Supports for Community Living (SCL)

1
Supports for Community Living (SCL)

• Vendor Payment Procedures for Individuals
  Admitted to SCL Care

2
What is SCL?

• Supports for Community Living (SCL) provides home
  and community based services for mentally
  retarded MA recipients who would otherwise
  require institutional care in an ICF/MR/DD
  facility.
• Intermediate care services for the mentally
  retarded and developmentally disabled are
  provided by community mental health centers
  certified by Medicaid.
• SCL is available statewide.
• Types of SCL Services are listed in Vol. IVA, MS
  2810

3
Who is eligible for SCL Services?

• The applicant must meet MA criteria for ICF/MR/DD
  level of care.
• The level of care is determined by the Peer
  Review Organization (PRO) using medical,
  psychological, and social data.
• The PRO will conduct patient status
  determinations by matching the individual's care
  needs with the level of care which meets those
  needs.

4
What Happens Next?

• The Department for Mental Health/Mental
  Retardation (MH/MR) produces a letter of approval
  and form MAP-24 (Admission/ Discharge Notice),
  and sends a copy to the Support Coordination
  Agency, the client and the local office.
• This letter shows the level of care met.
• The Support Coordination Agency sends form MAP-24
  to the local office showing provider name,
  provider number and date of admission.

5
Technical Eligibility for SCL

• The applicant must meet all technical eligibility
  requirements for MA eligibility including age,
  blindness, disability, enumeration, third party
  liability, etc.
• However, an individual who is not aged, blind or
  disabled may be eligible for SCL if MA eligible
  in another category and Kentucky Medicaid Program
  criteria is met.

6
Resource Eligibility for SCL

• All Regular AMA resource rules apply
• Excluded Resources are in Vol. IVA, MS 1880
• Transfer of Resources rules apply
• Estate Recovery rules apply
• Property Records and Liquid Asset Checks must be
  completed for SCL
• The resource limits for SCL are
• Single 2000
• Couple 4000

7
Income Eligibility for SCL

• Obtain a PA-1A form, and review these steps on
  pages 4 and 5 for Step I- MA Eligibility
• Compare gross income to the Special Income
  Standard if the applicant has been in LTC for 30
  full consecutive days or died prior to the 30th
  day.
• The 30 days may be spent in different facilities
  or different levels of care, including Hospice,
  HCBS or NF services.
• Do not use the special income standard if the
  applicant has not been in LTC for 30 full
  consecutive days. For these individuals,
  complete Step II.
• If gross income is equal to or less than the
  Special Income Standard the individual is MA
  eligible.
• If there is an excess in Step I, complete Step II
  for SCL.

8
Step II Processing

• If there is an excess in Step I, or in SCL less
  than 30 days, complete Step II to determine MA
  eligibility
• Consider gross income and/or net profit, less 20
  general exclusion and work related expenses, if
  appropriate.
• Deduct the MA Scale for 1.
• Deduct any verified, incurred medical expenses of
  the SCL individual (SMI, health ins. premiums,
  payments on a medical bill not covered by MA,
  etc.)
• Deduct the SCL standard.
• If there is no excess, the individual is MA
  eligible. Complete Step III to determine patient
  liability.
• If an excess remains, the individual is
  ineligible for a vendor payment. Explore a spend
  down.

9
Step III- Patient Liability

• Determine gross income and/or net profit
• Deduct the personal needs allowance (623 eff.
  1/06) or increased PNA, if appropriate.
• Deduct verified, incurred medical expenses of the
  SCL individual (SMI, health ins., etc.)
• Add any third party payment paid directly to the
  SCL provider, if appropriate.
• The result is the individual's patient liability
  or payment toward cost of care.

10
Income Considerations for Couples

• Income considerations for LTC couples vary
  depending upon whether only one or both members
  receive SCL or Waiver services.
• Procedures for and SCL recipient with a non-SCL
  spouse are in Vol. IVA MS 3550.
• Procedures for SCL Couples (both receiving care)
  are in Vol. IVA, MS 3540.
• The next few slides list the steps used for
  determining MA eligibility and Patient Liability
  for each of these situations.

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SCL Couples- Both in LTC

• Step I- MA Eligibility
• Calculate each members eligibility in this step
  separately.
• If each members income is equal to or less than
  the Special Income Standard, both are eligible.
  Go to Step III Patient Liability
• If one or both members of the couple are over the
  standard
• For SCL, ABI or ICF/MR/DD, complete Step II
• For all others, refer to MS 3505 for QIT
  procedures.

