8272 Continuing Financial Eligibility - HCBS eligibility continues until the individual no longer meets appropriate eligibility criteria or until circumstances have changed as indicated in this section. When HCBS services end, KEES must be updated effective the day following the last day of service. When HCBS termination is based on a functional reason the last day of service is provided by the care coordinator. If the person has moved out of state or has died, the last day of service is the day of the move or the client's passing. If eligibility has been terminated for another reason, the last day of service is the last day of the month in which the action became effective. Other adjustments will be made as follows:
8272.1 Medically Needy to HCBS - When an individual goes from independent living (including a non-Medicaid approved institution or specialized living arrangement) to an HCBS arrangement, the provisions of 8231 apply.
8272.2 HCBS to Medically Needy - When an eligible individual goes from an HCBS arrangement to independent living, a new 6-months base shall be established beginning with the month following the month the care arrangement ends.
8272.3 Long Term Care to HCBS - When an eligible individual goes from long term care in a Medicaid approved institution to an HCBS arrangement, the higher HCBS income standard shall be applied beginning with the month the HCBS arrangement begins and liability recomputed for that month. The resulting patient liability will be assigned entirely to the facility, even in instances where the total cost of care is less than the resulting liability. In these situations, KEES should not be updated with the HCBS information until the living arrangement changes (after the person physically leaves the facility). The new level of care and living arrangement codes care effective the date of discharge. HCBS Plans of Care may be backdated to ensure proper reimbursement to providers in these situations. Coordination between HCBS care coordinators and eligibility staff is necessary.
8272.4 HCBS to Long Term Care - When an eligible individual goes from an HCBS arrangement to long term care in a Medicaid approved institution, budgeting methodologies are dependent upon the anticipated duration of the stay.
If
the stay is expected to exceed the month of entrance and the two following
months, the obligation established for the month of entrance shall
remain in effect and will be applied to HCBS services provided in
the month. The current client obligation is left in place for the
period where HCBS payment is appropriate. LTC budgeting methodologies
begin the month following the month of entrance, unless the stay meets
the temporary criteria as noted in 8173.4
(2).
If the HCBS recipient
enters a State Hospital, the effective date of the new Level of
Care and Living Arrangement codes is the day following the day
of entrance into the State Hospital. Current coding in place authorizing
HCBS as well as the previously established client obligation should
be left in place for the date of entrance.
If
the HCBS recipient enters a Nursing Facility or Swing Bed Hospitals,
KEES should be adjusted with an effective date of the day of NF
entrance. The current Level of Care code should be left in place.
This combination of coding will allow both the NF and the HCBS
provider to receive reimbursement for services provided on the
day of entrance. The new Level of Care/Living Arrangement codes
authorizing only NF payment are effective the day following the
day of entrance into the NF.
Overstated eligibility is not considered in situations where the total client obligation is not paid out for HCBS care because the cost of services was less than the obligation.
If the stay is not expected
to exceed the month of entrance and the following month, HCBS budgeting
methodologies continue for the temporary period. Any HCBS obligation
would be applied to the HCBS services provided in either month and
no obligation applied to the cost of the institutional care. However,
because billing procedures differ for different institutional arrangements,
instructions for handling these situations also differ.
If the HCBS recipient
enters a State Hospital, no changes to KEES are necessary, and
the coding established for HCBS payment is left in place for the
duration of the temporary period. If a child receiving services
through the SED waiver is approved for the special 14 day funding,
HCBS coding remains in place for the full 14 days. Changes in
level of care and living arrangement would be made effective for
the 15th day.
If the HCBS recipient
enters a Nursing Facility or Swing Bed Hospital, the Living Arrangement
code is changed and left in place throughout the duration of the
temporary period. No other changes are necessary. If the individual
is hospitalized in general hospital prior to entrance into the
NF/Swing Bed, no change should be made until the NF stay begins.
However, the total anticipated length of stay should not exceed
the month of entrance and the two following months for these provisions
to be applicable.
In either case,
if the case is initially processed as being in temporary care and the
stay ends up exceeding those time lines, long term care policies shall
then be applied beginning in the third month following the month of entrance.
For all changes in financial factors, the change will be incorporated into the appropriate eligibility base. Necessary case action will be taken at the earliest possible time based on advance notice requirements.