Federal Regulation - 42 CFR 435.217

Individuals who are eligible to receive home and community based services, under a special waiver granted to the State's Medicaid program by the Centers for Medicare and Medicaid Services (CMS) are also eligible for the increased financial standard that is used for individuals in nursing facilities

These are individuals who would need to be in an institution if the special Medicaid community services were not available. They are also individuals who may not be eligible for SSI or SSP while living in the community because of excess income.

Delaware currently has a waiver for the mentally retarded (effective 7/1/83), the elderly and disabled (effective 7/1/86) and (effective 1/1/91) persons with Acquired Immune Deficiency Syndrome (AIDS) or other HIV-Related Disease (HRD). The Assisted Living Waiver which is a program of community-based residential services became effective October 1, 1998.

Medicaid eligibility under any HCBS waiver is not established until services under the HCBS waiver begin.

1. Only clients of the Division of Developmental Disabilities Services (DDDS) are eligible for this Waiver.

2. Initial medical eligibility is determined by DDDS staff. The DDDS Intake Coordinator makes a preliminary determination for each applicant for initial eligibility. Once an individual is placed in a residential facility, the social Service Benefits Administrator sends all waiver requests to the Medicaid Medical Review Team (MRT) for review. Based on the information provided on the comprehensive Medical Report (MAP-25), Social Evaluation Form, Cost Projection Data Sheet and the level of Care form, the MRT will either concur with the initial decision to approve or deny the applicant for an ICF/MR level of care.

3. The MRT signs off on all forms sent by the DDDS Social Service Benefits Administrator.

4. If the client is not already Medicaid eligible as an SSI recipient, DDDS submits an application to the appropriate Long Term Care Unit for financial eligibility determination. Eligibility determination is made by using financial criteria applied to those institutionalized and receiving Medicaid.

1. The Division of Services for Aging and Adults with Physical Disabilities (DSAAPD) determines medical eligibility for this waiver through their Pre-Admission Screening unit (PAS).

2. DSAAPD PAS must assure that the applicant is in need of nursing home (i.e., skilled nursing facility (SNF), or intermediate care facility (ICF) as defined by DSS/Medicaid.

3. The Long Term Care Financial Unit will determine eligibility using criteria in section 20103 .

1. All cases will be referred to the DSS Pre-Admission Screening Unit for initial medical eligibility.

2. The DSS PAS Units must assure that the applicant has a diagnosis of AIDS or HIV with at least two or more chronic related medical conditions to HIV/AIDS that would contribute to increased hospitalizations and be in need of institutional care.

3. Eligibility Determination

The Long Term Care Financial Units will determine eligibility by using criteria in section 20103 .

4. Once the medical and financial eligibility is completed, the financial eligibility worker will notify the Medicaid Waiver Administrator of financial eligibility and send the level of care packet to the case management agency and MRT for processing of a care plan for initial eligibility. Once the care plan information is completed, the case management agency sends documentation to the MRT for review and final approval.

Once medical and financial eligibility is completed, the financial eligibility worker will call the Medicaid Waiver Administrator to determine if a slot is available in the AIDS Waiver.

The Assisted Living Medicaid Waiver Program (ALMWP) provides community based residential services. The program is administered by the Division of Services for Aging and Adults with Physical Disabilities (DSAAPD). The program is funded by Delaware Medicaid and state general funds. It is targeted to older persons and adults with physical disabilities who need assistance with the Activities of Daily Living (ADL) AND meet Medicaid nursing facility admission criteria.

To be eligible for this program, individuals must:

♦ Be a resident of the State of Delaware

♦ Be eighteen years of age or older;

♦ Meet the Financial and Medical criteria for DSS Long Term Care Institutionalized Services

♦ Meet Assisted Living Program criteria as determined by DSAAPD

Medical eligibility is determined by Pre Admission Screening Units of either DSS or DSAAPD.

Financial eligibility is determined by the DSS Long-Term Care Financial Units.

Program eligibility is determined by DSAAPD. An individual must meet the following criteria:

Have need of an assisted living services on a regular weekly basis; AND

Be able to be maintained safely in the assisted living agency with the provision of the ALMWP services. Safety concerns must be brought to resolution through a mutually agreed upon Managed Risk Agreement.

