The Building Blocks for Alternative Care Eligibility

1
The Building Blocks for Alternative Care
Eligibility

• 2009 Age and Disabilities Odyssey
• Libby Rossett-Brown and Gail Carlson, DHS Aging
  and Adult Services Staff
• August 18th, 2008

2
Session Overview

• Background/history, basic services, Client
  Characteristics, Trends and Updates
• AC Fees Update
• Program/Financial Eligibility/Estate Claims
• Legislative Updates
• Resources

3
Acronyms

• AC
• AAA
• CDCS
• CG
• CM
• CMS
• DRA
• EW
• FFP
• FPG
• HCBS
• HHA
• LTCC
• Lead Agency

• Alternative Care Program
• Area Agencies on Aging
• Consumer Directed Community Supports
• Family or Informal Caregiver
• Case Manager or Care Coordinator
• Centers for Medicare and Medicaid
• Deficit Reduction Act of 2005
• Elderly Waiver
• Federal Financial Participation
• Federal Poverty Guidelines
• Home and community based services
• Home Health Agency
• Long-term Care Consultation
• County or tribal agency/organization under AC

4
More Acronyms

• MA
• MHCP
• NF
• NFCSP
• PCA
• PNA
• QI1
• QMB
• SLMB
• SRU

• Medical Assistance
• MN Health Care Services Program
• Nursing Facility
• Title IIIE National Family Caregiver Support
  Program
• Personal Care Attendant
• Personal Needs Allowance
• Qualifying Individuals Group 1
• Qualified Medicare Beneficiary
• Specified Low Income Medicare Beneficiary
• Special Recovery Unit

5
Program History

• Enacted into law by the State Legislature in 1980
• Appropriates a portion of the states share of
  nursing home funding to support services in the
  home
• Services provide a portion of necessary support
  to delay permanent nursing home care under MA

MN Statute, Section 256B.0913
6
AC Program

• Issue
• Older adults with chronic care needs did not have
  enough financial resources to purchase services,
  nor too little to qualify for public programs.
• They would enter the nursing home to receive
  care. And, in the course of their extended stay
  would deplete personal resources and assets to
  poverty levels, preventing them from returning
  home.
• Solution
• AC program was created to address an unmet need
  for long-term care in the community.

7
AC Program Goals

• Contain MA expenditures by funding care in the
  community.
• Maintain the moratorium on new construction of
  nursing home beds.
• Outcome
• Prevent impoverishment of older adults by
  assisting them to access services at an earlier
  point of need and prevents more costly levels of
  care

MN Statute, Section 256B.0913
8
AC Target Population

• Older adults who have chronic care needs
• Those with some financial resources to meet their
  own health-related needs and independent living
  need
• Those who are at risk of permanent NF placement.
• Total Eligible AC Clients FY08 5,069

9
AC Program Model

• Voluntary Enrollment
• Partnership between client and state
• Cost sharing model so individuals share in the
  cost of services and pay monthly fees
• AC pays for a portion of needed services only
• Long-term care services (no acute care)
• Individual budget caps equal to 75 of EW caps
  for similar persons (subject to LTCC and case mix
  assignment)

10
AC Services

• Service, definitions and standards same as EW
  unless defined in AC Statutes
• AC allows targeted funds, discretionary funds,
  nutrition services and a relative hardship waiver
• No transitional supports, AFC, customized living,
  24 hour customized living (formerly AL, AL) or
  residential care services
• Services and supports should not supplant other
  funding sources

11
AC Services

• Case Management
• Conversion Case Management
• For clients who are admitted to a nursing
  facility with plans to return to the community on
  the AC program
• Assists clients in accessing service plan,
  developing an individualized plan, authorizing
  and arranging services, ensuring health and
  safety, and a smooth transition from facility to
  home
• Pays for up to 100 consecutive days of service

12
Client Characteristics

• Average Age -83 100 - 32
• 74 Female 26 Male
• 2/3 are widowed
• 69 Live alone
• Case Mix A 63, B 14, D-7
• Average cost - 5,765 per client/year
• On program an average of 26months
• FY 09 Approx cost - 51 million

