Eligibility Online Manual
M1002A Community Choices Home & Community Based Waiver
Purpose: This section will assist in determining whether individuals are eligible for the Community Choices Home & Community Based Waiver while residing in the community or in an Assisted Living Facility.
Current Policy Effective Date: January 1, 2022
Date Last Reviewed:
Previous Policy: January 1, 2021
POL 1002A: DETERMINING ELIGIBILITY FOR COMMUNITY CHOICES HOME & COMMUNITY BASED WAIVER
1. Applicants Must Meet Basic Eligibility Factors
Refer to Section M600 for a description of all basic eligibility factors.
2. Applicants Must Meet Medical Necessity Requirement
Applicants must meet medical necessity. Medical necessity is verified through an LT 101 and stored on the Medicaid Waiver system. Upload the Medicaid Activation Waiver Screen showing the applicant has received a funding opportunity and a Plan of Care has been approved. This verifies the applicant has met the medical necessity requirement.
3. Applicants Must Be Aged, Blind Or Disabled
Applicants must meet one of the following factors:
Age – 65 or older.
Blind – legally blind based on Social Security standards.
Disabled – person who receives disability benefits from SSA, or is determined disabled by WDH.
4. Applicants Must Be Age 19 Or Older
5. SSI Eligibles Do Not Need To Submit Application
If the client becomes ineligible for SSI, an application will be required to determine continued eligibility.
6. Applicants Must Meet Income Requirements
Require the countable income to be within the maximum income standard. Refer to Medicaid Table 1A for the income standards. Refer to Section M901 to determine if income is countable. Provide an Income Trust Packet when the countable income is above the maximum income standard.
7. Applicants Must Meet Resource Requirements
Require the countable resources to be within the maximum resource standards. Refer to Medicaid Table 7 for the resource standards. Refer to Section M801 to determine if resources are countable.
8. Services Withheld For Resource Transfers
Resources cannot be transferred for less than fair market value during the look-back period prior to application or when clients are receiving benefits.
Refer to Section M803 for information on transferred resources and Section M804 for information on transfer penalties.
9. Clients Must Have Approved Plan Of Care
10. Benefits Begin First Day of Month Plan Of Care Is Approved
Benefits begin the first day of the month the plan of care is approved by WDH.
11. Clients May Enter Nursing Homes
Clients entering a nursing home and remaining for 30 days must have their coverage changed to Nursing Home Care. Refer to Section M1001A for additional eligibility information.
12. Clients Must Be Reviewed
Clients must be periodically reviewed every 12 months to determine continued eligibility. Refer to Section M1403 for information on reviewing eligibility.
A review is not required for SSI clients.
Clients must be reviewed for other Medicaid program eligibility before closing cases.
13. Clients May Lose Benefits
The case will close when any of the following occur:
Client is discharged from the the Community Choices Home & Community Based Waiver.
Client does not complete a review.
Client dies.
Client determined no longer eligible.
Reference:
Defining Age, Blind, Disabled: 42 CFR 435 Subpart F
Income: 42 CFR 435 Subpart K
Resources: 42 CFR 435 Subpart L
Defining Group: 42 CFR 435.217
Social Security Act §1902(a)(10)(A)(ii)
Clarifying Information:
1. Clients Pay No Patient Contribution.
Clients do not pay a patient contribution. There will be a patient contribution after 30 days if a client transfers to a nursing home.
Worker Responsibilities:
Accessing Waiver System To Determine Eligibility
1. Access the Medicaid Waiver System to determine status of the waiver process and verify the medical necessity requirement has been met.
1A. Log into Waiver System by Clicking on the "Medicaid Waiver System" tab in ECOM or access at https://waivers.health.wyo.gov.
1B. Enter your user name and password. Click on the "Log In" button.
1C. Review the Confidentially Agreement, Check the box indicating that you agree, and Click on the "Continue" button to proceed. This agreement must be completed the first time you log into the system and is required again every 45 days.
