Roads to Community Living
Purpose: To explain a long-term services and supports (LTSS) program called Roads to Community Living (RCL). RCL is for individuals who have been in a medical institution and may be able to live in the community if the additional services offered under RCL are provided. These services are provided either when the individual is in a medical institution or after they have been discharged.
You will be notified by an HCS or DDA case manager that a client has been discharged from the medical facility to the RCL program.
HCS social workers use the DSHS 14-443 Financial/Social Service Communication via barcode.
DDA case managers use the DSHS 15-345 CSO/DDA Communication.
Change the Medicaid program (Effective 10/2015)
Most of the RCL clients will be receiving an institutional medical under L02. For most cases, you will change the ACES medical coverage group to waiver eligibility under L42 (L41 for an SSI recipient).
RCL service lets you enter a future end date, this tells ACES to "push" the certification period to the end of the month of the RCL demonstration period. If the entered end date is prior to the certification period end date, ACES will not "pull" the certification period back and the AU will eventually close for 281 - no waiver in the month of RCL ending. If the RCL client is an SSI recipient use the L41 in ACES and code R under the institutional screen in ACES mainframe or the institutional tab in ACES 3G. The case manager will not know until the end of the demonstration period if the client will need waiver services or if care needs can be met with Community First Choice (CFC) services.
The case manager/social worker will notify financial if there has been a change in the 365 days by submitting a 14-443 or 15-345 with a new ending date.
What if the client is on the Modified Adjusted Gross Income (MAGI) program in the medical facility?
MAGI clients with the exception of N21 and N25 are eligible for RCL services. DSHS financial workers are unable to issue RCL letters or make any changes on a MAGI case as these cases are maintained by the Health Benefit Exchange/Health Care Authority (HCA).
What if the RCL client initially declines personal care services upon discharge?
The case manager/social worker will notify financial if the client has initially declined services upon discharge based on LTC chapter 29. Financial will add freeform text to the ACES award letter: If you choose to receive ongoing RCL services through your 365 day period, the amounts listed as total responsibility toward the cost of care will be your contribution to your provider. (Up to the cost of the actual services).
Provide continuous eligibility throughout the demonstration period
A change in financial circumstances that would ordinarily cause closure of the Medicaid assistance unit does not affect Medicaid eligibility for RCL clients. This only applies to Medicaid eligibility. The continuous eligibility guarantee does not apply to cash, food, or Medicare Savings programs.
If a change occurs that may cause ineligibility, advise the client and the case manager that the change may affect eligibility when the eligibility review is completed after the demonstration period.
Are there any exceptions to continuous eligibility?
Yes. The only exceptions are:
- Moving out of state
- incarceration for 30 days or more
- It is determined the client was not eligible for Medicaid on the day of discharge. An example of this is an unreported resource, a transfer of asset that occurred within the 5 year look-back, individual determined not to be a citizen or have a valid social security number.
What if there is mail return?
If mail is returned, see if a forwarding address is provided.
- If one is provided, update the address. No further action is necessary
- If one is not provided, attempt to call the client via the phone number or inquiring with the case manager as to the current address.
- If the financial worker is still unable to determine where the client is, terminate the medical for loss of contact/whereabouts unknown. Advance notice is not necessary.
- If the client provides an updated Washington address at any time during the original 365 day period, the assistance unit is reinstated from the month of termination through the end of the original 365 day certification period. A new application is not necessary.
Determine the client's cost of care
Depending on the client’s income amount, clients receiving RCL services may have to participate toward the cost of room and board and personal care in an alternate living facility (ALF) or for personal care costs in their own homes. Rules for determining the amount the client is responsible for are in WACs 182-515-1505 for HCS clients and 182-515-1510 for DDA clients
What happens at the end of the 365 day period?
For non-SSI clients an eligibility review will be sent to the client and/or the client's representative for the annual review. After the 365 day period, a redetermination must be made. The client must meet income and resource eligibility under the HCS or DDA Waiver.
In addition to the financial eligibility, functional criteria for the HCS or DDA Waiver must be met. This must be confirmed by the current case manager.