13
Alternative Care Program (AC)Update on Fees

• 7/18/09

14
Payment options include

• Personal checks, money orders, or cashiers checks
  made out to DHS and mailed to
• DHS-AC Premiums
• PO Box 64834
• St. Paul, MN 55164-0834
• Credit card payments made at
• http//payments.dhs.state.mn.us
• Payment plan
• Representative Payee or greater family
  involvement
• Automatic Withdrawal
• DHS 3389

15
Case managers can change fees on the service
agreement for the following month

• If there is a change of condition which results
  in a change in the cost of services
• If there is a change in the adjusted income or
  assets or
• A client enters a nursing facility as an
  admission for more than 30 days

16
Fees are waived under certain conditions

• Income and assets below minimal amounts
• CDCS - if the cost of services under CDCS is less
  than or equal to the cost of the same services
  under traditional option, the fees are waived
• Person is found eligible for AC but not yet
  receiving AC
• Married couple is requesting an asset assessment
  under the spousal impoverishment provision
• Client enters a nursing facility and is receiving
  case management only
• The AC fee waiver reason is identified on the
  screening document

17
If an AC client enters a nursing home for more
than 30 days

• Enter amount of 0 in the service agreement AC
  Premium field. Enter the following month in the
  Premium Effective Date field. Enter an exit
  screening document if conversion case management
  is not provided.
• For refunds for current or past months, contact
  DHS MADE at dhs.MADE_at_state.mn.us or fax
  651-431-7431

18
To change or cancel automatic withdrawal

• DHS 3389 has instructions
• Call [phone] or [phone] before the
  fifth of the month
• Provide name, case number, bank account number
  and indicate if this is a change or a request to
  stop the withdrawals

19
Overdue Fee Reports

• Infopac Report I90 reports clients who are
  overdue in paying their fees by county of service
• Cases are coded O for Open, C for Closed, or D
  for Deceased
• Case managers are required to contact clients who
  are more than 60 days late in paying their fees
  as long as they are open.
• Eligibility may be extended while making
  arrangements to pay outstanding fees.

20
Overdue Fee Reports

• If no arrangement is made to pay the fees, the
  client must be closed to AC for a minimum of 30
  days.
• Clients will continue to receive bills for 1 year
  after they are closed.
• When clients move to a new county, the new county
  is responsible for collecting the fees. The
  current county of service must update the
  screening document and service agreement before
  the client will show up on the new county

21
AC Monthly Fees
Income minus recurring and predictable medical
expenses
22
AC - Eligibility Criteria

• Age 65 years or older, and
• Assessed by the county LTCC team to have needs at
  a nursing facility level of care, and
• Type and amount of AC services available (based
  on 75 funding limit) will meet client needs and
  ensure health and safety, and

23
AC - Eligibility Criteria

• Applicant chooses to reside in the community, and
• Financial resources are most like within 4.5
  months of MA eligibility, and
• Capable of meeting own remaining health needs and
  long term care needs, as well as meeting a
  monthly fee requirement, and
• Did not improperly dispose of assets
• AC clients may also be eligible for Medicare
  savings programs such as QMB SLMB, and QI1

24
AC Financial Eligibility

• Involves both income and assets 25,000
• There is a difference depending on marital status
  and spouse status
• There can be allocation of assets and or income
  to the spouse for married persons.
• Determination of client monthly fee

25
Financial Eligibility for AC

• Monthly Income is gt1083 (120FPG) or
• assets are gt3000(MA asset limit) and
• total combined adjusted monthly income and assets
  are less than the projected nursing facility care
  cost for 135 days (MA asset limit of 3000)
• this is currently 25,036

26
Financial Eligibility for AC

• Income is 1083 and assets are 3000 applicant
  is ineligible for AC
• can be temporarily served under AC up to 60 days
  during their application to Medical
  Assistance/Elderly Waiver
• If income and assets available for NF care is
  greater than the projected nursing facility care
  cost for 135 days (MA asset limit of 3000)
  Client is ineligible for AC and cannot be
  temporarily served

27
Financial Worksheets

• Alternative Care Program Eligibility Worksheets
• - DHS- 2630A Married person with
• a community spouse
• - DHS-2630 Unmarried individuals,
• or Married couples when both may
• choose AC or a married person
• whose spouse is an EW recipient
• or is living in a nursing facility

