County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Overview of Home and CommunityBased Services HCBS Waiver Programs Number Page 051801 1 of 7 Revision Date 06012021 BackgroundThe Social Security Act Section 1915c permits states to request waivers to provide certain services to people at home or in the community as a cost neutral alternative to institutionalized health care provided such noninstitutionalized services meet the health and safety needs of the customer The goal is that the customer will experience an enhanced and enriched quality of life if allowed to return home or to the community PurposeThis section provides an overview of the Home and CommunityBased Services HCBS Waiver Programs and has been updated to include clarifications issued in All County Welfare Directors Letters ACWDLs 1819 2015 and MediCal Eligibility Division Information Letter MEDIL 2107 Policy051801A Home and CommunityBased Services HCBS Waivers There are currently five HCBS Waivers in effect in San Diego Home and CommunityBased Services for the Developmentally Disabled HCBSDD WaiverDDS Waiver Home and CommunityBased Alternatives HCBA Waiver Formerly Nursing FacilityAcute Hospital NFAH Waiver and InHome Operations IHO Waiver Multipurpose Senior Services Program MSSP Waiver Assisted Living Waiver ALW Acquired Immune Deficiency Syndrome AIDS Waiver The first four waivers allow for special MediCal rules also known as Institutional Deeming when determining MediCal eligibility for customers who are eligible to these waivers The AIDS Waiver follows regular MediCal rules A customer who has a Share of Cost SOC or is not property eligible for MediCal under regular incomeproperty rules may benefit from these waivers A customer may initiate the HCBS Waiver process by Applying for MediCal Contacting a waiver administrator Contacting a CareCoordinating Agency CCA that works with the waiver administrator The request for HCBS can be made verbally in writing or by answering yes to the question on the MediCal application For waivers that allow special MediCal rules the agency responsible for the waiver will refer the customer for a MediCal determination if they are not already receiving MediCal with no SOC and are eligible or potentially eligible for a particular waiver 051801B HCBS Waivers and Spousal Impoverishment SI Provisions SI Provisions allow the allocation of income and resources from the institutional spouse to the community spouse or other dependent family members Effective January 1 2014 the Affordable Care Act ACA broadened the definition of an institutionalized spouse to include HCBS recipients and those who have requested HCBS who generally reside in the home or in the community County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Overview of Home and CommunityBased Services HCBS Waiver Programs Number Page 051801 2 of 7 With this change SI provisions are an eligibility step rather than being included in the institutional deeming process and must be used to determine MediCal when a customer requests an HCBS waiver or HCBS waiver services rather than waiting for the waiver to be approved Use the manual 14152A HHSA Budget Steps for HCBS Spousal Impoverishment 012014 worksheet when determining eligibility from 012014112020 and the 14152 HHSA Budget Steps for HCBS Spousal Impoverishment 122020 worksheet when determining eligibility from 122020 and forward for HCBS SI to determine the spousal and dependent family member allocations as part of the eligibility process Note HCBS Waiver and LongTerm Care LTC benefits and services are provided to beneficiaries under the Modified Adjusted Gross Income MAGI coverage groups including the Optional Targeted Low Income Childrens Program OTLICP without time limits and no change in aid code if the customer meets eligibility criteria under MAGI The spousal and dependent family member allocation rules do not apply to MAGI Who SI Applies To SI provisions apply to married customers and Registered Domestic Partners RDPs who on or after January 1 2014 arewere New MediCal customers who requested HCBS waiver services inhome assistance or InHome Supportive Services IHSS In an HCBS waiver in institutional deeming aid codes 1X 1Y 6V 6W 6X or 6Y On a HCBS waiver wait list and are receiving MediCal or requesting MediCal Requesting or receiving HCBS waivers or program services including IHSS but were denied or discontinued due to excess property Receiving HCBS waiver or program services including IHSS and have a MediCal SOC Enrolled in InHome Supportive ServicesCommunity First Choice Option IHSSCFCO programs 2K aid code Requiring a Nursing Facility Level of Care NFLOC The request for HCBS or IHSS can be made verbally in writing or by answering yes to the question on the MediCal application Customers requesting IHSS do not need to say they are requesting IHSSCFCO Any IHSS request is adequate to initiate a referral to IHSS however the IHSSCFCO is the only program that provides the appropriate level of care to initiate the application of the SI provisions When to Apply SI ProvisionsApplicable Application Date SI provisions are applied the first month when both of the following exist The request for either HCBS or IHSS has been made The customer meets the NFLOC documented through the MC 604 MDV Doctors Verification form or through a Needs Assessment issued by the HCBS waiver or program See Desk Aid 94 for examples on establishing the applicable application date for SI Provisions and SI applied retroactively County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Overview of Home and CommunityBased Services HCBS Waiver Programs Number Page 051801 3 of 7 Once determined eligible using SI provisions the HCBS spouse remains eligible unless any of the following occur A change in circumstance for example Death moved out of state dissolution of marriage or the Continuous Period of Institutionalization ends Until the request for HCBS is denied for not meeting