center (SARC).

Redeterminations (RDs)

The EW must complete a Medi-Cal redetermination annually. SARC is also required to complete an annual medical recertification for the DDS-HCBS waiver program. Whenever possible, the two reviews should be aligned and completed in the same month.

As documentation of continued medical certification for the DDS-HCBS waiver, SARC will forward a copy of the annual medical recertification to the EW. This must be filed in the case record. If the EW has not received verification of recertification

Reviews case to determine Medi-Cal eligibility under the DDS-HCBS Waiver program, and submits a DDSD packet if necessary.

• Regular Medi-Cal criteria must be met (i.e., linkage, residency, cooperation, etc.), except parental/spousal income and property are waived and spousal impoverishment apply.

NOTE: If other family members receive Medi-Cal, the DDS-HCBS individual is treated as a Public Assistance (PA) recipient.

STEP WHO ACTION



from SARC by the time the annual Medi-Cal redetermination is due, the EW must request the SARC liaison to contact SARC for confirmation of medical eligibility for the waiver program.

Termination of DDS-HCBS Waiver

Should the individual lose his/her medical certification for the DDS-HCBS Waiver, eligibility under the regular Medi-Cal program must be explored prior to discontinuation.

The DDS-HCBS waiver does not apply to persons in LTC.

42.3 Model Nursing Facility (Model-NF) Waiver

The Model-NF Waiver, also called the “Katie Beckett” Waiver, provides limited enhanced Medi-Cal services to certain individuals who live at home instead of residing in an institution. This program is terminated and replaced by the Medi-Cal IHO Waiver program.

42.4 Model IHO Waiver

Similar to the former Model-NF Waiver, it allows persons who would otherwise reside in a skilled nursing facility to remain at home and obtain Medi-Cal eligibility without consideration of a parent’s income or resources if the applicant were a child or used spousal institutional deeming rules if the applicant lived at home with his/her spouse.

The services under the Medi-Cal IHO Waiver program include case management, private duty nursing, home health aides, personal care services, respite care, family training, and minor physical adaptations to the home

The three major provisions provided under this program which are not available to other Medi-Cal clients are:

• There is no deeming of parental or spousal income or resources. (Without the waiver, income and resources of the parent/spouse would be counted.)



• Eligible persons are provided skilled nursing at home, home health aid services, therapy, etc., in lieu of inpatient services.

• A second vehicle is exempt if the vehicle has been modified to accommodate the physical handicap(s) or medical needs of the client. Verification must be by the physician’s written statement of necessity.

Requirements

An applicant for the Medi-Cal IHO Waiver must meet all of the following requirements:

• Meets certain medical requirements which are determined by the Department of Health Services In-Home Operations (IHO).

• Is ineligible for “regular” Medi-Cal or has a Share of Cost (SOC) when parental/spousal income and property are considered.

• Meets all Medi-Cal requirements, however, parental/spousal income and property are not considered and spousal impoverishment provisions may be applied.

• Has Medi-Cal linkage (i.e., ABD-MN, AFDC-MN). A DDSD referral is required when no other linkage exists, the client requests it, or it is beneficial to the applicant (e.g., additional income deductions will eliminate or reduce the SOC).

• Is eligible for full scope Medi-Cal. (e.g., A person only eligible for restricted 58 Medi-Cal is not eligible for the Medi-Cal IHO Waiver.)

• May or may not have a SOC when the Medi-Cal IHO Waiver rules are applied.

Note:If the individual is eligible for zero SOC Medi-Cal when the income and resources of his/her parents or spouse are considered, there is no need for the special waiver program criteria. The EW must establish “regular” Medi-Cal.

42.4.1 Medi-Cal IHO Waiver Inquiries

Requests for consideration under the Medi-Cal IHO Waiver program can be initiated by the applicant, a physician, friends, family, LTC facility or hospital, or by a community agency.



42.4.2 DHS In-Home Operations (IHO) - Initial Screening

DHS IHO conducts an initial screening of each Medi-Cal IHO Waiver applicant to:

• Determine if the “medical” requirements of the program are met.

• Ensure that necessary, appropriate and quality medical and nursing services are authorized and provided in the home setting.

Criteria used to determine “medical” eligibility for the Medi-Cal IHO Waiver Program includes, but is not limited to:

• The applicant would require skilled nursing level care in a facility in the absence of waiver services.

• Participation in the waiver program is appropriate considering the patient's social and medical history, current medical condition and nursing care needs.

