Expanding Foundations: Long-Term Care

Transcription

1 Expanding Foundations: Long-Term Care Participant Guide 7800 E Orchard Road, Suite 280 Greenwood Village, CO 80111

2 Welcome Course Modules Group Expectations/Housekeeping Notes: Introductions Notes: Page 1 of 163

3 Long-Term Care Overview Objectives: After this module, participants will: Identify populations served by LTC medical assistance Recognize LTC waivers and their meanings Compare coverages of LTC waivers vs. general Medicaid Goal: To gain insight into what LTC Medicaid is Page 2 of 163

4 What is Long-Term Care? Long-Term Care covers a series of programs that provide medical care and non-medical support to those with a chronic illness or disability who need ongoing assistance with daily living activities. These programs expand eligibility criteria for targeted populations and include all coverages of traditional Medicaid. They can also provide additional services related to the individual s needs in order to provide an alternative to institutionalization. These services include: Services in the home Services in the community Services in assisted living Services in a nursing facility We will organize these programs into three categories for the purposes of learning (and later you will see patterns in CBMS data entry.) 30-day hospital stay For disabled persons Requires 30-day consecutive stay in a medical institution, nursing facility Nursing Facility Nursing home stays Covers the costs of care above the capabilities of the recipient HCBS Home and Community Based Services Provides services in home to prevent institutionalization (as a cost efficiency) Many different HCBS waivers related to condition and needs Page 3 of 163

5 HCBS Waivers What are waivers? Home and Community Based Services (HCBS) waivers are optional programs created by the State Legislature and approved by the Federal Government (Centers for Medicare & Medicaid Services). They allow the state to waive certain eligibility requirements for targeted populations and provide additional services in order to provide an alternative to institutionalization. Case Management Agencies (CMAs) determine a members level of care eligibility, manage waiver enrollments (some waivers are waitlisted), provide specific coverage details, and provide ongoing support to the member. As an eligibility worker, you will receive notification of the Case Management Agency findings for eligibility and CBMS data entry. The following outlines available waivers and coverages; they are for supplemental information only. You will not need to know specific coverages and should defer such questions to the applicant s Case Management Agency case manager. Adult Waivers HCBS-BI HCBS-CMHS HCBS-EBD HCBS-SCI HCBS-SLS HCBS-DD HCBS Waiver for Persons with Brain Injury Community Mental Health Supports Waiver HCBS Waiver for Persons who are Elderly, Blind, Disabled, living with HIV/AIDS HCBS Waiver for Persons with Spinal Cord Injury Supported Living Services Waiver Waiver for Persons with Developmental Disabilities Notes: Page 4 of 163

6 HCBS Waiver for Persons with Brain Injury (HCBS-BI) Functional Eligibility Home or community based alternative to hospital or specialized nursing facility care Age 16+ Brain injury as defined in the Colorado Code of Regulations Meets nursing facility or hospital level of care Enrollment cap: None Waiver services: Adult Day Services Consumer Directed Attended Support Services (CDASS) Specialized Medical Equipment and Supplies Behavioral Management Day Treatment Home Modifications Mental Health Counseling Non-medical Transportation Personal Care Respite Care Substance Abuse Counseling Supported Living Program Transitional Living Personalized Emergency Response System Case Management through Single Entry Point (SEP) agencies State Website: State Contact: Diane Byrne HCPF-LTSS C.R.S , as amended; 42 C.F.R HCPF 10.C.C.R , Section Notes: Page 5 of 163

7 Community Mental Health Supports Waiver (HCBS-CMHS) Functional Eligibility Home or community based alternative to nursing facility care Age 18+ Major mental illness diagnosis as defined in the Colorado Code of Regulations Meets nursing facility level of care Enrollment cap: None Waiver services: Adult Day Services Alternative Care Facilities Consumer Directed Attended Support Services (CDASS) Personal Emergency Response System Home Modifications Homemaker Services Non-medical Transportation Personal Care Respite Care Case Management through Single Entry Point (SEP) Agencies State Website: State Contact: Cassandra Keller HCPF-LTSS C.R.S , as amended; 42 C.F.R HCPF 10.C.C.R , Section Notes: Page 6 of 163

8 HCBS Waiver for Elderly, Blind, and Disabled (HCBS-EBD) Functional Eligibility Home or community based alternative to nursing facility care Age 18+ Functional impairment (aged 65+) or blind or physically disabled persons (age 18-64), or persons with HIV/AIDS Meets nursing facility level of care Enrollment Cap: None Waiver services: Adult Day Services Alternative Care Facilities Community Transition Services Consumer Directed Attended Support Services (CDASS) Personalized Emergency Response System Home Modifications Homemaker Services In-Home Support Services (IHSS) Non-medical Transportation Personal Care Respite Care Case Management through Single Entry Point (SEP) Agencies State Website: State Contact: Lana Eggers HCPF-LTSS C.R.S , as amended; 42 C.F.R HCPF 10.C.C.R , Section Notes: Page 7 of 163

9 HCBS Waiver for Persons with Spinal Cord Injury (HCBS-SCI) Functional Eligibility Home or community based alternative to hospital or nursing facility care Age 18+ Spinal cord injury as defined in the Colorado Code of Regulations Meets hospital or nursing facility level of care Enrollment Cap: None Available in Denver Metro Area only Waiver services: Adult Day Services Alternative Therapies Consumer Directed Attended Support Services (CDASS) In-Home Support Service (IHSS) Personalized Emergency Response System Home Modifications Homemaker Services Non-medical Transportation Personal Care Respite Care Case Management through Single Entry Point (SEP) Agencies State Website: State Contact: Lindsay Westlund HCPF-LTSS C.R.S , as amended; 42 C.F.R HCPF 10.C.C.R , Section Notes: Page 8 of 163

10 Supported Living Services Waiver (HCBS-SLS) Functional Eligibility Home or community based alternative to an intermediate care facility Age 18+ Developmental disability as defined in the Colorado Code of Regulations Meets the Intermediate Care Facility (ICF) level of care Enrollment cap: 3,012 Waiver services: Assistive Technology Behavioral Services Day Habilitation Services Dental Services Supported Employment Prevocational Services Home Modifications Homemaker Services Mentorship Personal Care Services Personalized Emergency Response System (PERS) Professional Services Respite Services Specialized Medical Equipment & Supplies Transportation Vehicle Modifications Vision Services Case Management through Community Centered Boards (CCBs) State Website: State Contact: Adam Tucker HCPF-DIDD C.R.S , as amended; C.R.S , as amended; 42C.F.R HCPF 10.C.C.R , Section ; CDHS 2 CCR Notes: Page 9 of 163

11 Waiver for Persons with Developmental Disabilities (HCBS-DD) Functional Eligibility Home or community based alternative to an intermediate care facility Age 18+ Developmental disability as defined in the Colorado Code of Regulations Meets the Intermediate Care Facility (ICF) level of care Enrollment cap 4,695 Waiver services: Behavioral Services Day Habilitation Dental Services Residential Habilitation Non-Medical Transportation Specialized Medical Equipment and Supplies Supported Employment Vision Services Case Management through Community Centered Boards (CCBs) State Website: State Contact: Joshua Negrini HCPF-DIDD C.R.S , as amended; C.R.S , as amended; 42C.F.R HCPF 10.C.C.R , Section 8.500; CDHS 2 CCR Notes: Page 10 of 163

12 Program of All-Inclusive Care for the Elderly (PACE) PACE is a Medicare and Colorado Medicaid managed care program that provides health care and support services. The goal of PACE is to help frail individuals live in their communities by providing services based upon their needs. Eligibility Age 55+ Meet nursing facility level of care Live in the area of a PACE organization (Adams, Arapahoe, Boulder, Broomfield, Denver, Jefferson, El Paso, Pueblo, Montrose, Delta and Weld counties) Able to live in a community setting without jeopardizing health or safety PACE services: Rehabilitative Therapies Physical, Occupational and Speech Adult Day Health Center Services Transportation to and from Day Center and Medical Appointments Home Care Services Respite Care and Caregiver Education Inpatient and Outpatient Hospital and Emergency Services Mental Health Services Meals and Nutritional Services in the Day Center Durable Medical Equipment and Supplies Case Management through PACE providers Denver Area- Innovage Greater Colorado PACE Boulder/Weld - TRU Community Care/TRU PACE Pueblo- Innovage Greater Colorado PACE El Paso- Rocky Mountain PACE Delta- Senior CommUnity Care/VOANS PACE Montrose- Senior CommUnity Care/VOANS PACE Notes: Page 11 of 163

13 Colorado Choice Transitions (CCT) Colorado Choice Transitions is funded by a Federal grant. The program provides assistance to help Long-Term Care residents relocate into the community using available home and community based services to support the transition. This is not an HCBS waiver, it is a program that provides services above and beyond a waiver s individual coverages. Eligibility Meet LTC requirements Currently reside in a LTC facility for a minimum of 90 consecutive days Able to obtain qualified housing Included waivers: HCBS BI; HCBS CMHS; HCBS DD; HCBS EBD; HCBS SLS Assistive Technology Extended Home Modifications Behavioral Health Support Independent Living Skills Training Caregiver Support Services Intensive Case Management Community Transition Services Mentorship Services Dental Services Enhanced Nursing Services Substance Abuse Counseling Specialized Day Rehabilitation Home Delivered Meals Vision Services Page 12 of 163

