GRH and Health Care

1
GRH and Health Care

• MA, GAMC and Waivers

2
Automatic Eligibility

• Receiving GRH payment
• MAmust have MA basis
• MA with waiver
• Eligible for MA payment of LTC services
• EW exception Must do EW calculation
• GAMCno MA basis
• May or may not receive GA grant

3
MA Spenddown

• Income over 867 (100 FPG)
• Spend down to 650 (75 FPG)
• What bills can be used?
• Medicare premiums paid by enrollee
• Remedial Care
• Waiver services
• What cant be used?
• GRH room and board costs

4
Remedial Care

• Special deduction for GRH
• Fixed amount updated twice yearly
• Allowed for anyone in a facility where county has
  a GRH agreement
• Applied against spenddown, or
• Deducted from income (EW)

5
Spenddown Example 1

• Client age 34, single, residing in rate 1 GRH
  facility (cost 776)
• Eligible for CADI waiver
• Receives RSDI of 1070
• Pays Medicare Part B premium of 96
• Eligible for GRH?
• No. 1070 - 20 general deduction and 96
• (84 12) PN gt 776
• What is his spenddown?

6
Example 1 Calculation

• Income exceeds 867
• 1070 650 420 spenddown
• Can he meet his spenddown?
• H bill (Medicare) 96
• P bill (remedial care) 210
• 420- 306 113 spenddown balance
• (MMIS recipient amount)
• Met with R bill (CADI services)

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Spenddown Example 2

• Client age 50, single, residing in a board and
  lodge with 1183 GRH rate
• Receives RSDI of 1571
• Not yet Medicare eligible
• Gets TCM services costing 286
• Not eligible for GRH grant
• What is his spenddown?
• 
  

8
Example 2 Calculation

• Income exceeds 867
• 1571 - 650 921 spenddown
• Can he meet his spenddown?
• P bill (remedial care) 210
• 921 - 210 711 spenddown balance
• (MMIS recipient amount)
• R bill (TCM) 286
• 711- 286 425 remaining balance
• Not enough bills at this timecant meet spenddown

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EW Eligibility

• Income under the SIS?
• Compute waiver obligation
• Income over the SIS?
• No community spouse Spenddown
• Community spouse LTC budget

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Example 3 SIS-EW

• Single client resides in GRH with assisted living
• Receives RSDI and pension of 1816
• Pays Medicare Part B of 96
• Has 15 Part D copays (initial month)
• Not eligible for GRH grant
• Does she have a waiver obligation?

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Example 3 Calculation

• Income is less than SIS of 1911
• Income deductions
• Medicare premium 96
• Maintenance needs allowance 860
• Remedial care 210
• Copays 15 (initial month only)
• 1816 1181 635 waiver obligation

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Example 4 SIS-EW and GRH

• Single client resides in adult foster care
• GRH rate 1 (776)
• Receives RSDI of 850
• QMB pays Medicare
• Is there a waiver obligation?

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Example 4 Calculation

• GRH
• 850 RSDI
• 20 general
• 830
• 96 personal needs
• 734
• 776 GRH rate
• -734
• 42 GRH grant

• SIS-EW
• 850 RSDI
• -860 maintenance needs
• 0 waiver obligation

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Example 5 Income Above SIS

• Single client resides in assisted living
• Receives RSDI and VA of 2075
• Pays Medicare Part B of 96
• Waiver obligation? Spenddown?

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Example 5 Calculation

• Income exceeds SIS of 1911
• 2075-6501425 spenddown
• H bill 96 (Medicare)
• P bill 210 (remedial care)
• Spenddown balance 1119
• Must meet with waiver services and other bills

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Example 6 SIS-EW with Community Spouse

• Wife resides in GRH with assisted living
• Receives RSDI and pension of 1816
• Pays Medicare Part B of 96
• Husband resides in their home
• Calculated spousal allocation 800
• Does she have a waiver obligation?

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Example 6 Calculation

• Income less than SIS
• Income deductions
• Medicare premium 96
• Maintenance needs allowance 860
• 1816 956 860 available to allocate
• Calculated allocation 800
• Remedial care 210
• No waiver obligation

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Example 7 Income Over SIS with Community Spouse

• Husband resides in assisted living
• Receives RSDI and VA of 2075
• Pays Medicare Part B of 96
• Wife resides in independent apartment
• Calculated spousal allocation 800
• What is the spenddown amount?

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Example 7 Calculation

• Use LTC calculation
• Income deductions
• -96 Medicare premium
• -84 personal needs
• -800 spousal allocation
• -210 remedial care
• 2075 1190 885 spenddown

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Example 8 Both Spouses on EW and in GRH

• Couple resides in apartment and both receive
  assisted living services through EW
• Husband receives 2000 RSDI and pension
• Wife receives 1200 RSDI
• Both pay Medicare Part B of 96
• Spenddown? Waiver obligation?

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Example 8 Calculation

• Husband
• Income exceeds SIS
• 2000
• 650
• 1350 spenddown
• H bill 96 (Medicare)
• P bill 210 (remedial)
• 1044 spenddown bal.

• Wife
• Income under SIS
• 1200
• 96 Medicare
• 860 Maint. Needs
• 210 remedial care
• 34 waiver obligation