clinical standard for the waiver The customer is not identified as IHSSCFCO recipient Note This will require communication between the IHSS Social Worker or the Waiver AdministratorCCA and Human Services Specialist HSS A 10day notice is required for negative action Refer to Processing Guide 25 when an HCBS Waiver is initiated by other than the waiver administratorCCA and no Needs Assessment for the waiver has been completed MC 604 MDV Doctors Verification FormNeeds Assessment The Doctors Verification form and the Needs Assessment serve different functions and are not interchangeable Both may be required for a customer requesting inhome care depending on the timing of the request for services and their individual circumstances A Needs Assessment establishes that the customer meets the NFLOC for at least 30 consecutive days and may state the HCBS waiver program for which the customer is approved When the Needs Assessment has been completed by IHSS or an HCBS coordinator before applying for MediCal Spousal Impoverishment SI provisions apply Any request for HCBS initiates the Doctors Verification Form process unless there already has been a Needs Assessment for a waiver program or IHSSCFCO completed for the customer including if the customer is on a waiting list A Doctors Verification form MC 604 MDV is required to be signed by the customer This form Authorizes the customers doctor to release information to the County Establishes if the customer meets the NFLOC for at least 30 consecutive days in the absence of HCBS Begins the Continuous Period of Institutionalization In the absence of a waiver Needs Assessment SI provisions are not applied until the Doctors Verification form MC604 MDV is completed and returned by the customers doctor When the completed form is received apply SI provisions retroactively on or after January 1 2014 if the date of NFLOC and the date of the request for IHSSHCBS waiver program of services occurred in the past A Doctors verification form is not required for customers who are active in the IHSSCFCO 2K aid code See Processing Guide 25 for the Doctors Verification Form process County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Overview of Home and CommunityBased Services HCBS Waiver Programs Number Page 051801 4 of 7 051801C Continuous Period of Institutionalization The Continuous Period of Institutionalization is the Timeframe beginning the day the request for either HCBS or IHSS has been made and the customer meets a NFLOC documented through the MC 604 MDV Doctors Verification form or through a Needs Assessment issued by the HCBS waiver program Period that determines the length of time the institutionalized spouse is eligible to SI provisions before being placed on a waiting list or participating in an HCBS waiver The SI provisions will remain only if the application for HCBS is completed prior to the Continuous Period of Institutionalization ending If an approved request for HCBS results in the customers placement on a waiting list the SI provisions continue to apply See Desk Aid 95 for an example of the Continuous Period of Institutionalization The Continuous Period of Institutionalization period ends when The request for HCBS is denied It is determined the customer is not an IHSSCFCO recipient 2K aid code The customer fails to follow through and complete the HCBS application process The HCBS spouse or institutionalized spouse does not receive HCBS waiver or program services or inpatient care in a medical institution or nursing facility for a full calendar month Follow the steps in Processing Guide 25 to refer and confirm that the application for HCBS has been completed before the end of the Continuous Period of Institutionalization Note If the community spouse also requests HCBS there is no longer a community spouse Spouses remain in separate MediCal Family Budget Units MFBUs and SI provisions will not apply in this scenario However the division of community property and income rules may apply 051801D Retroactive Application of SI Provisions for HCBS The retroactive evaluation of SI provisions for HCBS must be processed before current eligibility is established because the Community Spouse Resource Allowance CSRA applies once in the initial month of eligibility Retroactive SI eligibility must be confirmed prior to rescinding a case Apply the SI provisions retroactively under any of the following circumstances to cases where there would have been an eligible HCBS spouse on or after January 1 2014 when The County becomes aware of a case that meets these standards The customer is participating in the IHSSCFCO program in the 2K aid code with a SOC There is a new application or annual redetermination A fair hearing is requested The customer requests a retroactive redetermination The customer was denieddiscontinued due to excess income or property based on the community spouse residing in their own home not institutionalized Aid code 2K was implemented in September 2014 If the customer was IHSSCFCO eligible between January 1 2014 and September 1 2014 please elevate to MediCal program for assistance in verifying the IHSSCFCO level of care County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Overview of Home and CommunityBased Services HCBS Waiver Programs Number Page 051801 5 of 7 Use the manual 14152A HHSA Budget Steps for HCBS Spousal Impoverishment 012014 worksheet when determining eligibility from 012014112020 and the 14152 HHSA Budget Steps for HCBS Spousal Impoverishment 122020 worksheet when determining eligibility from 122020 and forward for HCBS SI to determine the spousal and dependent family member allocations as part of the eligibility process Refer to MPG 0913 for CSRA guidelines See Processing Guide 25 for the retroactive SI for HCBS evaluation procedures Desk Aids 94 and 95 have been created to provide case examples 051801E Retroactive Beneficiary Reimbursement Process BRP A customer may request reimbursement of