This program is a part of nursing home diversion (Missouri Care Options).  The purpose of this eligibility is to give equitable treatment of resources for married couples, by allowing a division of assets, to persons choosing to remain in their own homes rather than entering a nursing facility.  It also establishes a higher income level for all individuals receiving HCB waiver services, to encourage them to remain at home.

INDIVIDUALS WHO DO NOT MEET THE FOLLOWING REQUIREMENTS MAY BE FOUND MEDICAID ELIGIBLE USING ANY OTHER MA CRITERIA.

ELIGIBILITY REQUIREMENTS

There are four general eligibility requirements for individuals to receive Title XIX under HCB criteria.  An individual must:

• Be age 65 or older;

• Be determined by the Division of Aging (DA) to need:

1.     a nursing facility (NF) level of care; and

2.     be authorized to receive HCB waiver services;
 

• Have monthly income at or below $750.00; and

• Meet the Available Resource criteria.

When persons living in their own homes meet this criteria, they are eligible for a "T" level of care under the Medical Assistance (MA) Program.

NOTE:  These rules also apply when one member of a married couple meets the eligibility criteria.

1. Age

The individual must be age 65 or over.  Verify and record the age of the individual on  the IM-36.  Refer to Chapter XI, Section I, pages 1-3 for acceptable verification of age.  Persons under age 65 are not eligible under HCB waiver criteria.

2. Medical Need and Need and Authorization for HCB Waivered Services

HCB waiver services are extended to individuals who, in the absence of the waiver, would require nursing facility (NF) care.  Therefore, the individual must require a level of care provided by an NF.

These individuals also must have a need for HCB waiver services.  At present, the only HCB waiver services are Homemaker Chore and Respite Care.

The Division of Aging determines if an individual requires an NF level of care and the need for HCB waiver services. To be eligible for Medicaid, the HCB individual must be authorized by DA to receive HCB waiver services.  The date of Medicaid eligibility under these criteria cannot be prior to the date of the DA approval.

The IM-54A form has been developed to refer individuals to DA for the NF level of care and need for HCB waiver services determinations.  The IM-54A also contains the date DA authorized HCB waiver services.  Refer to Section L of this memorandum.  DA-124 forms are not used for HCB individuals.

3. Income

When the gross monthly income of the HCB individual is at or below $750.00, s/he meets the income criteria for HCB eligibility.  Only the income of that individual is considered.  When determining gross monthly income, follow the regular MA policy outlined in Chapter VI, pages 6-8a.  DO NOT INCLUDE THE INCOME OF THE SPOUSE OR ANY OTHER HOUSEHOLD MEMBER.

The $750.00 income standard is absolute.  Individuals cannot spenddown to become eligible under HCB waiver criteria.  Using the IM-30A, enter the gross income on line 5.  Compare this amount to $750.00.  Also record verification of income on the IM-30A.

NOTE:  Persons with income above $750.00 can become eligible for Medicaid using regular MA procedures.

If the non-HCB (community) spouse applies for IM assistance, do not consider the income of the HCB individual in that determination.

4. Available Resources

1. Resource Maximum

The resource maximum for this program is $999.99.  Determine as available resources anything that is considered under the December 1973 eligibility requirements for aged individuals.  Refer to Chapter XI, Sections IV and V.

2. Division of Assets

For married couples, a division of assets is required (when the HCB individual's income is below $750.00) to determine available resource eligibility under HCB waiver criteria.

Follow the policy in Chapter XI, Section V, pages 15-26 for determining the totalnonexempt assets, the spousal share and when Medicaid eligibility under the available resource criteria may begin.

NOTE:  When the HCB individual's income is greater than $750.00 per month, the couple is not eligible for a division of assets under HCB waiver criteria.  In these instances, regular MA resource criteria for couples in their own homes and regular MA spenddown budgeting procedures apply.

1. Month of Institutionalization

When one member of the couple is determined by DA to require both an NF level of care and HCB waiver services on or after January 1, 1993, complete the assessment for the month DA makes that determination.  For those cases authorized for HCB services prior to January 1, 1993, refer to Section E, Conversion of DA Caseload to Medicaid, in this memorandum.

When the HCB individual is already receiving Title XIX under any IM program, a division of assets is required to determine HCB waiver eligibility.

If both members of the couple are determined by DA to require both an NF level of care and HCB waiver services, the couple is not eligible for an assessment of assets or Title XIX using HCB waiver criteria.