14 Participant-Directed Programs Generally, HCBS services are provided through an agency. CDASS (Consumer Directed Attended Support Services) and IHSS (In-Home Support Services) are service delivery options designed to allow HCBS members to direct their support, as opposed to using an agency. More Support More Control Agency IHSS CDASS Selects, schedules and pays providers. You select the provider. Supervise work and direct care (within guidelines) You are the employer. You select, hire and train who you want. You have control over your Medicaid budget. Handles budgeting, billing, employment etc. IHSS employs and pays the provider, handles budgeting, provides backups and support. Support with HR functioning, training, budget compliance. Less Choice More Flexibility Be aware that these options exist for some but not all waivers. Defer specific questions to the appropriate Case Management Agency (CMA). Waivers that offer CDASS: Brain Injury (BI) waiver Community Mental Health Supports (CMHS) waiver Elderly, Blind and Disabled (EBD) waiver Spinal Cord Injury (SCI) waiver Waivers that offer IHSS: Children s Home and Community Based Services (CHCBS) waiver Elderly, Blind, and Disabled (EBD) waiver Spinal Cord Injury (SCI) waiver Page 13 of 163

15 Children s HCBS Waivers CHCBS HCBS-CWA HCBS-CES HCBS-CHRP HCBS-CLLI Children s HCBS Waiver Children With Autism Waiver Children s Extensive Support Waiver Children s Habilitation Residential Program Waiver Waiver for Children with a Life-Limiting Illness Notes: Page 14 of 163

16 Children s HCBS Waiver - (CHCBS) Home or community Medicaid benefits for children who would otherwise be ineligible for Medicaid due to excess parental income and/or resources Birth through age 17 Meet nursing facility or hospital level of care Enrollment cap: None Waiver services: Case Management In-Home Support Services Case Management through approved case management agencies State Website: State Contact: Dennis Roy HCPF-LTSS C.R.S , as amended; 42 C.F.R HCPF 10.C.C.R , Section 8.506; Notes: Page 15 of 163

17 Children with Autism Waiver (HCBS-CWA) Home or community Medicaid benefits for children Birth through age 5 Diagnosed with Autism with intensive behavioral needs Meets Intermediate Care Facility (ICF) level of care Up to 3 years of eligibility on waiver Enrollment cap 75 children Waiver services Behavioral Therapies Case Management through Community Centered Boards (CCBs) State Website: State Contact: Laura Russell HCPF-LTSS C.R.S , as amended HCPF 10.C.C.R , Section Notes: Page 16 of 163

18 Children s Extensive Support Waiver (HCBS-CES) Home or community Medicaid benefits for children Birth through age 17 Children birth through age 4 must have a developmental delay Children age 5-17 must have a developmental disability Meets Intermediate Care Facility (ICF) level of care Enrollment cap: 1,549 Waiver services: Adapted Therapeutic Recreation and Fees Assistive Technology Behavioral Services Community Connector Home Accessibility Adaptations Homemaker Parent Education Personal Care Professional Services Respite Specialized Medical Equipment and Supplies Vehicle Adaptations Vision Therapy Case Management through Community Centered Boards (CCBs) State Website: State Contact: Sheila Peil HCPF-DIDD C.R.S , as amended; C.R.S , as amended; 42 C.F.R HCPF 10.C.C.R , Section Notes: Page 17 of 163

19 Children s Habilitation Residential Program Waiver (HCBS-CHRP) Habilitative services for children and youth Birth through age 20 Children and youth in the custody of the County Department of Human/Social Services, residing in an out-of-home CHRP approved placement with a developmental disability (or delay age 0-4) Meets the nursing facility or hospital level of care Enrollment cap: children Waiver services: Cognitive Services Communication Services Community Connections Emergency Services Personal Assistance Self-Advocacy Supervision Services Travel Services Case Management through County Dept. of Human/Social Services State Website: State Contact: Nancy Harris DHS C.R.S (1) (1995 Supp); C.R.S (11) (1995 Supp) DHS, CWS, 10.C.C.R Section Notes: Page 18 of 163

20 Children with a Life-Limiting Illness Waiver (HCBS-CLLI) Medicaid benefits for children and youth with a life limiting illness, allows the family to seek curative treatment concurrently while the child is receiving palliative hospice care Birth through age 18 Meet the hospital level of care Enrollment cap: 200 Waiver services: Counseling and Bereavement Services Expressive Therapy Palliative and Supportive Care Respite Care Case Management through Single Entry Point Agencies (SEPs) State Website: State Contact: Laura Russell HCPF-LTSS C.R.S , as amended HCPF 10.C.C.R. 2505, Section Notes: Page 19 of 163

21 Nursing Facility Care Long-Term Care includes coverage for nursing facilities. Medicaid covers the difference between the actual nursing facility cost and what the member s income will be able to cover. Regional average pay rates are used to set the maximum LTC income limit average monthly private pay rates: Statewide Region I Region II Region III Region IV $7,828 $8,940 $8,095 $7,605 $6,674 Which region are you located in: REGION I: (Adams, Arapahoe, Boulder, Broomfield, Denver, and Jefferson) REGION II: (Cheyenne, Clear Creek, Douglas, Elbert, Gilpin, Grand, Jackson, Kit Carson, Larimer, Logan, Morgan, Park, Phillips, Sedgwick, Summit, Washington, Weld, Yuma) REGION III: (Alamosa, Baca, Bent, Chaffee, Conejos, Costilla, Crowley, Custer, El Paso, Fremont, Huerfano, Kiowa, Lake, Las Animas, Lincoln, Mineral, Otero, Prowers, Pueblo, Rio Grande, Saguache, Teller) REGION IV: (Archuleta, Delta, Dolores, Eagle, Garfield, Gunnison, Hinsdale, La Plata, Mesa, Moffat, Montezuma, Montrose, Ouray, Pitkin, Rio Blanco, Routt, San Juan, San Miguel) Page 20 of 163

22 Overview Wrap-Up Goal: To gain insight into what LTC Medicaid is Can you? Identify populations served by LTC medical assistance Recognize HCBS waivers and their meanings Compare coverages of HCBS waivers vs. general Medicaid Page 21 of 163

23 Eligibility Overview Objectives: After this module, participants will: Goal: To gain basic knowledge of LTC eligibility requirements List eligibility components for Long-Term Care Programs Identify the stakeholder responsible for determining each eligibility component Be able to determine the date of initial eligibility when financial, level of care, and disability criteria are met Vocabulary and Acronyms CCB: Community Centered Board ICF: Intermediate Care Facility NF: Nursing Facility SEP: Single Entry Point Agency CMA: Case Management Agency Page 22 of 163

24 Long-Term Care Eligibility After meeting the General Eligibility requirements for Medicaid (Citizenship, Identity, and Residency), Long-Term Care applicants must meet three additional criteria to be eligible for LTC services. Financial Eligibility Applicant Level of Care Disability Page 23 of 163

25 Level of Care Level of Care is determined by Hospitalization time or by a Case Management Agency (more on this later). These agencies also provide ongoing case management for waiver services and are the primary point of contact that your Medicaid member will interact with. Level of Care You may go to and locate your county s Single Entry Point Agency and write their contact info here: Name: Address: Phone: Single Entry Points (SEPs) Fax: Now find your county s Community Centered Board at and write their contact info here: Name: Address: Phone: Community Centered Boards (CCBs) Fax: Notes: Page 24 of 163

26 Disability Disability can be established in a number of ways: Being age 65 or older for the timeframe in which coverage is requested. Disability Age 65+ Or A Social Security determination of Disabled Social Security Or, if neither of these are met A determination can be made by our State contractor Name: Arbor E&T, Action Review Group Address: P.O Box 340 Olyphant PA Phone: (877) State Contractor Fax: (877) actionreviewgroupmrt@arboret.com Notes: Page 25 of 163

27 Financial Eligibility: Eligibility workers collect verifications of Level of Care and Disability as well as conduct a review of the member s finances to ensure financial eligibility is met. Specific financial guidelines will be reviewed in a future module but include: 1. Income 2. Resources 3. An audit for transferred assets Financial Eligibility Once the eligibility worker can verify that general, financial, level of care, and disability are met, an initial eligibility date can be set and coverage can begin. Eligibility Worker Notes: Income and Resources Page 26 of 163

28 AGE 65+ or Determined Disabled by Social Security? Check for existing disability determination Submit disability app. If needed Disability Determinations Arbor E&T State Disability Contractor Eligibility Worker Financial Determination Level of Care referrals (DSS-1) Notice of Approval and Income or Denial (DSS-1) Application notices Level of Care Determination (LOC cert) Case Management Agency (CMA) Upon approval, services are managed through CMA Administration of Waiver Services Page 27 of 163

29 Eligibility Begin Date Eligibility begins on the date the applicant/member meets all three eligibility criteria (the latter of all three dates). Retro Medicaid coverage can be applied 90 days prior to application, but the applicant must meet ALL ELIGIBLITY CRITERIA for those months. Let s take a look at some examples: A member applies on 10/15/20XX, on 12/02/20XX you note that they have: Been receiving SSDI benefits since 06/01/2013 Presented verification that financial eligibility has been met since 10/01/20XX Met HCBS-EBD Level of Care as of 11/28/20XX What is the first day that the member can be covered for LTC services? A member applies on 11/02/20XX. On 11/03/20XX you note that they have: Been age 65 since 12/14/2015 Presented verification that financial eligibility has been met since 10/01/20XX Met HCBS-NF Level of Care as of 09/02/20XX What is the first day that the member can be covered for LTC services? A member applies on 11/23/20XX. On 12/03/20XX you note that they have: Disability Onset of 01/23/2017 Presented verification that financial eligibility has been met since 09/01/20XX Been hospitalized since 10/18/20XX What is the first day that the member can be covered for LTC services? Page 28 of 163