outofpocket MediCal claims or services provided by an IHSS enrolled provider under the BRP See MPG 040210J for the BRP also known as the Conlan process See Processing Guide 25 for scenarios the HSS may encounter when processing retroactive eligibility under SI for IHSSCFCO and the appropriate referral process 051801F Manual Budget Evaluation A manual budget evaluation 14152A HHSA Budget Steps for HCBS Spousal Impoverishment 012014 andor 14152 HHSA Budget Steps for HCBS Spousal Impoverishment 122020 worksheet is required when SI provisions apply and the customer requests HCBS Under SI provisions for HCBS There is no 35 LTC needs allowance Spouses are in separate MFBUs even though the HCBS spouse may be in the home not in an institution Use all applicable NonMAGI program income deductions and disregards The Federal Poverty Level FPL and Maintenance Need limit for one person is used All applicable spousal and dependent family member income allocations apply 051801G HCBS Waiver AidCodes Waiver aid codes are not required to be present in the MediCal Eligibility Data System MEDS for customers eligible for a zero SOC under SI provisions or any other MediCal program if they meet HCBS waiver requirements and pass the Needs Assessment Waiver aid codes will still appear in MEDS for customers who require institutional deeming to be eligible for waiver services HCBS Waiver program aid codes are considered voluntary managed care enrollees The enrollment process is done through Health Care Options HCO MediCal beneficiaries with a zero SOC in a mandatory managed care plan aid code may choose to disenroll from managed care by completing HCO02 MediCal Waiver Program Exemption Certification The medical providers usually initiate this form 051801H Annual Redetermination Follow the annual redetermination process outlined in MPG 041501 Only information about the HCBS waiver customer is required The HCBS spouseAuthorized Representative AR community spouse or waiver administratorCCA need only confirm continued HCBS waiver participation if the period of HCBS participation or institutionalization continues Once eligibility under SI provisions has County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Overview of Home and CommunityBased Services HCBS Waiver Programs Number Page 051801 6 of 7 been established do not recalculate the CSRA verify the property of the community spouse or verify the NFLOC at the annual redetermination 051801I Early and Periodic Screening Diagnosis and Treatment EPSDT EPSDT is a MediCal benefit for customers under 21 years old which requires that States provide medically necessary screening vision hearing and dental services to MediCal beneficiaries The program may provide licensed skilled nursing in the home Therefore MediCal eligible children who are institutionalized will now be able to return home from institutionalization and those who are home can remain there when receiving additional medical services under the EPSDT program if certain criteria including cost effectiveness are met 051801J Supplemental Security Income SSI Personal Needs Allowance PNA Effective June 1 1990 federal law began allowing a former institutionalized SSI child the same PNA as an institutionalized SSI child if the noninstitutionalized child is in a home and a communitybased waiver applies The Social Security Administration SSA must confirm that a child is in a waiver program before the PNA can begin or continue Staff must request an authorization form from the childs parent or guardian before providing verification to SSA that the child is in a waiver program The information may be requested at the time the waiver coverage begins and then at the SSA redetermination The MediCal Waiver Information and Authorization form DHCS 7071 was developed to secure parental consent and allow to release this information to SSA In addition staff should be aware that in some cases when the waiver customer begins receiving the PNA MEDS will convert the waiver aid code to aid code 60 If this occurs and the waiver person is still living in the home and is ineligible for a regular SSI payment contact the Department of Health Care Services DHCS to have the aid code corrected Procedures Procedures for the HCBS Waiver programs are listed in Processing Guide 25 Program ImpactsForms 14152A HHSA Budget Steps for HCBS Spousal Impoverishment 012014 and 14152 HHSA Budget Steps for HCBS Spousal Impoverishment 122020 worksheet and the 14153 Referral to IHSS and HCBS Waiver Agencies have been added to Eligibility Forms Library EFL Automation SI approvals for HCBS in the California Work Opportunity and Responsibility to Kids Information Network CalWIN require a manual override Refer to the Business Environment Design Strategies BEnDS 49130 in Eligibility Essentials for CalWIN entries Special Indicator MC HCBS Spousal Impoverishment has been added to identify these cases References MEM PROC 19D MEPM Letter No 307 ACWDL 8777 9001 9003 9184 0322 0331 0331E 1236 1715 1725 1819 2015 MEDIL 1438 1810 2107 County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Overview of Home and CommunityBased Services HCBS Waiver Programs Number Page 051801 7 of 7 Sunset Date This policy will be reviewed for continuance by 06302024 Approval for Release Rick Wanne Director SelfSufficiency Services County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Home and CommunityBased Services for the Developmentally Disabled HCBSDD Waiver Number Page 051802 1 of 3 Revision Date 06012021 BackgroundThe Department of Health Care Services DHCS applied for and received federal approval from the Federal Centers for Medicare and Medicaid Services for the Home and CommunityBased Services for the Developmentally Disabled HCBSDD Waiver The Department of Developmental Services DDS Waiver is a subset of the HCBSDD Waiver PurposeThis section will provide guidance for processing the DDS Waiver portion of the HCBSDD Waiver This section is being updated to