2. Complete assigned tasks for applicants who are in the Medicaid Waiver System and meet the eligibility requirements.
2A. Click on the "View" icon next to the Last Name. The system will take you to the next screen and prompt you on what action needs to be completed.
2B. View, under Eligibility, a check mark by Review LT-101 verifies the Medical Necessity requirement has been met.
2C. The system will show Eligibility under Process, complete the determination:
2Ci) Click on Disability requirement has been met when the applicant or client is under 65, and has been determined disabled by SSA or WDH. (This field will only display when the applicant or client is under the age of 65.)
2Cii) Enter the Client ID # from WES.
2Ciii) Click on Has met the income and resource eligibility requirements.
2Civ) Click on "Save" and "Complete." This will complete the task and remove the case from your task list.
2D. The system will communicate the eligibility determination and place the individual on a waiting list.
2E. Pend the case in WES until a Plan Of Care is approved and a start date is provided through the Medicaid Waiver System.
2F. Send a Pending Notice in WES when the individual meets all eligibility requirements.
3. Complete assigned tasks for applicants who are in the Medicaid Waiver System and do not meet the eligibility requirements.
3A. Click on the "View" icon next to the Last Name. The system will take you to the next screen and prompt you to complete the required actions.
3B. The system will show Eligibility under Process, complete the determination:
3Bi) Click on Disability requirement has not been met when the applicant or client is under age 65, and has not been determined disabled by SSA or WDH. (This field will only display when the applicant or client is under the age of 65.) OR
3Bii) Click on Disability requirement has been met when the applicant or client is under age 65, and has been determined disabled by SSA or WDH. (This field will only display when the applicant or client is under the age of 65.) AND
3BiiA) Click on Has been denied financial eligibility.
3Biii) Click on "Save" and "Complete." This will complete the task and remove the case from your task list.
3C. The system will communicate the eligibility determination and notify the waiver program of the denial.
4. Complete a search for an existing waiver client who is being closed or an applicant who is on the waiting list who is being denied.
4A. Click on the "Search Cases" tab.
4B. Fill in any combination of information to find a client.
4C. Click on the "Search" button.
4D. Click on the "View" icon next to the client's name.
4E. Click on the drop down menu to select a reason for accessing this case and Click "Save."
4F. Enter closure or denial reason, the date the client was notified and the effective date of the closure or denial.
4G. Click "Close."
5. Receive notification from the Medicaid Waiver System when an applicant has a funding opportunity.
5A. Redetermine financial eligibility if 60 days has passed since initial application.
5B. Access the Medicaid Waiver System.
5C. View the Process, Funding Opportunity and Status, Confirm Financial, found under your assigned tasks.
5Ci) Click on Disability Requirement has been met. (This field will only display if the applicant or client is under the age of 65.)
5Cii) Click on Has met the income and resource eligibility requirements or
5Ciii) Click on Has been denied financial eligibility.
5Civ) Click on "Save" and "Complete." This will complete the task and remove the case from your task list.
5D. Notification will be sent from the Medicaid Waiver System with the approved Plan Of Care start date.
Determining Continued Eligibility If Client Loses SSI
1. Require a DHCF-300 Disability Application from the client to determine continued eligibility.
Determining Eligibility For Applicant That Does Not Meet Waiver Eligibility
1. Screen the applicant to see if the individual meets eligibility under another Medicaid group.
2. Deny the application when not eligible.
Applications Received For Applicants Not In The Medicaid Waiver System
1. Email the Waiver Program Manager to determine if an application has been received.
2. Screen the Medicaid application for eligibility under another group when an application has not been received by the Waiver Program Manager.
Closing Cases
1. Finalize eligibility and close benefits in WES when the applicant is no longer eligible
2. Allow 15-day closure notice when an adverse action has occurred.
3. Access the Medicaid Waiver System to communicate the eligibility determination.