SR 95-08 Dated 02/95

STATE OF NEW HAMPSHIRE

INTER-DEPARTMENT COMMUNICATION

SUMMARY

This SR introduces a new home and community based care program for individuals age 22 or older with acquired brain disorders (HCBC-ABD). This SR also obsoletes HCBC forms 517-1, 517-2, 517-3, and 517-4 and provides informational copies of new HCBC Form 517-A, B and C and their instructions. EMS changes are described in the text of the SR.

The major changes to previous HCBC-DD policy include:

•· Availability of HCBC-DD services to all developmentally disabled individuals who qualify for medical assistance, regardless of age, category or living arrangement; and

•· Changing the cost of care liability computation so that the board and care deduction is based on the AFDC payment standard or the adult standard of need (SON) that corresponds to the individual's actual living arrangement.

A new HCBC program allows specialized HCBC services for needy individuals with an

acquired brain disorder.

POLICY

Availability of HCBC-DD Services for Categorically and Medically Needy Individuals Regardless of Age or Living Arrangement

SR 87-43 restricted HCBC-DD services only to categorically needy adults who lived in community residences. SR 92-37 expanded the HCBC-DD program to allow HCBC-DD services for individuals who resided in enhanced family care facilities. SR 95-8 allows both categorically and medically needy individuals to be potentially eligible for HCBC-DD services, regardless of age, category or living arrangement. Part 223 of the Adult Assistance Manual has been revised to reflect the expanded HCBC-DD coverage, and new Part 230 has been added to explain assistance group composition requirements for HCBC-DD eligible individuals. New Part 241 has been added to the Family Assistance Manual to explain eligibility requirements of these HCBC -DD eligible individuals. In addition, the Table of Contents and Key Word Index to both manuals have been revised.

Both developmentally disabled adults and developmentally disabled children are now eligible for HCBC-DD services if the individual, in the absence of HCBC-DD services, would require placement in an intermediate care facility for the mentally retarded (ICF-MR).

To be eligible for HCBC-DD services, the individual must first be eligible for medical assistance as categorically or medically needy under one of the Division's existing programs. Some developmentally disabled children who are categorically needy may also qualify for a grant in addition to HCBC-DD services. These children may reside at home or in foster care, and include ANB, AFDC as well as foster care cases now being served by the Division for Children, Youth and Families.

Home and Community Based Care for Individuals with an Acquired Brain Disorder (HCBC-ABD)

A new HCBC coverage group allows categorically needy, medically needy medical assistance for specific services to individuals with an acquired brain disorder (HCBC-ABD). DMHDS is responsible for making medical ABD eligibility determinations. New Part 224 has been added to the Adult Assistance Manual and new Part 243 has been added to the Family Assistance Manual.

Definition of Acquired Brain Disorder

An acquired brain disorder is a non-congenital condition affecting the brain or nervous system and presents a severe lifelong disabling condition that impairs a person's ability to function in society. To be considered an acquired brain disorder, the disorder or insult must have happened before age 60 and be due to one or more of the following:

- Physical trauma due to a car, motorcycle, bicycle, or other related physical trauma or occurrence;

- An infectious disorder such as encephalitis or meningitis;

- Anoxia (lack of oxygen to the brain);

- Demyelinating (causing destruction of the myelin, the fatty substance which shields the nerves) and other inflammatory diseases such as multiple sclerosis;

- Other related disorders such as Huntington disease.

Prior Authorization from Division of Mental Health and Developmental Services (DMHM)

Before authorizing HCBC-ABD services, DMHDS determines that in the absence of HCBC services, the individual would require a skilled nursing facility or rehabilitation facility services. The authorization section of Form 517-A, DMHDS Information Release to DHS District Office, confirms that the individual has obtained prior approval for HCBC-ABD services. The procedural section of this SR describes this form in greater detail.

Age Criteria

Eligibility for HCBC-ABD is currently limited to individuals who are age 22 or older and who are eligible for one of the Division's medical assistance programs.

Appropriate Living Arrangements

There is no restriction on where individuals eligible for HCBC-ABD may live.

Types of Services Provided

In addition to services regularly provided under the Medicaid program, individuals eligible for HCBC-ABD are eligible for the following services: case management; personal care services, respite care; day habilitation; and environmental 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).

