How to Determine Financial Eligibility for the Alternative Care Program 2013 Age and Disabilities Odyssey Libby Rossett-Brown – Elderly Waiver/Alternative.

How to Determine Financial Eligibility for the Alternative

Care Program

2013 Age and Disabilities Odyssey

Libby Rossett-Brown – Elderly Waiver/Alternative Care Program Administrator

Gail Carlson – Alternative Care Operations

June 17, 2013

Session Overview

Understand the basic concepts of Alternative Care (AC) program eligibility

Understand how to determine AC Financial Eligibility using the AC Financial worksheets

How to determine the AC fees

Acronyms AC Alternative Care FFP Federal Financial Participation HCBS Home and Community Based Services PNA Personal Needs Allowance DHS Department of Human Services SRU Special Recovery Unit MA Medical Assistance EW Elderly Waiver LTCC Long Term Care Consultation NF Nursing Facility MNA Maintenance Needs Allowance LOC Level of Care

Purpose of the Alternative Care(AC) Program

Maintain people in their own homes – person chooses to live in the community

Connect people with services that they need

Support Caregivers Support choice and informed decision

making Prevent or delay NF admissions

Purpose of the Alternative Care(AC) Program

Move people out of institutions Prevent impoverishment of older adults by

assisting them to access services at an earlier point of need and prevent more costly levels of care

Contain MA expenditures by funding care in the home and community

Authority found in MN Statute, Section 256B.0913

State funded only

AC – Who Is Eligible Age 65 and older Have chronic care needs Chooses to reside in the community Have financial resources to meet their own

health related needs and independent living needs

At risk of NF placement as determined by the LTCC

May be eligible for Medicare Savings Programs

AC Program Model Voluntary Enrollment Payer of Last Resort Cost sharing by participants – fees

required Program and service is appropriate to

need Most cost effective way to meet the need Enhance self sufficiency Support and extend informal caregiving

Enrollment Process for AC

Community Assessment determines service needs – LTCC

County Social Service Department Tribal Entity Public Health Nurse/Social Worker AC financial eligibility determined by

the Case Manager

AC Financial Eligibility Financial resources are within 4.5 months

of Medical Assistance Eligibility ($25,881 7/1/13) and

Capable of meeting own remaining health needs and

Capable of meeting a monthly fee requirement

Spousal Impoverishment rules apply Did not improperly dispose of Assets

AC Financial Eligibility

Monthly income is >$1149 (7/1/13) or Assets are >$3000 (MA Asset limit) and Total combined adjusted monthly income

and assets are less than the projected nursing facility care cost for 135 days (+MA asset limit of $3000)

7/1/13 this is $25,881

AC Financial Eligibility

Income is ≤$1149 and assets are ≤$3000 applicant is ineligible for AC

Can be temporary served under AC up to 60 days during their application to Medical Assistance/Elderly Waiver

If income and assets available are greater than the projected nursing facility care cost for 135 days(+MA asset limit of 3000) client is ineligible for AC and cannot be temporarily served

AC Financial Worksheets Alternative Care Program Eligibility

Worksheets: DHS 2630A Married person with a

community spouse DHS 2630 Unmarried individuals, or

Married couples when both may choose AC or a married person whose spouse is an EW recipient or is living in a nursing facility

Case Manager determines financial eligibility

Financial Worksheets Monthly Income (line A)– this is gross income-

including all sources of earned and unearned income received by the applicant including:

- social security benefits - interest payments - pensions - annuity payments - payments from rental property and earnings - contract for deed payments Enter this figure as Gross Income on the LTCC

screening document

Financial Worksheets - Income Recurring and predictable monthly

expenses (line B)

– health insurance premiums,

- drug costs, - acute care costs that the client pays on a

monthly basis

***This cannot include the AC Fee

This is subtracted from line A and placed on line C

Financial Worksheets - Income

Clothing and Personal Needs Allowance-PNA (line D) – 7/1/13 $94

This is the amount that Medical

Assistance allows a person residing

in a nursing home to keep for

spending money

Financial Worksheets - Income Subtract the personal needs allowance

and the predictable medical expenses from the applicant’s income-

*The result is the amount of income

available to pay nursing home

costs each month

This is placed on line E and is also entered on the screening document as the AC Adjusted Income

Financial Worksheets - Income

Multiply the available income (line E)

by 4.5

*The result is the amount of income to

pay nursing home costs for 135 days

This is Line F

Financial Worksheets - Assets Individuals total non excluded assets –

Line G – This is also entered on the LTC screening document as Gross Assets.