When Medical Requirements are Met

If the applicant meets or is likely to meet the initial screening criteria, DHS IHO will refer the applicant to the County Welfare Department for a Medi-Cal eligibility determination.

42.4.3 EW - Medi-Cal Eligibility Determination

Institutional Deeming

The following income/property rules apply when determining Medi-Cal eligibility and SOC under the Medi-Cal IHO Waiver program:

• Parental/Spousal income and property are not considered.

• Spousal Impoverishment rules apply as if the applicant were institutionalized.

MFBU Determination

An individual who qualifies for Medi-Cal under the Medi-Cal IHO Waiver program is placed in his/her own MFBU. The maintenance need for one ($600) is used to determine the SOC.



The Medi-Cal IHO Waiver client is treated as a PA recipient in the MFBU of other family members.

Medi-Cal IHO Waiver Aid Codes

The following aid codes are used for the Medi-Cal IHO Waiver program:

Aid Code Description

6X Medi-Cal IHO Waiver (No SOC)

6Y Medi-Cal IHO Waiver (SOC)

Reporting Responsibilities

The client/caretaker relative must report all changes within 10 days.

Budget Methodology

Budget methodology for a Medi-Cal IHO Waiver case is determined by linkage.

• If the recipient is disabled (determined disabled by SP-DDSD or in receipt of Social Security payments based on disability), then ABD income deductions are used.

• If the recipient is eligible for Medi-Cal based on AFDC-MN/MI linkage, then AFDC-MN/MI budget methodology is used.

Note:The same aid code is used whether the recipient has been determined disabled or not. The EW must flag the case to ensure that the correct budget methodology is used.

Medi-Cal IHO Waiver Approval and Beginning Date of Aid

Prior to case authorization, the EW must contact the DHS IHO representative listed on the referral form to:

• Notify them of potential eligibility or ineligibility,• Request a Medi-Cal IHO Waiver Medical Eligibility Notice (MWP Letter 1)

confirming medical eligibility, if not already received, and• Request the effective date of the Medi-Cal IHO Waiver certification. The EW

must inform the DHS IHO representative if retro coverage has been requested.



The beginning date of aid can be no earlier than the effective date of the Medi-Cal IHO Waiver certification.

Notice of Action Requirement

The EW must issue a Notice of Action (NOA) approving (MC 343) or denying (MC 344) Medi-Cal to all Medi-Cal IHO Waiver applicants.

A copy of the NOA must also be sent to the Medi-Cal Program Coordinator.

Referring Agency

The DHS In-Home Operations (IHO) is the referring agency for the Medi-Cal IHO Waiver and will do a prescreening of income and property prior to referring the client to the county. The IHO address and phone number are as follows:

Department of Health Care Services In-Home Operations Branch 1501 Capitol Avenue, MS 4502 P.O. Box 997437 Sacramento, CA 95899-7437 Phone: (916) 552-9105, Fax: (916) 552-9150 or (916) 552-9151

42.5 Multipurpose Senior Service Program (MSSP) Waiver

The Department of Aging Multipurpose Senior Services Program (MSSP) Waiver has been in existence since 1983. The goal of the program is to arrange for and monitor the use of community services to prevent or delay premature institutional placement of persons 65 years or older. Prior to June 1, 2003, the In-Home Operations (IHO) processed these waiver program applications.

Effective June 1, 2003, an amendment to the MSSP waiver was recently approved by the Centers for Medicare and Medicaid Services. The amendment allows Eligibility Workers (EWs) to determine eligibility using institutional deeming rules (spousal impoverishment) for a person who:

• Moves from the institution and returns home to their spouse, or• Is already living at home with his or her spouse.



42.5.1 Benefits

The MSSP provides interdisciplinary (nurse and social work) care management services including the coordination and use of existing community resources. Care managers initiate and monitor the process of assessments, case plan development, service arrangement, ongoing monitoring and reassessments of client’s needs.

To arrange for services, care management staff first explore support that might be available through family, friends and community volunteers. Then they review existing publicly-funded services and make direct referrals. If needed services are not available through these resources, the care management team can authorize the purchase of some services from MSSP funds.

