826           HOME AND COMMUNITY BASED (HCBHome and Community Based) WAIVER SERVICES

826 A.      GENERAL PROVISIONS - HCBHome and Community Based WAIVER SERVICES

An individual who needs the level of medical care typically provided in a long-term care facility, such as a nursing home, may qualify for special health related services Medicaid normally does not cover. These services are provided in the home or in a community setting and are intended to provide enough additional help that the individual can continue to live in his or her home. These additional services are available only because the federal government has waived regular Medicaid coverage rules.  

Administering HCBHome and Community Based waivers is an interagency effort that involves the following agencies:

1)  Division of Public Assistance (DPADivision of Public Assistance) determines categorical and financial Medicaid eligibility;

2)  Division of Senior and Disability Services (DSDSDivision of Senior and Disability Services), also referred to as the waiver managing agency, performs the level-of-care (LOCLevel of Care) assessment with the assistance of private care coordinators and approves or denies all applicants for services under the appropriate HCBHome and Community Based waiver; and

3)  Division of Health Care Services (DHCSDivision of Health Care Services) processes and pays Medicaid claims submitted by a provider.

4)  Aging and Disability Resource Center (ADRCAging and Disability Resource Center) assists with providing a list of care coordinators.

826 B.      HCBHome and Community Based WAIVER TYPES

There are four HCBHome and Community Based Waivers approved for Alaska, each designed to serve a specific group of individuals:

1)  Children with Complex Medical Conditions (CCMCChildren with Complex Medical Conditions):  This waiver is for a child through age 21 who requires a level of care provided by a hospital or nursing facility.

2)  Individuals with Intellectual and Developmental Disabilities (IDDIntellectually Developmentally Disabled):  This waiver is for a child or adult that requires a level of care provided by an intermediate care facility for those with intellectual and developmental disabilities.

3)  Adults with Physical and Developmental Disabilities (APDDAdults with Physical and Mental Disabilities):  This waiver is for an individual age 21 and over who is both physically and developmentally disabled, that requires a level of long-term care provided by a nursing facility

4)  Alaskans Living Independently (ALIAlaskans Living Independently) (formerly known as ODA - Older and Disabled Adults): This waiver is for a disabled adult over 21 that requires a level of long term care provided by a nursing facility or adults age 65 and over that require a level of long term care provided by a nursing facility.

Transfer from one waiver classification to another because of age is not automatic (i.e., a CCMCChildren with Complex Medical Conditions child turning 22 is not automatically placed under the ALIAlaskans Living Independently waiver). Program specialists within DSDSDivision of Senior and Disability Services will work together to make the appropriate transfer and notify DPADivision of Public Assistance of the change.

Note:

A child who requires an institutional level of care but does not receive institutional or special HCBHome and Community Based waiver services may qualify for Medicaid under the Disabled Child at Home category (also known as TEFRA). See MS ADLTC 533.

826 C.      ELIGIBILITY FOR HCBHome and Community Based WAIVER SERVICES

Medicaid covers HCBHome and Community Based waiver services if the individual:

1)  Is eligible for an allowable Medicaid category under the relevant waiver as follows:

• CCMCChildren with Complex Medical Conditions and IDDIntellectually Developmentally Disabled -- any eligibility category (e.g., MAGIModified Adjusted Gross Income Medicaid, SSISupplemental Security Income Recipients, Special LTC, TEFRADisabled Child at Home, etc.).

• APDDAdults with Physical and Mental Disabilities -- any eligibility category (e.g., MAGIModified Adjusted Gross Income Medicaid, SSISupplemental Security Income Recipients, Special LTC, TEFRADisabled Child at Home, etc.).  Note: CAMAChronic and Acute Medical Assistance is not a Medicaid eligibility category.

• ALIAlaskans Living Independently -- -- any eligibility category if the recipient is over the age of 21 (e.g., MAGIModified Adjusted Gross Income Medicaid, SSISupplemental Security Income Recipients, Special LTC, TEFRADisabled Child at Home, etc.). Note:  CAMAChronic and Acute Medical Assistance is not a Medicaid eligibility category.

2)  Is determined by DSDSDivision of Senior and Disability Services to meet the appropriate level of care criteria;

3)  Is not under a penalty for transferring assets for less than fair market value; and

4)  Has been identified by DSDSDivision of Senior and Disability Services as the individual with the highest priority of those who are waiting for services under the relevant HCBHome and Community Based waiver.

