SR 03-28 Dated 05/03

STATE OF NEW HAMPSHIRE

INTER-DEPARTMENT COMMUNICATION

SUMMARY

This SR releases a new home and community-based care program that provides in-home supports for developmentally disabled individuals under age 21 who:

·   are Medicaid eligible as determined by the Department of Health and Human Services;

·   are eligible for the Division of Developmental Services (DDS) Area Agencies services as determined by the Area Agencies;

·   live at home with their family as determined by DDS;

·   meet Intermediate Care Facility for the Mentally Retarded (ICF/MR) level of care as determined by DDS; and

·   have certain individual and/or caregiver factors which impede the caregiver’s ability to care for the individual at home, as determined by DDS.

This SR also releases updates to DDS Form 517-B, Area Agency Information Release to DFA District Office, Home and Community-Based Care Waiver, and DDS Form 517-C, Payment Towards Cost of Care Agreement, and their instructions, to incorporate the new home and community-based care in-home supports (HCBC-IHS) program.

POLICY

Effective May 20, 2003 a new Home and Community-Based Care program, HCBC-IHS, will provide a variety of community-based services to certain developmentally disabled children so that the children are able to live at home with needed support, rather than being institutionalized.

Individuals may be eligible to receive HCBC-IHS services if all of the following criteria are met:

·   the individual is under age 21;

·   the individual is Medicaid eligible;

·   DDS Area Agency determines that the individual is eligible for the Area Agency services;

·   DDS Area Agency establishes that the individual is appropriate for community-based services;

·   the individual resides at home with their family, as determined by DDS;

·   DDS determines that in the absence of HCBC-IHS services, the individual would require placement in an intermediate care facility for the mentally retarded (ICF-MR);

·   DDS determines that the individual has certain individual and/or caregiver factors which impede the caregiver’s ability to care for their child; and

·   DDS approves the individual service agreement and individualized budget which determine the costs of the needed HCBC-IHS services.

HCBC-IHS Services

In addition to services regularly provided under the Medicaid state plan, individuals eligible for HCBC-IHS are eligible for:

·   service coordination;

·   enhanced personal care services;

·   consultative services;

·   respite care; and

·   home and vehicle modifications (changes to the residence necessary for the individual's health and/or safety or changes that would prevent institutionalization, such as a wheelchair ramp).

Individuals receiving HCBC-IHS are not subject to the service limits or co-payments on various medical services.

Financial Eligibility Criteria for HCBC-IHS Cases

HCBC-IHS cases may be either categorically or medically needy. If an individual is currently eligible for a Medicaid program, the individual is financially eligible for HCBC-IHS. If the individual is not income eligible for any Medicaid program, income eligibility is determined as follows:

Categorically Needy

The individual’s countable gross income does not exceed the $1,250 Nursing Facility CAP.

Medically Needy

The individual’s countable net income does not exceed the cost of the HCBC-IHS services.

Medically Needy In and Out

Individuals who are not financially eligible for HCBC-IHS because their income is too high may be potentially eligible for Medicaid as medically needy In and Out.

NOTE: The methodology for determining how income is counted toward eligibility is determined by the specific Medicaid program. For example, an individual whose eligibility is being determined for Healthy Kids Gold (poverty level) will include the parents’ income in the eligibility determination, if the child resides with the parents. An individual whose eligibility is being determined for home care for children with severe disabilities (HC-CSD) will not include the parents’ income, just the income and resources that belong to the child.

Prior Authorization from Division of Developmental Services (DDS)

Before authorizing HCBC-IHS services, DDS must:

·   confirm that the individual meets programmatic eligibility criteria; and

·   review the service agreement and individualized budget submitted in the application for services.

If DDS approves HCBC-IHS services, an electronic notification is made via New HEIGHTS alert on the Long Term Care/HCBC screen for HCBC-DD/ABD. The following special eligibility code will indicate the type of HCBC-IHS approval:

·   "CC", indicating a child from the community; or

·   "CI", indicating a child from an institution.

COST OF CARE COMPUTATION FOR HCBC-IHS MEDICAL ASSISTANCE-ONLY CASES

After the medical assistance-only individual is determined eligible for HCBC-IHS, the individual may be responsible for applying any of their available income toward their cost of care. DFA Family Services Specialist (FSS) must use the following steps to determine liability for, and, if liable, amount of, the cost of care.