include clarifications contained in All County Welfare Directors Letter ACWDL 1819 PolicyThe DDS Waiver is for customers no age limit diagnosed as developmentally disabled prior to their 18th birthday These customers must live at home and meet the admission criteria for an Intermediate Care Facility for the Developmentally Disabled ICFDD as defined in the California Health and Safety Code The San Diego Regional Center SDRC determines if the customercustomers family meets the criteria for the DDS Waiver program The waiver provides developmentally disabled customers who are Regional Center consumers the ability to receive care at home instead of care provided in an ICFDD or a State Developmental Center Procedure 051802A Referring Agency SDRC is responsible for the DDS Waiver referrals SDRC determines whether the customer is eligible to participate in the waiver program by reviewing the customers medical social and developmental care needs When appropriate the SDRC will refer the customer to MediCal for an eligibility determination or redetermination via the DDS Waiver Referral form DHCS 7096 If no responsible relative is available to act on behalf of the customer or the responsible relative does not wish to apply for the customer the SDRC representative may do so Staff may not share ongoing eligibility information with SDRC without a signed Authorization for Release of Information The Regional Center for San Diego and Imperial Counties is located at 4355 Ruffin Road Ste 205 8585762996 San Diego CA 921231648 858 5762873 Fax 051802B Eligibility Determination Refer to Processing Guide 25 for the steps to take when processing an application with a DDS Waiver referral County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Home and CommunityBased Services for the Developmentally Disabled HCBSDD Waiver Number Page 051802 2 of 3 051802C Beginning Date of Eligibility and Retroactive Coverage The effective date of eligibility for a customer using the special rules also known as Institutional Deeming under the DDS Waiver is the date the following two requirements are met The referring agency determines that it is medically appropriate for the Waiver customer to be in the Waiver Normally this is the date on the waiver referral The Human Services Specialist HSS determines that the Waiver customer meets the MediCal eligibility requirements under that Waiver If a customer requests retroactive MediCal coverage regular MediCal rules apply If the customer requests retroactive eligibility also be evaluated using the special rules under the Waiver contact the representative of the referring agency to inquire whether the Waiver also covers the retroactive period The response must be narrated in case comments In lieu of the customer completing the retroactive section of the Statement of Facts SOF the original referral form may include a cover letter requesting retroactive MediCal 051802D Institutional DeemingSpecial Rules When a DDS referral is received and its determined that the customer will be property ineligible or has a share of cost SOC using regular MediCal rules the special rules below apply The customer is treated as if they were institutionalized for purposes of the treatment of income and resources When the customer is a child parental income and resources are not considered even though the child lives in the home A second vehicle is exempt if the vehicle has been modified to accommodate the physical handicaps or medical needs of the customer Verification is by the physicians written statement of necessity The customer is in their own MediCal Family Budget Unit MFBU If other family members wish to be aided the customer is treated like those on public assistance PA The waiver customer may be used to link other family members although the customer is not in the familys MFBU The DDS customer must be eligible for full scope benefits with or without a SOC Note A customer residing in a nursing home under the limited stateonly aid code of 53 in another limitedscope aid code or a customer age 26 or older who does not have satisfactory immigration status SIS is not eligible Use the most beneficial fullscope MediCal program to determine eligibility that is applicable to the customer for example Pickle the Aged and Disabled AD program or the Medically Needy MN program Eligibility is based on the customers own income and resources including amounts remaining after Spousal Impoverishment SI provisions are applied A disability determination is not required unless Eligibility is based on a MediCal program requiring that the customer be disabled The customer has no other basis for linkage There would be an advantage if the customer were disabled for example income deductions available only to the disabled If this is a child the determination of disability may be advantageous in the future when they become an adult Note The Institutional DeemingSpecial Rules do not apply to the Modified Adjusted Gross Income MAGI MediCal program County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Home and CommunityBased Services for the Developmentally Disabled HCBSDD Waiver Number Page 051802 3 of 3 051802E Aid Codes The following aid codes are used for DDS Waiver eligible cases when Institutional DeemingSpecial Rules are applied 6VDD Waiver Zero SOC 6WDD Waiver SOC 051802G Notice of Action NOA Use appropriate approval denial or discontinuance NOA MC 341 DDS Waiver approval NOA MC 342 DDS Waiver denialdiscontinuance NOA Program ImpactsAutomation The Collect Individual Attributes Detail window in the California Work Opportunity and Responsibility to Kids Information Network CalWIN must be completed to ensure eligibility is determined under the DDS Waiver Refer to the Business Environment Design Strategies BEnDS 49130 in Eligibility Essentials for CalWIN entries when applying SI Forms and Document Capture Image all appropriate forms into the case record References MEPM 19D ACWDL 1715 1725 1819 MEDIL 