12
SCL Couples- Both in LTC

• Step II- MA Eligibility for SCL, ABI or ICF/MR/DD
  
• If only one member of the couple had an excess in
  Step I, use only that members income and
  expenses for Step II, and use the MA Scale for 1.
• If both members had an excess in Step I, use
  income and expenses of both members, and use the
  MA Scale for 2. (If both are in SCL, ABI or
  ICF/MR/DD)
• If one or both members still have an excess, they
  are not eligible for LTC payment. Explore Spend
  Down.
• If the individual/couple now has no excess, they
  are MA eligible. Go to Step III to determine
  patient liability.

13
SCL Couples- Both in LTC

• Step III calculations vary depending on living
  situation.
• Both members in the same facility (or both at
  home)
• Total income of the couple and allow half (½) to
  each.
• Total the allowed expenses, and allow half (½) to
  each.
• Complete Step III separately for each member of
  the couple, using half the income and half the
  expenses.
• Each in a different facility (not living
  together)
• Consider only the income/expenses of the
  individual.
• Complete Step III separately for each individual,
  using their own income and expenses only.

14
SCL Individual with Non-LTC Spouse

• Step I- MA Eligibility
• Only SCL individuals income is considered.
• If gross income is less than or equal to the
  Special Income Standard, the individual is MA
  eligible. Complete Step III for Patient
  Liability.
• If there is an excess in Step I, complete Step II
  for the SCL individual.

15
SCL Individual with Non-LTC Spouse

• Step II- MA Eligibility
• Use only the SCL individuals income and expenses
  for Step II, and the MA Scale for 1.
• If the individual still has an excess after this
  step, they are not eligible for a vendor payment.
  Explore a Spend Down.
• If the individual now has no excess, they are MA
  eligible. Go to Step III for patient liability.

16
SCL Individual with Non-LTC Spouse

• Step III- Patient Liability Use only the income
  and expenses of the SCL individual in this step.
• Calculate the community spouse income allowance,
  and allow this as a deduction in Step III.
  None of the spouses income is counted towards
  the LTC case.
• If there are dependents, calculate the Family
  Income Allowance. Once again, this is a
  deduction. None of the income of a dependent
  is counted towards the LTC case. See below.

17
Community Spouse Income Allowance

• For Non-SSI individuals, KAMES will complete
  these steps
• Total the Community Spouses monthly shelter
  expenses.
• Subtract the Comm. Spouse Shelter Allowance (482
  eff. 7/05)
• The remainder is the excess shelter expense for
  the Spouse.
• Add excess shelter expense to the Minimum Comm.
  Spouse Income Allowance (1,604 eff. 7/05) called
  the Family Income Allowance on KAMES
• The result is the Community Spouse Income
  Allowance, not to exceed the Maximum (2,489 eff.
  1/06) Subtract the community spouses income from
  the allowance to determine the amount which may
  be deemed from the SCL individual to the spouse.
  
• Use form PA-1A, Supplements B and C to deem
  income to the community spouse. See MS 3550 for
  more details.

18
Example

• 745- Monthly shelter expenses
• -482- Shelter minimum eff. 7/05
• 263- Excess shelter expenses
• 1604- Minimum Comm. Spouse Allowance
• 1867- Comm. Sp. Income Allowance
• -1000- Comm. Spouses gross income
• 867- Amount of SCL members income that
  will be deemed to the Community Spouse

19
Family Income Allowance

• This deduction is allowed if there is a minor
  child, dependent child, dependent parent, or
  dependent siblings of either the SCL individual
  or their Community Spouse, who resides with the
  community spouse.
• Calculate the Family Income Allowance as follows
  
• Subtract the dependents gross income from the
  Family Income Allowance Standard (1,604 eff.
  7/05).
• Allow ? of the remainder (rounded) as the
  deduction
• Compute a family income allowance for each
  dependent member separately.

20
Example

• 1604- Family Income Allowance eff. 7/05
• - 825- Dependents gross income
• 779 3 259.6666
• Round this amount to 260, and this is the Family
  Income Allowance for this dependent.
• If there are more dependents, complete these
  calculations separately for each.

21
SCL Individual with Non-SCL Spouse

• Step III- Patient Liability Calculations
• Determine gross income/net profit of the SCL
  recipient. Do not count any of the Spouses
  income.
• Deduct PNA (623 eff. 1/06) or increased PNA
• Deduct the Comm. Spouse Income Allowance
• Deduct the Family Income Allowance, if
  appropriate
• Deduct verified, incurred medical expenses
• Add any third party payment paid directly to the
  SCL provider, if appropriate.
• The result is the individual's patient liability
  or payment toward cost of care.

22
Children Receiving SCL

• Income and resources of the childs parent/s are
  considered in the month of admission.
• Beginning the month after the month of admission,
  consider only the childs income and resources.
• Because of these rules, many children in LTC are
  ineligible for month of admission, but are
  eligible beginning the month after separation.
• Form PA-1A Supp. D is used for Ineligible Child
  Allocations and Parental Surplus calculations.