Procedures for Determining Cost of Care Liability

Procedures for determining the individual’s responsibility for applying any of their available income toward the cost of care differ based upon applicant or recipient status and the category of assistance. Refer to the financial eligibility criteria section of this SR for the income and resource requirements to determine eligibility as categorically or medically needy, and to the appropriate heading below.

·   Applicants

For HCBC-eligible applicants, the cost of services amount is only required for medical assistance-only cases. This figure is not required for financial assistance applicants. The Area Agency provides the cost of services amount to the individual and notes this amount on DDS Form 517-B, Area Agency Information Release to DFA District Office, Home and Community-Based Care Waiver. This amount may be provided as the estimated monthly cost of services when the individual is new to the HCBC program and the established monthly cost of services has not yet been determined. As with all verifications, the applicant or the applicant’s authorized representative is ultimately responsible for providing essential eligibility information, including the cost of services amount.

·   Recipients

For ongoing medical assistance-only cases, the established monthly cost of services is required at redetermination or whenever the cost of services amount changes. The cost of services amount is not required for financial assistance cases. The area agency provides the cost of services amount to the District Office or the individual and notes this amount on DDS Form 517-B. As with all verifications, the recipient or the recipient’s authorized representative is ultimately responsible for providing essential eligibility information, including the cost of services amount.

Procedures for Determining the Cost of Care Payment

To assist the FSS in calculating the cost of care payment, the Area Agencies will complete DDS Form 517-C, Payment Towards Cost of Care Agreement. This form will be filled out and sent under the Area Agency letterhead at the initial application, redetermination, or when a change occurs in an individual’s income or service cost, affecting Medicaid eligibility. The Area Agencies will not provide information concerning service costs if the individual’s gross income is equal to or less than $1,250 per month.

The same income used to determine eligibility is used to determine cost of care liability (see "Note" on previous page). If the individual is employed and/or has unearned income, apply all appropriate earned and unearned income disregards, then deduct the following items from net income in the sequence specified below:

1. Maintenance Allowance Deduction: $1,250;

2. Part B Medicare Premium, if paid by the individual; and

3. Medical Expenses:

(a) Amounts incurred for medical expenses or remedial care, including health care premiums, are allowable as cost of care deductions provided the amounts are not covered by third party payment or medical assistance, and the individual is liable for payment of said expenses; and

(b) Currently obligated prior unpaid medical debts.

The balance remaining after the above deductions are applied is the amount that must be paid by the individual towards the cost of services provided under HCBC-IHS.

RELATED POLICY CLARIFICATION

Although an individual who is developmentally disabled (DD) or an individual with an acquired brain disorder (ABD) is considered to be an assistance group size of one for purposes of determining HCBC eligibility, income used to determine the individual’s HCBC-DD or HCBC-ABD eligibility is that income that is counted under the appropriate eligibility program. For example, if a child resides with their parents and the eligibility program is TANF or Healthy Kids, the child’s parent’s income is counted in the eligibility determination. The Family Assistance Manual was revised accordingly.

DDS FORMS REVISIONS

DDS Form 517-B, Area Agency Information Release to DFA District Office, Home and Community-Based Care Waiver, and DDS Form 517-C, Payment Toward Cost of Care Agreement, and instructions, have been updated to include HCBC-IHS. Both forms and their respective instructions are attached for reference.

NEW HEIGHTS CHANGES AND PROCEDURES

Effective May 20, 2003, New HEIGHTS will be programmed with two new eligibility values:

·   "CC", indicating a child from the community; and

·   "CI", indicating a child from an institution.

The DFA District Office FSS worker completes the "Long Term Care, Home Community-Based Care (HCBC)" screen in New HEIGHTS by selecting:

·   the individual's name; and

·   HCBC type "DD" for HCBC-IHS. NOTE: "IHS" has not been added to the choices of "DD", "ABD", or "ECI" at this time. Use DD and note the type of assistance in case comments.

DDS will:

·   enter the appropriate HCBC code (CC or CI) on the "Long Term Care, Home Community Based Care (HCBC)" screen;

·   enter the date of the decision, the approval period begin date, the review date, and the special eligibility information; and

·   complete prior authorization.