2. ISMT 

When processing ISMT transactions for HCB individuals, enter 999999999 as the vendor number.  The system will show "HCB Waiver" as the institution name.  Use 999999999 ONLY for the ISMT transaction.  Do not enter 999999999 in IMu5.

3. Entry Into a Medicaid Certified Bed

If either member of the couple subsequently enters a Medicaid certified bed, continue to use this assessment of assets.

As noted in Chapter XI, Section V, page 16 2., a., assessments are completed when the first continuous period of institutionalization begins.  HCB waiver individuals are considered institutionalized, therefore, only one division of assets is required.

Thus, assessments must now be completed for institutionalized individuals based on their first continuous period in a Medicaid certified bed beginning after September 30, 1989, OR their first continuous receipt of HCB waiver services after December 31, 1992, whichever is earlier.

An additional division of assets also is not required when the non-HCB waiver spouse subsequently enters a Medicaid certified bed.  In these cases, the HCB waiver spouse becomes the community spouse and the non-HCB waiver spouse becomes the institutionalized spouse.

If the non-HCB spouse enters a Medicaid certified bed, allow the couple 90 days to complete the transfer of assets to the spouse who remains at home.  Do not approve the application until the institutionalized spouse signs the IM-79 form.  Refer to Chapter XI, Section V, pages 24 and 25.

5. Conversion of DA Caseload to Medicaid

The Division of Aging currently has a caseload of people who receive HCB waiver services.  Some of these people receive the services only through the Social Services Block Grant (SSBG), because they are not Medicaid recipients.  Others receive these services through SSBG and Medicaid, because they are spenddown recipients.

It is important to convert this caseload to Medicaid under the new HCB waiver criteria as quickly as possible.  Quick conversion will allow the state to achieve maximum cost savings and will allow more people to remain in their homes longer.  With this in mind, the Division of Family Services and the Division of Aging have planned a cooperative effort to ensure a timely and orderly conversion.

A listing of cases will be sent to each DFS county, identifying HCB waiver recipients.  A duplicate of this listing will go to DA case managers.  The listings will identify HCB waiver recipients in the following statuses:  1)application status for Medicaid, 2)single individuals receiving Medicaid spenddown, 3)married individuals receiving Medicaid spenddown, and 4)recipients of HCB waiver services in none of the first three statuses.

When the listings are received, take the following action:

1. Applications

For those individuals on the listing in application status, determine Medicaid eligibility for January 1, 1993, and later in accordance with the new HCB waiver criteria.  The listing is verification that the individual meets HCB waiver criteria; an IM-54A is not needed from the Division of Aging.

If the application is processed before you receive the listing, convert the active case to HCB criteria effective January 1, 1993.

NOTE:  For married individuals, determine from the listing if the HCB waiver recipient's spouse is also an HCB waiver recipient.  If so, eligibility should be determined using regular Medicaid rules.

2. Single Spenddown Recipients

For those individuals on the listing identified as single spenddown recipients, review the case to ensure the individual is single.  Determine if the individual's income (as outlined under "C. Income" in this memorandum) is at or below $750 per month.  If so, enter an IMU5 transaction zeroing out field 32 Medicaid Termination Date and changing the budget figures to reflect the $750 income standard.

The listing is verification that the individual meets HCB waiver criteria; an IM-54A is not needed from the Division of Aging.

Send an IM-33 to notify the individual that s/he is no longer spenddown but will receive Medicaid as long as s/he continues eligible under the HCB waiver criteria.

Complete the above actions on these cases by December 31,1992.

3. Married Spenddown Recipients

For those individuals identified as married spenddown recipients, review the case to ensure the individual is married.  If so, check the listing to determine if the individual's spouse is also an HCB waiver recipient.  If so, no further action is necessary.

If only one member of the couple is an HCB waiver recipient, determine if that individual's income (as outlined under "C. Income" in this memorandum) is at or below $750 per month.  If so, enter an IMU5 transaction zeroing out field 32 Medicaid Termination Date and changing the budget figures to reflect the $750 income standard.

The listing is verification that the individual meets HCB waiver criteria; an IM-54A is not needed from the Division of Aging.

Send an IM-33 to notify the individual that s/he is no longer spenddown but will receive Medicaid as long as s/he continues eligible under the HCB waiver criteria.

If the individual's spouse is also a Medicaid spenddown recipient, complete a budget adjustment to determine eligibility for this person as an individual.  If the person is no longer spenddown, enter an IMU5 transaction and notify the individual of this change.  If the person remains spenddown, no action is necessary until the next reapplication.

