CONNECTICUT DEPARTMENT OF SOCIAL SERVICES
UNIFORM POLICY MANUAL

EXCERPTS RELATING TO THE HOME CARE PROGRAM

8040 This chapter describes the eligibility requirements for the Connecticut Home Care
Program for Elders (CHC). This program provides home health and community based
services under either a waiver to the Medicaid program or under an appropriation by the
General Assembly. The financial eligibility requirements for these two parts of the
program differ. The Medicaid waiver requirements are specified under UPM 2500 "Medical
Coverage Groups" and other areas of the UPM. [click for more on waiver]  This section of the manual applies to the
state-funded portion of the program. The state-funded portion is not an entitlement
program and services and access to services may be limited based on available funding.
The Department may place new applicants on a waiting list in order of their date of
application within the program region.

8040.05 Rights and Responsibilities.

A. The following are the rights afforded each applicant/recipient:

1. the right to waive participation by refusing an assessment and a right to refuse to accept the plan of care.

2. the right to confidentiality. All records will be available only to those directly administering the program or providing care. Information will not be available to others without the client's permission.

3. the right to appeal any decision made by either the access agency or the Department of Social Services is done solely through the Administrative Appeal process. The right to a hearing is confirmed by this regulation to afford applicants and recipients an opportunity to review eligibility decisions.

4. the right to a comprehensive initial assessment of health and social needs, an annual reassessment, and ongoing coordination and monitoring of services prescribed to meet changing needs.

5. a right to a description of services and corresponding charges before any such services are rendered and to be informed of the procedure for payment.

6. the right to be informed of any obligation he or she has to contribute toward the cost of service according to a sliding fee scale.

7. the right to be informed of all requirements necessary for program participation.

8. the right to be informed of the person supervising his or her care and how that person may be contacted.

B. The following are the responsibilities of the applicant/recipient:

1. he or she must supply information needed to carry out a comprehensive health, social and financial assessment.

2. he or she is expected to cooperate with Department staff, case managers, and service providers and participate, to the extent possible, in the development and implementation of the plan of care.

3. he or she must meet third party payor regulations to the best of his/her ability.

4. he or she must apply for Medicaid and cooperate in the application process if requested by the Department.

8040.10 A. Screening for Participation

The Department screens individuals for possible participation in the Connecticut Home
Care program. An individual is first screened for the Medicaid Waiver portion of this
program. If the individual does not meet the eligibility criteria for participation in
he Medicaid Waiver portion of this program, he or she is screened for participation in
the state-funded portion of the program. Individuals in the following circumstances are
screened for participation in the Connecticut Home Care program:

1. those individuals identified by a nursing facility, who are expected to be admitted into a nursing home directly from their home in the community within 60 days; or

2. those individuals expected to be admitted into a nursing home upon hospital discharge, when they had been admitted to the hospital directly from their home in the community; or

3. those individuals who are currently institutionalized but would be able to remain at home without risk to their or others safety if home care services were provided; or

4. those individuals who contact the Department and want to be considered for participation in the program.

B. Application

1. Prospective applicants residing in nursing homes or inpatients in hospitals may start the initial screening process by completing a home care request form and a financial application form.

2. Prospective applicants living in the community may start the initial screening process by telephoning the Department's Alternate Care Field Office and completing a financial application form.

3. All applicants requesting services under the Connecticut Home Care Program for Elders must comply with the requirements for applying for Medicaid if requested by the Department.

C. Initial Screening of Individuals for Possible Program Participation

Within a reasonable time of receipt of a complete financial application form, a health care professional will determine:

1. whether the applicant meets the functional level for admission to the CHC program;

2. whether the individual is at risk of institutionalization or inappropriately institutionalized;

3. whether the applicant is an appropriate referral for a full assessment;

4. whether immediate nursing home admission is necessary without an assessment of the individual's potential for community placement.

D. Activity Subsequent to Initial Screening

1. Within a reasonable time of completion of the referral by the Department, an access agency worker contacts the applicant and schedules a full assessment.