The Electronic Data System’s AIM system will notify the Area Agency and recipient of the eligibility determination.

NOTE: There is a known problem in New HEIGHTS that once eligibility cascades past the individual eligibility calculation for "PLC", the system will ignore all income and open HCBC. If a case fails eligibility due to income at the PLC level, do not confirm HCBC eligibility until financial eligibility is manually calculated and the individual is determined to be financially eligible for HCBC.

POLICY MANUAL REVISIONS

Revised Family Assistance Manual Topics

Section 241.01  Assistance Group Composition (HCBC-DD)

PART 242 HOME AND COMMUNITY-BASED CARE FOR IN-HOME SUPPORTS (HCBC-IHS)

Section 242.01  Assistance Group Composition (HCBC-IHS)

Section 242.02   Required Verification (HCBC-IHS)

Section 243.01  Assistance Group Composition (HCBC-ABD)

PART 511  COMMON TYPES OF INCOME: VA AID AND ATTENDANCE ALLOWANCE (VA A&A)

Section 611.01  Computing Eligibility

PART 614  COST OF CARE (HCBC-DD/ABD/IHS)

Section 614.01  Cost of Care: HCBC-DD/ABD

Section 614.03  Cost of Care: HCBC-IHS

Revised Adult Assistance Manual Topics

PART 167   EXTENDED MEDICAL ASSISTANCE DUE TO THE PICKLE AMENDMENT

Section 167.05  Losing Pickle Status

PART 201   GENERAL INFORMATION

PART 222   HOME AND COMMUNITY-BASED CARE FOR IN-HOME SUPPORTS (HCBC-IHS)

Section 222.01  Verification: HCBC-IHS

PART 225  ASSISTANCE GROUP

PART 230   ASSISTANCE GROUP COMPOSITION FOR HCBC-DD/ABD/IHS

Section 230.01  HCBC-DD/ABD/IHS Financial Assistance

Section 230.03  HCBC-DD/ABD/IHS Medical Assistance

PART 233  ASSISTANCE GROUP COMPOSITION FOR QMB, QDWI, SLMB OR SLMB 135

PART 511  INCOME TYPES: VA AID AND ATTENDANCE ALLOWANCE

PART 601   TABLE B INCOME LIMITS FOR HCBC INDIVIDUALS

Section 603.03  Employment Expense Disregard

Section 603.05  Adult Standard Disregard

PART 605  DEDUCTIONS

PART 613  COMPUTING ELIGIBILITY

PART 617  GRANT DETERMINATION

PART 622  BUDGETING: HCBC-IHS

Section 622.01  HCBC-IHS Financial Assistance

Section 622.03  HCBC-IHS Medical Assistance

Section 622.05  Cost of Care: HCBC-IHS Medical Assistance

Section 622.07  Payment for Cost of Care: HCBC-IHS Medical Assistance

IMPLEMENTATION

The policy released in this SR is to be applied to all eligibility determinations made on or after May 20, 2003.

CLIENT NOTIFICATION

The Division of Developmental Services has targeted developmental disability area agencies and their family support staff which are in direct contact with individuals who meet HCBC-IHS criteria, and has advised these groups of the availability of HCBC-IHS services.

TRAINING

No Family Services Specialist training is planned.

DDS FORMS POSTING INSTRUCTIONS

DISPOSITION

This SR may be destroyed or deleted after its contents have been noted and the revised manual topics released by this SR have been posted to the On-line manuals.

DISTRIBUTION

This SR will be distributed according to the electronic distribution list for the Office of Health Planning and Management and Division of Family Assistance policy releases. This SR, and revised On-Line Manuals, will be available for agency staff in the On-Line Manual Library, and for public access on the Internet at http://www.dhhs.state.nh.us/DHHS/DFA/LIBRARY, effective July 1, 2003.

This SR, and printed pages with posting instructions, will be distributed under separate cover to all hard copy holders of the Family Assistance, Adult Assistance, and Forms Manuals.

OHPS/BJR:jg

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CERTIFICATE OF DESTRUCTION

I certify that all copies of Form 517-B and Form 517-C, dated 2/95, SR 95-8, have been destroyed.

Office Manager:    District Office     

Return this certificate to DHHS Stock Control, 6 Hazen Drive, Concord, NH 03301, after the instructions in the SR have been carried out.