DMHDS Completion of Form 939, Special Eligibility Authorization

As with all HCBC eligible individuals, HCBC-ABD individuals are not subject to the service limits or copayments on various medical services. In order to insure that the service limits and copayments are not imposed, DMHDS will complete Form 939, Special Eligibility Authorization, and assign special eligibility code AA or AB to show that the case is HCBC eligible. Prior to release of this SR, these codes were used only for HCBC-DD cases.

Financial Eligibility Criteria for HCBC-DD and ABD Cases

HCBC-DD/ABD cases may be potentially elioihie as categorically or medically needy

• Eligibility for Categorically Needy Medical Assistance

If the individual's net income exceeds the AFDC payment standard or the appropriate adult standard of need used to determine eligibility for financial assistance, gross income does not exceed the nursing facility CAP of $1159 and resources do not exceed $1000 for AFDC related cases or $1500 for adult category cases, the individual is financially eligible as categorically needy.

• Eligibility for Medically Needy Medical Assistance

If the individual's gross income is over the nursing facility CAP of $1159 but net income is equal to or less than the individual's cost of HCBC-DD/ABD services, and resources are less than or equal to $2500, the individual is financially eligible as medically needy. An individual would also be financially eligible as medically needy if gross income were less than or equal to the nursing facility CAP, but resources were over $1000 (AFDC limit) or $1500 (adult category limit) and less than or equal to $2500.

• Eligibility for Medically Needy In and Out Medical Assistance

If the individual's gross income is over the nursing facility CAP of $1159 and net income is more than the cost of HCBC-DD/ABD services, and resources are less than or equal to $2500, the individual is potentially eligible as medically needy In and Out. Net income is compared to the protected income level (PIL) to determine the spenddown amount. The cost of care expenses can be used to meet the spenddown. Once the spenddown is met, the individual would be eligible for medical services offered to Medicaid recipients, but would not qualify for coverage of HCBC-DD/ABD services.

Cost of Care Computation for HCBC-DD and HCBC-ABD Cases

Individuals eligible for HCBC-DD/ABD services are required to make a cost of care payment if the individual has a cost of care liability. The amount of payment required is based on the results of the cost of are computation described in this section. The nursing facility computation is used to determine liability for cost of care for categorically needy medical assistance for HCBC-DD and HCBC-ABD cases whose net income is over the AFDC payment standard or the adult standard of need for financial assistance.

• If the individual is employed and/or has unearned income, all appropriate earned and unearned income disregards must be applied to gross earned income before the following deductions are used to determine the cost of care.

• if the individual has a spouse in a nursing facility, the individual would be considered the community spouse and may be entitled to an income allocation from the institutionalized individual in accordance with Adult Assistance Manual Part 625.

Items Deducted in the Cost of Care Determination

If an individual lives in an independent living arrangement, the $40 personal needs allowance is the first deduction in the cost of care determination. The other items are then deducted in the sequence listed below.

• Personal Needs Allowance (for independent living arrangements only)

The personal needs allowance is $40 per month. This amount is not deducted for individuals who live in enhanced family care facilities, residential care facilities or community residences, because the $40 personal needs allowance has already been included in the standard of need.

• Maintenance Allowance

The actual rate to be used is based on the AFDC payment standard or the adult standard of need which corresponds to the individual's living arrangement.

Example

If a HCBC-DD AFDC child were eligible for medical assistance under AFDC or the poverty level program, the rate would be based on the AFDC payment standard for a group size of one.

In most situations, an allowance-for a group size for one would be used. However, if the individual were residing with one's spouse and/or dependent child, the board and maintenance allowance would be adjusted to recognize the needs of the additional individual(s).

- If the developmentally disabled adult resided with a spouse, the board and care maintenance allowance is based on a household size of 2 to represent the spouse's needs.

• The Part B Medicare Premium

If the Division is not paying for the part B premium, the District Office must allow the amount that the individual is required to pay.

• Medical Expenses

- Amounts incurred for medical expenses or remedial care are allowable as cost of care deductions provided the amounts are not covered by third party payment or medical assistance.

- Currently obligated prior unpaid medical debts.

