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Supports for Community Living (SCL). Vendor Payment Procedures for Individuals Admitted to SCL Care. What is SCL?.

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supports for community living scl

Supports for Community Living (SCL)

Vendor Payment Procedures for Individuals Admitted to SCL Care

what is scl
What is SCL?
  • Supports for Community Living (SCL) provides home and community based services for mentally retarded MA recipients who would otherwise require institutional care in an ICF/MR/DD facility.
  • Intermediate care services for the mentally retarded and developmentally disabled are provided by community mental health centers certified by Medicaid.
  • SCL is available statewide.
  • Types of SCL Services are listed in Vol. IVA, MS 2810
who is eligible for scl services
Who is eligible for SCL Services?
  • The applicant must meet MA criteria for ICF/MR/DD level of care.
  • The level of care is determined by the Peer Review Organization (PRO) using medical, psychological, and social data.
  • The PRO will conduct patient status determinations by matching the individual's care needs with the level of care which meets those needs.
what happens next
What Happens Next?
  • The Department for Mental Health/Mental Retardation (MH/MR) produces a letter of approval and form MAP-24 (Admission/ Discharge Notice), and sends a copy to the Support Coordination Agency, the client and the local office.
  • This letter shows the level of care met.
  • The Support Coordination Agency sends form MAP-24 to the local office showing provider name, provider number and date of admission.
technical eligibility for scl
Technical Eligibility for SCL
  • The applicant must meet all technical eligibility requirements for MA eligibility including age, blindness, disability, enumeration, third party liability, etc.
  • However, an individual who is not aged, blind or disabled may be eligible for SCL if MA eligible in another category and Kentucky Medicaid Program criteria is met.
resource eligibility for scl
Resource Eligibility for SCL
  • All “Regular” AMA resource rules apply
  • Excluded Resources are in Vol. IVA, MS 1880
  • Transfer of Resources rules apply
  • Estate Recovery rules apply
  • Property Records and Liquid Asset Checks must be completed for SCL
  • The resource limits for SCL are:
    • Single: $2000
    • Couple: $4000
income eligibility for scl
Income Eligibility for SCL

Obtain a PA-1A form, and review these steps on pages 4 and 5 for Step I- MA Eligibility:

  • Compare gross income to the Special Income Standard if the applicant has been in LTC for 30 full consecutive days or died prior to the 30th day.
  • The 30 days may be spent in different facilities or different levels of care, including Hospice, HCBS or NF services.
  • Do not use the special income standard if the applicant has not been in LTC for 30 full consecutive days. For these individuals, complete Step II.
  • If gross income is equal to or less than the Special Income Standard the individual is MA eligible.
  • If there is an excess in Step I, complete Step II for SCL.
step ii processing
Step II Processing

If there is an excess in Step I, or in SCL less than 30 days, complete Step II to determine MA eligibility:

  • Consider gross income and/or net profit, less $20 general exclusion and work related expenses, if appropriate.
  • Deduct the MA Scale for 1.
  • Deduct any verified, incurred medical expenses of the SCL individual (SMI, health ins. premiums, payments on a medical bill not covered by MA, etc.)
  • Deduct the SCL standard.
  • If there is no excess, the individual is MA eligible. Complete Step III to determine patient liability.
  • If an excess remains, the individual is ineligible for a vendor payment. Explore a spend down.
step iii patient liability
Step III- Patient Liability
  • Determine gross income and/or net profit
  • Deduct the personal needs allowance ($623 eff. 1/06) or increased PNA, if appropriate.
  • Deduct verified, incurred medical expenses of the SCL individual (SMI, health ins., etc.)
  • Add any third party payment paid directly to the SCL provider, if appropriate.
  • The result is the individual's patient liability or payment toward cost of care.
income considerations for couples
Income Considerations for Couples
  • Income considerations for LTC couples vary depending upon whether only one or both members receive SCL or Waiver services.
  • Procedures for and SCL recipient with a non-SCL spouse are in Vol. IVA MS 3550.
  • Procedures for SCL Couples (both receiving care) are in Vol. IVA, MS 3540.
  • The next few slides list the steps used for determining MA eligibility and Patient Liability for each of these situations.
scl couples both in ltc
SCL Couples- Both in LTC

Step I- MA Eligibility:

  • Calculate each member’s eligibility in this step separately.
  • If each member’s income is equal to or less than the Special Income Standard, both are eligible. Go to Step III – Patient Liability
  • If one or both members of the couple are over the standard:
    • For SCL, ABI or ICF/MR/DD, complete Step II
    • For all others, refer to MS 3505 for QIT procedures.
scl couples both in ltc1
SCL Couples- Both in LTC

