LTC Services Melody Sanders, Health Care Training Judie Hughes, Health Care Training MFWCAA (Fall 2009)
Agenda • Introduction. • Have You Ever? • New LTC Courses! • MA-LTC Eligibility Determination. • TPL – Medicare. • Break • Asset Assessments. • Income and Calculations.
Have You Ever… Had an request for MA-LTC with more than 5 transfers? Had an MA-LTC receive a lump sum income? Had a client with LTC coverage?
Have You Ever… Had a client with a high Medicare premium? Stumped your supervisor? Attended the MFWCAA conference?
Sequencing of LTC Courses • 10 online courses. (40 hours) • 1 classroom course. (4 days) • 5 training cases.
LTC Online Courses • Annuities 101 / Advanced Assets • Intro to MA-LTC • MA-LTC Basics • MA-LTC Requirements • Asset Assessment • Annuities and MA-LTC • MA-LTC Transfers • LTCP • Income and MA-LTC • LTC Training Caseload Summary
LTC Handouts and Cases REMEMBER! Bring online handouts and case materials to the MA-LTC Systems course!
LTC Resources • HCPM • Manual Letters • Bulletins • MAXIS POLI/TEMP • MMIS User Manual • Health Care Training Courses • HealthQuest
Who is covered by MA-LTC? • LTCF residents. • HCBS waiver program recipients.
Basic MA vs. MA-LTC Meet basic MA eligibility requirements first! • SSN • Citizenship/Identity • Immigration Status • Residency • Basis of Eligibility Then apply MA-LTC eligibility requirements.
“Otherwise Eligible” All basic MA and MA-LTC eligibility requirements are met, but for a transfer penalty. • Verifications provided. • Asset-eligible. • Home Equity Limit met. • DHS named PRB, when required.
First Month of MA-LTC Request • Applying basic MA rules for MA-LTC. • Applying MA-LTC requirements. • Requesting appropriate verifications.
Request Month Determination • Date request for MA-LTC received. • DHS-3531 (Application) • DHS-3543 (Request) • HCAPP or CAF with DHS-4803
Request Month Determination • Date of LTCC (HCBS clients). • DHS-5181. • Anticipate services within 30 days from LTCC or date of request, whichever is later.
Request Month Determination • Date of LTCF admission and anticipated date of discharge. • DHS-1503 • Must reside for at least 30 consecutive days.
Request Month Determination • Retroactive months requested. • No limit for MA enrollees residing in LTCF. MA begin date or date of admission, whichever is later. • Eligibility for waiver services cannot begin earlier than LTCC date (month).
LTCF Example 1 Rodney requests MA and MA-LTC. • Request date April 15. • 3 months retro requested. • Admitted to LTCF on February 10. Action: February is month of request for MA-LTC. January is month of request for basic MA.
LTCF Example 2 Chester MA enrollee for 2 years. • Request date April 15 using DHS-3543. • No retro requested. • Admitted to LTCF previous December. Action: December is month of request for MA-LTC.
Waiver Example Elroy requesting MA and MA-LTC. • Request date April 3. • 3 months retro requested. • LTCC completed March 30. • DHS-5181 indicates services anticipated to begin 30 days from LTCC date. Action: March is month of request for MA-LTC.
OHC/TPL DHS-5590 – LTC/Waiver Case Checklist Row for Third Party Liability information available.
Types of TPL • Car Insurance • Workman’s Compensation • Homeowner’s Insurance • Medicare • Employer Health Care Coverage
Medicare • Part A – Hospitalization • Part B – Medical • Part C – Medicare Advantage • Part D – Prescription Drug
Benefits: Inpatient Hospitalization Inpatient Care in a Skilled Nursing facility Hospice Limited Home Health Care Monthly Premium Deductibles (2009 - $1,068) Coinsurance / Copayments Medicare Part A - Hospitalization
Medicare Part B - Medical • Benefits • Medically-necessary services for diagnosis or treatment of medical condition. • Preventive services • Monthly Premium ($96.40/month + or -) • Deductible ($135/year) • Coinsurance (20% of services)
Medicare Part C - Advantage • Part A • Part B • Part D (sometimes)
Medicare Part D – Prescription Drug Provided through an insurance or other private companies approved by Medicare. • Medicare Prescription Drug Plans • Medicare Advantage Plans.
Medicare Part D - Benefits • Formulary determines drugs covered. • Prior authorization for certain prescriptions • Quantity limits. • Step Therapy.