If the financial eligibility determination period has expired, and the individual has been unable to obtain placement in a suitable and acceptable assisted living facility, the application will be denied.

There is a maximum number of individuals who may be served under the Assisted Living Medicaid Waiver each fiscal year. The total unduplicated number of recipients served under the program within the year cannot exceed the maximum number as approved by the Centers for Medicare and Medicaid Services (CMS). DSAAPD monitors the number of individuals receiving ALWP services so the maximum number will not be exceeded.

In order for an individual to be eligible for the Assisted Living Program, the individual’s cost of care cannot exceed the cost of their care if the same individual was institutionalized. An average monthly cost for institutionalized individuals is used to determine the amount that may be spent on Assisted Living eligibles. A DSAAPD worker determines the cost effectiveness.

The assisted living provider may NOT bill MEDICAID for room and board. The assisted living provider may bill for services for any day that the recipient is present in the facility for any part of the day. The assisted living provider may NOT bill for any day that the consumer is absent from the facility for the entire day.

The assisted living provider shall NOT provide services for an individual that has been bedridden for 14 consecutive days unless a physician certifies that the consumer’s needs may be safely met by the service agreement.

There are no Medicaid bed hold days for hospitalization.

9 DE Reg. 998 (12/01/05)

Upon approval the Medicaid Financial Unit will send a notice of acceptance to the applicant or his representative, and ALMWP provider. The notice to the provider will include patient pay amount, amount to be protected for medical insurance and personal needs, effective date of Medicaid coverage, and Medicaid recipient’s billing ID number.

See DSSM section 20720 for Patient Pay Calculation policy. If the consumer has income under the Adult Foster Care standard, there will be no patient pay amount.

Collection of the patient pay amount from the consumer or his representative is the responsibility of the assisted living provider.

Assisted living services include the following:

Personal services assistance with the activities of daily living (ADL)

Nursing services

Meal services

Social/emotional services

Assistance with instrumental activities of daily living (IADL)

DSSM POL-20700.5 ACQUIRED BRAIN INJURY MEDICAID WAIVER

DSSM POL-20700.5.A ABI MEDICAID WAIVER DEFINED

1. The Acquired Brain Injury (ABI) waiver program is a home and community based services program funded by the Division of Medicaid and Medical Assistance (DMMA).

2. The ABI waiver is operated by the Division of Services for Aging and Adults with Physical Disabilities (DSAAPD).

3. This waiver is targeted to individuals with an acquired brain injury aged 18 years of age and above.

4. The individual must meet Medicaid criteria for nursing home admission.

5. The earliest implementation for the ABI waiver is December 1, 2007.

DSSM POL-20700.5.B ABI ELIGIBILITY CRITERIA

1. The individual must be a Delaware Resident.

2. The individual must meet the financial and medical criteria for the DMMA Long

Term Care Medicaid Program.

3. Medical eligibility is determined by the DSAAPD Pre-Admission Screening Unit. DSAAPD also accepts Long Term Care medical eligibility determinations performed by the DMMA Pre-Admission Screening Unit.

4. Financial eligibility is determined by the DMMA.

5. The individual must meet program eligibility guidelines (see DSSM 20700.5.C).

DSSM POL-20700.5.C ABI PROGRAM ELIGIBILITY

1. The individual must have an injury to the brain which is not hereditary or congenital, degenerative, or induced by birth trauma.

2. The individual must have a need of at least one enhanced ABI waiver service in addition to case management.

3. The individual must have a physical, cognitive, and/or behavioral symptom of an ABI, which requires supervised and/or supportive care.

4. The individual must be at risk of placement or currently residing in a nursing facility.

5. The individual must have completed or no longer benefit from intensive inpatient, post-trauma or rehabilitation program(s).

6. The individual must accept and maintain case management services.

DSSM POL-20700.5.D ABI NUMBER OF PARTICIPANTS

1. There is a maximum number of participants who may be served under the ABI waiver program each year.

2. The total unduplicated number can not exceed the maximum number approved by the Centers for Medicare and Medicaid Services (CMS).

3. The DSAAPD will monitor the number of participants.

DSSM POL-20700.5.E ABI COST EFFECTIVENESS REQUIREMENT

1. The cost of care for an ABI waiver recipient can not exceed the cost of care if institutionalized.

2. The cost of care is determined on an aggregate basis which considers all ABI waiver recipients.

3. An average monthly cost for institutionalization is used to determine the amount that may be spent on an ABI waiver recipient’s care.

