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 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 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 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 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 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. 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 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. 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 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 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 theUPM 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 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. 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 UPM 3500.01
Definitions Community Spouse UPM 4000.01 Treatment of Assets - Definitions Community Spouse
1. The Department does not deem assets from
spouses who are living apart. Community Spouse
C. Deductions For CBS Units UPM 5035.25 C. Deductions For CBS Units UPM sec. 5035.30
A. Use of
Community Spouse Allowance (CSA) Back to
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