Include the value of all assets owned by the applicant including:

- Cash - All Bank accounts – checking, savings, CD’s - Annuities - IRA/KEOGH any other pensions

Financial Worksheets - Assets

Other assets: - Stocks and Bonds - Trust funds that are available - Contract for Deed - Cash surrender value of Life

Insurance - Real property not used as

applicant’s primary residence (lake homes)

- boats, campers, motorcycles

Financial Worksheets-Assets

Individuals Assets that are not included in the total include:

- Homestead property including

contiguous land

- Personal effects

- household goods and furnishings

- the value of one vehicle

Financial Worksheets - Assets

Incurred Unpaid Past medical bills (Line H) Bills owed by the individual that are

payable which will not be payable by Medicare or medical insurance

Subtract any of the above medical bills from the total assets (Line G) the result is placed on (Line I)

Financial Worksheets - Assets

List $1500 if there are no burial accounts (Line J)

Subtract Line I minus Line J

*The result is the amount of assets which are available to fund nursing home care

(Line K) Enter this value as AC Adjusted Assets on the screening document

Financial Worksheets – Determination of Eligibilty

Add the amount of income available to pay for 135 days of nursing facility care to the (line F)

Amount of assets available to fund nursing facility care. (line K)

Place the sum of Line F + Line K on Line LAnd compare it to the figure on Line M which is the nursing facility cost for 135 days + MA asset limit - 7/1/13 $25,881

Financial Worksheets – Determination of Eligibilty

If this figure (line L) is less than or equal to the nursing facility cost for 135 days + MA asset limit- on (Line M) currently $25,812 and 7/1/13 will be $25,881

The client is financially eligible for the AC Program. **Unless there is an uncompensated transfer of assets

The income (Line A) has to be > $1149 7/1/13 OR the Assets (Line G) are >$3000

Financial Worksheets – Determination of Eligibility

If the income in Line A is ≤$1149 and assets are ≤$3000 (Line G) applicant is ineligible for AC

Can be temporary served under AC up to 60 days during their application to Medical Assistance/Elderly Waiver

If income and assets available are greater than the projected nursing facility care cost for 135 days(+MA asset limit of 3000) client is ineligible for AC and cannot be temporarily served

Financial Worksheets

Asset Transfer: When a client, client’s spouse, or client’s representative gives away, sells, conveys ownership and/or reduces control, or disposes of any income or asset or any interest in an asset (other than spousal allocations of assets or income)

Financial Worksheets

Improper/Uncompensated Asset Transfer: An asset that is sold, given away, or otherwise disposed of for less than fair market value. This may include giving away income or assets, selling property for less than fair market value, purchasing property for more than fair market value or refusing an inheritance, cash gifts, establishing a life estate or creating a trust.

Transfer of Assets

When an applicant makes an improper transfer of asset within in the previous 60 months (Look back period) they are ineligible to receive AC services for a period of time that is calculated.

If an applicant is in a penalty period for a federal program they may not receive AC services.

Transfer of Assets

Statewide Average Payment for a Skilled Nursing Facility (SAPSNF)-which is the average monthly payment statewide for skilled nursing care. It is used to calculate the penalty period for an improper transfer.

As of 7/1/13 = $5583 –This is used as a divisor and the resulting number is the number of months the client may not receive any AC services.

Transfer of Assets

Determine the penalty period for an uncompensated transfer by dividing the

uncompensated value of asset by the SAPSNF which is $5583 7/1/13

The result is the number of months the client is ineligible to receive AC services. Begin counting the penalty period on the date that the person is otherwise found eligible for the AC program through the number of months that was calculated, including partial months of service when the penalty period is ending.

Transfer of Asset Example

Mr. Summer gave his son $15,000 on April 5, 2013. He applied for AC services on June 1, 2013 and was considered eligible.

$15000 ÷ 5371 = 2.81 Count 2.8 months of ineligibility from June 1, 2013. July, August, and most of Sept

AC Financial Eligibility

There is a difference depending on the marital status and the program status of the spouse

Spousal impoverishment rules apply in the AC program as they do for Medical Assistance (MA) long term care

AC clients who are married – need to be referred for an MA Asset Assessment

Asset Assessments

DHS 3340A – Asset Assessment results is completed by the financial assistance division and determines the community spouse asset allowance.