Obsolescence of HCBC Forms 517-1. 512-2 517-3. and 517-4. and DMHDS Release of New Forms 517-A and B

SR 87-43 released HCBC-DD forms 517-1, Letter of Authorization 517-2, Payment Toward Cost of Care Agreement, 517-3, Notification of Adverse Action and 517-4, Denial for Continued Home and Community Based Care Services. All these forms have been obsoleted and replaced with new Form 571-A, DMHDS Information Release to Division of Human Services DO, Form 571-B, Area Agency Information Release to Division of Human Services DO, and Form 517-C, Payment Toward Cost of Care Agreement. The Forms Manual has been updated to remove the DMHDS forms. The new forms are to be posted in the back of the Forms Manual, because they are Division of Mental Health and Developmental Service forms instead of Division of Human Services forms. Only the copies of these forms posted to the Forms Manual will include this SR number and date.

Each form and its usage is explained briefly below. The forms instructions attached to this SR provide more detailed information. Note that there is no Certificate of Destruction for the obsoleted forms in the SR, because the obsoleted forms are DMHDS forms and not retained in Stock Control. However, if District Offices have unused old copies, they should destroy or recycle them when this SR takes effect.

DMHDS is responsible for ordering and supplying these forms to area agencies. Therefore, they will not be retained in Stock Control or distributed to District Offices. DMHDS will officially release these forms through an Informational Release.

• New Form 517-A incorporates information previously noted on Forms 517-1, 517-3 and 517-4. Form 517A confirms that the individual is eligible for either HCBC-DD or ABD services, and provides the start and end date of services. This form also notifies District Offices when HCBC services have been denied or terminated. DMHDS initiates this form. A copy is attached for reference. The actual form will be printed on DMHDS letterhead.

• Form 517 B is a newly developed form which enables the area agency to report HCBC related information on initial cases, at redetermination and when changes occur. Information provided includes the estimated or established cost of services, and changes in living arrangement. A copy is attached for reference. The actual form will be printed on area agency letterhead.

• Form 517-C, Payment Toward Cost of Care Agreement is a three section form. The area agency completes section one to advise District Offices that a payment toward cost of care agreement is required of HCBC-DD and ABD recipients who are eligible for medical assistance only. The area agency then forwards the form to the District Office for completion of a cost of care determination on section two. The District Office then forwards the form to the area agency for the recipient's signature. When the form is completed and signed by the recipient’s legal guardian/authorized representative and witnessed, it acknowledges the recipient's responsibility to pay a specific monthly amount toward the cost of care. The area agency gives the recipient the original completed form and provides the District Office with a completed copy.

EMS CHANGES

Current Changes

The only EMS change being done at this time is the renaming of old special review reasons 022 (Special Mail Review - SCARS) and 023 (Prior Earned Income - SCARS). Special review reason 022 is now used to identify HCBC-DD cases, and special review reason 023 is now used to identify HCBC-ABD cases. The data base for current and closed cases with special review reasons 022 and 023 will be purged, so that these codes can now be used for HCBC cases. Case Action Order Handbook ITEM C has been revised to reflect renaming of these codes.

Upcoming EMS Changes

A forthcoming SR will release EMS HCBC related changes. The changes below are summarized for informational purposes.

• Living arrangements code N and M currently have a 2 step computation: financial assistance and categorically needy medical assistance at the nursing facility (NF) level using the NF CAP as the gross income limit. When systems changes are done, a third step will determine. medically needy medical assistance at the NF level using the cost of HCBC as the net income limit. Codes M and N are used for HCBC-DD cases. Once EMS changes are complete, HCBC-ABD cases will also get a 3 step computation similar to codes M and N. The only difference is that ABD cases may be subject to the independent living rate standard of need in step 1.

• Use of nursing facility code 601 will be expanded so that it also represents the cost of

services in the HCBC computations.

INTERIM PROCEDURES FOR HCBC ELIGIBLE INDIVIDUALS UNTIL SYSTEMS CHANGES ARE COMPLETE

Procedures differ based on applicant or recipient status, the category of assistance, and whether the case is money payment eligible, or eligible for medical assistance only. Refer to the financial eligibility criteria section of this SR for the income and resource requirements to determine eligibility as categorically and medically needy, and to the appropriate heading below.

Cost of Services

• 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 Form 517-B. For new applicants, 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 client or the client's authorized representative is ultimately responsible for providing essential eligibility information, including the cost of services amount. If the area agency is unable to provide this amount within the application processing time frames, eligibility for medical assistance must be denied.