30 Overview Wrap-Up QA Knowledge Check Goal: To gain basic knowledge of LTC eligibility requirements Can you? List eligibility components for Long-Term Care Programs Identify the stakeholder responsible for determining each eligibility component Determine the date of initial eligibility when given that financial, level of care, and disability are met Page 29 of 163

31 Level of Care Goal: To gain further understanding of Level of Care, and the associated business processes to meet this requirement Objectives: After this module, participants will be able to: Perform data entry on the Level of Care Summary page in CBMS Perform data entry on the Long-Term Care pages in CBMS Read the LOC certification and extract necessary information for eligibility determinations Vocabulary and Acronyms HCBS: Home and Community Based Services NF: Nursing Facility (may be called LTC facility) ICF: Intermediate Care Facility (institution for individuals with intellectual disabilities) ACF: Alternative Care Facility (also referred to as assisted living facility) LOC: Level of Care LOC certificate: Form used to report Level of Care SEP: Single Entry Point CCB: Community Centered Board Spectrum of Care Long-Term Hospital Care Alternative Care Facilities More Skilled Care More Independence Nursing Facilities HCBS In-Home Services Page 30 of 163

32 Level of Care Requirements Level of Care can be met in two ways: By meeting ICF, NF or hospital Level of Care CMAs will conduct the assessment. By being in a medical institution for at least 30 consecutive days Considered hospital Level of Care for entirety of hospital stay once 30 days are met (or upon death if 30 days would have been required). Can be a combination of Hospital, NF and HCBS if respective assessments are made prior to discharge What do I do? For Nursing Facilities and HCBS, you will send a referral (DSS-1) to the appropriate CMA for every LTC application you receive. The CMA will determine Level of Care, effective date, and waiver type. Within 10 days you will receive a status update or a LOC cert indicating LOC approval/denial, effective date, and waiver type. For 30-day medical, you will need to request and track admission and discharge records to verify 30 consecutive days Notes: Page 31 of 163

33 Level of Care Referrals: CMA referrals should be made timely as they often set the eligibility date. Delays can be costly to the member. Hospital: Discharge planner should make a referral to CMA and have LOC assessed prior to discharge when discharging directly to HCBS/PACE or Nursing Facility. If stay is 30 days or more, Level of Care is considered met until discharge (entirety of stay). If stay is less than 30 days, LTC will not provide coverage unless discharged directly to NF or HCBS (and 30 days are subsequently met). Nursing Facility: Make a referral to SEP for LOC assessment upon admission from community or upon discharge to HCBS or PACE. HCBS/PACE: Eligibility Worker makes referral to CMA when application is received. Page 32 of 163

34 Eligibility Site - SEP/CCB Communication Communication between the Case Management Agency (CMA) and Eligibility Site is required to facilitate the delivery of services to Medicaid members. The Eligibility Site needs LOC assessed to approve benefits, and the CMA cannot initiate services until an approval communication is received from the Eligibility Site. Individual Eligibility Sites and SEPs all have different capabilities and limitations so they set up their own communication processes related to these capabilities and limitations. You will need to check your local process, but in general the following needs to be communicated: Notice of an application (DSS-1) Eligibility Sites will send a referral for a LOC assessment CMAs will enter a PEAK application or send notice that LTC is being requested LOC referral to CMA (Reverse Referral or DSS-1) Includes name, SSN, Address, DOB, phone number, confirmation of application/ltc request receipt CMA may send receipt notice, forward relevant waiver requests to CMA CMA notice of LOC results Denial -> can deny application Approval includes certification, (LOC cert) Waiver type Effective date Eligibility Site notice including (Income Information Sharing Form) Approval, Eligibility Begin Date, Income (sources and amounts) Income used for some waiver service patient payments Denial, with reason. (POI, resources etc.) Applications received through PEAK automatically notify the CMA. Page 33 of 163

35 Long-Term Care Certification A complete LOC assessment is documented here. The form contains the necessary information to perform data entry in CBMS. May not be the start date! (Private pay or Medicare) Applies to 30 day and 5615 s. Informational. Identifies Nursing Facility or Case Management Agency (This may not be the SEP or CCB.) Waiver Type CBMS fields, Start Date is the LOC eligibility date at initial application. Page 34 of 163

36 PEAK LOC Notice Page 35 of 163

37 Data Entry Required LOC pages in CBMS by LTC program 30-Day Med Requires LTC Institution Requires LTC Level of Care NF HCBS Requires LTC Institution Requires LTC Level of Care Requires LTC Level of Care Notes: Page 36 of 163

38 LTC Institution Page The page documents institutionalizations for NF and 30-day cases. Effective Begin Date: App date or retro date at intake. Actual date of change for ongoing. Effective End Date: Will populate when Discharge Date is entered. Institution Name and Per Diem Rate: Informational but required. Per Diem Rate may autopopulate. Admit Date: Actual date of entry. Used to track eligibility dates for NF and 30-day. Discharge Date: Actual date of discharge. Used to track eligibility dates for NF and 30-day. Admitted from home: Adult Financial field to define Personal Needs Allowance eligibility. Consecutive 30 days Death: Overrides 30-day requirement if patient died. Willing to Allocate: No will disallow the Monthly Income Allowance (MIA); Yes' will cap the MIA to the Amount field, blank will allow the full MIA. Spousal Allowance Amount: Use if Minimum Basic Allowance or Minimum Monthly Maintenance Needs Allowance (MMMNA) is increased by court order. Page 37 of 163

39 Name: Select the Institutionalized Individual s name from the drop down. EBD: App date or retro date at intake. Actual date of change for ongoing. Search Icon : Click on this Icon to search for name of the Institution provided. Admit Date: Actual date of entry Discharge Date: Actual date of discharge Page 38 of 163

40 Business Name: Enter the name where the individual resides and click on Search box. Summary: Click on the institution found to highlight the record and select the Detail button. Status and National Provider ID: Ensure that the Status is Active and the ID number is populated and correct. Page 39 of 163

41 Select: Once you have verified that the institution record is valid, highlight the institution record and click on Select. Institution Name: Once you select the institution, the institution name will be populated along with the Per Diem Rate. Per Diem Rate: If this amount is incorrect please update. Complete applicable field within this page and save your updates. Run EDBC and authorize Medical Assistance. Page 40 of 163

42 LTC Level of Care This page in CBMS sets the LTC coverage dates. Pull the information from the LOC certification (ULTC). Effective Begin Date: Opens window, match to Start Date. LOC Type: Waiver on certification, or hospital for 30-day LOC Decision: Select approved, denied, pending Start Date: LOC cert date - determines med span End Date: LOC end date - determines med span Confirmation #: Informational on LOC cert CCT Eligible: This affects services! CCT Yes will be reflected on the LOC cert *RARE* Effective End Date: Do not fill unless ending services or changing programs! But! Be sure to fill when ending services or changing programs. Notes: Page 41 of 163

43 Data Entry Practice Open CBMS and use the forms to complete data entry. When you have finished, you may check the answers on the back. Example: Application Date 12/01/ /13/ /13/2017 Page 42 of 163

44 Page 43 of 163

45 Example: End date your previous records. Now let s try HCBS. The application date is still 12/01/ /24/ /30/2018 Page 44 of 163

46 ***Here HCBS-BI coverage can t begin until 12/24/2017. The member may still be eligible for another MA category prior to 12/24/2017. The case will deny LTC on 12/01/2018 if you do not update this record at RRR. Again, end date this record for your next scenario. Page 45 of 163

47 Example: Application Date 12/01/2017. Nursing Facility 12/28/ /30/2018 Page 46 of 163

48 Save and leave this page in your case. We will use it later. **Do not delete this record to allow for ease of processing when entering TWFCs later. (As they need LOC met.) Page 47 of 163

49 Updating Records or Changing Waivers One Primary MA Category per day CBMS and the Medical Assistance billing system will not allow multiple programs to be active on the same day. This creates an odd situation in which individuals discharging or switching waivers have to be on one program or the other. Let s say an individual leaves a NF on 12/30/2017 and goes to HCBS-BI (on 12/30/2017). Which program should be entered in CBMS on 12/30/2017? Current business processes communicated to all programs give the priority to the new waiver program. In this scenario, the NF will not submit a bill for 12/30/2017. We will end date the NF 12/29/2017 (one day early) and enter a new record starting 12/30/2017. Switching from NF to HCBS On the Insitution Summary page everything is entered as usual. Still use the actual date of discharge for the Discharge Date field (it isn t the field that determines the med span). Saving after entering the Discharge Date will auto-populate the Effective End Date. Page 48 of 163

50 The Level of Care Summary page determines the Med Span. On this page is where a day must be shaved off. Your existing Level of Care Summary page will be populated already. You will need update the End Date as the date prior to discharge. SAVE! Then update the Effective End Date again as the date prior to discharge. Save again. You cannot change both End Dates at the same time. Click to populate the new record. Page 49 of 163

51 You will complete the new record using your new LOC certification, including the Start Date, End Date, Level of Care Type and Confirmation Number. The new LOC cert should have a Start Date that is the same as the NF discharge date. (Talk to your CMA if it is not!) If this scenario happened to be a CCT case you will get a pop-up asking to double check the LOC certification when you change CCT Eligible to Yes. Remember, however, a member is required to be in a facility a minimum of 90 days before eligible to receive CCT. Once you are sure the data entry is correct you can run EDBC, review Wrap-Up, and authorize. The Med Span will show: NF/Hospital 300% Institutionalized - 12/28/2017 through 12/29/2017 The Nursing Facility will not bill the discharge date 12/30/2017. The HCBS provider can. ***This does count as consecutive days for the purposes of 30-day med*** Page 50 of 163

