Medicaid Waiver for Home and Community Based Services 525-05-25-10

(Revised 2/1/22 ML #3663)

In order for services to be payable under the provisions of the Medicaid waiver for Home and Community Based Services, the individual receiving the service must meet all of the following:

Recipient of Medicaid Program under the State Plan for Medical Assistance as set forth in Service Chapter 510-05, Medical Assistance Eligibility Factors;

Age 18 or older and physically disabled as determined by the Social Security Administration or the State Review Team, or be at least 65 years of age;

Eligible to receive care in a skilled nursing facility;

Participate to the best of their ability in a comprehensive assessment to determine eligibility and develop a person centered plan for receiving home and community-based services as an alternative to institutional care;

Have a Person Centered Plan of Care, developed and approved by the individual or legal representative and HCBS case manager that adequately meets the health, safety, and personal care needs of the recipient;

Voluntarily choose to participate in the home and community-based program after discussion of available options. This is documented by completion of Explanation of Client Choice, SFN 1597;

Service/care is delivered in the recipient’s or family member's private family dwelling (house, apartment, or camper if the camper is located in a long term campground that rents by the month/year etc.) or recipient is receiving a community-based service of adult foster care, adult day care, non-medical transportation, or adult residential service. The renter’s living area should consist of a bedroom with or without bath and possibly a sitting area. Congregate/group meals may be available or meals may be eaten off site. For unique circumstances, contact the HCBS Program Administrator for consideration.

With the exception of institutional respite, Medicaid Waiver funds may not be used to provide care in any institutional setting i.e. nursing home or hospital.

Must receive services on a monthly basis. If a current recipient has not utilized services within a 30-day period of time, a citation may be requested (if appropriate) to terminate the case. However, if the services are expected to resume within 3 months, it is allowable for the case to remain open. This does not require approval from a Program Administrator. (See below for service requirements specific to Spousal Impoverishment cases).

If a current recipient enters a skilled nursing facility or swingbed, and it is anticipated that the length of stay will be 3 months or less, it is allowable for the case to remain open. This does not require approval from a Program Administrator.

If the individual has not received services because a provider has not been secured, and the individual is still eligible and wants to continue pursuing a provider, the case must remain open. The case manager must make a quarterly contact with the individual. If the individual will incur a case management fee, they must be informed of this. The case manager is required to continue attempts in securing a provider. In doing so, they may need to staff the situation with Aging Services administrators and/or discuss strategies with the individual such as publishing an advertisement for service providers, etc.

For further instruction and examples, please reference HCBS Policy & Procedure Manual: Closures, Denials, Terminations, Reductions, and Transfer of Services 525-05-40.

Not eligible for and/or receiving services through other Medicaid Waivers or private funding sources.
The individual's impairment is not the result of a mental illness, intellectual disability or a closely related condition.

Financial Information for Medicaid Waiver HCBS:

Spousal Impoverishment

Spousal Impoverishment applies to the Medicaid Waiver programs only. The applicant/recipient must be authorized and receiving a Waiver service on a monthly basis.

Institutional Spouse and Community Spouse (both eligible for Medicaid Waiver Services.

If both of the spouses are residing in the home and are screened at nursing facility level of care (LOC) then spousal impoverishment cannot apply.

When determining spousal impoverishment asset and income limits, see Medicaid Program Service Chapter 510-05. (The amounts change annually.)

Charging for Services

If an individual has a recipient liability, it is the responsibility of the provider to collect the individual's share of the cost directly from the individual or their identified legal payee.

Handling of Collections

Accounts Receivable Manual, Service Chapter 115-40 shall be followed for all collection procedures.

Confidentiality of Financial Records

Financial information regarding a Medicaid waiver recipient shall remain confidential except where otherwise provided by law or departmental policy. (See Accounts Receivable Manual, Service Chapter 115-40.)

If the individual's Medicaid was or would be closed due to not meeting recipient liability (after adding the medical expenses, plus the case management fee, plus the cost of their Medicaid State Plan Personal care) then the individual may receive SPED personal care services if they are otherwise eligible.
Overpayment

If there are credible allegations that an individual or their legal representative concealed or misrepresented financial or functional information with the purpose of obtaining eligibility for HCBS, the Department may recoup the overpayment.