2 00medicaideligibility by HC120614115447

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									                 Home and Community Based Services Manual

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                                                                    MEDICAID ELIGIBILITY
Medicaid, Title XIX, is a federal entitlement program. The Department of Social Services (DSS),
MO HealthNet Division (MHD) administers the Medicaid program in Missouri. Individual
eligibility for Medicaid benefits is determined by DSS, Family Support Division (FSD) through
application of a number of specific program eligibility requirements (see Appendix 1 of this
Chapter).
Participants must be eligible for and have active Medicaid benefits prior to the initial prescreening
for Home and Community Based Services (HCBS). The Department of Health and Senior
Services, Division of Senior and Disability Services (DSDS) or its designee administer the HCBS
program. Medicaid status verification is available upon entry into the HCBS Web Tool. Within
the ‘Eligibility’ tab of the Participant Case Summary Screen within the HCBS Web Tool, the
following information will be available for the users to assist in determining appropriate eligibility
status:
 Eligibility determination messages indicating that the participant has met or not met Medicaid
  funding and age requirements;
 Medicaid Eligibility (ME) Code (see Appendix 3 of this Chapter);
Prior to all HCBS authorizations, the ME code shall be reviewed to ensure that the participant is
eligible for specific service(s) requested.
 Note:        The    following    link    provides    further          ME       code     descriptions
http://www.dss.mo.gov/mhd/providers/pdf/puzzledterm.pdf.
 Spenddown Indicator;
 Gross Income;
 HCB indicator;
 Transfer of Property; and
 Participant’s age
Medicaid funded HCBS are authorized to persons who are:
 Determined eligible for Medicaid by FSD for payment of such services (see ‘Special
  Limitations’ included in this policy);
 Agreeable to an assessment and will participate in the development of a person centered care
  plan;
 Determined eligible for nursing facility level of care or higher (See Policy 4.10);
 Assessed to have an unmet need which can be met through authorization of HCBS as an
  alternative to nursing facility placement; and
 Assessed to meet the eligibility requirements for each particular authorized service, as
  described in Chapter 3 (i.e., age, ability to self direct services, etc.).

Special Limitations
Spenddown (See Appendix 1 of this Chapter)

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Participants who meet all of the other Medicaid eligibility requirements, but have income in excess
of the established monthly income limit to be eligible for Medicaid, are considered spenddown
participants. The HCBS Web Tool will provide system messages to alert the user as to whether or
not the participant has met their spenddown liability for the current date.
New HCBS Referrals for Spenddown Participants
Upon receipt of a referral for a Medicaid spenddown participant who has met their spenddown
liability for the current date, DSDS or its designee shall:
   Initiate and complete the HCBS process within the HCBS Web Tool; and
   Instruct the participant that during periods of ineligibility costs incurred for HCBS will be the
    participant’s responsibility.
Note: Upon completion of the service planning for a spenddown participant with active benefits
that will be authorized for Aged and Disabled Waiver services, an IM-54A for HCB Medicaid
determination shall be forwarded to FSD if the participant’s income appears to meet the
requirements for HCB Medicaid. (See below and Appendix 1)
Upon receipt of a referral for a Medicaid spenddown participant who has not met their spenddown
liability for the current date DSDS or its designee will:
   Be unable to process the referral within the HCBS Web Tool; and
   Refer the participant to FSD for information on Medicaid benefits, and instruct the participant
    to contact DSDS or its designee for HCBS eligibility determination when Medicaid benefits
    are active.
Reassessment of Existing HCBS Spenddown Participants
At reassessment, a spenddown participant must either have met spenddown liability for the current
date or have met spenddown liability at least once within the previous three months in order to
continue with the reassessment process. DSDS or its designee shall:
   Review the eligibility determination message within the HCBS Web Tool or MO HealthNet’s
    emomed.com system in order to validate that the participant is eligible for the HCBS
    reassessment process;
   Initiate and complete the HCBS reassessment process within the HCBS Web Tool; or
   Initiate the Adverse Action process (see Chapter 5) and proceed with closing the case and the
    associated activities if spenddown liability has not been met within the last three months.

Home and Community Based Medicaid (HCB Medicaid) (see Appendix 1 of this Chapter)
Determination of HCB Medicaid eligibility requires inter-agency cooperation between FSD and
DSDS or its designee. The Home and Community Based Referral (IM-54A) shall be used to
facilitate communication between the agencies regarding the HCB Medicaid eligibility
requirements. The IM-54A, when utilized, shall be scanned and attached to the HCBS Web Tool.