1438 Sunset Date This policy will be reviewed for continuance by 06302024 Approval for Release Rick Wanne Director SelfSufficiency Services County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Home and CommunityBased Alternatives HCBA Waiver Number Page 051803 1 of 3 Revision Date 06012021 BackgroundThe Department of Health Care Services DHCS applied for and received federal approval from the Federal Centers for Medicare and Medicaid Services CMS for the Home and CommunityBased Alternatives HCBA Waiver PurposeTo provide guidelines for the processing of the HCBA Waiver This section is being updated to include clarifications contained in All County Welfare Directors Letter ACWDL 1819 PolicyThe DHCS HCBA section determines if the customer no age limit meets the criteria for the HCBA Waiver The HCBA Waiver was limited to people who require Nursing Facility level of Care NFLOC or subacute services for at least 90 consecutive days but who wish to live at home or in the community Effective January 1 2014 customers who require NFLOC or subacute services for at least 30 consecutive days are eligible to receive the waiver HCBA waiver services provided include but are not limited to Case management skilled nursing home health aides language services speech hearing family training and therapy physical therapy and adaptations to the home Inpatient status before enrollment of waiver services is not required Procedure 051803A Referring Agency The referring agency for the MediCal HCBA Waiver is the DHCS HCBA Section The purpose of HCBA is to ensure that necessary appropriate and quality medical and nursing services are authorized and provided in the home setting HCBA staff facilitate the proposal documentation and development between each waiver participant and provider This process allows for review of all issues related to the level of care evaluation of durable medical equipment medication nursing hours cost effectiveness and verification by HCBA staff that the home environment is appropriate to meet the health and safety needs of the customer Final approvals of individual waiver requests are subject to review by a medical physician and other staff When the medical assessment is completed the Human Services Specialist HSS receives a copy of the MediCal HCBA Waiver MediCal Eligibility Notice from the MediCal Program Specialist Some customers receiving benefits under the Department of Developmental Services DDS Waiver may be referred by DHCS HCBA to change to the HCBA Waiver due to a better match for services The HSS receives a copy of the MediCal HCBA Waiver Eligibility Notice from the MediCal Program Specialist The HSS must change the aid code to the appropriate MediCal HCBA Waiver aid code see 051803C to determine the beginning date of eligibility Note Customers under the age of 21 must be able to access a waiver service which is not covered under the Early and Periodic Screening Diagnosis and Treatment EPSDT program Refer to 051801 for EPSDT information County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Home and CommunityBased Alternatives HCBA Waiver Number Page 051803 2 of 3 051803B Eligibility Determination Refer to Processing Guide 25 for the steps to take when processing an application with an HCBA Waiver referral 051803C Beginning Date of Eligibility and Retroactive Coverage The effective date of eligibility for a customer using the special rules under the HCBA Waiver is the date the following requirements are met The referring agency determines that it is medically appropriate for the Waiver customer to be in the Waiver Normally this is the date on the HCBA Waiver referral or The person requests both MediCal and Home and Community Based Services HCBS for the Waiver customer and the completed Doctors Verification form has been received and The HSS determines that the Waiver customer meets the MediCal eligibility requirements under that Waiver If a customer requests retroactive MediCal coverage regular MediCal rules apply If the customer requests retroactive eligibility also be evaluated using the special rules under the Waiver contact the representative of the referring agency to inquire if the Waiver also covers the retroactive period The response must be narrated in case comments In lieu of completing the retroactive section of the Statement of Facts SOF the original referral form may include a cover letter requesting retroactive MediCal 051803D Institutional DeemingSpecial Rules When an HCBA referral is received and its determined that the customer will be property ineligible or has a Share of Cost SOC using regular MediCal rules the special rules below apply The customer is treated as if they were institutionalized for purposes of the treatment of income and resources If the customer is a child parental income and resources are not considered even though the child lives in the home A second vehicle is exempt if the vehicle has been modified to accommodate the physical handicaps or medical needs of the customer Verification is by the physicians written statement of necessity The customer is in their own MediCal Family Budget Unit MFBU If other family members wish to be aided the customer is treated like those on public assistance PA The waiver customer may be used to link other family members although the customer is not in the familys MFBU The HCBA customer must be eligible for full scope benefits with or without a SOC Note A customer residing in a nursing home under the limited stateonly aid code of 53 in another limitedscope aid code or a customer age 26 or older who does not have satisfactory immigration status SIS is not eligible Use the most beneficial fullscope MediCal program to determine eligibility that is applicable to the customer for example Pickle the Aged and Disabled AD program or the Medically Needy MN program Eligibility is based on the customers own income and resources including amounts remaining after Spousal Impoverishment SI