562           PROCESSING HCBHome and Community-Based WAIVER CASES

A recipient in many Medicaid eligibility categories may receive HCBHome and Community-Based waiver services.  In most cases, it is appropriate for an applicant of HCBHome and Community-Based waiver services to be referred to the DDSDisability Determination Service for a disability determination.  See APA Manual Section 425 and Administrative Procedures Manual Section 115-9.  More liberal income requirements usually apply to disability-related Medicaid eligibility categories.  It can work to the recipient’s advantage to have Medicaid eligibility based upon disability.  Eligibility for HCBHome and Community-Based waiver services must not be delayed because of a pending disability determination if eligibility for Medicaid can be found in a non-disability eligibility category recognized by the relevant waiver.  For example, eligibility for MAGIModified Adjusted Gross Income Medicaid may work for an individual waiting for the disability determination needed to qualify for HCBHome and Community-Based services under the ALIAlaskans Living Independently) waiver.

562 A.      MAGIModified Adjusted Gross Income WAIVER CASES

For a MAGIModified Adjusted Gross Income case, for an adult or child that has HCBHome and Community-Based waiver services approved, you can add the waiver code to the MAGIModified Adjusted Gross Income case.  MAGIModified Adjusted Gross Income cases do not impose cost of care liability.  If the MAGIModified Adjusted Gross Income Medicaid recipient reports that they will be considered disabled for more than 12 months or it is determined that their MAGIModified Adjusted Gross Income Medicaid eligibility is expected to end within the current certification period, refer the recipient to SSISupplemental Security Income or DDSDisability Determination Service for a disability decision.  If the MAGIModified Adjusted Gross Income recipient does not pursue this disability determination, their case will continue.  If their case closes for other reasons and they do not have a disability decision in place, they will need to reapply for Medicaid.

The LOCLevel of Care determination for an HCBHome and Community-Based waiver services recipient must be reviewed every year.  The health condition of an HCBHome and Community-Based waiver recipient may improve to the point that may no longer meet an institutional LOCLevel of Care.  DSDSDivision of Senior and Disabilities Services will send a copy of the LOCLevel of Care denial letter to the DPADivision of Public Assistance LTCLong Term Care team.  When notified of a LOCLevel of Care denial and Medicaid eligibility is still approved, end the persons eligibility for HCBHome and Community-Based waiver services by removing the waiver coding on the MEREMedical Reference screen.  Send notice M716, Long Term Care Ends-Medicaid coverage will continue.  If both the LOCLevel of Care is denied and there is no eligibility in a category of Medicaid, send the appropriate notice of the Medicaid and waiver closure.

562 B.      APAAdult Public Assistance RELATED MEDICAID OR LTCLong Term Care MEDICAID WAIVER CASES

For ongoing SSISupplemental Security Income children, TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 and Adults receiving APAAdult Public Assistance-related Medicaid these cases do have a transfer of asset penalty and cost of care liability so the ET will have to send the Medicaid Transfer of Asset Declaration M723 or MED 3 to the recipient for completion, if they haven't already provided verification.  When the LOCLevel of Care or Support Plan are approved from DSDSDivision of Senior and Disabilities Services convert the case to waiver.  If a TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 child is approved waiver, notify Comagine Health at AKTefra-Waiver@Qualishealth.org that the HCBHome and Community-Based waiver services are approved.

562 C.      NEW APPLICANT FOR MEDICAID PENDING DDSDisability Determination Service & WAIVER

Check eligibility under all Medicaid categories.  If there is no eligibility under a Medicaid category and if the applicant doesn't have a disability determination, a state only determination will be needed.  Complete the financial eligibility determination.  This may include informing the applicant of the need to spend down resources, establish a Qualifying Income Trust, etc.  Pend the case for the required forms to pursue a DDSDisability Determination Service determination, refer the applicant to DSDSDivision of Senior and Disabilities Services for a HCBHome and Community-Based waiver services eligibility determination and care coordinator arrangements.  If financial eligibility cannot be established or if the DDSDisability Determination Service determination is a denial of disability, deny the Medicaid application and notify DSDSDivision of Senior and Disabilities Services so they can stop processing the request for HCBHome and Community-Based waiver services.  If the client requests a fair hearing due to DDSDisability Determination Service denial, notify DSDSDivision of Senior and Disabilities Services that the DDSDisability Determination Service denial is being appealed and waiver processing should continue.  If financial eligibility is determined and finding a disability is made, (if needed), keep the case in pended status until DSDSDivision of Senior and Disabilities Services has approved HCBHome and Community-Based waiver services.  If DSDSDivision of Senior and Disabilities Services approves HCBHome and Community-Based waiver services, authorized Medicaid.  If DSDSDivision of Senior and Disabilities Services denies HCBHome and Community-Based waiver services and there is no other category they are eligible for, deny the Medicaid case.  Check to see if the client would be eligible for regular APAAdult Public Assistance related Medicaid category with the use of a trust in place.

562 D.      HCBHome and Community-Based WAIVER CASES WITH TITLE IV-E ELIGIBLE INDIVIDUALS

When a Title IV-E eligible child in state protective custody is approved for HCBHome and Community-Based waiver services you must notify the OCSOffice of Children's Services case worker of the HCBHome and Community-Based waiver approval.  Send the MED 1, MED 2 and MED 3 forms for the OCSOffice of Children's Services caseworker to complete.  Once the appropriate HCBHome and Community-Based waiver code is added to the MEREMedical Reference screen and CANOCase Notes is done notify the OCSOffice of Children's Services caseworker that the case has been updated.  The OCSOffice of Children's Services caseworker will continue to maintain the case and original case file.  Keep track of the review dates for these cases and check after each renewal month to ensure that the child is still eligible for HCBHome and Community-Based waiver and the codes are correct.

562 E.    HCBHome and Community-Based WAIVER CASES FOR A PERSON WHO HAS NO OPEN MEDICAID CASE

When notified by DSDSDivision of Senior and Disabilities Services that a LOCLevel of Care determination is pending and a support plan is in development for a person who has no current Medicaid involvement and that the person will have to apply for Medicaid.  Send the application, either GEN 50C or MED 4 and corresponding forms to the person.  Add the individual to a tickler file of the other individuals who are in the process of getting LOCLevel of Care determination or awaiting completion of a support plan.  If the forms are returned, determine eligibility for any category they are eligible for.  If the forms are not returned, notify DSDSDivision of Senior and Disabilities Services there is no eligibility for Medicaid because they didn't apply.

562 F.   HCBHome and Community-Based WAIVER CASES FOR A WOMAN RECEIVING BREAST AND CERVICAL CANCER MEDICAID  (LADIES FIRST)

HCBHome and Community-Based waiver services can be added to Breast and Cervical Cancer cases, they do not need a disability determination.  For recipients who appear financially eligible for APAAdult Public Assistance-related or LTCLong Term Care Medicaid, the caseworker should recommend, but cannot require, that she pursue a disability determination so that when treatment ends and eligibility has ended under the BCCBreast and Cervical Cancer category, the woman can be transitioned to those Medicaid eligibility categories.

562 G.    FAIR HEARINGS

An applicant or recipient of HCBHome and Community-Based waiver services who has been denied LOCLevel of Care may request a fair hearing.  The Division of Health Care Services represents the state for these hearings.