Lifetime Care Agreement by qyp20863

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									                         COMMONWEALTH OF KENTUCKY
                       Cabinet for Health and Family Services
                     Department for Community Based Services

                                 OPERATION MANUAL               OMTL-383
                                    Volume IVA

                     Medicaid (MA) and State Supplementation
                                Table of Contents                R. 4/1/11

MEDICAID                                                        1000-1349

   Introduction to Medicaid                                     1000-1049

       Providing Medicaid                                            1000

       Definitions                                                   1010

       Abbreviations                                                 1015

       Agency Responsibility                                         1020

       Classification of Eligible Groups                             1030

       One Category of Assistance                                    1040

   Medicaid Benefits                                            1050-1249

       Introduction to Medicaid Benefits                             1050

       Medicare/Medicaid Recipients                                  1060

      Co-Pay for Medicaid Recipients                                 1065

       Alternate Birth Centers                                       1070

       Ambulance Transportation                                      1080

       Ambulatory Surgical Centers                                   1090

       Audiology Services                                            1100

       Chiropractic Services                                         1105

       Dental Services                                               1110

       Dialysis                                                      1120

       Family Planning Services                                      1130

       Hospital Benefits                                             1140

       Laboratory and X-Ray                                          1150


                                           1
    Long Term Care                                 1160

    Mental Health                                  1170

    Nurse-Midwife Services                         1180

    Optional Services                              1190

    Pharmacy Benefits                              1200

    Physician Services                             1210

    Primary Care Center/Rural Health Clinic        1220

    Vision Care                                    1230

Disclosure of Information                      1235-1239

    Disclosure of Information                      1235

KYHealth Card                                  1240-1249

    KYHealth Card                                  1240

    Non-Receipt of KYHealth Cards                  1245

Use of Medicaid                                1250-1349

    DCBS Responsibilities                          1250

    Lock-In                                        1260

    Over-Use Identification                        1270

    Lock-In Restrictions                           1280

    Lock-In Procedures                             1290

    Lock-In Change                                 1300

    OIG Responsibilities                           1310

    Removing Lock-In                               1320

    Lock-In Rights                                 1330

    Kentucky Health Partnership Managed Care       1340

    Managed Care Definitions                       1342

    KYHealth Card and Managed Care Card            1344



                                    2
       Worker Responsibilities/Beneficiary Groups       1346

       Guaranteed Coverage                              1348

CASE ACTION                                         1350-1549

   Application                                      1350-1419

       Application for Entitled Benefits                1350

       Eligibility for Entitled Benefits                1353

       Application After Denial of SSI Benefits         1360

       Application Process                              1370

       Authorized Representative (AR)                   1371

       Adult MA Interview Process                       1372

       Taking the Adult MA Application                  1373

       Applications for the Deceased                    1374

       Out of State Applicants                          1376

       Caseload Responsibility                          1378

       Adult Medicaid Documentation                     1380

   Case Decision                                    1420-1479

       Scope of Investigation                           1420

       Case Number Assignment                           1425

       Authorizing Benefits                             1430

       Special Circumstance Processing                  1435

       Case Record                                      1440

       Effective Dates for Retroactive Medicaid         1450

       Effective Date for Ongoing Medicaid              1460

       Standards of Promptness                          1470

       Assignment of Caseload Codes                     1475

       Caseload Code and County of Residence            1476




                                           3
   [Recertification/Interim Changes                                  1480-1509

       Adult MA Recertifications/Interim Changes                        1500]