2. The assessment consists of the following:

a. verifying and documenting the level of need;

b. identifying the services needed to allow the applicant to remain at home;

c. developing an individual plan of care;

d. determining the availability of the needed services;

e. establishing whether the individual can be offered community based services.

3. After the plan of care is developed, the access agency:

a. explores the potential of services available through the individual's family, neighborhood, and community;

b. ensures that the state's cost of services to be provided to the applicant does not exceed the limits set by the program;

c. requires the applicant to sign a consent to services form, if applicable;

d. determines the amount the client must contribute towards the cost of services by using the Department sliding fee scale;

e. requires the applicant to sign a fee agreement form, if applicable.

E. The Redetermination Process

1. A review of the financial eligibility criteria is conducted annually.

2. A review of the plan of care is conducted every 6 months.

F. Beginning Date of Assistance

The beginning date of assistance is the later of the following dates:

1. the date of application; or

2. the earliest date that the plan of care can be implemented after all eligibility requirements are met.

G. Ending Date of Assistance

1. When a recipient is in need of placement in a nursing home, the ending date of assistance is the date the recipient is determined to need permanent placement.

2. When a person dies, the ending date of assistance is the date of death.

3. When a person becomes ineligible for any other reason, the ending date of assistance is the last day of the month in which the recipient ceases to be eligible.

4. When a client requests to be discontinued, the ending date is the date the client requests discontinuance.

H. The Hearing and Appeal Process

1. An individual or authorized representative may appeal any decision made by the access agency by requesting, in writing, that the access agency review its decision. Decisions that may be appealed include but are not limited to the following:

a. decisions that affect the type or quantity of service; or
b. decisions that affect the amount of the financial contribution; or
c. the denial of an assessment.

2. If the applicant is not satisfied with the results of the access agency review, he or she may appeal the decision by requesting, in writing, that he or she be given a Hearing by the Department of Social Services.

3. The individual may challenge any decision made by the Department of Social Services or the access agency by writing to the Department of Social Services Administrative Appeals Unit within 60 days from the date that the Department mails a notice of action.

4. If the individual requests a Hearing within 10 days of the notice of adverse action, the Department will not take the adverse action unless requested by the client.

5. Connecticut Home Care applicants and recipients have a right to appeal any decision made by either the access agency or the Department of Social Services solely through the Administrative Appeal process. The right to a hearing is confirmed by this regulation to afford applicants and recipients an opportunity to review eligibility decisions.

8040.15 Assistance Unit Composition.

The individual applying for Connecticut Home Care for the Elderly is an assistance unit of one.

8040.20 Categorical Eligibility Requirements.

A. Age

The individual must meet one of the following criteria:

1. be 65 years of age or older; or

2. on June 19, 1992, have been receiving services under the Home Care Demonstration Project previously operated by the former Department on Aging; or

3. as of June 30, 1992 have been receiving services from any of the
following programs:

a. the Promotion of Independent Living for the Elderly Program previously operated by the Department on Aging; or

b. the Pre-admission Screening/ Community Based Services program formally operated by the Department of Income Maintenance.

B. Institutionalization

1. The individual must be either inappropriately institutionalized or at risk of institutionalization in order to receive Home Care services. A person is considered to be at risk of institutionalization when he or she:

a. is in danger of hospitalization or nursing facility placement due to his or her medical, functional or cognitive status; or

b. is presently institutionalized but would be able to remain at home if home care services were provided.

2. With the use of home care services, the individual must be able to avoid institutionalization.

C. Cost Effectiveness

The recommended plan of care must be cost effective, as stipulated in the State of Connecticut Regulation for Connecticut Home Care for the Elderly.