4. The DSAAPD determines cost effectiveness.

DSSM POL-20700.5.F ABI NOTIFICATION OF APPROVAL

1. The DMMA will send a notice of Medicaid approval.

2. The notice will be sent to the applicant or representative.

3. If the recipient is in an Assisted Living facility a notice of approval will also be sent to the provider.

4. The notice to the provider will include the effective date of Medicaid coverage,the patient pay amount, and the Medicaid identification number.

DSSM POL-20700.5.G ABI POST ELIGIBILITY BUDGETING

1. DSSM policies 20720 and 20995.1 will be followed to calculate patient pay amount.

2 Persons residing in an Assisted Living facility will have a personal needs allowance equal to the current Adult Foster Care Rate.

3. Persons who are in a community based setting will have an income needs allowance equal to 250% of the Federal Benefit Rate.

4. Collection of the patient pay amount is the responsibility of the provider.

DSSM POL-20700.5.H ABI BILLING OF APPROPRIATE DAYS

1. The waiver provider may not bill for any day the individual is absent from the program, excluding case management services. (Case management services are billed monthly, and are still utilized up to 30 days of hospitalization.)

2. The waiver provider may bill for services rendered to the individual.

3. Assisted Living providers may not bill Medicaid for room and board.

DSSM POL-20700.5.I ABI PROGRAM ABSENCES DUE TO HOSPITALIZATION

1. ABI waiver services will terminate upon the 31^st day of hospitalization.

2. There are no Medicaid bed hold days for hospitalization.

3. The DMMA will redetermine financial eligibility for continued Medicaid coverage.

DSSM POL-20700.5.J ABI MEDICAID WAIVER PROGRAM SERVICES

1. ABI waiver services will include:

Case Management

Assisted Living and Enhanced Assisted Living

Day Habilitation

Cognitive Services

Adult Day Services (Level I - Basic & Level II – Enhanced)

Personal Care

Respite Care

Personal Emergency Response System

2. Residents of an Assisted Living facility will receive services in accordance with the Division of Long Term Care Residents Protection regulation codified at 16 DE Admin. Code 3225.

11 DE Reg. 1054 (02/01/08)

8 DE Reg. 557 (10/01/04)(Section 20700.5 added)

11 DE Reg. 1055 (02/01/08) (Sections Repealed)

Repealed, Effective February 10, 2009.

8 DE Reg. 1625 (05/01/05)

12 DE Reg. 1088 (02/01/09)

20720 Patient Pay Calculation

There are allowable deductions from the monthly income. These are deducted to determine the recipient’s share of his/her cost of care.

Effective 4/1/94 an allowance of 150% of the Federal Poverty Level will be protected for the Elderly and Disabled (E/D) Waiver. Effective 5/1/95 the E/D Waiver personal needs allowance was changed from the Adult Foster Care limit to the special income level for institutionalized individuals. The special income level is the current income standard

Effective 8/1/95, the personal needs amount for the HIV/AIDS Waiver will be the current income standard (250% of the SSI income level).

An amount equal to the current Adult Foster Care (AFC) rate is protected for the DDDS Waivers. The AFC rates are based on the current SSI income level plus $140.00.

In order to be considered a dependent, the spouse and/or children must be claimed on the applicant's income taxes as a dependent. A spouse is the husband or wife of the applicant who is living with the applicant or was living with the applicant prior to institutionalization.

If the applicant is responsible for the support and maintenance of the spouse and/or children, (i.e. provides them with food and shelter) the following calculations would be completed to determine the protected amount.

An amount up to the current SSI payment standard may be protected for the spouse. Monthly allowances for dependents other than the spouse are based on the current TANF standard of need.

If the spouse or other dependents have income their net income (gross income minus work expense and child care costs) should be deducted from the standards given above. Use standard SSI and TANF deductions. The amount remaining (if any) would then be protected for the dependent.

Please note, spouses with income less than the SSI standard should be encouraged to contact the Social Security Administration Office to apply for benefits.

Medical expenses not subject to payment by 3rd party, such as:

1. Health insurance premiums

2. Necessary medical or remedial care not covered under the Medicaid State Plan such as hearing aids, dentures, etc.

NOTE: Medicare deductibles and co-insurance charges are paid by Medicaid directly.