   Negative Action                                                   1510-1540

       Timely Notice of Decrease/Discontinuance                          1510

       Reasons for Negative Action                                       1530

       Misrepresentation and Fraud                                       1540

   Out of State Inquiries                                            1545-1549

       Recipients Moving Into or Out of Kentucky                         1547

TECHNICAL ELIGIBILITY                                                1550-1749

   General Requirements                                              1550-1579

       Introduction                                                      1550

       Enumeration                                                       1560

       SSN Applications                                                  1562

       Failure to Comply with Enumeration                                1564

       Enumeration Good Cause Criteria                                   1566

       Use of SSN                                                        1568

   Citizenship and Identity                                          1570-1579

       Citizenship and Identity Requirements for Adult MA Programs       1570

       Adult MA Case Processing for Citizenship Verification             1575

       Criteria for Qualified Aliens                                     1577

       Time-Limited Eligibility                                          1578

       Extension of Time-Limited MA                                      1579

   Residency                                                         1580-1659

       Introduction                                                      1580

       Placement by Another State                                        1590

       Prisons/Public Institutions                                       1600

       Interruption of Public Institutional Status                       1610


                                         4
       Home Incarceration                                         1615

       Spouse Abuse Center                                        1620

       Emergency Shelter                                          1630

       Specific Prohibitions                                      1640

       Disputed Residency                                         1650

   Third Party Liability (TPL)                                1660-1689

       Introduction                                               1660

       Third Party Assignment                                     1670

       TPL and SSI                                                1680

   KHIPP                                                      1690-1699

       KHIPP Overview                                             1690

   Category Requirements                                      1700-1749

       Aged                                                       1700

       Blind                                                      1710

       Disabled                                                   1720

FINANCIAL ELIGIBILITY                                         1750-2799

   Introduction                                               1750-1769

       Introduction to Financial Eligibility                      1750

   Relative Responsibility                                    1770-1849

       Applicant Living with Spouse                               1770

       Applicant Living with Dependent Child                      1790

       K-TAP and Family Related MA Recipient Who Enters LTC       1800

       Blind or Disabled Child Living With Parents                1810

       Blind or Disabled Child Living Apart From Family           1820

   Resources                                                  1850-2049

       Overview of Resources                                      1850



                                           5
    Resource Limits                                                     1860

    Verification and Documentation                                      1870

    Excluded Resources                                                  1880

    Annuities                                                           1890

    Life Expectancy Table                                               1900

    Earned Income Tax Credit                                            1920

    Home Equity Plans                                                   1930

    Jointly Held Resources                                              1940

    Lifetime Care Agreement                                             1960

    Liquid Assets                                                       1970

    Recognition of an Institutionalized Individual’s Homestead Resources 1975

    Non-home Real Property                                              1980

    Nonrecurring Lump Sum                                               1990

    SSI Essential Person Resources                                      2000

    Trusts                                                              2010

    Consideration of Income From a Medicaid Qualifying Trust Established 2011
    On or Before 8/1/93

    Vehicles                                                            2030

    Overview of Burial Reserves                                         2031

    Burial Reserves Definitions                                         2032

    Excluded Burial Items                                               2033

    Burial Trust Funds                                                  2034

    Cash Set Aside for Burial Purposes                                  2035

    Life insurance Policies                                             2036

    Pre-Arranged Funeral Contracts                                      2037


Transfer of Resources                                             2050-2119

    Transfer of Resources                                               2050


                                     6
    Calculating Life Estate Transfers/Terminations                        2055

    Life Estate Table                                                     2056

    Exceptions to Transfer of Resources                                   2070

    Consideration of Transferred Resources                                2080

    Entering Transfer of Resources Disqualifications                      2081

    Special Procedures for Transfer of Resources by a Power
    of Attorney/Legal Guardian                                            2105

    SSI Recipients and Transfer of Resources                              2110

Institutionalized/Community Spouse Resources                          2120-2179

    Special Resource Considerations For an Institutionalized Spouse       2120
    With a Community Spouse

    Resource Assessment                                                   2130

    Community Spouse Resource Allowance Calculation                       2135

    Resource Eligibility Determination For Applicants with a              2140
    Community Spouse