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                                                                       MEDICAID ELIGIBILITY
Initial HCBS Referral for Medicaid Spenddown Participants
Upon receipt of a referral for an Aged and Disabled Waiver (ADW) service (see Chapter 3) for a
Medicaid spenddown participant who is 63 years of age or older, DSDS or its designee shall:
   Review the gross income amount reported in the Eligibility Tab on the Participant Case
    Summary to determine if the spenddown participant’s income is within the HCB income
    standard (see Appendix 2 of this Chapter);
   Initiate the HCBS process within the HCBS Web Tool
   Check the ‘HCB Medicaid Referral’ box within the Eligibility Tab to enable the PreScreen;
   Complete the HCBS process within the HCBS Web Tool which must include at a minimum
    the documented need and authorization of an ADW service;
Note: Medicaid spenddown participants who have not met their spenddown liability may be
authorized pending HCB Medicaid eligibility approval notification from FSD.
   Complete the HCB referral form IM-54A and forward to FSD for HCB Medicaid evaluation.
Note: if the original referral was received via an IM-54A from FSD, the referral shall be
processed as above.
FSD will communicate approval or denial of HCB Medicaid by completion of the IM-54A. When
information from FSD indicates that the participant is not eligible for HCB Medicaid, the
‘Reassessment of existing HCBS spenddown participants’ policy as described above shall be
followed when a reassessment is required.
Current HCBS Participant
When DSDS or its designee identify a current HCBS participant who may now meet HCB
Medicaid eligibility, i.e. meets age eligibility and ADW service need identified, DSDS or its
designee shall initiate the IM-54A and forward to FSD.
At any point during an HCB Medicaid participant’s authorization period, if DSDS or its designee
determine that the participant no longer needs ADW services, DSDS or its designee shall:
   Complete and forward an IM-54A to FSD; and
   Initiate the adverse action process (See Chapter 5).

Blind Pension (BP) ME code ‘02’
Participants with an ME code of ‘02’, BP, have restricted medical assistance benefits through state
only funds and are not eligible for services funded through the ADW or the Independent Living
Waiver (ILW). However, ME code ‘02’ participants are eligible for State Plan services (see
Chapter 3). The HCBS Web Tool will provide a warning message to alert the user that the
participant is only eligible for state plan HCBS.
When a current HCBS participant’s Medicaid eligibility changes to ME code ‘02’ DSDS or its
designee shall:
   Close all waiver services, if authorized; and

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   Initiate the adverse action process (See Chapter 5).

Ticket to Work Health Assurance (TWHA) – Premium ME code ‘85’
These participants shall be (re)assessed and care plans developed as appropriate based on their
service needs and eligibility requirements i.e., age.
New HCBS Referrals for TWHA Participants
Upon entry into the HCBS Web Tool, participants eligible for Medicaid as TWHA-premium ME
code ‘85’ will display the following eligibility determination message: “Ticket to work premium
has been paid for the current month.” DSDS or its designee shall:
   Initiate and complete the HCBS process within the HCBS Web Tool; and
   Instruct the participant that during periods of ineligibility, due to non-payment of the
    premium, costs for HCBS will be the participant’s responsibility.
Upon receipt of a referral for a Medicaid TWHA participant who has not paid their premium for
the current date, DSDS or its designee will:
   Be unable to process the referral within the HCBS Web Tool; and
   Instruct the participant to contact DSDS or its designee for HCBS eligibility determination
    when Medicaid benefits are active.
Reassessment of Existing TWHA Participants
At reassessment, if a previously authorized TWHA-premium participant has not paid the premium
for the current month, the following message will display within the HCBS Web Tool, “Ticket to
work premium has not been paid for the current month.” A TWHA participant must either have
paid the premium for the current month or have paid the premium at least once within the previous
three months in order to continue with the reassessment process. DSDS or its designee shall:
   Review the eligibility determination message within the HCBS Web Tool or MO HealthNet’s
    emomed.com system in order to validate that the participant is eligible for the HCBS
    reassessment process;
   Initiate and complete the HCBS reassessment process within the HCBS Web Tool; or
   Initiate the Adverse Action Process (see Chapter 5) and proceed with closing the case and the
    associated activities if the TWHA premium has not been paid within the last three months.

Transfer of Property Penalty
A "Y" in the “Transfer of Property” field in the ‘Eligibility’ tab will indicate that the participant is
in a transfer of property penalty. These participants have limited Medicaid benefits and are not
entitled to ADW services. FSD determines the length of the penalty if a participant has sold,
traded, or given away property for which fair and valuable consideration was not received.
The transfer of property penalty does not apply to State Plan or ILW services; therefore, Medicaid
eligible participants may be authorized for those services as identified through the assessment and
person centered care planning process.

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