52 Level of Care Goal: To gain further understanding of Level of Care, and the associated business processes to meet this requirement Objectives: Can you? Perform data entry on the Level of Care Institution page in CBMS Perform data entry on the Long-Term Care Level of Care page in CBMS Read the LOC certification and extract necessary information for eligibility determinations Page 51 of 163

53 Financial Eligibility Overview Costs and Considerations Average private pay rate for a nursing facility (monthly): Statewide $7,828 Region I $8,940 Region II $8,095 Region III $7,605 Region IV $6,674 Page 52 of 163

54 Brainstorming The rising cost of high level of care means that even individuals in significantly higher income groups need help with medical expenses. Furthermore, lifetime accumulated assets can be drained quickly. This dynamic creates a new set of considerations in setting eligibility criteria. Consider the motivations and concerns of the four most common stakeholders. Applicant: Spouse: Needs, wants, and motivations regarding income and resources Children: Taxpayer: How do these motivations and concerns change in the following situations? Income Resources High Income High Resources High Income Low Resources Low Income Low Resources Low Income High Resources Page 53 of 163

55 Estate Recovery Medicaid Estate Recovery became a federal requirement for states as part of the Omnibus Budget Reconciliation Act of The goal of the program is to help cover the cost of providing services to Medicaid beneficiaries from the estates of Medical Assistance recipients. Medicaid.Recovery@state.co.us is the unit . The Department may recover payments made for all Medical Assistance paid on behalf of an individual who was institutionalized at the time he/she received Medical Assistance; OR, For persons age 55 at the time they received Medical Assistance, the Department may recover Medical Assistance provided for Nursing Facility care, Home and Community Based Services, and related hospital and prescription drug services. 10 C.C.R , Section Estate recovery applies to members regardless of their category of eligibility and may apply to MAGI members under the circumstances noted above. Page 54 of 163

56 Health Management Systems (HMS) Health Management Systems is a vendor that performs contractual work on behalf of the Department of Health Care Policy and Financing (HCPF). Among other things, HMS handles most Estate Recovery functions. Part of their routine business requires requesting case files from Eligibility Sites to fulfill these duties. As a contracted vendor working on behalf of HCPF, these requests are valid and authorized by the Department and under HIPAA regulations. Eligibility Sites do not need any further permissions or written authorizations to share these casefiles with HMS. Page 55 of 163

57 Spousal Impoverishment In 1988, Congress set up provisions for Medicaid that seek to protect against a healthy spouse becoming impoverished due to a recipient spouse becoming institutionalized. Because of these provisions financial eligibility has different standards when the spouse of the recipient is still in the community. The non-institutionalized spouse is referred to as a Community Spouse (as they remain in the community). The specific protections will be highlighted as we discuss financial eligibility. How do we prevent spousal impoverishment? MA LTC eligibility provides separate eligibility guidelines when there is a Community Spouse to ensure that the spouse s basic needs are met: Monthly Income Allowance (MIA) Reserves income for the Community Spouse Community Spouse Resource Allowance (CSRA) Allows for more assets to be saved for the Community Spouse Consider spouses married until legally separated. Divorce and legal separation of assets are recognized Recognize common-law marriages Page 56 of 163

58 Resources Objectives: Goal: To understand resource eligibility rules and processes as well as the laws and problems that guide them. After this module, participants will be able to: Identify different resource limits for LTC Identify, calculate, and data enter a TWFC/POI Spend down a mock case without a TWFC or private payment by using exempt resources List references to aid in data entry Vocabulary and Acronyms CSRA: Community Spouse Resource Allowance TWFC: Transfer without fair consideration POI: Period of ineligibility Page 57 of 163

59 Resource Overview How resources are evaluated is related to some of the topics we have covered earlier. We will identify these ideas as we continue learning about resource policies. What is and is not recoverable under Estate Recovery Protections against spousal impoverishment Taxpayer interest in ensuring the applicant contributes what they can Allowable use of an applicant s own resources Spousal Protection Taxpayer Interest Estate Recovery Resource Eligibility Applicant Rights While evaluating resource eligibility, you will be checking for if/when the applicant becomes eligible against their resource limit AND you will be auditing transactions to ensure the applicant has not transferred assets to become eligible for Medicaid (transfers without fair consideration). Transfers may be in the form of giveaways, but may also exist in the way some assets are structured. Page 58 of 163

60 Transfers Without Fair Consideration (TWFC) Taxpayer interest All resources disposed of within 5 years of application are presumed to have been done with the intent of gaining Medicaid or avoiding estate recovery. The burden of proof lies with the applicant to dispute this presumption. While verifying an individual s resources, you will also be reviewing statements to spot additional (undeclared) resources, suspicious transfers, and potential sources of income. Any resource available to the eligibility worker can validly be considered when researching TWFC. Transfers without fair consideration may include any situation in which the value leaving one s estate is greater than the value of what is returned. Page 59 of 163

61 What is a TWFC? What is a TWFC What is sometimes a TWFC What is not a TWFC Gifts, Giveaways Transfers into irrevocable trusts Pre-payment of the applicant's expenses Exchanges for something of non-equal value Annuties Transfers to a Spouse Resources used for the benefit of someone else Life Estates Purchases made for the applicant Transfers to avoid Estate Recovery Promissory Notes Resources otherwise disposed of Page 60 of 163

62 Periods of Ineligibility (POI) Taxpayer interest TWFCs are accounted for in order to protect the taxpayer. The funds lost in the TWFC could have been used to pay for care rather relying on Medicaid. When a transfer has occurred you will assess a period of ineligibility that is determined by the total amount of transferred resources. The ineligibility period is based on the amount of time those funds would have paid for care. Because the program deals with the costs of institutionalization, we use the average rate of nursing home care (statewide average this time). The POI bars the member from receiving waiver services and NF coverage, but still allows Medicaid coverage. Total TWFC State avg. private pay rate POI (in months) Additional Criteria The POI can be started only if/when the claimant is otherwise eligible for LTC. You will still need to pursue and establish all other eligibility criteria. Income trusts would need to be established if applicable. Disability must be met. A valid LOC certification with a start date must be received. Checks against the resource limits must be made. When all of this is complete, the POI will start on what would have been the Eligibility Begin Date. The applicant must remain eligible for LTC while serving the POI. Eligibility will be verified when the POI ends. LTC services may begin the day after the last day of the POI. 1) CBMS will show approved for LTC. 2) Med-span will show LTC-YX which denies all waiver services. 3) State plan Medicaid coverage still exists. 4) Redeterminations and waiver renewals will be conducted until POI is served. 5) Trust deposits are waived during the POI. Page 61 of 163

63 Example A $100,000 vacation property was given to an adult child As a giveaway, the $100,000 is a TWFC An $11,000 car was sold to a friend for $1000 Non-equal exchange - the difference of $10,000 is a TWFC $100,000 $10,000 $90,000 in payments in college expenses were made for grandchildren Purchase made for someone else s benefit - the $90,000 is a TWFC $90,000 $200,000 is the total TWFC $200,000 $7828 $200, months Convert the partial month to days.54 months 30 days per month 16.2 days Include the entire partial day 25 months, 16 days Or 2 years, 1 month, 16 days Applicant will be ineligible for LTC services for 2 years, 1 month and 16 days from the date that they would have become eligible. Page 62 of 163

64 Hand calculation Make up a scenario. Calculate it by hand now and then data enter the numbers into CBMS. $7828 Convert the partial month to days 30 days per month Include the entire partial day Or Page 63 of 163

65 How to Generate the POI Navigate to the Resource Summary page. In the Type field select the Liquid Asset that you wish to dispose. Once on the Liquid Asset Resource section, select the Disposition button. Page 64 of 163

66 Disposition Page 65 of 163

67 Run EDBC After the Disposition data entry is complete run EDBC and view your Eligibility Summary. In this scenario, the member still is passing. Select Initiate Wrap Up Review all of your Wrap Up pages in the queue. Page 66 of 163

68 Wrap Up Once you are on Medical Financial Eligibility Program list page, highlight the individual - and select the button. Select the Resource Test tab, then select the Individual Details button. Page 67 of 163

69 Individual Details Select the TWFC-POI button. At last! We have discovered the POI details! Note the lack of a POI year(s) field. Check the dates and don t get confused. In this example, the POI Begin Date and End Date reflect 25 months 16 days as calculated. (There are slight variations due to the number of decimal places CBMS uses and whether the last month is 30 or 31 days. No correction is necessary if within a few days.) The TWFC and POI information is displayed only for the first EDBC run. All subsequent EDBC runs will have no results here. Double check the calculation before authorizing! Page 68 of 163

70 After Authorization The information in the TWFC Details page will display in the Sanctions and POIs, and Disqualifications page. Med Span Will display LTC-YX which allows State plan Medicaid benefits without waiver services. Redeterminations and LOC referrals can be conducted as normal. At this time deposits into the income trust are waived while serving the POI. Page 69 of 163

71 Investigating Resources Taxpayer interest For Long-Term Care, the application or additional information package is the main source of information to request and review, but keep in mind you may and should use any resource available to you. When/What to Request Application Received Resources declared on application can be requested immediately. Transfers may be declared on application. LTC requested for existing Medicaid member An additional information packet will be mailed out asking for resource declaration. Upon receipt, you may generate a verification checklist. LTC allows for a look back of up to 5 years to determine eligibility. In practice, you are asked to verify all resources and request statements for the 3 months prior to eligibility (to cover retro months). If there is reason to suspect assets have not been disclosed or have been transferred, you will need to request additional information as necessary. Also, you must request verification of any disposition of resources the applicant declared in their application. Notes: Page 70 of 163