28
Financial Worksheets

• Monthly Income this is gross income-including
  all sources of earned and unearned income
  received by the applicant including
• - social security benefits
• - interest payments
• - pensions
• - annuity payments
• - payments from rental property
• and earnings
• - contract for deed payments

29
Financial Worksheets

• Recurring and predictable monthly expenses
• health insurance premiums,
• - drug costs,
• acute care costs that the client pays on a
  monthly basis
• This cannot include the AC Fee

30
Financial Worksheets

• Clothing and Personal Needs Allowance-PNA
  current 89
• This is the amount that Medical
• Assistance allows a person residing
• in a nursing home to keep for
• spending money

31
Financial Worksheets

• Subtract the personal needs allowance and the
  predictable medical expenses from the applicants
  income-
• The result is the amount of income
• available to pay nursing home
• costs each month
• Multiply the available income by 4.5
• The result is the amount of income to
• pay nursing home costs for 135 days

32
Financial Worksheets

• Individuals total nonexcluded assets
• Include the value of all assets
• owned by the applicant including
• - Cash
• - All Bank accounts checking,
• savings, CDs
• - Annuities
• - IRA/KEOGH any other pensions
• - Stocks and Bonds
• - Trust funds that are available
• - Contract for Deed
• - Cash surrender value of Life Insurance
• - Real property not used as applicants
  primary
• residence
• - boats, campers, motorcycles

33
Financial Worksheets

• Individuals Assets that are not included in the
  total include
• - Homestead property including
• contiguous land
• - Personal effects
• - household goods and furnishings
• - the value of one vehicle

34
Financial Worksheets

• Incurred Unpaid Past medical bills
• Bills owed by the individual that are payable
  which will not be payable by Medicare or medical
  insurance
• Subtract any of the above medical bills from the
  total assets
• Subtract 1500 if there are no burial accounts
• The result is the amount of assets which are
  available to fund nursing home care

35
Financial Worksheets-Program Eligibility

• Add the amount of income available to pay for 135
  days of nursing facility care to the
• Amount of assets available to fund nursing
  facility care.
• If this figure is less than or equal to the
  nursing facility cost for 135 days MA asset
  limit- currently 25,036
• The client is financially eligible for the AC
  Program. Unless there is an uncompensated
  transfer of assets

36
Financial Worksheets

• Asset Transfer When a client, clients spouse,
  or clients representative gives away, sells,
  conveys ownership and/or reduces control, or
  disposes of any income or asset or any interest
  in an asset (other than spousal allocations of
  assets or income)

37
Financial Worksheets

• Improper/Uncompensated Asset Transfer An asset
  that is sold, given away, or otherwise disposed
  of for less than fair market value. This may
  include giving away income or assets, selling
  property for less than fair market value,
  purchasing property for more than fair market
  value or refusing an inheritance, cash gifts,
  establishing a life estate or creating a trust.

38
Financial Worksheets

• Statewide Average Payment for a Skilled Nursing
  Facility (SAPSNF)-which is the average monthly
  payment statewide for skilled nursing care. It is
  used to calculate the penalty period for an
  improper transfer.
• As of 7/1/09 5,006 This is used as a divisor
  and the resulting number is the number of months
  the client may not receive any AC services.

39
Financial Worksheets

• Determine the penalty period for an
• uncompensated transfer by dividing the
  uncompensated value of asset by
• the SAPSNF which is currently 5,006.
• The result is the number of months the client is
  ineligible to receive AC services. Begin counting
  the penalty period on the date that the person is
  otherwise found eligible for the AC program
  through the number of months that was calculated,
  including partial months of service when the
  penalty period is ending.

40
Transfer of Asset Example

• Mr. Summer gave his son 20,000 on June 1, 2009.
  He applied for AC services on July 1, 2009 and
  was considered eligible.
• 20,000 5006 3.99 Count 3.9 months of
  ineligibility from July 1, 2009. July, August,
  Sept and most of October 2009 he is ineligible.