Coordination with the agency case managing the service is important. If the client is no longer eligible under financial rules for the L22 program or eligible for a non institutional CN Medicaid program, the financial worker will need to notify the case manager to close services on day 366 or as soon as possible once the review is completed. During the redetermination period, keep the Medicaid open even if it goes beyond 365 days unless we know the client is not eligible for any other Medicaid program.
If the client is eligible for a non institutional categorically needy Medicaid program, Medicaid personal care (MPC) can be considered.
EXAMPLE: RCL clients can start receiving services prior to the discharge from the medical institution. An example of this is a person who assists the client, (called a Community Choice Guide), to find housing before they are discharge. Upon discharge, the client may choose not to have personal care services during the 365 days. The social worker/case manager will inform the financial worker that the client is discharged under RCL and is declining ongoing services.
The financial worker will change the program from L01/L02/L95 to L41/L42 if it is a SSI related client and issue an award letter. The financial worker will note in the freeform text of the ACES letter: If you choose to receive ongoing RCL services through your 365 day period, the amounts listed as total responsibility toward the cost of care will be your contribution to your provider. (Up to the cost of the actual services).
NOTE: During the 365 day period after discharge from the Medical institution, Medicaid is continued. A reconsideration is done for Medicaid eligibility beyond the 365 day period.
The agency authorizing services will communicate to the financial worker by the 365th day.
- HCS social workers use the DSHS 14-443 Financial/Social Service Communication via barcode.
- DDA case managers use the DSHS 15-345 CSO/DDA Communication.
This communication should include what services if any will be authorized beyond the 365th day. (either CFC or Waiver services).
For MPC, a client would need to be eligible for a non institutional Medicaid program.
If services are not authorized by HCS or DDA, redetermine Medicaid eligibility using non institutional Medicaid rules.
What happens if a client receiving RCL returns to a Medical institution during the 365 period?
If the RCL client returns to a medical institution for a short stay (under 30 days), treat the case like any other short stay. Keep the case active on the current Medicaid program active in the community and issue the Medical facility an award letter using the short stay screen.
If the RCL client returns to a medical institution and the placement is projected for over 30 days, the case will need to be changed back to the institutional program (L02, L95 track for SSI related, K track for children).
- Make sure the eligibility review is pulled back in ACES to reflect the month that is one year later than the last review was completed.
- If it has been over a year since a review has been completed, do the program change and pull the eligibility review to the last review while a redetermination is being made.
- Send a new eligibility review for completion
- Set a barcode tickler to check the status.
- Keep the Medicaid case open while doing a redetermination of eligibility.
- Once a client is no longer in the RCL program, they must meet the income and resource eligibility for institutional medical.
It is possible that a client will be reenrolled in the RCL program again as part of discharge planning. If a client is placed back into the community under the RCL program, they are reenrolled in RCL for what remains of their 365 days. If the original 365 day end date has been changed, the social worker or case manager will notify the financial worker.
Can clients who have previously completed their 365 day demonstration project reenroll in RCL? If so, how?
Yes, clients who are reinstitutionalized after their 365 day demonstration period is over may be reenrolled in RCL if the need is clearly stated and the new plan of care has been reviewed. The purpose of reenrollment planning is to ensure that a thorough look is taken at why the original plan did not result in long term successful community placement, and to outline how the new plan addresses the identified gaps.
If the client has been subsequently reinstitutionalized for at least 90 consecutive qualified days, he/she may be reenrolled in RCL for another 365 day demonstration period using the following process. All processes outlined above apply for the 2nd enrollment.
How can the financial worker tell if it is an RCL case?
- Indicate in the narrative and behind the INST screen "Roads to Community Living RCL" client
- For DDA clients, indicate on the AREP screen Case manager-RCL program with the case manager's address.
- Create a note in the barcode electronic record. In the ECR select the first tab (under the client ID number). This will take you to a screen where you can add notes to the case. This note will always pop up whenever the worker goes into the ECR to review the case. Indicate: Roads to Community Living (RCL) case.
There is no code for the RCL program in ACES until 10/2015.
For SSI related clients use the same rules and coding as the L22 program.
For SSI clients at home in residential settings, use the same rules and coding as the L21 program.
- If service is authorized by HCS, code as a COPES case in ACES.
- If service is authorized by DDA, code as a DDA Waiver in ACES.