Eligible clients may be linked to services that include, but are not limited to:

• Care Management • Personal care

• Adult social day care • Respite care

• Housing assistance • Transportation

• Protective services • Special communications

• Meal services • Skilled nursing health care

42.5.2 Eligibility Requirements

The individual must meet the following MSSP eligibility requirements:

• Age 65 or older• Eligible for full-scope Medi-Cal• Meets all other Medi-Cal requirements (e.g., residency, etc.)• Is medically certified for the MSSP by the local MSSP site• Currently or would be ineligible for “regular” Medi-Cal due to excess property,

has or would have a Share of Cost (SOC) WHEN spousal income and resources are considered.

Note:If the client is eligible for zero SOC Medi-Cal even when spousal income and resources are considered, then there is no need to set up an MSSP Waiver.



42.5.3 Referring Agency

The California Department of Aging (CDA) is the referring agency for the MSSP. CDA contracts with either public entities or private nonprofit agencies to operate the MSSP program at the local level.

In Santa Clara County, the Council on Aging of Silicon Valley (COASV) listed below will identify potentially eligible persons for the MSSP waiver by reviewing the applicant’s health, psychosocial needs, and functional status before making a referral to the Social Services Agency. COASV will refer and complete the “California Department of Aging (CDA) Waiver Referral” (MC 364) and mail it directly to the Assistance Application Center (AAC).

Council on Aging of Silicon Valley, Inc. 2115 The Alameda San Jose, CA. 95126 Phone: (408) 296-8290 Fax: (408) 249-8918

Release of Information

Eligibility Staff may share ongoing eligibility information with COASV. A release of information is not required.

42.5.4 Redeterminations (RD)

The EW must complete a Medi-Cal redetermination annually. The Council on Aging of Silicon Valley (COASV) is also required to complete an annual medical recertification for the MSSP waiver program. Whenever possible, the two reviews should be aligned and completed in the same month.

As documentation of continued medical certification for the MSSP waiver, COASV will forward a copy of the annual medical recertification to the EW. This must be filed in the case record. If the EW has not received verification of recertification from COASV by the time the annual Medi-Cal redetermination is due, the EW must request it from COASV for confirmation of medical eligibility for the MSSP waiver program.

42.5.5 Termination of MSSP Waiver

If the individual loses his/her medical certification for the MSSP Waiver, eligibility under the regular Medi-Cal program must be explored prior to discontinuance. A ten-day Notice of Action is required.



42.5.6 Eligibility Determination

When an MSSP referral form for a married applicant/ recipient is received and the EW determines that the individual is ineligible for Medi-Cal due to excess community property or is eligible for Medi-Cal but would end up with a SOC using regular Medi-Cal rules, institutional deeming rules apply.

The following Medi-Cal eligibility determination rules apply:

• The applicant/recipient is treated as if he or she was in LTC (institutionalized) for purposes of the treatment of income and resources.

• Spousal impoverishment rules apply

• The MSSP eligible individual is in his/her own Medi-Cal Family Budget Unit (MFBU). If other family members wish to be aided, the MSSP individual is treated similar to those on public assistance. The MSSP individual may be used to link other family members (i.e., ABD-MN) even though the MSSP individual is not in the family’s MFBU.

• The individual must be eligible for FULL scope Medi-Cal benefits. Note: A person residing in a nursing home under the limited state-only Aid Code 53, or a person in another limited-scope aid code, or a person who does not have satisfactory immigration status is not eligible for MSSP waiver.

• The EW must use the most beneficial full-scope Medi-Cal program applicable to the client (e.g., Pickle, Aged and Disabled Federal Poverty Level Program, ABD-MN program). Eligibility is based on the individual’s own income and resources, including amounts remaining after spousal impoverishment rules are applied. Example: An aged individual may be eligible for the Aged and Disabled (A&D) Federal Poverty Level (FPL) program after spousal impoverishment rules are applied. He/she would then be reported to MEDS using the MSSP No SOC Aid Code.



42.5.7 MFBU Determination

An individual who qualifies for Medi-Cal under the MSSP Waiver program is placed in his/her own MFBU.

IF... THEN...

There are multiple persons in the same household applying for these waivers,

Each person is in his/her own MFBU.

Other family members are applying for or are receiving regular Medi-Cal,

The MSSP Waiver person should be treated similar to public assistance (PA) persons. They are not in the MFBU with other family members, however, they may be used to link other family members.

42.5.8 MSSP Process

MSSP Determination For a New Applicant

The following procedures are followed when determining Medi-Cal under the MSSP waiver program:

STEP WHO ACTION

1 COASV Initiates an application by mailing a “California Department of Aging Waiver Referral” (MC 364) to Assistance Application Center (AAC).