Medicare Part D - Costs • Premium (varies based on plan chosen) • Copayment (based on drugs/plan) • Deductible (up to $295) • Extra help or Low-Income Subsidy • No coverage between $2,700 - $4,350. • Coverage and copayments begin at $4,351.
Medicare and MA-LTC Costs client is responsible for may be used as: • Deduction on LTC income calculation. • Health care expense to meet medical spenddown.
Asset Assessment • Method of establishing value of assets attributed to the LTC spouse. • Attributed assets used to determine asset-eligibility for MA and MA-LTC.
Required Asset Assessment • LTCF residents with a community spouse. • EW clients with a community spouse.
Community Spouse Asset Allowance Amount of the couple’s counted assets the community spouse may retain at the time the LTC spouse requests MA-LTC. • Estimated (upon requested asset assessment) • Actual (upon request for MA-LTC – required asset assessment)
MA-LTC Request To determine assets attributable to LTC spouse use: • Actual CSAA. • Verified assets owned by couple in first month of request for MA-LTC.
Step 1 • Evaluate assets owned in first month of request based on asset assessment rules. • Use evaluation to determine total countable assets owned by the couple.
Step 2 Actual CSAA: • ≥ Total Countable Assets • All counted asset attributable to CS. • Only excluded assets owned by LTC spouse attributable to LTC spouse. • < Total Countable Assets • Go to Step 3.
Steps 3a and 3b a. Total counted asset owned by CS based on evaluation in Step 1. b. CS total counted assets is: • > Actual CSAA, CS must contribute to cost of care. • = Actual CSAA, go to Step 4. • < Actual CSAA, go to Step 3c.
Steps 3c and 3d c. Actual CSAA - CS counted asset total (3a) = additional attributable counted asset needed. d. Attribute LTC spouse’s counted assets to CS up to actual CSAA. • Remaining LTC spouse assets attributable to LTC spouse. • Go to Step 4.
Step 4 Evaluate asset attributable to LTC spouse using basic MA eligibility rules.
Step 5 Answer questions.
Income Basics • Verification of income mandatory. • Type of income calculation determined by: • Household composition. • Basis of eligibility. • MA-LTC request date. • The living arrangement. • Transfer penalty.
Monthly Reporting Bulletin 09-21-12 • No monthly reporting for medical spenddowns. • Continued monthly reporting for certain clients using an LTC income calculation.
Frank Example • Resides in LTCF. • Receives $1,086.40 RSDI/month. • Pays Medicare Part B ($96.40). • Receives land payments 2x/year. • March ($8,000) • November ($8,000) • Land in life estate (unavailable). • Liability insurance of $465 paid in November. • Property taxes $1,090 x 2/year.
Receipt of Lump Sum • Case note facts regarding the amount and frequency of payments. • Set DAIL/WRIT for when a lump sum payment is due. • Calculate obligation using anticipated income. • Recalculate when income actually received and review asset-eligibility.
Combination LTC/Medical Spenddown • Obligation changes from LTC spenddown to a combination LTC/Medical spenddown. • Do not close eligibility unless client requests closure. (Even if medical spenddown portion not met.) • Review of assets in the month following the month in which the combination spenddown occurred.
Frank Example • Resides in LTCF. • Receives $1,086.40 RSDI/month. • Pays Medicare Part B ($96.40/month). • Receives land payments 2x/year. • March ($8,000) • November ($8,000) • Land in life estate (unavailable). • Liability insurance of $465 paid in November. • Property taxes $1,090 x 2/year.
Rental Income Deductions • Interest and escrow portions of a mortgage payment. • Real estate insurance. • Repairs (minor corrections to an existing structure)- example for Frank’s repairs to a tile – but not putting in new tile. • Property taxes • Lawn care. • Snow removal. • Advertising for tenants. • Utilities. • Property management fees paid to a third party. Do not carry excess expenses over to other tax years or use excess expenses to offset other income.
Sally Example • Owns a home ($15,000 equity) and will not return. • Resides in LTCF. • RSDI recipient - $834/month. • Granddaughter moves into home – pays $50/month rent.
Considerations • Assets. • Homestead exclusion after six months. • Care of enrollee exclusion. • Up for sale. • Income-producing asset. $6000, 6%. • Expenses. • Up keep expenses. • Available income.
Income-Producing Property Exclude up to $6,000 in equity value. • Limited to combined equity of all property meeting 6% rule. • Each property must meet 6% rule. • Continue to exclude up to 24 months if earnings on property drop below 6%.
Allowable Rental Expenses • Interest and escrow of mortgage payment. • Homeowner’s insurance. • Repairs as needed. • Property taxes.