8040.25 Technical Eligibility Requirements.

To be eligible for this program the individual must:

A. be a citizen or an eligible non-citizen as defined under Medicaid
(cross ref. 3005.05); and

B. be a resident of this state as defined under Medicaid (cross ref. 3010.05); and

C. not be eligible for home care services under the Medicaid Waiver program.
(cross ref. 2540.92).

8040.30 Procedural Eligibility Requirements.

To be eligible for this program the individual must:

A. disclose a Social Security Number or apply for one; and

B. provide information using a financial application form, health screening form, and/or a home care request form; and

C. make application for the Medicaid program when requested by the Department, cooperate in the eligibility process, and accept Medicaid benefits if eligible; and

D. agree to an assessment; and

E. sign a consent to services form, if applicable; and

F. sign a client fee agreement form, if applicable; and

G. provide verification to corroborate essential factors pertaining to eligibility (cross ref. 1540); and

H. sign a declaration of citizen or non-citizen status (cross ref. 3535) and;

I. cooperate in securing support from a legal liable relative as defined under Medicaid (cross ref. 3515); and

J. complete an annual redetermination form.
 

8040.35 Treatment of Assets.

A. Countable Assets

Assets in the Connecticut Home Care Program for Elders are treated in the same way and to the same extent as in the Medicaid Program except for the Spousal Assessment provision covered under the Medicare Catastrophic Coverage Act (MCCA). There is no need to complete a spousal assessment in the state-funded Connecticut Home Care Program for Elders. All other assets for married individuals are treated the same as they are for MCCA spouses.

B. Asset Limits

1. For an individual, assets may not exceed the minimum Community Spouse Protected Amount (cross ref. 4022.05).

2. For a married individual, the couple's total assets may not exceed
150% of the minimum Community Spouse Protected Amount (cross ref. 4022.05).

C. Exemptions to the Asset Limit

1. Persons who were receiving services as of June 19, 1992 under the Home Care Demonstration Project are asset eligible for the Connecticut Home Care Program for Elders, regardless of the amount of their assets.

2. Persons who were receiving services as of June 30, 1992 under the following programs are asset eligible for the Connecticut Home Care Program for Elders, regardless of the amount of their assets:

a. Preadmission Screening (PAS/CBS); or

b. Promotion of Independent Living Program (PIL).

D. Transfer of Assets

All aspects of the policy used in the Medicaid program concerning transfers of assets apply to the Connecticut Home Care Program for Elders clients except for those individuals identified in C, above. 

8040.40 Treatment of Income.

A. Excluded Income

Income which is excluded in the Medicaid program is also excluded in the Connecticut Home Care Program for Elders.

B. Countable Income

1. For a single individual, gross income of the individual after any exclusions, is compared to the income limit to determine income eligibility.

2. For a married individual, gross income of the individual, after any exclusions, is compared to the income limit to determine income eligibility.

C. Income Limits

The gross income limit for an individual must be less than or equal to
300% of the maximum Supplemental Security Income (SSI) limit for an individual living independently.

D. Exemptions to the Income Limit

1. Persons who were receiving services as of June 19, 1992 under the Home Care Demonstration Project are income eligibile for the Connecticut Home Care Program for Elders, regardless of the amount of their income.

2. Persons who were receiving services as of June 30, 1992 under the following programs are income eligible for the Connecticut Home Care Program for Elders , regardless of the amount of their income:

a. Preadmission Screening (PAS/CBS); or

b. Promotion of Independent Living Program (PIL).

8040.45 Calculation of Income Applied to the Cost of Care.

A. Except for those noted in B below, the following rules are used when calculating income applied toward the cost of care:

1. eligible individuals who receive Connecticut Home Care for Elders services under the state-funded portion of this program, are required to contribute to the cost of those services in accordance with a sliding fee scale established by the Department.

2. an individual's countable income is determined using the rules found under Income Eligibility (cross ref. 8040.40).

3. an individual whose countable income is less than 150% of the Federal Poverty Level does not contribute to the cost of services.

4. an individual whose countable income equals or exceeds 150% of the Federal Poverty Level contributes up to the amount noted on the sliding fee scale.

5. the monthly amount that an individual must pay is the lesser of the cost of the Connecticut Home Care Program for Elders services received by the individual or an amount set forth on a sliding fee schedule established by the Department.

6. the scale is developed by:

a. establishing income ranges which each represent increments of
25% of the Federal Poverty Level, starting with the range which represents 150% to 175%;and

b. establishing an amount that represents the midpoint of that income range by averaging the high point and low point of the range; and

c. determining the amount of the individual's "base payment" by calculating 11% of the midpoint income of individuals with income in the range of at least 150% but less than 175% of the Federal Poverty Level, and increasing the percentage used in the calculation by one percent for each 25 percentage point increase in the Federal Poverty Level.

d. the sliding fee scale will be updated annually when the Federal Poverty Level is increased.