826 D.      LIMITATIONS ON THE NUMBER SERVED

Even if an individual qualifies for HCBHome and Community Based waiver services, the services may not always be available. Each waiver has a limit on how many people it can serve. When the limit is reached, DSDSDivision of Senior and Disability Services will prioritize the needs of applicants waiting for HCBHome and Community Based waiver services. When services under a specific waiver become available again, DSDSDivision of Senior and Disability Services will select the next person with the highest need for services and begin the process of making a level of care determination and developing a plan of care.

Some applicants may be financially eligible for Medicaid only under the Special Long Term Care LTC) eligibility category. The applicant needs DSDSDivision of Senior and Disability Services approval for HCBHome and Community Based waiver services documenting they meet the categorical requirement of needing an institutional level of care. When an applicant is placed on a DSDS prioritized waiting list, determine regular Medicaid eligibility in another eligibility category. This may require making a referral to the TEFRADisabled Child at Home category or providing the applicant with information about establishing a Medicaid qualifying trust.

If there is no eligibility for an individual in another category of Medicaid, deny the application and notify DSDSDivision of Senior and Disability Services of the denial.

Some applicants may be accessing non-Medicaid services from DSDSDivision of Senior and Disability Services, who have never applied for Medicaid. When DSDSDivision of Senior and Disability Services selects that person from the prioritized waiting list, DSDS will instruct the individual to apply for Medicaid and notify DPADivision of Public Assistance that a level of care assessment is beginning.

826 E.      HCBHome and Community Based WAIVER REFERRALS AND INTERAGENCY COMMUNICATIONS

Refer a Medicaid applicant or recipient to ADRCAging and Disability Resource Center if they are interested in receiving waiver services. When a Medicaid applicant or recipient expresses interest in receiving waiver services and does not have an assigned care coordinator, provide the ADRCAging and Disability Resource Center contact numbers at (907) 343-7770 or toll free at 1-877-625-2372, and instruct the person or guardian to contact  for names of care coordination agencies in the person's community. In most instances, an individual seeking HCBHome and Community Based services under the CCMCChildren with Complex Medical Conditions and IDDIntellectually Developmentally Disabled waivers will already be receiving services from DSDSDivision of Senior and Disability Services, and DSDS will notify the DPADivision of Public Assistance eligibility office. If no Medicaid application is on file, email DSDSDivision of Senior and Disability Services informing them that a Medicaid application is needed.

With the assistance of a care coordinator agency, DSDSDivision of Senior and Disability Services determines whether the individual meets the requirements for HCBHome and Community Based waiver services. DSDSDivision of Senior and Disability Services will email DPADivision of Public Assistance when an individual is determined eligible for HCBHome and Community Based services under a specific HCBHome and Community Based waiver and if that waiver’s limit is reached. When DSDSDivision of Senior and Disability Services denies a request for HCBHome and Community Based waiver services, the DPADivision of Public Assistance LTC Unit receives a copy of the denial letter and takes the appropriate case actions.

When an individual is not a Medicaid recipient and requests HCBHome and Community Based waiver services from DSDSDivision of Senior and Disability Services, the individual is given a Medicaid application and referred to DPADivision of Public Assistance.

Medicaid pays the expense of assessing eligibility for HCBHome and Community Based services. The regular Medicaid coupon is used for ongoing Medicaid recipients. For an applicant, issue a non-standard Recipient Identification Card. See section 805-A (2).

Note:

Copy the client’s care coordinator with all EISEligibility Information System notices sent to an HCBHome and Community Based waiver services applicant or recipient. DPADivision of Public Assistance must have a signed release of information prior to sharing any notices or case information with the Care Coordinator.

826 F.      HCBHome and Community Based WAIVER SERVICES AND INSTITUTIONAL ELIGIBILITY

For the purpose of determining MAGIModified Adjusted Gross Income Medicaid eligibility, an individual receiving HCBHome and Community Based waiver services is considered to be institutionalized. Policy applicable to institutionalized individuals, such as Preventing Spousal Impoverishment (ADLTC MS 553), also apply to individuals receiving HCBHome and Community Based waiver services.

Note:

Although there is no resource test for MAGIModified Adjusted Gross Income Medicaid eligibility, if a MAGIModified Adjusted Gross Income Medicaid applicant or recipient needs institutionalization or HCBHome and Community Based waiver services, DPADivision of Public Assistance must complete a 5 year look back as outlined in ADLTCAdult Disabled and Long Term Care MS 554(D) to ensure that a non-allowable transfer has not occurred. If it has, a TOATransfer of Assets penalty must be applied. 

826 G.     PROCESSING HCBHome and Community Based WAIVERS AND EISEligibility Information System CODES

Refer to ADLTC MS 560 for the Medicaid screening coupon process, ADLTC MS 561 for EISEligibility Information System HCBHome and Community Based Codes, and ADLTC MS 562 for processing HCBHome and Community Based waiver cases.