An amount of assets are allocated to the community spouse to prevent spousal impoverishment.

The minimum asset allowance $32,890 and the maximum is $115,920

Minimum spousal monthly income is $1,940 as 7/1/13

Asset Assessment Per Medical Assistance eligibility policy, the total assets

owned by the couple from which the community spouse’s asset allowance will be identified are reviewed on a specific date. The date is the earliest of the 1st day of the 1st continuous period of:

Admission to a medical Hospital Admission to a nursing facility Receipt of home care services that would be

covered by Elderly Waiver (EW) or AC or the Long term care consultation (LTCC) date whichever is later

Case Management service may be considered a home care service for the purpose of setting an asset assessment date

Financial Eligibility for AC (Married)

Use E-Doc DHS 2630A – AC Program Eligibility worksheet for a married person with a community spouse

Line K – enter the total marital assets from the asset assessment and then enter

the community spouse asset allowance h from the asset assessment on Line L –

Financial Eligibility for AC (Married)

Line M – subtract the community spouse asset allowance from the couples total marital assets.

This figure is the amount of gross assets that is entered on the LTCC screening document

The unpaid medical bills and burial deductions are the same as for not married

Financial Eligibility for AC (Married) The minimum spousal income allocation is listed

on the worksheet (Line A) currently $1892 and will be $1940 7/1/13

The allocation to the community spouse is the community spouses monthly income subtracted from the minimum spousal allocation

(Line D) The result is subtracted from the gross income

of the applicant (Line C) and placed on (Line E) Line C applicants gross monthly income is

also placed on the screening document

Financial Eligibility for AC (Married)

The personal needs allowance is also subtracted as well as the recurring predictable monthly medical expenses

The result is Line I which is the applicants available monthly income and this is also entered on the screening document as AC adjusted income

Financial Eligibility for AC (Married)

Line I is multiplied by 4.5 to determine the income available for 135 days of nursing home care and the result is placed in Line J.

As similar to the AC worksheet for unmarried You add the Income available Line J to the assets Line Q and place sum in Line R And compare it to the figure on Line S which is the nursing facility cost for 135 days + MA asset limit - 7/1/13 $25,881

AC Monthly Fees – Cost Sharing

Fees are used to help fund the program Fees are based on income and assets;

sliding fee scale-0%, 5%,15% or 30% of the cost of AC services

Dollar amounts and effective date of fees are entered into the service agreement MMIS screen when a client enters the AC Program, even if the amount due is $0;

All Alternative Care services shall be included in the estimated costs for the purpose of determining the fee.

See Bulletin 12-25-05 for detailed information on AC Fees

AC Monthly Fees

• *Income minus recurring and predictable medical expenses

Client Income* Gross Assets

Monthly Fee

Income<100% FPG($958) and

<$10,000 $0

Income>=100% ($958) and <150% FPG ($1437) and

<$10,000 5% cost of AC Services

Income>=150%($1437) and <200% FPG ($1915) and

<$10,000 15% cost of AC Services

Income >=200% FPG ($1915) OR

>=$10,000 30% cost of AC Services

• 20

AC Monthly Fees – Cost Sharing

Case Managers can change fees on the service agreement for the following month:

If there is a change in condition which results in a change in the cost of services;

If there is a change in the adjusted income or assets;

A client enters a nursing facility as an admission for more than 30 days

Over Due Fees

Case managers need to work with clients and their families to make arrangements to pay overdue fees (including a partial payment plan); however clients be ineligible for the AC Program after 60 days of nonpayment of fees.

Eligibility may be extended while making arrangements to pay outstanding fees

256B.0913 Subdivision 4

Fees may be waived if: A person is residing in a NF and receiving case

management only A married couple is requesting an asset assessment

under the spousal impoverishment provision A person is eligible for AC but has not received any

services A person has chosen CDCS for which the cost of

services is not greater than the cost of services minus the monthly fee that would otherwise be assessed

Income and assets determine that the fee can be waived The client is on temporary AC

The AC waiver reason is identified on the screening document

AC Program Eligibility Worksheet

Financial worksheet requires the applicant’s signature

Applicant understands that everything is true and correct

They understand estate claim information – form DHS 5186

Resources

Libby Rossett-Brown Elderly Waiver/Alternative Care Program Administrator

651-431-2569 [email protected]

County’s Social Service Department County’s Income Maintenance Department

AC Operations Questions: Gail Carlson 651-431-2586

[email protected]