    Patient Liability Transfer of Resources                               2150

    Additional Considerations                                             2160

    Recertification/Interim                                               2170

Income                                                                2180-2209

    Introduction                                                          2180

    Income Limits                                                         2190

    Income Rounding                                                       2200

Unearned Income                                                       2210-2399

    Unearned Income                                                       2210

    Annuities                                                             2220

    Adult MA: Child and Spousal Support                                   2230

    Contributions                                                         2240

    Farm/Business                                                         2250


                                      7
    Home Equity Plans                                        2260

    Income Supplementation                                   2270

    Loans                                                    2290

    Long Term Care Insurance                                 2310

    Other Unearned Income                                    2320

    Promissory Notes, Loans, Mortgages, Land Contracts       2330

    Statutory Benefits                                       2340

    SSI                                                      2350

Earned Income                                            2400-2464

    Earned Income                                            2400

    Contract Employment                                      2410

    Occasional and Commissioned Employment                   2420

    Other Earned Income                                      2430

    Seasonal Employment                                      2440

    Self-Employment                                          2450

    Wages                                                    2460

Nonrecurring Lump Sum                                    2465-2469

    Nonrecurring Lump Sum                                    2465

Excluded Income                                          2470-2479

    Excluded Income                                          2470

Deductions                                               2480-2489

    Deductions                                               2480

PASS                                                     2490-2559

    Plan for Achieving Self Support (PASS)                   2490

Calculating Income                                       2560-2599

    Technically Eligible Applicant                           2560



                                     8
        Technically Eligible Applicant and Spouse                                2570

        Technically Eligible Applicant with Technically Ineligible Spouse        2580

    Companion Cases                                                          2600-2649

        Companion Cases Introduction                                             2600

        Both Individual and Spouse are Technically Eligible                      2610

        Technically Eligible Individual with Technically Ineligible Spouse       2620

        Aged, Blind or Disabled MA With a Family MA or AFDC Related MA
        Companion Case                                                           2630

    Spend Down                                                               2650-2799

        Introduction to Spend Down                                               2650

        Determining the Family Size                                              2655

        Companion Case Spend Down                                                2660

        Establishing the Quarter                                                 2670

        Quarters for Companion Case Spend Down                                   2680

        Spend Down Excess                                                        2690

        Spend Down Medical Expense Verification                                  2700

        Spend Down Medical Expense Restrictions                                  2710

        Considering Medical Expenses in Spend Down                               2720

        Allowable Spend Down Medical Expenses                                    2730

        Spend Down Case Decision                                                 2740

Consumer Directed Option (CDO)                                               2800-2800

        Consumer Directed Option (CDO)                                           2800

Supports for Community Living (SCL)                                          2810-2899

    Introduction to SCL                                                      2810-2829

        SCL Waiver Program                                                       2810

        Michelle P. Waiver                                                       2815

        Technical Eligibility Requirements                                       2820



                                          9
   SCL Eligibility Determination                     2830-2899

       SCL Eligibility Determination Procedures          2830

       SCL Individual                                    2840

       SCL Child                                         2850

       SCL Individual with Non-SCL Spouse                2860

       SCL Couple                                        2870

       SCL Income and Resource Consideration             2880

       SCL Case Action                                   2890

       SCL Notice Procedures                             2895

HOME AND COMMUNITY BASED SERVICES                    2900-2999

   Introduction to HCBS                              2900-2919

       HCBS Waiver Program                               2900

       Technical Eligibility Requirements                2910

   HCBS Eligibility Determination                    2920-2999

       Medicaid Eligibility                              2920

       Patient Liability                                 2930

       HCBS Individual                                   2940

       HCBS Child Living with Parent                     2950

       HCBS Recipient with Non-HCBS Spouse               2960

       HCBS Recipient with HCBS Spouse                   2970

       Income and Resource Consideration                 2980

       Case Action                                       2990

       HCBS Notice Requirements                          2995

OTHER WAIVER PROGRAMS                                3000-3049

   Acquired Brain Injury Eligibility Determination   3000-3029


       ABI Waiver Program                                3000



                                        10
       ABI Medicaid Eligibility Determination                                 3005

       ABI Patient Liability Determination                                    3010

       ABI Individual                                                         3015

       ABI Recipient with Non-ABI Spouse                                      3017

       ABI Recipient with ABI Spouse                                          3020

       ABI Income and Resource Consideration                                  3025

       ABI Long Term Care (LTC) Waiver                                        3030

HOSPICE PROGRAM                                                          3050-3299

   Introduction                                                          3050-3099

       Scope of Program                                                       3050

       Hospice Rates                                                          3060

       Hospice Technical Eligibility Requirements                             3070

       Hospice Notice Procedures                                              3080

   Noninstitutional Hospice Procedures                                   3100-3179

       Noninstitutional Hospice Medicaid Eligibility                          3100

       Noninstitutional Hospice MA Effective Date                             3110

       Noninstitutional Hospice Patient Liability                             3120

       Noninstitutionalized Hospice Individual or Child Living with Parents   3130

       Noninstitutionalized Hospice Couple                                    3140

       Noninstitutionalized Hospice Applicant with Non-Hospice Spouse         3150

       Noninstitutional Hospice Income and Resource Consideration             3160

       Noninstitutional Hospice Case Action                                   3170

   Institutional Hospice Procedures                                      3180-3299

       Institutional Hospice MA Eligibility Determination                     3180

       Institutional Hospice MA Effective Date                                3190

       Institutional Hospice Patient Liability                                3200

       Institutionalized Hospice Individual                                   3210


                                         11
       Institutionalized Hospice Child                               3220

       Institutionalized Hospice Individual with Non-Hospice         3230
       Community Spouse