Any amount remaining after the above calculations will be paid to the provider by the Waiver recipient.

Patient pay amount will be included on the HCBS referral form forwarded to the HCBS Case Manager. The Case Manager notifies the recipient of the patient pay amount.

For DDDS Waiver recipients, any amount remaining will be paid to DDDS. Patient pay amount will be included on the budget sheet forwarded to the DDDS Waiver Administrator.

20740 Hospitalization

Hospitalization exceeding 30 consecutive days for the Elderly and Disabled Waiver and the AIDS Waiver and 14 consecutive days for the MR Waiver.

HCBS Case Manager notifies the Financial Unit that Waiver services are terminated. Medicaid case remains open while the patient is hospitalized and no patient pay to hospital is required for the month of admission to the Hospital.

20760 Redetermination

A redetermination of eligibility must be performed annually.

LTC POL-20800 Determining Eligibility for the Acute Care Program

This policy applies to all applications received for Medicaid payment of Inpatient hospitalization or rehabilitation.

Thirty Consecutive Days of Hospitalization

Eligibility for this program will only be determined once the individual has been hospitalized for 30 consecutive days, unless:

• the discharge plan is for nursing home placement; or

• the individual is seeking out of state inpatient rehabilitation placement.

Licensed and Certified Hospital or Rehabilitation Facility

The medical facility must be licensed and certified as a Title XIX Acute Care or Rehabilitation Medical Facility.

The Acute Care facility must be engaged in providing diagnostic and therapeutic services for medical diagnosis, treatments, and care of injured, disabled, or sick persons. These services must be provided by or under the supervision of physicians. Continuous twenty–four (24) hour nursing services are provided.

The Rehabilitation facility may be a freestanding rehabilitation hospital or a rehabilitation unit in an Acute Care hospital.

Medical Eligibility Requirements For In State Hospitalization and/or Rehabilitation

Medical eligibility for Inpatient hospitalization/rehabilitation services received within the state is determined by the Division of Medicaid and Medical Assistance Pre-Admission Screening (PAS) units. The individual must have required the level of care provided by a hospital during the time of his/her hospitalization, as determined by the PAS units.

Anyone 65 years of age or older, or statutorily blind would meet the medical eligibility criteria if they were in need of acute care services during the time of their hospitalization.

Medical Eligibility Requirements For Out of State Rehabilitation

Medical eligibility for Inpatient Rehabilitation services to be received out of state is determined by the Division of Medicaid and Medical Assistance Medical Director. The individual must require:

• close medical supervision by a rehabilitation physician;

• twenty-four (24) hour nursing supervision;

• an intensive level of physical, occupational or speech therapy; or

• psychological services; or

• prosthetic-orthotic services.

The individual must be able to tolerate and participate in all required therapies or services.

Medical eligibility must be reviewed on a bi-weekly basis.

Prior authorization must be requested and approved before out of state placement is made.

Financial Eligibility Requirements

Financial eligibility is determined by the Division of Medicaid and Medical Assistance Financial units. An individual must meet income and resource guidelines.

Income Guidelines

The income limit is equal to 100% of the Federal SSI Standard. However, if the individual is going to a nursing home directly from a hospital or rehabilitation facility, the higher income limit of 250% of the Federal SSI standard will be applied.

For out of state rehabilitation the income limit is 250% of the Federal SSI standard.

Refer to DSSM sections 20200, 20210, and 20240 for additional guidelines regarding income.

Resource Guidelines

The resource limit is $2,000.00. Refer to DSSM sections 20300 – 20360, and 20400 for additional information on determining countable resources.

Spousal

If applicable, Spousal Impoverishment rules should be followed. (DSSM 20900)

Financial Redetermination

A redetermination of the individual’s financial eligibility should be completed at six month intervals.

Post Eligibility Budgeting

There is a patient pay requirement for these individuals. The patient pay amount is determined in accordance with DSSM section 20600 - (Post-Eligibility Definitions/Procedures). Notification of patient pay amount and approval must be sent to the appropriate hospital/rehabilitation social worker.

Medicaid Eligibility Effective Date

In no case shall the effective date of eligibility be earlier than the first day of hospitalization.

13 DE Reg. 263 (08/01/09)