provisions are applied A disability determination is not required unless Eligibility is based on a MediCal program requiring that the customer be disabled The customer has no other basis for linkage County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Home and CommunityBased Alternatives HCBA Waiver Number Page 051803 3 of 3 There would be an advantage if the customer were disabled for example income deductions available only to the disabled If this is a child the determination of disability may be advantageous in the future when they become an adult Note The Institutional DeemingSpecial Rules do not apply to the Modified Adjusted Gross Income MAGI MediCal program 051803E Aid Codes The following aid codes are used for MediCal HCBA Waiver eligible cases when Institutional DeemingSpecial Rules are applied 6X MediCal HCBA Waiver Zero SOC 6Y MediCal HCBA Waiver SOC 051803F Notice of Action NOA Use appropriate approval denial or discontinuance NOA MC 343 HCBA Waiver approval NOA MC 344 HCBA Waiver denialdiscontinuance NOA Program ImpactsAutomation The Collect Individual Attributes Detail window in the California Work Opportunity and Responsibility to Kids Information Network CalWIN must be completed to ensure eligibility is determined under the HCBA Waiver Refer to the Business Environment Design Strategies BEnDS 49130 in Eligibility Essentials for CalWIN entries when applying SI provisions Forms and Document Capture Image all appropriate forms into the case record References ACWDL 0331 0331E 1725 1819 MEDIL 1438 MEPM 19D Sunset Date This policy will be reviewed for continuance by 06302024 Approval for Release Rick Wanne Director SelfSufficiency Services County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Department of Aging Multipurpose Senior Services Program MSSP Waiver Number Page 051804 1 of 3 Revision Date 06012021 BackgroundThe Department of Health Care Services DHCS applied for and received federal approval from the Federal Centers for Medicare and Medicaid Services CMS for the Multipurpose Senior Services Program MSSP Waiver PurposeThis section provides guidelines for processing of the MSSP Waiver This section is being updated to include clarifications contained in All County Welfare Directors Letter ACWDL 1819 PolicyThe MSSP Waiver Program is limited to customers who are Aged age 65 or older Receiving fullscope MediCal Certifiable for placement in a nursing facility Living within Aging and Independent Services AIS service area Able to be served within the programs cost limitations Eligible for care management services Many of the waiver participants live at home and were on MediCal before being accepted into the Waiver Services include case management adult social day care housing assistance protective services personal care respite care transportation meal and special communication services Procedure 051804A Referring Agency The California Department of Aging CDA is the referring agency AIS is the local administrator in San Diego County The assessment for the MSSP waiver is completed before the customer is referred to the County The MSSP customer is referred using form MC 364 Effective January 1 2014 the MSSP Waiver process may be initiated by the customer spouse or Authorized Representative AR when applying for MediCal Refer to Processing Guide 25 when a waiver is requested by other than CDA 051804B Eligibility Determination Refer to Processing Guide 25 for the steps to take when processing an application with a MSSP Waiver referral 051804C Beginning Date of Eligibility and Retroactive Coverage The effective date of eligibility for a customer using the special rules also known as Institutional Deeming under the MSSP Waiver is the date the following two requirements are met The referring agency determines that the customer is medically eligible to the Waiver Normally this is the date on the MSSP Waiver referral The Human Services Specialist HSS determines that the Waiver customer meets the MediCal eligibility requirements under that Waiver County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Department of Aging Multipurpose Senior Services Program MSSP Waiver Number Page 051804 2 of 3 If a customer requests retroactive MediCal coverage regular MediCal rules apply If the customer requests retroactive eligibility also be evaluated using the special rules under the Waiver contact the representative of the referring agency to inquire if the Waiver also covers the retroactive period The response must be narrated in case comments In lieu of completing the retroactive section of the Statement of Facts SOF the original referral form may include a cover letter requesting retroactive MediCal 051804D Institutional DeemingSpecial Rules When an MSSP referral is received and its determined that the customer will be property ineligible using regular MediCal rules the waiver allows for institutional deeming the special rules below apply A second vehicle is exempt if the vehicle has been modified to accommodate the physical handicaps or medical needs of the customer Verification is by the physicians written statement of necessity The MSSP customer is in their own MediCal Family Budget Unit MFBU If other family members wish to be aided the customer is treated like those on public assistance The customer may be used to link other family members although the customer is not in the familys MFBU The MSSP customer must be eligible for full scope benefits with or without a Share of Cost SOC Note A customer residing in a nursing home under the limited stateonly aid code of 53 in another limitedscope aid code or does not have satisfactory immigration status SIS is not eligible Use the most beneficial fullscope MediCal program to determine eligibility that is applicable to the customer for example Pickle the Aged and Disabled AD program or the Medically Needy MN program Eligibility is based on the customers own income and resources including amounts remaining after