Medicaid Policy
Medicaid Policy
Individuals referred for the waiver who are not already on Medicaid or who have not already applied must file an application for Medicaid
To be eligible for the NCW, individuals must meet all the following criteria:
Be age 65 or older, or 18 through 64 and disabled as determined by SSA or the Medicaid Disability Review Office; and
For the NCW waiver, individuals are 18 the month after their 18th birthday
2. Meet eligibility criteria for a Medicaid coverage group; and
Individuals may qualify under a community Medicaid group for aged or disabled persons, under a Special Income group, or under the Spenddown Waiver group (386-3).
3. Meets the level of care criteria as determined by the Office of Long Term Care Services and Supports (OLTSS) (380-1).
Other Waiver Specific Rules for the NCW
Resources and Spousal Impoverishment (Assessment of Assets)
Married individuals applying for the New Choices Waiver, except those who will be on the MWI coverage group, need to have an assessment of assets completed, unless the individual's spouse does not meet the criteria of being a community spouse. Follow the rules in 573 for the assessment. Apply the spousal resource assessment to determine resource eligibility.
For individuals who were not in a nursing home prior to entering the NCW, set the assessment date as follows.
For individuals entering the waiver from a hospital, use the date of entry to the hospital as the assessment date. Ask the individual if he wants Medicaid coverage to pay for the hospital stay.
Individuals entering the waiver from an assisted living facility, use the level of care date on the original 927 as the assessment date.
Single individuals must meet the aged, blind or disabled one-person asset test.
For any individual in the MWI group, see 386-3 MWI coverage group policy. Individuals eligible under the New Choices Waiver MWI category will not need an assessment of assets.
What does the individual pay?
Members who qualify in the SSI, SSI Protected and 100% FPL groups will not have a contribution to the cost of care.
MWI members will have to pay an MWI premium.
Members who qualify in the Special Income group receive certain deductions from their total income to determine their cost-of-care. See section 409-16 for post-eligibility deductions.
Members with income over the special income limit (spenddown group) will receive the regular aged, blind or disabled deductions to determine their spenddown.
The PMV rule applies to NCW waiver members if someone else pays some or all of the member's shelter costs.
Apply the PMV rules in section 403-11 when:
The member lives in a private residence and someone other than the member or member's spouse pays the shelter costs.
The member lives in a residential institution (like an assisted living facility) and someone else pays some or all of the member's shelter costs.
The member lives in a residential institution and pays less for room and board than what the facility has otherwise stated is the room and board charge. In this case the facility is providing in-kind income in the form of shelter.
Do not apply the PMV rule when:
The member lives in a residential institution with the spouse and the spouse pays some or all of the room and board costs.
The member lives in a residential institution and the facility agrees to accept less than what the facility would otherwise charge as payment in full, or the facility and member agree that the member will incur a legal indebtedness to the facility for the difference between the actual cost and what the member can pay. Such agreements must be written.
If the member lives in a not-for-profit residential institution, the value of shelter provided in-kind to the member may be excluded. It is excluded if the institution has tax-exempt status, is not paid the full value of the shelter costs, and does not have an express obligation to provide shelter costs to the member. The shelter may also be excluded if the institution is one of the agencies listed in 403-11.
Transfer of Assets rules (575) apply only to the Special Income group, do not apply transfer of asset policies to any of the Community Medicaid Coverage groups or to the Spenddown Waiver group.
If a penalty period for a transfer of assets was in place while the individual was in a nursing home, the penalty period would not apply after the individual leaves the institution.
A penalty period that began while someone was in an institution continues to run. If the individual returns to an institution while the penalty period is still in effect, Medicaid will not cover the institutional costs.
If a member eligible under the Special Income group transfers assets for less than fair market value resulting in a penalty period, that penalty period will carry over to eligibility under the New Choices Waiver until the end of the applicable penalty period. The member would not be eligible for waiver services until the penalty period ends, but can qualify for regular Medicaid services.