72 Additional Sources of Information To be checked as part of the eligibility process: CBMS entries Resource records within 5 years need resolution DMV Records of vehicle ownership County Assesor Real property ownership and transactions are recorded Financial transfers Suspicious, large or recurring transactions to unknown account? Direct Deposits SSA or income records may suggest additional accounts County/MA site processes You will need to check with your office to see which tools and resources are available to you. County Assessor information is typically available through the individual county s website, but the process to access this information varies from county to county. Notes: Page 71 of 163

73 Spent Assets When resource verifications are submitted, you will need to review transactions as well as balances. This review is primarily a check for additional resources and potential transfers, but also may be needed to identify a date when resource eligibility is met. Allowable transfers, expenses Medicaid will not dictate or penalize someone for how they choose or chose to Applicant Rights spend money, as long as their purchases are/were for themselves. They are additionally allowed to prepay some expenses, pay down debt, and purchase exempt resources (some of which are exempt and do not result in a TWFC). Suspicious transactions Don t worry about the small stuff. You should be looking for large transactions (~$500+) or recurring transactions that cannot be identified. You may request check images or receipts as part of your investigation but it is not always necessary. Use your best judgment about how much you will require, but the larger the transaction the more likely you should require verification. Note: Page 72 of 163

74 Common situations and things to consider: Transfer to xxxxxxxxxxxxxxx $1200 Do you have a record of an account ending in 0873? What is the context of this transfer? You likely need to verify ownership of the account. It could be another account owned by the applicant or a TWFC. Transfer from xxxxxxxxxxxxxxxxx $840 Ownership and context This could be income or another owned account. Payment to Super Life Insurance group $56.67 Do you have a record of this policy? Cash withdrawal $640 Some people simply use cash to make purchases. Repeated withdrawals or one-time large withdrawals may need further investigation. Consider the starting balance, how expenses are paid, and use common sense. $1200 per month could reasonably be living expenses; $8000 per month probably is not. Deposits - Cash, check, direct $ Potential income? Shared accounts create a situation where this can be seen as available income. Match up ownership (payslip) and advise split accounts. Payment to big box store, grocery store etc $xxxx Context is important. Purchases made for oneself are ok, but trust your gut if something doesn't add up. e.g. Landscaping, Inc. $8000 is suspicious when the applicant is in a senior living community. Big Talk Financial Group $12,000 Obvious need for verification: receipt, usage, new account, etc. Nursing Care, Living communities etc $6247 Extremely common for individuals transitioning from private pay to Medicaid. People on private for extended periods likely started with substantial assets. You may need to request funds from a larger timeline. This may include tracking account closures and funds transferring between multiple accounts to make payment. Often times this includes tracking the day the applicant becomes resource eligible to facilitate transfer from private pay to Medicaid. Notes: Page 73 of 163

75 $2000 $3000 $4000 $123,600 EF: Long-Term Care Participant s Guide Resource Limits M MA LTC does have resource limits and generally requires the applicant to use their assets to pay for their own care prior to becoming eligible. Individual Limit Couple Both receiving LTC benefits Married Both receiving LTC benefits Both are in the same room of a Nursing Facility Community Spouse Resource Allowance -In addition to the $2000 Individual Limit -Combined resources at initial application -Assets must be transferred to Community Spouse by RRR. $2000 limit applies from that point Disregard Current Income Income is income in the month received; the funds are not considered a resource until the following month. When a statement contains a balance that includes the current month s income, this should be disregarded from CBMS by entering the Amount of Balance Considered Current Income field. For joint accounts, CBMS disregards income prior to applying percent of ownership Page 74 of 163

76 Community Spouse Resource Allowance (CSRA) The first component of protection from spousal impoverishment applies to initial eligibility determinations for LTC while the spouse of the applicant remains in the community. Initial Eligibility Verify and total all assets owned by the couple. Apply CSRA $123,600 PLUS the individual limit of $2000. Spousal Protection On Approval Notify the recipient that assets will need to be transferred into the Community Spouse's name only by Redetermination. At Redetermination Look only at individual recipient's resources and apply individual limit ($2000). Spousal assets will not be looked at nor will CSRA apply again.*** *** For conditional eligibility due to an exemption (e.g. intent to sell) spousal assets and the CSRA limit will apply until the conditional eligibility exemption is resolved. At Redetermination Verify the transfer and change the Percent Owned accordingly. $2000 individual limit will apply from here forward. (Spouse s resources will not be verified or counted again.) Page 75 of 163

77 Increasing the CSRA Spousal Protection S The CSRA can be increased by the eligibility worker, under a specific scenario: When the Community Spouse s income + the MIA is less than the MMMNA, then the CSRA may be increased. The amount is determined by the estimated cost of an annuity that would generate the amount of income necessary to supplement the spouse s income to the MMMNA. The applicant must obtain three estimates of the cost of an annuity The amount of the lowest estimate shall be used to establish the increase in the CSRA The applicant is not required to purchase the annuity in order to increase the CSRA Note: In order for an increase to the spousal allowance the applicant will be in a lowincome/high-resource situation Amounts Spouse Income MIA MMMNA amount Combined Spouse Income Income + MIA MMMNA shortfall In this scenario, there is a $1000 shortfall in achieving the full MMMNA. An applicant can get three estimates of the annuity cost that would produce $1000/month income. The lowest estimate of the annuity cost can be added to the CSRA amount at initial eligibility. So, if the cost was $100,000, then the new CSRA would be $123,600 + $100,000 or $223,600. Page 76 of 163

78 Data Entry Under Individual Attributes, Living Arrangements should be Unshared for HCBS or Nursing Facility for unmarried applicants. For couples, select Home with Community Spouse or Nursing Facility with Community Spouse for the applicant, and Home with Institutionalized Spouse for the community spouse. Note: A Nursing Facility living arrangement will discontinue Food Assistance and Adult Financial programs. Relationship screen: Page 77 of 163

79 Spending Activity You are a lawyer. You are advising a couple attempting to become eligible for LTC. One of them has applied for LTC. They have $3200 income, a house, a car, and a lot of countable cash. Your task is to make the couple eligible for LTC without a TWFC and without paying for their own care by purchasing exempt resources. Page 78 of 163

80 Annuities An annuity is a contract between an individual and a commercial company in which the individual invests funds and the company pays installment payments either for life or for a fixed amount of time. Vocabulary Annuitant: An individual who is entitled to received payments from an annuity Annuitization Period: The period of time during which an annuity makes payments to an annuitant Annuitized: An annuity that has become irrevocable and is making payments to an annuitant Non-assignable: An annuity that cannot have its owner or annuitant changed under any circumstance Balloon Payment: A lump sum equal to the initial annuity premium less any distributions paid out before the end of an annuitization period Beneficiary: An individual or individuals entitled to receive any remaining payments from an annuity upon the death of the annuitant Irrevocable: An annuity that cannot be canceled, revoked, terminated, or surrendered under any circumstance What to request The purchase date and terms of the contract are needed. The complete copy of the contract must be provided. The prospectus will provide a summary of the details, costs and benefits. The terms of the annuity define how eligibility will be evaluated. You may have access to annuity details request form that can be filled out and signed by the annuity provider that captures the relevant annuity details. Page 79 of 163

81 Three Types of Annuities There are three basic types of annuities for the purposes of eligibility evaluation. If the annuity can be cashed out or sold, it is considered a resource. If it cannot be cashed out or sold, it will be income if the terms are compliant with Medicaid policy (TWFC if not). Revocable annuities Can be canceled, revoked, terminated or surrendered Can have its owner and/or annuitant changed Countable asset Based on the principal plus accumulated interest Payments are not counted as income Irrevocable assignable annuity Can have its owner and/or annuitant changed Cannot be canceled, revoked, terminated or surrendered Countable asset Based on the principal plus accumulated interest Payments are not countable as income Irrevocable non-assignable annuities Purchased in the last 5 years Must have HCPF named as the remainder beneficiary in: The first place OR The second place after a spouse, minor, or disabled child Purchased outside the 5-year look-back Is not a TWFC Not a countable resource Payments are countable as income Page 80 of 163

82 Additional criteria if purchased within 5 years The annuity must: a) Be purchased through a valid commercial company that is licensed to sell annuities b) Be annuitized for the individual or individual's spouse c) Be actuarially sound so that the payments do not exceed the annuitant's (or spouse s) life expectancy (tables at J) d) Have payments during the annuitization period that are equal to the amount used to purchase the annuity with no deferral or balloon payments One last piece Irrevocable non-assignable annuities that meet the following criteria are not TWFC and are not countable assets: Individual Retirement Annuities (IRA) under Internal Revenue Service (IRS) codes 408(b) 408(q) IRA s purchased with proceeds from one on the following: i) 408 (a) ii) 408 (c) iii) 408 (p) iv) 408A Roth IRA v) 408 (k) simplified employee pension plan These annuities are actually retirement plans; the annuity was purchased to produce retirement income. The payments are viewed as Unearned Income. Page 81 of 163

83 Annuity Flow Chart Annuity Irrevocable Revocable Non-Assignable Assignable This is a countable resource Purchased over 5 years ago Purchased within the 5-year lookback This is a countable resource Disbursements are Unearned Income HCPF is not a beneficiary HCPF is listed as a beneficiary This is a TWFC Actuarially Sound, with no deferral or balloon payments Payments exceed expected life expectancy Balloon payments or deferrals are allowed Annuitized to individual or spouse Annuitized to someone else This is a TWFC This is a TWFC Not purchased from a valid commercial company Purchased from a company licensed to sell annuities This is a TWFC This is a TWFC Disbursements are Unearned Income Page 82 of 163