       Institutionalized Hospice Couple                              3240

       Institutional Hospice Income and Resource Consideration       3250

       Institutional Hospice Case Action                             3260

LONG TERM CARE                                                   3300-3799

   Introduction to LTC                                           3300-3349

       Who is Eligible for LTC Vendor Payment                        3300

       Special Procedures for LTC Applicants                         3320

       Residence Requirements for LTC                                3330

   Case Action                                                   3350-3449

       SSI Recipient in LTC                                          3350

       F, G, or H Individual in LTC                                  3360

       LTC Admission without Medicaid                                3370

       Patient Status Not Met                                        3380

       QMB Recipient in LTC                                          3390

       K-TAP and Family Related MA Recipient in LTC                  3400

       SSI/SSP Recipient Entering LTC                                3410

       Medicare Recipient in LTC                                     3420

       Medicare and Medicaid Recipient in LTC                        3430

   Income Calculation                                            3450-3499

       Cost of Care                                                  3450

       Countable Income                                              3460

       Excluded Income for LTC/Waiver                                3470

       Deductions and Allowances                                     3480

   Eligibility Determination                                     3500-3649


                                          12
    Special Income Standard                              3500

    Qualifying Income Trust                              3505

    LTC MA Effective Date                                3510

    Interruption of Stay                                 3520

    LTC Individual                                       3530

    LTC Couple                                           3540

    LTC Individual with Community Spouse                 3550

    LTC Blind or Disabled Child                          3560

    LTC for K-TAP and Family Related MA                  3570

    Spend Down for LTC                                   3580

    Change in Status                                     3590

    PA-62 Notification                                   3600

    Effective Date of Vendor Payment                     3610

Patient Status Determination                         3650-3699

    Peer Review Organizations                            3650

    Peer Review Organization Initial Certification       3660

    Peer Review Organization Denial                      3670

    Peer Review Organization Reconsideration             3680

    Peer Review Organization Appeal                      3690

ICF/MR/DD                                            3700-3719

    Privately Owned/Operated Facilities                  3700

    State Owned/Operated Facilities                      3710

Money Follows the Person (MFP)                       3715-3719

    Money Follows the Person (MFP)                       3715

Estate Recovery                                      3720-3799

    Introduction to Estate Recovery                      3720



                                      13
       DCBS Responsibilities                                              3730

NONEMERGENCY MEDICAL TRANSPORTATION                                3800-4149

   Introduction                                                    3800-3849

       Nonemergency Medical Transportation                                3800

       Non-Emergency Medical Transportation Brokers                       3810

MEDICAID WORKS                                                     3900-4149

       Medicaid Works Overview                                            3900

       Medicaid Works Application                                         3910

       Medicaid Works Substantial Gainful Activity (SGA)                  3912

       Medicaid Works Financial Eligibility                               3920

       Medicaid Works Premium Payments                                    3930

       Denial/Discontinuance Codes for Medicaid Works                     3940

       Medicaid Works Disqualifications                                   3950

       Medicaid Works Recertifications/Interim Changes/Untimely Changes   3951

PASS THROUGH                                                       4150-4299

   Requirements                                                    4150-4209

       Pass Through Overview                                              4150

       Acronyms and Definitions                                           4155

       Concurrent SSI/SSP                                                 4160

       Disabled Adult Child                                               4180

       Disabled Early Widows and Widowers or Disabled Surviving           4190
       Divorced Spouses With No Medicare Part A