23
Children Receiving SCL

• Step I- MA Eligibility
• Total gross income of the SCL child, and add the
  gross income of the parents.
• If this gross income is equal to or less than the
  special income standard and the child has been in
  SCL for 30 full consecutive days, the child is MA
  eligible. Complete Step III to determine patient
  liability.

24
Children Receiving SCL

• Step II- MA Eligibility
• If there is an excess in Step I or the child in
  SCL less than 30 days, complete Step II to
  determine MA eligibility.
• Use form PA-1A, Supp. D to complete this step,
  since Step II on PA-1A, pg 4 doesnt include all
  needed calculations for children in LTC.
• Prior to determining MA eligibility in Item II of
  the Supp. D, you will need to calculate the
  Ineligible Child Allocation and the Parental
  Surplus.
• Obtain PA-1A Supp. D to follow the next few
  slides.

25
Ineligible Child Allocation

• If the SCL childs parents have other children in
  the home that are not eligible for LTC, complete
  these calculations on PA-1A Supp. D, Page 2
• Enter the Ineligible Sibling Allocation (302
  eff. 1/06)
• Subtract the gross income of the Ineligible child
• The remainder is a deduction allowed from the
  parents income.
• Enter this amount on Page 1, line 10 of the Supp.
  D

26
Calculating the Parental Surplus

• On Page 1 of the PA-1A Supp. D- Item I
• Total the Parents unearned income, and subtract
  20 general exclusion. The result is their
  countable unearned income.
• Calculate gross earned income, subtract any
  remainder of 20 exclusion, and other
  work-related deductions in Vol. IVA, M.S. 2480,
  if appropriate The result is the countable
  earned income.
• Combine countable earned and unearned income, and
  subtract the Parental Allocation amount (amounts
  change yearly in January- See Vol. IVA, M.S.
  1760).
• Subtract the Ineligible Child Allocation,
  calculated earlier.
• The result is the Parental Income deemed
  (considered) toward the childs LTC case.

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Step II- MA Eligibility for SCL Child

• Follow these steps listed on PA-1A, Supp. D, Page
  1, Item II
• Total unearned income for the child, and subtract
  the 20 general exclusion. The result is the
  childs countable unearned income.
• Total earned income for the child, subtract any
  remainder of the 20 exclusion, and work-related
  deductions in Vol. IVA, M.S. 2480.
• Combine countable earned and unearned income of
  the child.
• Add the parental surplus income from Item I. The
  result is the countable income for the SCL child.
• Allow verified, incurred medical exp. of parents,
  siblings, and child
• Subtract the MA Scale for 1 (217).
• Subtract the SCL Standard. If no excess, child
  is MA Eligible.
• If any excess income remains, the child is MA
  ineligible, explore a spend down for any medical
  expenses.

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Children Receiving SCL

• Step III - Patient Liability
• Combine gross income/net profit of the SCL child
  and excess income of the parent/s. (Income minus
  MA Scale for the appropriate family size,
  excluding SCL child)
• Deduct PNA (623 eff. 1/06) or increased PNA.
• Deduct verified incurred medical expenses of SCL
  child.
• If income of the parent is considered, deduct
  verified, incurred medical expenses of the
  parent.
• Add any third party payments directly to the SCL
  provider.
• Result is Patient Liability or payment toward
  cost of care.

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Medicaid Recipients Admitted to SCL

• If the SCL individual is already receiving MA
  through SSI, SSP or Pass through
• Authorize vendor payment upon receipt of MH/MR
  letter of approval and form MAP-24.
• LTC information is entered on KAMES or PA-62
• Program code and case status code are not
  changed.
• Send MA-105 to recipient and SCL provider if the
  case is on the PA-62 system. Otherwise KAMES
  will send notices as required.

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MA Recipients Admitted to SCL-Continued

• Exception SSP for Caretaker Services can only
  continue if the Caretaker provides services not
  included in SCL care.
• If these individuals are subsequently discharged
  from SCL, MA eligibility should continue in the
  original category, if all criteria of that
  program are still met.

31
Medicaid Effective Dates

• The MA effective date is the first day of the
  month the individual met Kentucky Medicaid
  Program criteria for SCL as indicated on the DMS
  letter of approval.
• Example PRO certified that the individual met
  SCL level of care on May 12th. MA Eligibility
  should begin May 1st.

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Conclusion

• SCL services are provided to prevent
  institutionalization for an individual who would
  otherwise be admitted to ICF/MR/DD.
• The local office will receive an MH/MR letter of
  approval and form MAP-24 for SCL recipients.
• AMA Technical and Resource eligibility rules
  apply.
• MA Eligibility and Patient Liability calculations
  are similar to other LTC, and are completed using
  the PA-1A, Pages 4 and 5.
• MA Recipients admitted to SCL are eligible for a
  vendor payment upon receipt of MAP-24 and letter
  of approval.