84 Data Entry The data entry walks you through the requirements to decide how the annuity is evaluated. Remember to add payments to income when applicable. Page 83 of 163

85 Page 84 of 163

86 Trusts What is a trust? A trust is an arrangement in which a party is given property on the condition it is used to benefit someone else. Settlor Transfers ownership of property to the Trust Trustee agrees to administer the trust Trustee Holds and administers property under terms set by Settlor Property is used to benefit the beneficiary Beneficiary Receives benefits from the trust under terms set by Settlor Trust as a legal entity Trusts serve as a separate entity in property law. It is important to realize that the trust is a framework for holding assets. We can visualize a trust as a container that assets can be placed into or removed from. This concept is important to understand because what is contained in a trust may not be specified in the trust document. Consequently, you may be required to request information from the member or applicant to determine exactly what assets are contained in the trust. Assets Trust Page 85 of 163

87 What s the problem with trusts? Because trusts are a separate legal entity, it is not clear how the assets in the trust affect an individual s income and resources. Refer to HCPF Trust Department with questions regarding these entities. Life insurance policies Trusts Home Estate Accounts Annuities Page 86 of 163

88 Trust Evaluation Process Let s take it a step at a time. Gather all information related to the Trust The complete trust document (including any amendments) Funding information, transaction history, and listing of assets in trust (up to 5 years) Trust Approval Procedures ALL TRUSTS MUST BE SUBMITTED AND REVIEWED BY THE TRUST UNIT AT HCPF! E.7 (BEWARE of attorneys who tell you that a trust is not required to be provided. That assertion is not true!) You are not expected to be versed in the law of trusts and estates. There is a dedicated team at HCPF who will review the terms of the trust for you. Using the Trust Transmittal Form, , fax, or mail the trust and supporting documents to the Trust Unit at HCPF. Please remember to provide any information that you believe will be helpful to assist the reviewer. Page 87 of 163

89 Feedback from the Trust Unit at HCPF The Trust Unit will review the terms of the trust and if it is a recognized Medicaid exempt trust the Unit will issue an approval. For any other type of trust the Trust Unit will examine the terms and provide an opinion regarding any impact of the trust on the assets of the individual, member or spouse. The unit WILL NOT go through the assets of the trust or calculate the POI based upon any TWFC. Back to you What do I do? Now that you know what type of trust you are looking at you will need to apply the relevant rules which include: Calculating any POI based upon a TWFC at funding Calculate the amount of available resources or income Identifying fixed distributions, to calculate periodic income At RRR, review trust accountings to calculate any countable income or resources. Apply the Relevant Rule Medicaid Approved Trusts Federal law does allow for certain types of trusts to be exempt from the income and resource rules in Medicaid. Transfers to these trusts are generally allowable under certain conditions. The three types of trusts recognized by Medicaid to be exempt from income and resource rules require that HCPF be paid any remaining balance upon termination. Thus, these trusts are often referred to as payback trusts. Disability Trusts Funding: E.6.b The individual must be disabled and under the age of 65 when the trust is established Once established, the trust may stay in effect after the individual turns 65 If any funds are added to the trust after age 65, the transfer to the trust will be considered a resource Eligibility Assets in a valid disability trust are not countable resources If non-countable resources are purchased using trust funds, they are non-countable If countable resources are purchased using trust funds, they are countable Distributions made for food or shelter are countable (in-kind income). Distributions of cash are countable (unearned income) Page 88 of 163

90 Disability trusts terminate upon death or when no longer required for eligibility in Colorado. The Trust Unit at HCPF should be notified when either of these situations occur, in order for any assets remaining in the trust to be recovered. Pooled Trusts E.6.c A trust consisting of individual accounts established for disabled individuals for the purpose of establishing resource eligibility for Medical Assistance Minimum criteria include: Funding Must be established by the disabled individual, parent, grandparent, legal guardian or the court Meet Social Security disability criteria Established and managed by a non-profit association that is approved by the IRS Separate account is maintained for each beneficiary (assets are combined for investment purposes). The beneficiary as a joinder agreement that is submitted to the trust unit at HCPF for approval. The sole lifetime beneficiaries of each trust account are the individual for whom the trust is established and the Department. Created for the benefit of a person with a disability under age 65 to establish or maintain resource eligibility. If created for the benefit of a person with a disability over age 65, TWFC determination must be made for each transfer. When the individual passes away or the trust terminates, payback to HCPF applies only if the pooled trust chooses not to retain the funds. Income Trusts Addressed in Income section Page 89 of 163

91 Non-Medicaid Approved Trusts You will encounter many different types of trusts that are not recognized as exempt from Medicaid s income and resource rules. For example, trusts are often utilized as a vehicle for estate planning. Non-Medicaid approved trusts are examined by the Trust Unit at HCPF to determine any effect of the trust on the income and resources of the member or applicant. Third Party Trusts Third party trusts are established using assets of someone other than the applicant or spouse (and is not a TWFC at funding). The terms of the trust determine whether it is a countable resource (i.e. any portion available to the member or spouse). If a trustee has discretion in distributing income or resources, the trust is not a countable resource, but distributions are countable. Required income distributions are countable income. Required principal distributions are a countable resource. Revocable Trusts The trust can be revoked at any time by the settlor, so it is not a TWFC when funded. All assets of the trust are countable resources (nothing is exempt when in the trust.) Payments that are not for the benefit of the member or spouse are considered a TWFC. Irrevocable Trusts The trust cannot be revoked by the settlor after it has been established. The Trust Unit will examine the terms of the trust and when it was funded. This review will determine whether the creation of the trust should be deemed a TWFC or whether the assets are available to the member, applicant, or spouse. Funding prior to the 5-year look back is not a TWFC. All funding within 5 years is a TWFC unless the assets are available, in which case the assets are countable. Any funds that can be used to make payments to or for the benefit of the member is a countable resource. Payments made to or for the beneficiary are considered income. Page 90 of 163

92 Data Entry All assets contain the Trust icon and can be connected to a trust. The Trust button opens the Trust Summary page. Page 91 of 163

93 Data Entry, Continued Fill out fields that are applicable. Much of the information will be blank as the page is attempting to capture all types of trusts and help identify the type and what is countable. As always, give detailed Case Comments and view Wrap Up to ensure everything is counting as intended. Page 92 of 163

94 Life Estates and Promissory Notes Life Estates occur when someone gives or sells the inheritance rights to a property. Because this action circumvents Estate Recovery this is considered a TWFC unless Fair Market Value is received in return. Calculating this takes into consideration what was received and life expectancy. Promissory Notes occur when an asset or cash is given to someone in exchange for a promise to make a fixed amount of payments (like a Mortgage). Again, this situation is considered a TWFC in most cases. You will be looking at beneficiaries, payment terms, life expectancy and asset value (i.e. can the note be sold?). Due to their rarity, Life Estates and Promissory Notes will not be covered in this class, but know that evaluation criteria exist in Volume 8 if you run into one. Page 93 of 163

95 Resources Wrap-up Objectives: Can you? Identify different resource limits for LTC Identify, calculate, and find data entry procedures for a TWFC/POI Spend down a mock case without a TWFC or private payment by using exempt resources List references to aid in data entry Goal: To understand resource eligibility rules and processes as well as the laws and problems that guide them. Page 94 of 163

96 Income Objectives: After this module, participants will be able to: Goal: To understand income eligibility rules and processes as well as the laws and problems that guide them. Identify program Income limits Identify the need for, collect, gain approval for, and data enter an Income Trust Calculate allowable deductions and what is to be retained in an Income Trust Page 95 of 163

97 How Income is Counted at Eligibility For the purposes of determining eligibility, look only at the individual gross income of the person applying for benefits. There are no income disregards or deeming procedures to worry about at this time. How this looks: H No disregards for child support, garnishments, alimony, medical expenses, etc. (at eligibility) One spouse applying, other remains in community Both Spouses applying for HCBS One spouse Institutionalized, Community Spouse is now applying for HCBS Children Applicant's Income only. Community Spouse's income does not impact eligibility. Income of each spouse is used to determine eligibility individually. Count Community Spouse's income AND count income received from Monthly Income Allowance (MIA). Do not count parents' income P Ownership of Income Jointly owned income will be divided in proportion to the individual s stake. 50/50 will be used for married couples if no other documentation of interests exists I Notes: Page 96 of 163

98 Types of Income Earned Income -Any payments received from employment -Net income from selfemployment -Honoraria -In-kind Income Exempt Income -SSI -Veterans Aid and Attendance (A&A) -Veterans unreimbursed medical expenses (UME) - Reverse mortgage payments K,L -Pensions, Social Security -Workers Comp/disability benefits -Veterans benefits -Alimony, maintenance - Inkind support and maintenance -Interest, dividends, royalties -Gifts, prizes, inheritance -Some Annuity payments Unearned Income **Apply VA A&A and UME exemptions only when a breakdown has been provided. Notes: Page 97 of 163

99 Income Limits Long-Term Care eligibility is tied to the SSI rate. The income limit is set at 300% of SSI ($2250 in 2018), but there is an option available for those whose incomes are over 300%. Applicants can defer their additional income into an Income Trust to become eligible. Income over regional average private pay rate Income ineligible In person's best interest to pay private rate Income from $2250 to regional avg. private pay rate Income eligible if they set up an Income Trust Excess income is deposited into Income Trust Income from $0 to $2250 Income eligible No trust is needed Notes: Page 98 of 163