   Financial Eligibility                                           4220-4249

       Resources                                                          4220

       Income Calculation                                                 4230

       Applicant with Eligible Spouse                                     4235

       Applicant with Ineligible Spouse                                   4240



                                          14
       Pass Through for Individual Losing SSP                        4245

   Case Action                                                   4250-4299

       Application Process                                           4250

       Discontinuances                                               4260

       Pass Through Individual Moving to a Nursing Facility or
       Institutional Hospice                                         4270

       Pass Through Individual in Receipt of Waiver or
       Non-Institutional Hospice Services                            4280

QUALIFIED DISABLED WORKING INDIVIDUALS                           4300-4399

   QDWI                                                          4300-4399

       Introduction                                                  4300

       General Information                                           4310

       Technical Eligibility                                         4320

       Financial Eligibility                                         4330

       QDWI Effective Dates                                          4340

       Interims/Recertifications                                     4350

LOW INCOME SUBSIDY (LIS)                                         4390-4399

       Medicare Part D                                               4390

       LIS Medicare Savings Program                                  4395

QUALIFIED MEDICARE BENEFICIARIES                                 4400-4549

   Introduction to QMB                                           4400-4419

       Medicare Savings Program Overview                             4400

   Technical Eligibility                                         4420-4449

       Mail-In Applications for Medicare Savings Programs            4420

       Technical Eligibility for Medicare Savings Program            4430

   Financial Eligibility                                         4450-4499

       Resource Limits for Medicare Savings Program                  4450

       Income Limits for Medicare Savings Program                    4455


                                       15
       Medicare Savings Program Income                                   4460

       Medicare Savings Program Deductions                               4470

   Case Action                                                       4500-4549

       Medicare Savings Program Case Actions                             4500

       QMB, SLMB, OR QI1 Effective Date                                  4515

       Accretes, Deletes, and Restorations                               4525

       Ex-Parte with QMB, SLMB, OR QI1                                   4535

      Specified Low-Income Medicare Beneficiaries (SLMB) Resources       4570

SUPPLEMENTAL SECURITY INCOME                                         4650-4899

   SSI Applications                                                  4650-4749

       Duplicate Applications                                            4650

       Entitlement                                                       4655

       Potential SSI Applications                                        4660

       MA Eligibility for Deceased Applicants                            4662

       SSI Financial Standards                                           4670

       SSI Financial Eligibility                                         4680

       Institutionalized Applicants                                      4690

       SSI Essential Person                                              4700

       Residency                                                         4710

       MA Eligibility for SSI Recipients                                 4720

   SSI Discontinuance                                                4750-4899

       Medicaid Eligibility Redetermination                              4750

       Grandfathered Disabled Children                                   4752

       GDC Recertification                                               4753


       SSI Discontinuance and System Activity                            4770

       SSI Discontinuance Listings                                       4780


                                           16
       SSI Discontinuance Notices                           4790

       Assignment of SSI Discontinuance                     4800

       Processing Time Frames                               4810

       Case Decision                                        4820

INTRODUCTION TO STATE SUPPLEMENTATION                   4900-4949

   Introduction                                         4900-4929

       [State Supplementation Payments (SSP) Overview      4900]

       SSP Standards                                        4910

   Application                                          4930-4949

       Application Process                                  4930

       Recertification/Review Process                       4940

TECHNICAL ELIGIBILITY FOR STATE SUPPLEMENTATION         4950-5099

   Basis of Eligibility                                 4950-4999

       SSI Recipients                                       4950

       Non-SSI Individuals                                  4960

       Enumeration                                          4970

   Third Party Liability                                5000-5019

       Third Party Liability (TPL) Assignment               5000

   Residency                                            5020-5049

       General Requirements                                 5020

   Special Needs                                        5050-5099

       PCH and FCH                                          5050

       Caretaker Services                                   5060

       Temporary Stay in a Medical Institution              5070

FINANCIAL ELIGIBILITY FOR STATE SUPPLEMENTATION         5100-5149

   Resources                                            5100-5109



                                        17
       Resources                          5100

   Income                             5110-5149

       Introduction to Income             5110

       Deductions/Exclusions              5120

       Couples Living Together            5130

       Couples Living Apart               5140

       Elder Shelter                      5145

STATE SUPPLEMENTATION                 5150-5299

   Case Action                        5150-5209

       Category Change                    5180

   Erroneous Payments                 5210-5299

       Erroneous Payments                 5210

       Return of SSP Checks               5235




                                 18

								
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