41
Financial Worksheets

• Lookback Period The maximum number of prior
  months used to determine if an improper transfer
  has taken place. The lookback period for
  transfers into an irrevocable trust is 60 months.
  Beginning 2/1/09 the phase in of the 60 month
  look back period began. The phase in is in one
  month increments. August 2009 the lookback period
  is 43 months. Sept 2009 the lookback period is 44
  months. The full 60 month lookback period will be
  in place 2/1/2011.

42
Financial Eligibility for AC(Married)

• Asset Assessment a determination for the AC
  program cannot be made until a Medical Assistance
  Asset Assessment (DHS-3340A) has been completed
  and the financial assistance division determines
  the community spouse asset allowance. An amount
  of assets are allocated to the community spouse
  to prevent spousal impoverishment.
• The minimum asset allowance is 31,094 and the
  maximum is 109,560
• Minimum spousal monthly income is 1823

43
Asset Assessment

• Per Medical Assistance eligibility policy, the
  total assets owned by the couple from which the
  community spouses asset allowance will be
  identified are reviewed on a specific date. The
  date is the earliest of the 1st day of the 1st
  continuous period of
• Admission to a medical Hospital
• Admission to a nursing facility
• Receipt of home care services that would
  be covered by EW or AC or the LTCC date whichever
  is later
• Case Management service may be considered a home
  care service for the purpose of setting an asset
  assessment date

44
Financial Eligibility for AC(Married)

• When the community spouse asset allowance has
  been determined subtract this figure from the
  couples total assets. The remaining assets are
  considered available to the client.
• Then subtract any medical bills and a burial
  allowance if appropriate.
• The result is the asset amount used to compute AC
  eligibility.

45
Financial Eligibility for AC(Married

• The minimum spousal income allocation is listed
  on the worksheet.
• The allocation to the community spouse is the
  community spouses monthly income minus the
  minimum monthly spousal allocation.
• This result is subtracted from the gross income
  of the applicant.

46
Income Allocation Example

• Mr Evergreen has been assessed to need AC
  services. Mrs Evergreen does not need any
  services. She is the community spouse
• Mrs Evergreens monthly income is 900.
• 1823(min monthly income allocation) minus 900
  923 this is the amount that will be allocated
  from Mr Evergreen to Mrs Evergreen.

47
Income Allocation Example

• Mr Evergreens income is 2000. Subtract the
  income allocation of 923 1077 is the amount
  of countable income for Mr. Evergreen.
• From this you would subtract predictable monthly
  medical expenses and clothing and personal needs
  allowance-the result would be Mr Evergreens
  available monthly income.
• Multiply this amount by 4.5 to determine the
  income available for 135 days of nursing home care

48
Federal Deficit Reduction Act (DRA)

• Changes since the Federal Deficit Reduction Act
  (DRA) of 2005
• -AC start date for penalty period is the date of
  the application to the AC program for a person
  who would otherwise meet all other eligibility
  criteria, except for the transfer, and the
  transfer was made on or after 2/8/2006
• - There is no longer a disregard for transfers
  of assets for less than fair market values for
  amounts of 200 or less in total value for one
  month. This is effective 7/1/2006 and effects new
  requests for payment as well as AC clients
  already receiving services.
• - Look back period will be 60 months for
  transfers that have occurred on or after 2/8/06.

49
Federal Deficit Reduction Act (DRA)

• 7/1/2006 a 500,000 Home Equity limit affects
  eligibility for applicants and enrollees who
  request payment of AC services. An exception
  would be the property is the primary residence
  of a spouse, minor child, or any child of any age
  with a disability.
• AC applicants and clients will be required to
  state the value of their homestead on the Client
  Disclosure Form (DHS-3548)-this form is required
  annually for all AC clients
• Instructional bulletins 06-21-14, 06-21-13 and
  07-21-05 refer to MA payment of LTC services but
  AC uses the same policy.

50
Federal Deficit Reduction Act (DRA)

• New Instructions have been issued for Annuities
  and the payment of Long term care services.
  Instructional Bulletin 08-21-04
• These instructions do not apply to the AC program
  at this time. Clients will need to understand
  that they will need to comply with these new
  provisions if they apply for Elderly Waiver or
  for Payment in a Nursing Facility.
• Further questions on the provisions should be
  referred to the County Financial Worker

51
Estate Claim Recovery

• Effective 7/1/2003, DHS and the county pursue
  estate claims for people that use the AC Program
• An Estate claim is a method of recovering AC
  payments from the estate of a deceased person
• It is only payable from the assets in the estate
  of the recipient of AC services
• The estate will pay a portion of the claim before
  it will give heirs any inheritance.
• The estate may include a life estate or any joint
  tenancy interests in real estate that is owned at
  the time of death.