100 What is a trust? A trust is an arrangement in which a party is given property on the condition it is used to benefit someone else. Settlor Gives ownership of a property to the trust Trustee agrees to administer the trust Trustee Holds and administers property under terms set by Settlor Property or income is used to benefit the beneficiary Beneficiary Receives benefits from the trust under terms set by Settlor ***HCPF will NOT act as trustee for Medicaid members*** Notes: Page 99 of 163

101 Income Trusts E.6 An income trust may be established to create income eligibility for Nursing Facility care, HCBS or PACE (An Income Trust cannot be used for hospitalization eligibility). Applicants with incomes above the 300% SSI limit, but below the regional private pay rate, can make themselves eligible by establishing an Income Trust. The Income Trust establishes HCPF as the sole beneficiary so that HCPF receives any balance upon termination of the trust. The remaining funds reimburse Medicaid for services rendered at the point the member is no longer eligible or is deceased. How does it work? The individual receiving HCBS benefits is entitled to $2250 (300% SSI) for personal use in each month that coverage exists. Any additional income above the 300% is retained in the trust. You will check the accounting at redetermination to ensure ongoing compliance. What do I do? Send the applicant the income trust packet which includes instructions for setting up their Income Trust. They must return the packet signed and completed. You will then forward the completed trust form and any power of attorney to the HCPF Trust Unit using the trust transmittal form. The Trust Unit will review the trust document for compliance and send you an approval. State approval is required prior to authorizing benefits. Notes: Page 100 of 163

102 HCBS Cash Flow Eligibility worker checks balance each redetermination Income Trust Account (Keeps excess) Allowable Disbursements Other Allowables Trust maintenance costs - up to $20/mo. (i.e. bank fees) MIA, Dependent Allowance Member retains $2250 (HCBS and PACE) Page 101 of 163

103 HCBS Cash Flow Alternative Applicant keeps 300% SSI ($2250), makes allowable disbursements Eligibility worker checks balance each redetermination Other Allowables Allowable Disbursements Trust maintenance costs up to $20/mo. MIA, Dependent Allowance Income Trust Account Page 102 of 163

104 Medicaid Income Trust Who is the: Settlor? Trustee: Person designated by the Settlor to administer the trust Beneficiary? Trustee Responsibilities The Trustee of the income trust is responsible for making the necessary disbursements from the trust and must keep the trust s bank account separate from any other accounts or funds. Eligibility workers should notify both the member and the trustee of the amounts that must be retained and disbursed in each month. Notes: Page 103 of 163

105 Allowable Deductions 300% SSI This amount is 300% SSI for HCBS and PACE (in the home or community) rate of $2250. Applicants on HCBS or PACE are allowed to retain this income. Monthly Income Allowance (MIA) Spousal Protection T LTC provides a calculation to ensure the basic needs of the Community Spouse are met. This amount is an allowable disbursement from the Income trust for all LTC programs. *Note if these funds are not made available to the spouse then the MIA will not be allowed. Minimum Basic Allowance (MMMNA) is $2030 through Max MMMNA is $3090 in Minimum Basic Allowance $2, Compute any Excess Shelter Allowance by calculating the actual shelter costs: House Payment/Rent 2 Required Maintenance Fee 3 Insurance (homeowners/renters) 4 Taxes (on property only) 5 Utilities (actual or $469, whichever is larger) 6 Total of Actual Shelter Costs (Lines 2 through 6) $ Subtract 30% of the Basic Allowance $ Excess Shelter allowance (if this result is less than 0, enter 0) $ Community Spouse's Medicare, Health insurance or Medical expense 10 MMMNA equals the basic allowance plus any excess shelter allowance, and must not exceed the maximum MMMNA of $3090 (Court Ordered) Exceptional circumstances which would result in financial duress to the community spouse 11 Total amount of the MMMNA (Line ) $2, Subtract the Community Spouse's own income (i.e. sources other than public assistance) 13 This results in the "Monthly Income Allowance (MIA)," the contribution for the community spouse's monthly income needs $2, Page 104 of 163

106 Family Dependent Allowance Spousal Protection T1c An additional allowance is available for dependents residing with the Community Spouse. Dependents can be children, parents or siblings of either spouse who are claimable as a dependent for federal tax purposes. FORMULA: 1/3 Basic Allowance (MMMNA) Dependent's Income Dependent Allowance 1/3 basic allowance is $677 through at least Trust Maintenance Fees Actual fees up to $20. These are expenses such as bank charges. Approved PETI expenses Medical expenses not covered by Medicaid. Medicare Part B premiums will typically be the only expense and this will be explored in depth when we talk about nursing homes. Other items are *Rare* and will not be covered in this class, but include pre-authorized private health insurance and necessary uncovered services such as dental, chiropractic etc. Expenses over $400/yr. must also be pre-authorized. Page 105 of 163

107 Data Entry: Income Trust entry Upon receiving approval, you will adjust the applicant s income below the 300% SSI standard by documenting expenses and transfers into the Income Trust. (Otherwise the case will be denied for being over-income) From an Income source, select the tab and then select the tab. Name of Transfer Recipient can be the applicant. The Income Trust Approved by HCPF Reason will deduct the Amount Transferred amount from the applicant s gross income. It is best practice to use a non-interfaced source of steady income. If attached to an interface source, the interface will end date the window containing this deduction and close the case for being over-income. Name of Transfer Recipient: Applicant Amount Transferred: (Total Income - $2250) + $$$$ (to account for SSA cents and COLA) Reason: Income Trust Approved by HCPF Source: HCPF Trust Officer Page 106 of 163

108 Pending for Income Trust Income Trust Pending and Client Statement will allow the case to pend indefinitely (and not enter the EPG report) as long as the Income Trust has been entered as received on the Additional Information tab. Page 107 of 163

109 Income Trust Auto-Mail Using the tab you can have CBMS mail the Income Trust packet for you. Effective Begin Date and Date Given must be entered as the same date and EDBC must run. Page 108 of 163

110 Example: Application Date 12/1/2017, member receiving $2,500/monthly Private Retirement, no other deductions Page 109 of 163

111 Page 110 of 163

112 Income Wrap-up Objectives Can you? Identify program Income limits Goal: To understand income eligibility rules and processes as well as the laws and problems that guide them. Identify the need for, collect, gain approval for, and data enter an Income Trust Calculate allowable deductions and what is to be retained in an Income Trust Page 111 of 163

113 Nursing Facilities and 5615s Objectives After this module, participants will: Goal: To understand how Nursing Facility (NF) rules differ from HCBS rules Calculate patient payments Apply appropriate deductions to Nursing Facility cases Complete 5615s based on set circumstances Nursing Facilities Living Arrangements and PNA The primary factor for nursing facilities in eligibility is the PNA (personal needs allowance). When a member is in a nursing facility, food and shelter are being provided so Medicaid no longer allows for these types of expenses to be included through a PNA. Additionally, Food Assistance and Adult Financial programs will be reduced or eliminated according to their rules (read through Living Arrangement window discussed earlier). The nursing facility PNA for 2018 is $84.41 which is intended to cover personal needs that are not provided by the nursing facility. Additional allowances are still allowed, we will cover these allowances when discussing 5615s. Payment Model Eligibility Workers will calculate what the applicant is allowed to retain similar to the Income Trust calculations earlier. The remainder will be the patient payment to the nursing facility. The nursing facility will bill one amount to the patient and the remainder to Medicaid. *Note: Income Trusts still must be created, but nothing will be retained. Page 112 of 163

114 NF - Cash Flow Eligibility worker checks balance and verifies patient payment Income Trust makes disbursements (nothing new will be retained) Allowable Disbursements Other Allowables Trust maintenance costs up to $20/mo. MIA, Dependent Allowance PNA to applicant ($84.41) Nursing Facility (Bills Medicaid for remainder) Page 113 of 163

115 NF - Cash Flow Alternative Applicant keeps $84.41, makes allowable disbursements Allowable Disbursements Income Trust (No new money) Eligibility worker checks balance and verifies patient payments Other Allowables Trust maintenance costs up to $20/mo. MIA, Dependent Allowance OR Home Maintenance Allowance Nursing Facility (Bills Medicaid for remainder) Page 114 of 163

116 Additional Allowable Deductions for NF All the same allowable deductions discussed earlier apply to NF with a few additions and adjustments: Personal Needs Allowance The NF rate for 2018 is $ Because the NF takes care of all other basic needs (food, medical, and shelter), the PNA is only intended to cover things like personal hygiene items. Some Veterans are eligible for an increased amount ($90) Home Maintenance Allowance V.3.g.ii Cannot be applied when a Community Spouse or Dependent allowance is applied This allowance is intended to offset home costs when a member is institutionalized If shelter costs are documented, you may apply the support and maintenance standard allowance ($270 in 2018) This allowance requires an intent to return home and can only be applied for up to 6 months Earned Income V.3.d.ii Institutionalized residents engaged in income-producing activities Allowed to retain the first $65 PLUS half of the remaining gross earned income Federal Assistance Overpayments V.3.b.ii.7 Mandatory repayments Uncovered medical or remedial care expenses Medicare Part B Ongoing Medicare Part D ***PETI expenses do not change patient payment*** Page 115 of 163

