560           HOME AND COMMUNITY-BASED (HCB) WAIVER SERVICES

560 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 (DPA), determines categorical and financial Medicaid eligibility;

2. Division of Senior and Disability Services (DSDS), also referred to as the waiver managing agency, performs the level-of-care (LOC) assessment with the assistance of private care coordinators and approves or denies all applicants for services under the appropriate HCB waiver; and

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

560 B.       HCB WAIVER TYPES

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

1. Children with Complex Medical Conditions (CCMC):  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 (IDD):  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 (APDD):  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 (ALI) (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.

5. Individualized Supports (IS):  This waiver is for a child or adult with intellectual and developmental disabilities that meets an ICF/IDDIntermediate Care Facility for the Intellectually Developmentally Disabled level of care who can be supported safely in a non-residential community setting with less intensive supports than those offered under the IDDIndividuals with Intellectual and Developmental Disabilities waiver.

Note:

Alaska is also implementing the Community First Choice (CFC) Program. The CFCCommunity First Choice Program allows Alaska to cover a range of home and community based services under its State Plan, rather than a waiver. CFCCommunity First Choice services include targeted case management, chore, personal care services, enhanced personal care services, lifeline installation, and lifeline monthly services.

To receive CFCCommunity First Choice services, the individual must qualify for Medicaid as determined by DPADivision of Public Assistance and meet a qualifying level of care as determined by SDSSenior Disability Services.

Since CFCCommunity First Choice services are not waiver services, DPADivision of Public Assistance will not need to utilize special coding in EISEligibility Information System to show that an individual is eligible for these additional State Plan services. When SDSSenior Disability Services determines that an individual is eligible for CFCCommunity First Choice services, DHCSDivision of Health Care Services will track eligibility in MMISMedicaid Management Information System.

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 Disabilities 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 TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248).  See MS 533.

560 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, IDDIndividuals with Intellectual and Developmental Disabilities, and IS -- any eligibility category (e.g., MAGIModified Adjusted Gross Income, SSISupplemental Security Income Recipients, Special LTCLong Term Care, TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248, etc.).

• APDDAdults with Physical Developmental Disabilities -- any eligibility category (e.g., MAGIModified Adjusted Gross Income, Breast and Cervical Cancer Medicaid, SSISupplemental Security Income Recipients, APAAdult Public Assistance Recipients, Special LTCLong Term Care, etc.).  Note: CAMAChronic & Acute Medical Assistance is not a Medicaid eligibility category.

• ALIAlaskans Living Independently) -- (formerly known as ODAOlder or Disabled Adults)-- any eligibility category if the recipient is over the age of 21 (e.g., MAGIModified Adjusted Gross Income, Breast and Cervical Cancer Medicaid, SSISupplemental Security Income Recipients, APAAdult Public Assistance Recipients, Special LTCLong Term Care, etc.).  Note: CAMA is not a Medicaid eligibility category.

2. Is determined by DSDSDivision of Senior and Disabilities 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 Disabilities Services as the individual with the highest priority of those who are waiting for services under the relevant HCBHome and Community-Based waiver.

560 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 Disabilities 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 Disabilities 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 Support Plan.

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 Disabilities 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 DSDSDivision of Senior and Disabilities Services prioritized waiting list, determine regular Medicaid eligibility in another eligibility category.  This may require making a referral to the TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 category or providing the applicant with information about establishing a Medicaid qualifying trust.

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

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

560 E.       HCB WAIVER REFERRALS AND INTERAGENCY COMMUNICATIONS

Refer a Medicaid applicant or recipient to DSDSDivision of Senior and Disabilities Services 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 Aging and Disability Resource Center contact number at 1-877-625-2372 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 IDDIndividuals with Intellectual and Developmental Disabilities waivers will already be receiving services from DSDSDivision of Senior and Disabilities Services, and DSDSDivision of Senior and Disabilities Services will notify the DPADivision of Public Assistance caseworker.  If no Medicaid application is on file, email DSDSDivision of Senior and Disabilities Services informing them that a Medicaid application is needed.  

With the assistance of a care coordinator agency, DSDSDivision of Senior and Disabilities Services determines whether the individual meets the requirements for HCBHome and Community-Based waiver services.  DSDS 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 Disabilities Services denies a request for HCBHome and Community-Based waiver services, the DPADivision of Public Assistance LTCLong Term Care 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 Disabilities Services, the individual is given a Medicaid application and referred to DPADivision of Public Assistance.

If an individual already has an open Medicaid case (Eligibility Code 11, 20, 24, 50, 51, 52, 54, and 69), there is no need to issue a waiver screening or disability determination screening coupon.  Medicaid will pay these expenses without a special screen coupon.

For a Medicaid applicant or an individual receiving Medicaid with a different Eligibility code than listed above, a DE 25 coupon needs to be issued if the individual needs a disability determination and a WD 19 coupon needs to be issued if the individual needs a waiver screening.  The screening coupon must be issued on a separate Medicaid case number.

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. DPA must have a signed release of information prior to sharing any notices or case information with the Care Coordinator.

560 F.       HCB WAIVER SERVICES AND INSTITUTIONAL ELIGIBILITY

For the purpose of determining 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 (Section 553), Transfer of Assets (Section 554), and Post-Eligibility (Section 570), also apply to individuals receiving HCBHome and Community-Based waiver services.