2 COASV Contact Person at AAC

Receives the MC 364 and monitors the status.

3 Clerical Follows application processing per District Office procedures:

• Completes the “Application for Cash Aid, Food Stamps, and/or Medi-Cal Assistance” (SAWS 1) and “Identification and Intake Record” (SC 41) Note: The date the county receives the referral form is to be used as the date of application.

• Performs file clearance.

4 COASV Contact Person at AAC

Assigns the application as follows:

If there is: Then:

An open case record, Refer the application to the current worker's supervisor.

No open case record, Refers the application to an EW Supervisor who then assigns it to the EW.



MSSP Determination for a Currently Eligible Medi-Cal Recipient

The following procedures are to be followed when a “California Department of Aging Waiver Referral” (MC 364) is received by a continuing EW:

STEP WHO ACTION

1 EW Supervisor

Receives the MC 364. Establishes a control system and assigns to current EW.

2 EW Completes case processing as follows:

• Receives the MC 364.• Reviews case to determine Medi-Cal eligibility under the MSSP Waiver

program. Regular Medi-Cal criteria must be met (i.e., linkage, residency, cooperation, etc.). However, the MSSP applicant is treated as if he/she was institutionalized for purposes of the treatment of income and resources and spousal impoverishment rules apply. NOTE: If other family members receive Medi-Cal, the MSSP individual is treated as a Public Assistance (PA) recipient.

Note: The EW must send an MSSP approval, denial or discontinuance NOA as follows: 1) Original to the MSSP individual 2) Copy to COASV (MSSP referring site)

5 EW Completes case processing as follows:

• Receives the application and MC 364• Mails a a letter (i.e., SC 50) and a Medi-Cal adult intake application

packet for completion• Schedules face-to-face interview, if requested• Determines Medi-Cal eligibility under the MSSP Waiver program.

Regular Medi-Cal criteria must be met (i.e., linkage, residency, cooperation, etc.). However, the MSSP applicant is treated as if he/she was institutionalized (in LTC) for purposes of the treatment of income and resources and spousal impoverishment rules apply. NOTE: If other family members receive Medi-Cal, the MSSP individual is treated as a Public Assistance (PA) recipient.

• Determines if there is a SOC under the MSSP Waiver program.

STEP WHO ACTION



42.5.9 MSSP Examples

Example 1

John is a 70-year-old applicant who is referred to the county by the COASV. He is living at home with his spouse. They have no minor children living in the home. The EW determines that he is property eligible but is not eligible for the Aged and Disabled (A&D) Federal Poverty Level Program and would have a SOC as an ABD-MN person. The EW then applies spousal impoverishment rules. John may allocate the lesser of his maximum income available for allocation or the community spouse income allocation (CSIA) to his spouse. His monthly SOC is based on the remaining amount of his income.The EW approves and sets up the individual in the appropriate MSSP aid code. If his spouse has income and is receiving Medi-Cal, his spouse may have an increased share of cost due to the new CSIA and a ten-day NOA is required.

Example 2

Tom is 65 years old and currently eligible in the ABD-MN program with a monthly SOC of $1,000. The EW receives the MSSP referral. He is living at home with his spouse and there are no minor children in the home. After the EW applied the spousal impoverishment rules (CSIA), he is determined eligible for no SOC MSSP.

Example 3

Paul is 80 years old and referred to the county for an MSSP evaluation. He is living at home with his spouse and there are no minor children in the home. The EW determines that he is property ineligible for any Medi-Cal program and his own income is below the ABD-MN limit. The EW then applies the spousal impoverishment rules (CSRA) and finds him to be property eligible. Since his income is already below the ABD-MN limit, there is no need to allocate any of his income to his spouse.

42.6 Additional Waiver Programs

There are four additional waiver programs currently available. Regular Medi-Cal eligibility rules apply and are administered by DHS.



42.6.1 In-Home Medical Care Services (IHMC) Waiver

The IHMC Waiver is available to individuals who, in the absence of the waiver, would require at least 90 days of care in an acute hospital. Services provided include, but are not limited to:

• Case Management • Utility coverage

• Skilled nursing • Minor physical adaptations to the home

• Home health aides

Eligibility Requirements

Special Medi-Cal eligibility rules DO NOT apply.

If the applicant is living in the home, he/she is NOT in a separate MFBU from his/her parent/spouse.

Referring Agency

Medical certification for the IHMC Waiver is completed by DHS IHO.