Complete the above actions on these cases by December 31, 1992.  While an assessment is necessary for these cases, do not delay action to complete one.  Make arrangements to complete an assessment for the month of January and have the IM-79 Intent to Transfer Assets form signed by no later than March 31, 1993.

4. SSBG Non-Medicaid Recipients

Individuals on the listing that are not included in the three above, are SSBG Non-Medicaid recipients.  Beginning in December, Division of Aging case managers will:

• Review their case files on these individuals to determine if they potentially meet the HCB waiver Medicaid criteria.

• For those that meet the criteria, contact the individuals to determine their interest in Medicaid.

• For those potentially eligible for and interested in Medicaid, send under a cover letter, DFS application forms packets and encourage the claimants to return the forms to the DFS office to apply for assistance.


NOTE:  DA staff in your county office may request forms to make up these packets.  Please assist them in getting the proper forms.  In a sample packet for DA managers, we included the IM-1, IM-2D (IM-2 not required for these applications), IM-3, IM-6, IM-6AR, IM-7, IM-9, IM-78, IM-79, and a verification guide.

• For those individuals that receive application packets, notify DFS of the identifying information, the date of application request, and the name and telephone number of the DA case manager.  This will be in the form of a copy of the cover letter DA gives to claimants with the application packet.

      DFS staff will:

• Use as the application date for these cases the date of request supplied by the DA case manager on the cover letter.

• Not require a face to face interview for these cases.

• Notify the DA case manager of receipt of the application for assistance, as DA will follow up with the claimants who fail to complete the application.

• Determine eligibility for these applications within 45 days using the HCB waiver criteria outlined in this memorandum.

• Notify DA of the decision on the application via form IM-54A.

6. Transfer of Property

Follow the policy in Chapter XI, Section IX, pages 12-22 for determining transfers of property.  Persons determined to have transferred property without receiving fair and valuable consideration are not eligible for Medicaid using HCB waiver criteria.

Couples who have transferred property are eligible for an assessment of assets.  Eligibility for Title XIX using HCB waiver criteria cannot begin until the penalty period expires.  Use the spenddown/non-spenddown criteria for establishing eligibility for Medicaid for persons who transfer property.

7. Citizenship, Residence, Social Security Number

Use the policy in Chapter XI to determine eligibility on the factors of citizenship, residence and Social Security Number.

NOTE:  These factors apply only to the HCB individual.  If the spouse is not applying for assistance, do not verify these factors for that spouse.

8. Prior Quarter

Individuals found eligible under HCB criteria may be approved for prior quarter coverage in the DA NF level of care and need for waivered services determinations include prior quarter.

Because these provisions are not effective until January 1, 1993, coverage using these guidelines cannot begin prior to January 1, 1993.

9. Time Limits for Application Processing

Process applications for MA using HCB criteria within 45 days from date of application.

10. Reinvestigations

Reinvestigate HCB cases on an annual basis, the same as any other MA case.

11. IMU5

Process HCB cases in IMU5 in the same manner as any other non-spenddown MA case with the following exception:

Enter $750.00 in Field 33 (Exp/Eil).  The $750.00 amount identifies these cases as HCB.

12. IM-54A Form

The IM-54A is used by DFS to refer applicants to DA for an NF level of care and need for HCB waivered services determination.  DA uses the form to notify DFS if the claimant needs or does not need an NF level of care or HCB waivered services.

DA will respond on the IM-54A with its decision and the date the claimant was authorized for HCB waiver services.  DFS also uses the IM-54A to notify DA of the effective date of Medicaid eligibility or the date the application was rejected.

When a non-vendor claimant, who has not contacted DA, requests a division of assets, complete the identifying and DFS section of the form.  Send the form to the local DA case manager.  DA completes the DA section of the forms and returns it to the DFS caseworker.  When eligibility or ineligibility is established, send another copy to the DA case manager.

13. Fact Sheet and Verification Guide

To assist DA in explaining these new eligibility criteria and help claimants provide necessary verification, we have developed the "Home and Community Based Waiver Services Fact Sheet" and the "Verification Guide for HCB Medicaid Applications".  These two documents are attached to this memorandum, as county staff also may find them useful.  

• Review this memorandum with all appropriate staff.
• Convert DA caseload individuals to Medicaid as outlined in this memorandum.
• Effective January 1, 1993, accept applications for MA based on the criteria outlined in this memorandum.
• File the IM-54A form and instructions.