B. Individuals whose income and assets are over the CHC limits must pay their total cost of care, including management costs (cross ref. 8040.40). Once these individuals' assets are below the CHC program limit, these individuals are required to contribute to their cost of care in accordance with A above.

8040.50 Recovery.

The Department recovers assistance using the same rules as those used in the Medicaid program (cross ref. 7500).


Federal Law

Definition of institutionalized spouses which includes those on the
Medicaid waiver:

42 U.S.C. 1396r-5(h) DEFINITIONS.—In this section:

(1) The term “institutionalized spouse” means an individual who—

(A) is in a medical institution or nursing facility or who (at the option of the State) is described in section 1902(a)(10)(A)(ii)(VI), and
(B) is married to a spouse who is not in a medical institution or nursing facility;

but does not include any such individual who is not likely to meet the requirements of subparagraph (A) for at least 30 consecutive days.
(2) The term “community spouse” means the spouse of an institutionalized spouse..

42 U.S.C. sec. 1396a(a)(10)(A)(ii)(VI)
SEC. 1902. [42 U.S.C. 1396a] (a) A State plan for medical assistance must—
(10) provide—

(A) for making medical assistance available, including at least the care and services listed in paragraphs (1) through (5), (17) and (21) of section 1905(a), to—

(ii) at the option of the State, to any group or groups of individuals described in section 1905(a) (or, in the case of individuals described in section 1905(a)(i), to any reasonable categories of such individuals) who are not individuals described in clause (i) of this subparagraph but

(VI) who would be eligible under the State plan under this title if they were in a medical institution, with respect to whom there has been a determination that but for the provision of home or community-based services described in subsection (c), (d), or (e) of section 1915 they would require the level of care provided in a hospital, nursing facility or intermediate care facility for the mentally retarded the cost of which could be reimbursed under the State plan, and who will receive home or community-based services pursuant to a waiver granted by the Secretary under subsection (c), (d), or (e) of section 1915,

Uniform Policy Manual
UPM 2540.92
Individuals Receiving Home and Community Based Services (Program: MAABD-CN)

    A. Coverage Group Description

This group includes individuals who:

    1. would be eligible for MAABD if residing in a long term care facility (LTCF); and

    2. qualify to receive home and community-based services under a waiver approved by the Health Care Financing Administration; and

3. would, without such services, require care in an LTCF.

B. Duration of Eligibility

Individuals qualify for Medicaid as categorically needy for as long as they meet the conditions above and receive home and community-based services under a waiver.

C. Income and Asset Criteria

1. The Department determines income eligibility under this coverage group by comparing the individual's gross income to the Special Categorically Needy Income Limit (CNIL), set at 300% of the maximum SSI amount for one person. To qualify as categorically needy, the individual's gross income must be less than the special CNIL.

2. The Department uses the AABD asset limit to determine eligibility.

UPM 3028.05  Transfers of Assets

            A..    General Statement

                There is a period established, subject to the conditions described in this chapter, during which institutionalized individuals are not eligible for certain Medicaid services when they or their spouses dispose of assets for less than fair market value on or after the look-back date specified in paragraph C.  This period is called the penalty period, or period of ineligibility.

            B.    Individuals Affected

                1.    The policy contained in this chapter pertains to institutionalized individuals and to their spouses.

                2.    An individual is considered institutionalized if he or she is receiving:

                    a.    LTCF services; or

                    b.    services provided by a medical institution which are equivalent to those provided in a long-term care facility; or

                    c.    home and community-based services under a Medicaid waiver (cross reference: 2540.92).

UPM sec. 3028.10

The transfers described in this subject do not render an individual ineligible for Medicaid or subject to a penalty period.