DHS In-Home Operations (IHO) Intake Unit 700 North Tenth Street P.O. Box 942732 Sacramento, CA 95814 Phone: (916) 324-1020, Fax: (916) 324-5544

42.6.2 Nursing Facility (NF) Services Waiver

The NF-Services Waiver (formerly referred to as the Skilled Nursing Facility Waiver) is available to adults who are physically disabled and would otherwise require nursing facility or subacute services for at least 90 days. (NOTE: Children under 21 can receive these services through the EPSDT program.)

Services provided include, but are not limited to:

• Case Management • Utility coverage

• Skilled nursing • Minor physical adaptations to the home






Referring Agency

Medical certification for the NF-Services Waiver is completed by DHS IHO.

DHS In-Home Operations (IHO) Intake Unit 700 North Tenth Street P.O. Box 942732 Sacramento, CA 95814 Phone: (916) 324-1020, Fax: (916) 324-5544

42.6.3 Acquired Immune Deficiency Syndrome (AIDS) Waiver

The AIDS Waiver is available to individuals with a diagnosis of Human Immunodeficiency or Acquired Immune Deficiency Syndrome (AIDS) with symptoms related to Human Immunodeficiency Virus (HIV) disease who would otherwise require care in a skilled nursing facility or acute care hospitals. Services provided include, but are not limited to:

• Case Management • Non-emergency medical transportation

• Skilled nursing • Equipment and minor physical adaptations to the home

• Attendant Care • Nutritional counseling

• Psycho-social counseling • Nutritional supplements/home delivered meals

• Homemaker services




• Home health aides



Referring Agency

Medical certification for the AIDS Waiver is completed by DHS Office of AIDS.

DHS Office of AIDS Community Based Case Section 611 North 7th Street P.O. Box 942732 Sacramento, CA 95814 Phone: (916) 327-6768, Fax: (916) 327-3177

42.7 Severely Impaired Working Individuals Program (Aid Code 8G)

42.7.1 Background

The SSI program encourages severely disabled persons to seek and maintain employment through a work incentive program known as the Continued Medicaid Eligibility program [Section 1619(b)]. This program provides zero share of cost Medi-Cal to working SSI beneficiaries even if their earnings are too high to allow an SSI cash payment. These individuals appear on MEDS as SSI/SSP recipients (i.e. Aid Code 60), but do not receive a cash grant.

An individual terminated from Continued Medicaid Eligibility for reasons other than his/her earnings and who continues to be blind/disabled is potentially eligible for the Severely Impaired Working Individual program (Aid Code 8G).

42.7.2 Eligibility Requirements

Individuals terminated from Continued Medicaid Eligibility may be eligible for zero share of cost Medi-Cal under the Severely Impaired Working Individual program. The individual must meet all of the following four basic requirements:

• Depends on Medi-Cal to continue working,

• Meets all SSI/SSP requirements, except for earnings,

• Does not have sufficient earnings to replace SSI cash benefits, Medicaid and the cost of publicly funded personal and attendant care, and



• Received SSI or Continued Medicaid Eligibility in the month immediately preceding the first month eligibility for the Severely Impaired Working Individual program.

Spousal/parental income and property are considered when determining if the applicant meets the requirements listed above.

Model Waiver Referral

A Severely Impaired Working Individual frequently meets the criteria for medical certification under the Model Waiver program. If the above criteria is not met when spousal/parental income and property is considered, the EW must determine if the criteria is likely to be met using the Model Waiver Medi-Cal eligibility rules. [Refer to “EW - Medi-Cal Eligibility Determination,” page 42-13.] If so, the applicant must be referred to the Medi-Cal Program Coordinator for a Model Waiver referral.

42.7.3 Procedure

Medi-Cal applicants applying for the Severely Impaired Working Individual program will identify themselves to the EW. It is anticipated that very few individuals will fall into this category. Should one be encountered, ask the Medi-Cal Liaison contact the Medi-Cal Program Coordinator for complete procedures.

42.8 Limited Services Due to Program Abuse [Proc. 19-A]

42.8.1 Background

The Department of Health Services (DHS) has developed procedures to identify and resolve Medi-Cal program abuse by recipients. Recipients who seek out and repeatedly obtain unnecessary services are placed on Limited/Restricted Service Status. Providers are alerted through the Medi-Cal verification system that for these recipients, prior authorization is required for certain services.

Any Medi-Cal recipient can be placed on Limited/Restricted Service Status.