52
Estate Claims

• Claims against the estate of AC client are for
  services provided minus premiums paid and are
  pursued by the county recovery unit and DHS.
• The claim will be filed after the death of the
  person who received AC or upon the death of the
  survivor of the married couple.
• New form DHS 5186 explains estate claims and
  recovery
• Past due premiums will become a part of estate
  recovery
• Estate claims already imposed on clients over 55
  on SLMB, QMB, QI1

53
Estate Claims

• Liens on real property were repealed for the AC
  program 7/1/05 but it should be noted that the
  definition of an estate for recovery purposes has
  been expanded to include the life estate and
  joint tenancy interests, when the recipient dies.

54
Long Term Care (LTC) Insurance

• Deficit Reduction Act (DRA) gives states
  authority for LTC Partnerships
• More people will be buying LTC insurance that may
  or may not be partnership qualified
• This will have an effect on Protected assets for
  Medical Assistance
• Clients can become eligible for MA sooner.
• Client with LTC Insurance Partnerships should be
  encouraged to apply for Medical Assistance.

55
Long Term Care (LTC) Insurance

• Long term care insurance should be coded as a
  policy in MMIS/TPL
• LTC insurance should also be used when
  determining the clients service payment needs.
• Long term care insurance payments need to be used
  for the payment of services prior to AC

56
Service Changes for AC

• - addition of extermination and pest control to
  Chore service
• - Flexible Case Manager standards-(CDCS)
  developed by the department
• -Specialized Supplies and Equipment-more service
  definitions
• -

57
Service Changes for AC

• Environmental Modifications If for any
  unforeseen reason, the individual does not enroll
  in AC (due to death or a significant change in
  condition) the modification or adaptation that
  was provided may be covered through State
  Administrative funds.

58
Contract Template

• All providers must have a contract with a lead
  agency. The department has provided a
  standardized template for contracts with
  providers that lead agencies may use. For all
  contracts renewed after April 20, 2009, counties
  must use the standardized template. IB09-25-03
• contains the template and details.

59
Legislative Changes

• Provider service rates are to be reduced to
  reflect a 2.58 COLA reduction effective 7/1/09.
• Case Mix cap limits were reduced by 2.23
  effective 7/1/09

60
Case Mix L

• Amendments to Minnesota Statutes, sections
  256B.0915 and 256B.0913 were approved by
  Minnesota Legislature creating a new community
  budget and case mix cap for individuals with not
  or low needs of certain activities of daily
  living.
• The new classification is referred to as case mix
  L.

61
Case Mix L

• Criteria related to Case Mix L
• No need for regular staff intervention because
  of the need for cognitive or behavioral support(
  the score in the behavior item is less than 2)
• OR
• No special nursing need (special nursing
  is defined as a score in clinical monitoring of 2
  and special treatment is equal to or greater than
  1)
• AND.

62
Case Mix L

• No dependencies in activities of daily living
• OR
• Only 1 dependency in bathing, dressing, grooming
  or walking
• OR
• A dependency score of less than 3 if eating is
  the only dependency in activities of daily living.

63
Case Mix L

• As outlined in amendment to Minnesota Statutes
  2008, section 256B.0913, subdivision 4 The
  monthly cost of AC services funded by the program
  cannot exceed 600 per month for all new
  participants enrolled in the program on or after
  July 1, 2009. This monthly limit shall be
  applied to all other participants who meet this
  criteria after reassessment.
• The budget cap was further reduced to 587 per
  month after applying required legislative
  reductions.

64
Thank you!

• Gail Carlson, AC Program Research Analyst
  gail.v.carlson_at_state.mn.us for operations and
  data questions
• Libby Rossett-Brown, EW/AC Program Administrator,
  libby.rossett-brown_at_state.mn.us for eligibility
  and service, asset transfer and DRA