            A.    Transfer of the Home

                    2.    For purposes of this chapter, the word "home" refers to:

                    a.    the real property used as principal residence by an institutionalized individual immediately prior to his or her institutionalization; or

                    b.    the real property used as principal residence by the spouse of the institutionalized individual; or

                    c.    the real property used as principal residence by an individual receiving home and community-based services under a Medicaid waiver.

3028.25    Hardship

            B.    Undue Hardship Conditions

                When an individual would be in danger of losing payment for LTCF or equivalent services described at 3028.05 B solely because of the imposition of a penalty period, the Department does not impose such penalty under the following conditions:

                1.   
                    b.    The medical provider has threatened to terminate home and community-based services being provided under a Medicaid waiver;  [etc]

UPM 3500.01    Definitions

        Community Spouse

        A community spouse is an individual who resides in the community, who does not receive home and community based services under a Medicaid waiver, who is married to an individual who resides in a medical facility or long term care facility or who receives home and community based services (CBS) under a Medicaid waiver.

UPM 4000.01 Treatment of Assets - Definitions

       Community Spouse

        A community spouse is an individual who resides in the community, who does not receive home and community based services under a Medicaid waiver, who is married to an individual who resides in a medical facility or long term care facility or who receives home and community based services (CBS) under a Medicaid waiver.


UPM 4025.65.B.  Circumstances in Which Assets Are Not Deemed

1.    The Department does not deem assets from spouses who are living apart.

                2.    Spouses are considered to be living apart under the following circumstances:

                    a.    one spouse has left the home and does not return; or

                    b.    both are residing in the different rooms in the same boarding home; or

                    c.    both are residing in the same long term care facility; or

                    d.    one spouse is a receiving home and community based services (CBS) under a Medicaid waiver.

UPM 5000.01  Treatment of Income - Definitions

        Community Spouse

            A community spouse is an individual who resides in the community, who does not receive home and community based services under a Medicaid waiver, who is married to an individual who resides in a medical facility or long term care facility or who receives home and community based services (CBS) under a Medicaid waiver.

            Continuous Period of Institutionalization

            A continuous period of institutionalization is a period of 30 or more consecutive days of residence in a medical institution or long term care facility, or receipt of home and community based services (CBS) under a Medicaid Waiver.


UPM 5035.20

C. Deductions For CBS Units

The following monthly deductions are allowed from the income of assistance units receiving Community Based Services:

1. an amount to meet the basic community maintenance needs of the individual to the extent that it is equivalent to:

a. the MNIL for one person for those who are eligible under the model waiver; or

b. 200% of the Federal Poverty Level for those eligible under the PAS or DMR waiver;

2. an amount of income diverted to meet the needs of a family member who is in the community home to the extent of increasing his or her income to the MNIL which corresponds to the size of the family;

3. Medicare and other health insurance premiums, deductibles, and coinsurance costs when not paid for by Medicaid or any other third party;

4. expenses recognized as medical costs for which the recipient is currently liable, and which are not covered by Medicaid

UPM 5035.25

C. Deductions For CBS Units

The following monthly deductions are allowed from the income of assistance units receiving Community Based Services:

1. an amount to meet the basic community maintenance needs of the individual to the extent that it is equivalent to:

a. the MNIL for one person for those who are eligible under the model waiver; or

b. 200% of the Federal Poverty Level for those eligible under the PAS or DMR waiver;

2. a Community Spouse Allowance (CSA), when appropriate; (Cross Reference 5035.30)

3. a Community Family Allowance (CFA), when appropriate; (Cross Reference 5035.35)

4. Medicare and other health insurance premiums, deductibles, and coinsurance costs when not paid for the Medicaid or any other third party;

5. expenses recognized as medical costs for which the recipient is currently liable, and which are not covered by Medicaid. 

UPM sec. 5035.30

    A.    Use of Community Spouse Allowance (CSA)

                1.    The CSA is used as an income deduction in the calculation of the post-eligibility applied income of an institutionalized spouse (IS) only when the IS makes the allowance available to the community spouse (CS) or for the sole benefit of the CS.

                    (Cross Reference 5035.25)
           
                2.    For the purpose of using a CSA, the Department considers a CS to include a spouse receiving home and community based services under a Medicaid waiver.

 
 

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