42.8.2 DHS Responsibility

The Department of Health Services prepares and sends a “Notice of Action, Medi-Cal Coverage Restricted” (MC 1705) to the client at least 10 days before restricted service status becomes effective. A copy of the MC 1705 is sent to the County and forwarded to the EW. The NOA must be scanned into IDM.

Limited/Restricted Service is in effect for a minimum of one year, unless altered by DHS or a state hearing decision.

Note:Limited/Restricted service status SHALL NOT be lifted because of the hearing request.

The “restricted service” messages are:

• Restricted Drugs, coded “R1”• Restricted Scheduled Drugs, coded “R5”• Restricted M.D. Visits, coded “R11”• Restricted Drugs/M.D., coded “R12”• Restricted to Primary M.D., coded “R14”• Restricted to Primary M.D./Drugs, coded “R15”

DHS reviews and, if appropriate, authorizes all Medi-Cal drug and/or M.D. visit requests for the customer. (Providers have been informed by provider bulletin that prior departmental approval is required by the special coding indicated.)

42.8.3 County Responsibility

EWs are responsible for accepting and forwarding requests for state hearing from persons who want to appeal their restricted service status. Send the requests to the Appeals Unit.

• Restricted service beneficiaries may request a state hearing within 90 days of the initial action by DHS.

• Restricted service status SHALL NOT be lifted because of the hearing request.

There is no effect on the other MFBU members when a person in the MFBU is placed on limited/restricted status.



42.8.4 Medi-Cal Benefits Issuances

There are NO special indicators which the EW must enter into CalWIN for those persons who have been placed on limited/restricted status.

• DHS will automatically input information into MEDS indicating the person (for has been placed on limited service status.

• DHS will also automatically input restricted service status information into MEDS for persons with a share-of-cost and who are placed on limited services.

42.9 Limited Services for MIAs in SNF/ICF [Proc. 19-C]

42.9.1 Background

The State discontinued the Medically Indigent Adult (MIA) category from the Medi-Cal program, with a few exceptions, effective January 1, 1983.

One of the exceptions is the category of MIAs residing in a skilled nursing facility (SNF) or intermediate care facility (ICF) who are identified by Aid Code 53. While a MIA is residing in an SNF/ICF, they are entitled to all benefits normally covered by Medi-Cal. However, should that MIA person become an inpatient at an acute care hospital, any services provided during that hospital stay will not be covered by the Medi-Cal program.

42.9.2 County Responsibility

If acute care is needed, it may be provided through the Ability to Pay Determination (APD) program at Valley Medical Center. The EW must refer any aid code 53 MIA person to the APD program when that person becomes an inpatient at an acute care facility. DO NOT refer customer to the VMC Medi-Cal Unit.

Note:The aid code 53 person who goes to an acute care hospital other than VMC will usually be referred by the hospital to VMC if he/she has no other health coverage.



If a disability evaluation is subsequently approved, Aid Code 53 shall be changed to a disabled aid code category effective with or retroactive to the disability onset date. [Refer to “Family Members in Long Term Care or Board and Care,” page 60-35 for more information regarding MIAs in LTC.]

42.9.3 Medi-Cal Benefits

Aid Code 53 identifies a recipient as eligible for Medi-Cal benefits limited to services received while residing in an SNF/ICF. The Medi-Cal record for persons who are eligible for Aid Code 53 contains the following restriction message:

“Services to acute hospital inpatients are not covered.”

42.9.4 Retroactive Medi-Cal

MIAs may be eligible for retroactive Medi-Cal if both of the following conditions are met:

• The MIA resided in an SNF/ICF for one day or more during the month of application, AND

• The MIA resided in an SNF/ICF for one day or more during the retroactive month(s) for which Medi-Cal coverage is requested.

The retroactive month(s) are also coded with Aid Code 53, and the same services are covered in the retroactive month as in the current month of eligibility.

42.9.5 Undocumented Immigrants in LTC

There are special procedures for non-linked undocumented immigrants who are in LTC. Do not use Aid Code 53 for an undocumented person unless he/she is seeking PRUCOL status from INS. [Refer to “PRUCOL for Undocumented Individuals in LTC or Receiving Renal Dialysis,” page 41-20 for complete information.]


Documents

Medi-Cal Handbook State Waiver Programs and Limited ... · State Waiver Programs and Limited Services ... under the age 21 who have full scope Medi-Cal eligibility. ... parental/spousal