117 Medicare Part B Premiums How the Buy-in works: (Medicare Savings Plan) May June July SSA April payment (in May) Medicaid in May Buy-in begins with June payment SSA May pays in June Member paid a premium SSA June pays in July SSA May payment (in June) Buy-in has not happened Member paid a premium SSA June payment (in July) Buy-in is applied Buy-in will continue State paid the premium LTC includes the buy-in. The Medicare buy-in eligibility begins the following month (to allow for communication between the state and Medicare); BUT because SSA pays one-month behind, the credit won t be seen for 2 months. What do I do? 1. Know the two-months rule which begins with Medicaid eligibility, not NF eligibility. 2. Apply the deduction for the initial month and the next month. 3. Remove the deduction for the following month s use admit month and first full month. 5. Be sure you know when the member is and is not paying the premium.! 1. Always check the interfaces to verify the member is actually paying Medicare premiums. 2. They may be in the 24-month waiting period or simply not signed up! 3. Other Medicaid programs will also pick up this premium. 4. The deduction only applies in the months in which the member actually paid. For problems (like buy-in not picking up) contact the Buy-in Officer: Sharon Brydon Sharon.Brydon@state.co.us Page 116 of 163

118 5615s V 5615s are used by Nursing Facilities to submit a bill to Medicaid. As the eligibility worker, you must document and authorize eligibility dates and patient payments which involves calculating and documenting allowable deductions such as the MIA and a few others unique to NF cases. First let s take a look at the form itself. Page 117 of 163

119 Section I Section I is filled out by whoever initiates the form. Nursing Facilities have a need for billing; Eligibility Sites may reach out for income/deduction changes or corrections. You won t always have all this info. Nursing facilities won t have (but need) the member s State ID. Section II This section will be filled out by the Nursing Facility. The LTC Institution page in CBMS has a location to enter the provider s name. The Per Diem rate will not always populate; defer to this form when needed. Page 118 of 163

120 Section III V3 Completion and accuracy is the responsibility of the Eligibility Site. This section sets the patient payment and Medicaid bill. All income and deductions must be verified and documented. Errors cause a burden to the member and facility (via claims). Since Section III is ultimately the most important part of the 5615 form, we will be addressing it in greater detail in a moment. Page 119 of 163

121 Section IV Completion is the responsibility of the facility. Admitted to Medicaid is the date the facility expects to begin billing Medicaid. This date is not always the eligibility begin date and that is OK. This date is more to communicate expected transfers from private pay or Medicare to Medicaid. It may be better to think of it as the day the facility hopes to begin billing Medicaid. Admitted to Medicare documents if/when Medicare is paying for care. We will address this more when we run some scenarios. Re-admitted to Medicaid generally outlines a change in pay source or level of care, (Medicaid to private to Medicaid, or facility to hospital to facility). Hospital days communicate changes for med spans, billing, and 30-day compliance. Date of discharge/death: Hopefully the applicable date is communicated to you. The date sets closure or HCBS transfers. Page 120 of 163

122 Section V & VI Filled out by Eligibility Site. Section V is for transferring cases between counties. o New counties need the billing information. o The facility needs to know who is handling the case. Section VI is likely going to be re-designed; think of it as Eligibility Status for now. o Approved, Discontinued, Denied should operate like checkboxes. o The Effective Date is the eligibility begin date. o The Comments section can/should be used for anything! (Think Section 3). o Sign in the County Technician space and date Page 121 of 163

123 Calculating Patient Payments Income Section III Part A. Documenting all gross income. Feel free to rename sources as needed for organization and readability. Total all income on the bottom line. State Pension 1200 Special Rules SSI income is not countable towards a patient payment. SSI income will be reduced to $30 or eliminated (if other income exists) while the member is in a nursing facility. Recipients may be eligible for PNA Adult Financial supplement. Veteran Aid and Attendance and Unreimbursed Medical expenses are also not countable for a patient payment and will be reduced while the member is in a nursing facility. In both situations, you should document the full amounts as income AND as a deduction. Best practice is to notify SSA or VA of the living arrangement. ***SSA payments typically contain $0.XX cents when interfaced. These cents are deducted out by Medicare premiums. When Medicaid picks up the Medicare buy-in, these cents are still interfaced, but not actually received. You should not count the partial dollar as income on the *** Page 122 of 163

124 Deductions Section III Part B Documenting all allowable deductions. The 5615 suggests some of the more common allowable deductions, but there is not room for every situation. Once again feel free to strike out and re-write any line you see fit for clarity. Part B 134 Calculating Deductions Use the calculation sheets we went over in the income section (there is a NF version). MIA (Line 13) is the spousal allowance, line 18 can be used for dependent care. You will need to keep track of temporary deductions like Medicare Part B and Home Maintenance Allowance; they do not have dedicated lines on the calculations sheet but need to be included on the Patient Payment Section III Part C Use this section to calculate the patient payment. The patient payment is generally total income minus total deductions, but there are several rules and exceptions we will walk through. There is space to note changes in payment. This most often is for temporary deductions, but there may be a change in income. These changes must be explained in the comments section below. Page 123 of 163

125 Patient Payment Rules Admitted from or discharged to home For the admit month a zero ($0) patient payment is allowed if the funds were committed elsewhere. (Home to hospital to facility within a month meets this criteria as well) Patient paid for rent, food, etc. then entered a nursing facility. For the discharge month, a zero ($0) patient payment is allowed if the funds are needed for living expenses within the month. Patient was discharged to home, now needs to pay for food, rent etc. Patient payment funds made to other facility A zero ($0) patient payment is allowed in the admit month when the full patient payment was made to another facility. Communicate with the original nursing facility as needed. Transfers between facilities, to and from hospitals, or to a hospital then to a new facility are the most likely scenarios. Double check the per diem rate of the original facility multiplied by the number of days stayed is at least the patient responsibility. Page 124 of 163

126 Medicare Payments Medicaid pays last, so payments must adjust to situations when Medicare coverage exists. Medicare coverage applies when a member comes directly from a hospital where they had a consecutive 3-night stay and skilled nursing level of care is met. The Medicare benefit fully covers care for days 1-20 and requires a co-pay (currently $167.50/day) for days Eligibility for the benefit resets after 60 days without a need for skilled nursing care. Days 1-20 fully covered Days $167.50/day copay Days 101+ patient pays full amount This system does cause odd scenarios where the patient payment is not zero or all excess income The patient was not admitted from home within the month so the admit month cannot be zero. If there are only a few days left in the month, the per diem rate is less than the patient payment. You would need to calculate the actual amount due for remaining days; the patient should not pay more than that amount. This situation will occur in one of our scenarios. ALSO Qualified Medicare Beneficiaries (QMB)have a special scenario here. Medicaid pays all Medicare co-pays for this group. Because days are technically a copayment, QMB eligible will not have a patient payment for 100 days IF the stay is covered under Medicare. The nursing facility will identify Medicare coverage and the date it started, but do not assume they are clear on the odd scenarios this creates. LTC insurance Long-Term Care insurance is not considered income for eligibility, but any insurance payments are applied prior to Medicaid payments. Generally, LTC insurance will not affect anything, but in some scenarios, it may result in there being nothing left for the patient to pay so they keep their income. We will show this scenario as well. Page 125 of 163

127 5615 Scenarios Level 1 - SSI Only The member receives only $750 SSI. Enters Nursing Facility on Jan. 13 th and is fully eligible at this time. What will the 5615 look like? Page 126 of 163

128 The important part to capture is the SSI exempt portion. SSI payments may not contribute to a patient payment. You may have deducted $750 as Other or noted a different Personal Needs Allowance. SSI-only individuals will always have a $0 Patient Payment. OR The individual s SSI payment will be reduced to $30/mo. by SSA. The member may be able to supplement this amount by applying for the Adult Financial PNA. The PNA would be adjusted again in that scenario. Page 127 of 163

129 Level 2 - QMB from home An unmarried individual with QMB buy-in enters a Nursing Facility from home on Jan. 13 th and is otherwise eligible. SSDI income of $859/mo. QMB beneficiary. Page 128 of 163

130 Level 3 - QMB from hospital with Medicare Now let s use the Medicare dates in the same situation of $859/mo. total income and entered the Nursing Facility on Jan. 13 th. Notice the facility has informed you of Medicare eligibility. Assume a Per Diem of $250. April 22 nd is the 101 st day. Page 129 of 163

131 Level 4 - SlimB with Medicare days Let s change it up a little: a SlimB beneficiary with $1150/mo. SSA income, and is otherwise eligible. This time they enter the facility on Jan. 7 th, after being hospitalized since Dec. 28 th. Again, the Per Diem is $250. Complete Section III Page 130 of 163

132 Level 5 - More Deductions Alright let s look at some deductions now. An unmarried applicant walks into a nursing facility. This person is new to Medicaid and is approved for LTC-NF as of the entry date of Jan. 7th. They have a verified mortgage of $650/mo. and intend to return home within 6 months. You have a note indicating this is a medically reasonable timeframe. Member s income is $1500 SSA with a Part B premium of $134. How will this 5615 look? Page 131 of 163

133 Level 6 - Bring back Medicare This is the same scenario but adding Medicare days and admit from home. Participants should look carefully at the timeframe. What does Section III look like? Page 132 of 163

134 Level 7 - LTC insurance Let s stick with our profile but drop the Medicare days again. $1500, $134 Part B, $270 HMA and Jan. 7 th. This time there is a LTC insurance benefit of $3000/mo. for the first 3 months! Page 133 of 163

135 Level 8 - Couples Edition In this scenario our patient is married. Add a spousal allowance of $ Remove LTC insurance. Page 134 of 163

136 Level 9 - Consider the Children We will add some income to get a bigger picture. There is $1500/mo. SSA and an additional $2500/mo. in a private retirement. The $134 Med B still applies as does the $ Spousal Allowance. This member also has a 15-year-old who is claimed on their taxes. Page 135 of 163

137 Level 10 - Putting it All Together In this scenario: Medicare days, not admitted from home, $1500 SSA, $2500 private retirement, $134 Med B, a $ spousal allowance, and a teenager. What does Section III look like? Page 136 of 163