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Applications for LTSS
Purpose: This section describes the application processes used by Aging and Long-term Supports Administration (ALTSA) when determining financial eligibility for Long-Term Services and Supports (LTSS).
How to Apply
PBS will complete a referral using the 07-104 when an application is received on an active MAGI case. Add text stating that unless an assessment is completed and determines HCB Waiver is needed, the client will remain on MAGI. The PBS will send a general correspondence letter to the client indicating the application was received and since the client is currently receiving Medicaid services, additional information is not needed unless the assessment indicates HCB waiver is needed .
NOTE: If an 18-005 is received on an active MAGI case and the client is in a NF or Hospice care center, no action is needed by the PBS. MAGI covers NF and Hospice under the scope of care. Exception is N21/N25 AEM MAGI.
The interview can be conducted in person or by phone. If the client or representative can't be reached, send a letter of request for what is needed based only on what was declared and ask the person to call you and arrange the interview.
The PBS must:
- Go over the application, particularly what was declared in the income and resource sections. Ask about other resources not declared on the application. General open-ended questions about resources and income should also be asked. Family members and other representatives are often just learning about the client's income and resources when they apply. Open-ended questions often reveal that additional sources of income and assets may exist.
- If not already authorized, request authorization for AVS for client and any applicable financially responsible people. Ensure AVS procedures are followed.
- Ask about any transfers, gifts, or property sales during the 5-year look back and the circumstances of why they were made.
- Ask about other medical coverage. If there is other medical coverage and you can obtain the information during the interview, complete a 14-194 medical coverage form and send to the HIU. Otherwise, send the form to the client for them to complete and return.
- Ask if there are unpaid medical expenses and request verification if medical expenses exist. Ask if any of these bills were within the last 3 months.
- Explain the financial and social service functional eligibility process. Explain to the applicant that there is a PBS and a social worker making determinations concurrently for LTSS eligibility.
- For in home service applicants, discuss the food assistance program and inquire if the household would like food benefits.
- Explain the medical service card, automatic Medicare D enrollment if not on a creditable coverage or Medicare D PDP plan.
- Explain the Medicare savings program (MSP). If the applicant is eligible for a MSP based on income and resource guidelines and all information is received to determine eligibility for MSP, do not hold up processing this program while the LTSS medical is still pending.
- Explain what participation and room and board is, how the amount is determined and that it must be paid to the provider.
- Explain what Estate Recovery is and mail the Estate Recovery fact sheet if the applicant has not received one.
- Explain what changes of circumstances need to be reported
- In the case of the community spouse, explain how all resources in excess of the $2,000 resource limit must be transferred to the spouse within 1 year and the requirement to provide verification of this by the first annual review.
- Explain what proof is needed to complete the application and that a follow-up letter will be sent indicating what is needed. Encourage the applicant to begin gathering required documents as soon as possible in order to expedite the application. Explain how to request an extension if more time is needed.
Document the interview in the ACES narrative.
- Statements made by the client or their representative.
- Eligibility decisions made and actions taken on the case; and
- Why the actions were taken.
- An ongoing permanent history of actions and decisions made;
- A support of eligibility, ineligibility and benefit determination;
- Credibility for decisions when used as evidence in legal matters;
- A trail for reviewers to determine the accuracy of the benefits issued.
Follow these principles when documenting:
- Clear - Use readily understood language.
- Concise - Documentation is subject to public review. Stick to the facts relevant to determining eligibility or benefit level.
- Complete - The documentation must support the eligibility decision and allow a reviewer to determine what was done and why.
- Consistent - Explain how conflicts or inconsistencies of information were resolved. Demonstrate the reasonableness of decisions. Ensure what you document accurately describes what happened with the case.