• Recipients

For ongoing medical assistance only cases, the established monthly cost of services will be 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 Form 517-B. As with all verifications, the client or the client's authorized representative is ultimately responsible for providing essential eligibility information, including the cost of services amount. If the area agency is unable to provide this figure within the redetermination processing time frames, eligibility for medical assistance must be terminated.

Adult Financial Assistance Cases

If the HCBC case is eligible for financial assistance, enter special review reason 022 (HCBCDD) or 023 (HCBC-ABD) in field B-1 5 and a special review date that coincides with the redetermination date. No additional special procedures are required.

Adult Medical Assistance Cases

• If gross income is less than the CAP and resources are $1500 or less, enter the MA case type 0 in field C-1 1 (categorically needy).

• If gross income is over the CAP or if resources are over $1500, enter the MA case type 2 in field C-1 1 (medically needy).

• Also enter the following:

- Special review reason O22(HCBC-DD) or O23 (HCBC-ABD) infield C-15 and a special review date in field C-16 that coincides with the redetermination date;

- Auto eligible code 4 ( bypasses all criteria) in field C-21; and

- The cost of HCBC services as code 601 (nursing facility rate) in field 1-44 and corresponding amount in field 1-45. (These entries will be necessary for the NF computation when systems changes are complete. Note that Case Action Order Handbook ITEM I has been revised accordingly.)

AFDC Financial Assistance Cases

If the income of a HCBC eligible child is high enough to cause the AFDC case to close, the entire case is no longer eligible for financial assistance. The only situation in which a child living in the home can be removed from an AFDC financial assistance case is when the child receives SSI payments.

Separate AFDC Medical Assistance Case for SSI Eligible Children When Other Members Receive AFDC

• Currently, if a child is receiving SSI and the child's family is receiving AFDC financial assistance, the child is established separate medical assistance case with the parent as the caretaker relative not included (group member code D in field 1-16). These procedures remain unchanged.

• If an SSI eligible child in a separate MA case is also eligible for HCBC-DD services, enter the appropriate EMS codes listed for the adult categories, since there is potential for the child to receive additional income.

Children with Severe Disabilities (CSD)

If the child's income is too high to retain Current eligibility, enter the appropriate EMS codes listed for the adult categories.

Home Care for Children with Severe Disabilities (HC-CSD)

To be eligible for HCBC-DD services, the child's gross income must be under the nursing facility CAP. If resources are $1000 or less, the child is categorically needy. If resources are over $1 000, but do not exceed $2500, the case is medically needy. Enter the appropriate EMS codes for the adult categories, but do not enter the auto eligible code,

NOTE: If the child's income is too high to receive HCBC-DD services, a HC-CSD child

may be eligible for some HCBC services under CSD or another Division program.

AFDC Medical Assistance Only Cases and PoveM Level Cases with HCBC Eligible Children Determine if the child's income is within the income limits for the type of assistance received. 0 If yes, no action is necessary.

• If the child's income is too high to retain current eligibility,

- Establish the child as a separate medical assistance case with the parent as the caretaker relative not included (group member code D in field 1-16).

- Enter the appropriate case type, and

- Enter the appropriate EMS codes listed for adult categories.

IMPLEMENTATION

The revised policy is to be applied to all eligibility determinations made on or after the effective date of this SR.

CLIENT NOTIFICATIQN

The Division of Mental Health and Developmental Services has targeted groups which are in direct contact with individuals who meet ABD criteria, and has advised these groups of the availability of ABD services. These groups include the N.H. Head Injury Foundation, various rehabilitation hospitals throughout the state and family support groups.

TRAINING

New hire Case technician in November of 1994 addressed the revised policy. If the need for additional training should arise, District Offices should contact their Regional Administrator.

MANUAL PAGE CHANGES

In addition to the manual page changes addressed in the text of this SR, the Key Word Index has been changed to include "currently obligated unpaid prior medical debts." This entry has been added at District Office request.

POSTING INSTRUCTIONS

DISPOSITION

This SR may be destroyed after its contents have been noted and its posting instructions have been carried out.

DISTRIBUTION

This SR only is being distributed according to the distribution list for the Family, Adult Assistance and Forms Manuals and the Case Action Order Handbook. The SR and manual pages will be distributed to all holders of the Family, Adult Assistance and Forms Manuals and the Case Action Order Handbook.

OES/SJC:s

Attachments