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, the LOTC screen must be updated. Except for use of the TC code noted below, the effective dates on LOTC fields are updated to 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 ILC/case manager. 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 a person goes from independent living (including a non-Medicaid approved institution or specialized living arrangement) to an HCBS arrangement accordance with 8231.
8272.2 HCBS to Medically Needy - When an eligible individual goes from an HCBS arrangement to independent living, a new 6 month 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, the LOTC screen in KAECSES 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 case managers and EES 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, a TC (Temporary Care) Living Arrangement code should be entered 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.
If the total client obligation is not paid out for HCBS care because the cost of services was less than the obligation, because of this change, no medical overpayment will be considered.
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 LOTC 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 from HC to TC 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, the HC code should be left in place 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.