Spousal Impoverishment SI provisions are applied Note The Institutional DeemingSpecial Rules do not apply to the Modified Adjusted Gross Income MAGI MediCal program 051804E Aid Codes The following aid codes are used for MediCal MSSP Waiver eligible cases when Institutional DeemingSpecial Rules are applied 1X MSSP Waiver Zero SOC 1Y MSSP Waiver SOC 051804F Notice of Action NOA Use appropriate approval denial or discontinuance NOA MC 365 MSSP Waiver approval NOA MC 366 MSSP Waiver denialdiscontinuance NOA Program ImpactsAutomation The Collect Individual Attributes Detail window in in the California Work Opportunity and Responsibility to Kids Information Network CalWIN must be completed to ensure eligibility is determined under the MSSP Waiver County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Department of Aging Multipurpose Senior Services Program MSSP Waiver Number Page 051804 3 of 3 Refer to the Business Environment Design Strategies BEnDS 49130 in Eligibility Essentials for CalWIN entries when applying SI Forms and Document Capture Image all appropriate forms into the case record References ACWDLs 0322 1725 1819 MEDIL 1438 MEPM Article 19D Sunset Date This policy will be reviewed for continuance by 06302024 Approval for Release Rick Wanne Director SelfSufficiency Services County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Assisted Living Waiver ALW Number Page 051805 1 of 4 Revision Date 06012021 BackgroundThe Department of Health Care Services DHCS applied for and received federal approval from the Federal Centers for Medicare and Medicaid Services CMS for the Assisted Living Waiver ALW PurposeThis section provides policy guidelines for processing the ALW This section is being updated to include changes contained in All County Welfare Directors Letter ACWDL 1819 PolicyThe ALW provides a viable alternative to longterm care for certain customers because it allows customers to live in the community while receiving many of the services that would be available in longterm care The ALW provides the assisted living benefits in two settings Residential care facilities for the elderly RCFEs Publicly funded senior andor disabled housing PSH ALW benefits include Assisted living benefit as rendered by the RCFE setting Assisted living benefit as rendered by a MediCal licensed and certified home health agency in the PSH setting Care coordination MediCal eligible customers residing in an ALW provider site and enrolled into the ALW have the following characteristics Have fullscope MediCal eligibility without a MediCal share of cost SOC Determined to have enough disposable income by DHCS Are aged or disabled Note Blind customers for the ALW will need to be determined disabled to be part of this waiver Meet the Nursing Facility A or B Level of Care NFLOC Are at least 21 years of age Customers ineligible for the ALW are those who Reside in a residential care facility under state only aid code 53 Are in a limited scope aid code due to failure to comply with Deficit Reduction Act DRA citizenship and identity regulations Are persons age 26 or older who do not have Satisfactory Immigration Status SIS Are enrolled in another Home and CommunityBased Services HCBS waiver Note The ALW is available in San Diego and there are ALW provider facilities in San Diego For a list of ALW facilities go to httpswwwdhcscagovservicesltcDocumentsListofRCFEfacilitiespdf County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Assisted Living Waiver ALW Number Page 051805 2 of 4 Procedure 051805A Referring Agency The waiver is operated by the DHCSLongTerm Care Division Monitoring and Oversight Section MOS DHCS has also contracted with Care Coordinator Agencies CCAs to conduct some aspects of the ALW process The CCAs conduct the Level of Care Assessment for customers who are approved MediCal with or without a SOC or if married or have a registered domestic partner were denied due to excess property 051805 B Eligibility Customers from any county may request enrollment into this waiver if they are willing to move to an ALW provider site in another county Therefore any county may be required to make a MediCal eligibility determination using ALW eligibility rules for a waiver customer who resides in its county but who if enrolled in the ALW will move to another county where an ALW facility is located Regular MediCal rules for determining which county is responsible for the eligibility determination apply When one countys MediCal resident wants to enroll in the ALW and will then move to an ALW provider site in another county then The current County of residence will determine whether an intercounty transfer is appropriate The current County will conduct any necessary MediCal eligibility determination for that resident An intercounty transfer is not required when there is a married couple both receiving MediCal and one moves into a longterm care or assisted living facility in another county and one stays in the current county When a customer asks the county about the ALW Assist the customer with their MediCal needs be it applying for MediCal or a change in circumstance Refer the customer to the CCA a list of CCAs can be found at httpswwwdhcscagovservicesltcDocumentsCareCoordinationAgenciespdf Refer to processing Guide 25 for steps when ALW is requested and no referral from the CCA has been received 051805C Institutional DeemingSpecial Rules When an ALW referral is received and its determined that the customer will be property ineligible or has a SOC using regular MediCal rules the special rules below apply The customer is treated as if they were institutionalized for purposes of the treatment of income and resources If the customer is a child parental income and resources are not considered even though the child lives in the home A second vehicle is exempt if the vehicle has been modified to accommodate the physical handicaps or medical needs of the customer Verification is by the physicians written statement of necessity The customer is in their own MediCal Family Budget Unit MFBU If other family members wish to be aided the customer is treated like those on public assistance PA The waiver customer may be used to link other family members although the customer is not in the familys MFBU County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Assisted Living Waiver ALW Number Page 051805 3 of 4 The ALW customer must be eligible for full benefits with or without a SOC Use the most beneficial fullscope MediCal program to determine eligibility that is applicable to the customer for example Pickle the Aged and Disabled AD program or the Medically Needy MN program Eligibility is based on the customers own income and resources including amounts remaining after Spousal Impoverishment SI are applied Evaluate as if the customer were residing in a licensed Board and Care BC Deduct the greater of the excess BC deduction or the 315 Petit v Bonta deduction for personal care service see MPG 100608 The amount to be used as the paid amount to the licensed BC facility is the AL facility rate determined as follows The difference between the Supplemental Security IncomeState Supplemental Program SSISSP nonmedical BC payment level and the minimum personal care and incidentals needs rate is defined for purposes of the AL waiver as the AL facility rate For example as of December 1 2020 the AL facility rate to be used is 106937 12063713700 see MPG 111A A disability determination is not required unless Eligibility is based on a MediCal program requiring that the customer be disabled The customer has no other basis for linkage There would be an advantage if the customer were disabled for example income deductions available only to the disabled If this is a child the determination of disability may be advantageous in the future when they become an adult Note The Institutional DeemingSpecial Rules do not apply to the Modified Adjusted Gross Income MAGI MediCal program Refer to processing Guide 25 for steps when the customer is treated as if they were institutionalized for purposes of determining the amount of income and property the waiver customer has 051805D Aid Codes If a customer is determined eligible for zero SOC MediCal using the Institutional DeemingSpecial Rules they must be placed in one of the following aid codes 14 for aged 64 for disabled 051805E Notice of Action NOA If a customer is to move into an ALW provider site and is then eligible using regular MediCal rules use a regular MediCal NOA If eligibilityineligibility is based on the use of the special ALW rules also known as Institutional Deeming use one of the three ALW specific notices of action below MC 240 Approval for Enrollment in Assisted Living Waiver with MediCal Changes for Beneficiary MC 241 Approval for Enrollment in Assisted Living Waiver and Initial MediCal only use if initial eligibility and ALW eligibility is determined simultaneously County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Assisted Living Waiver ALW Number Page 051805 4 of 4 MC 242 Denial of Enrollment in Assisted Living Waiver andor MediCal Referral Form Program ImpactsForms and Document Capture The ALW NOAs are not available in CalWIN but are available in the Eligibility Forms Library EFL and Xerox Follow existing procedures to Document Capture any client correspondence issued outside of CalWIN Automation Refer to the Business Environment Design Strategies BEnDS 49130 in Eligibility Essentials for CalWIN entries when applying SI References ACWDL 9001 1725 1819 MEPM Letter No 307 MEPM Article 19D MEDIL 1438 Sunset Date This policy will be reviewed for continuance by 06302024 Approval for Release Rick Wanne Director SelfSufficiency Services County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Acquired Immune Deficiency Syndrome AIDS Waiver Number Page 051806 1 of 2 Revision Date 06012021 BackgroundThe Department of Health Care Services DHCS applied for and received federal approval from the Federal Centers for Medicare and Medicaid Services CMS for the Acquired Immune Deficiency Syndrome AIDS Waiver PurposeThis section will provide guidelines for the processing of the AIDS Waiver It has been updated to reflect changes provided in All County Welfare Directors Letter ACWDL 1819 PolicyThe AIDS Waiver is limited to customers with a diagnosis of Human Immunodeficiency Virus HIV or AIDS with symptoms related to HIV disease who would otherwise require care in skilled nursing facilities or acute hospitals Services provided include Case management Skilled nursing Attendant care Psychosocial counseling Nonemergency medical transportation Homemaker services Equipment and minor physical adaptations to the home Limited room and board supplement for infants and children in foster care Nutritional counseling Nutritional supplementshome delivered meals Procedure 051806A Referring Agency Medical certification for the AIDS Waiver is completed by the California Department of Public Health Office of AIDS The medical assessment for this waiver is completed before the customer is referred to the County There should be few if any of this type of referral to the County 051806B Eligibility Process using regular MediCal eligibility rules including the application of Spousal Impoverishment SI provisions if applicable no other special MediCal eligibility rules apply 051806C Notice of Action NOA When a customers MediCal eligibility is approved or denied use a regular MediCal NOA County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Acquired Immune Deficiency Syndrome AIDS Waiver Number Page 051806 2 of 2 Program ImpactsAutomation Refer to the Business Environment Design Strategies BEnDS 49130 in Eligibility Essentials for CalWIN entries when applying SI References MEM PROC 19D ACWDL 9001 1715 1725 1819 MEDIL 1438 Sunset Date This policy will be reviewed for continuance by 06302024 Approval for Release Rick Wanne Director SelfSufficiency Services