Step II- MA Eligibility for SCL, ABI or ICF/MR/DD

  • If only one member of the couple had an excess in Step I, use only that member’s income and expenses for Step II, and use the MA Scale for 1.
  • If both members had an excess in Step I, use income and expenses of both members, and use the MA Scale for 2. (If both are in SCL, ABI or ICF/MR/DD)
  • If one or both members still have an excess, they are not eligible for LTC payment. Explore Spend Down.
  • If the individual/couple now has no excess, they are MA eligible. Go to Step III to determine patient liability.
scl couples both in ltc2
SCL Couples- Both in LTC

Step III calculations vary depending on living situation.

Both members in the same facility (or both at home):

  • Total income of the couple and allow half (½) to each.
  • Total the allowed expenses, and allow half (½) to each.
  • Complete Step III separately for each member of the couple, using half the income and half the expenses.

Each in a different facility (not living together):

  • Consider only the income/expenses of the individual.
  • Complete Step III separately for each individual, using their own income and expenses only.
scl individual with non ltc spouse
SCL Individual with Non-LTC Spouse

Step I- MA Eligibility

  • Only SCL individual’s income is considered.
  • If gross income is less than or equal to the Special Income Standard, the individual is MA eligible. Complete Step III for Patient Liability.
  • If there is an excess in Step I, complete Step II for the SCL individual.
scl individual with non ltc spouse1
SCL Individual with Non-LTC Spouse

Step II- MA Eligibility

  • Use only the SCL individual’s income and expenses for Step II, and the MA Scale for 1.
  • If the individual still has an excess after this step, they are not eligible for a vendor payment. Explore a Spend Down.
  • If the individual now has no excess, they are MA eligible. Go to Step III for patient liability.
scl individual with non ltc spouse2
SCL Individual with Non-LTC Spouse

Step III- Patient Liability: Use only the income and expenses of the SCL individual in this step.

  • Calculate the community spouse income allowance, and allow this as a “deduction” in Step III. None of the spouse’s income is counted towards the LTC case.
  • If there are dependents, calculate the Family Income Allowance. Once again, this is a “deduction”. None of the income of a dependent is counted towards the LTC case. See below.
community spouse income allowance
Community Spouse Income Allowance

For Non-SSI individuals, KAMES will complete these steps:

  • Total the Community Spouse’s monthly shelter expenses.
  • Subtract the Comm. Spouse Shelter Allowance ($482 eff. 7/05)
  • The remainder is the excess shelter expense for the Spouse.
  • Add excess shelter expense to the MinimumComm. Spouse Income Allowance ($1,604 eff. 7/05) called the “Family Income Allowance” on KAMES
  • The result is the Community Spouse Income Allowance, not to exceed the Maximum ($2,489 eff. 1/06) Subtract the community spouse’s income from the allowance to determine the amount which may be deemed from the SCL individual to the spouse.
  • Use form PA-1A, Supplements B and C to deem income to the community spouse. See MS 3550 for more details.
example
Example

$745- Monthly shelter expenses

-$482- Shelter minimum eff. 7/05

$263- Excess shelter expenses

+$1604- Minimum Comm. Spouse Allowance

$1867- Comm. Sp. Income Allowance

-$1000- Comm. Spouse’s gross income

$867- Amount of SCL member’s income that will be deemed to the Community Spouse

family income allowance
Family Income Allowance

This “deduction” is allowed if there is a minor child, dependent child, dependent parent, or dependent siblings of either the SCL individual or their Community Spouse, who resides with the community spouse.

Calculate the Family Income Allowance as follows:

  • Subtract the dependent’s gross income from the Family Income Allowance Standard ($1,604 eff. 7/05).
  • Allow ⅓ of the remainder (rounded) as the “deduction”
  • Compute a family income allowance for each dependent member separately.
example1
Example

$1604- Family Income Allowance eff. 7/05

- $825- Dependent’s gross income

$779 ÷ 3= 259.6666…

  • Round this amount to $260, and this is the Family Income Allowance for this dependent.
  • If there are more dependents, complete these calculations separately for each.
scl individual with non scl spouse
SCL Individual with Non-SCL Spouse

Step III- Patient Liability Calculations:

  • Determine gross income/net profit of the SCL recipient. Do not count any of the Spouse’s income.
  • Deduct PNA ($623 eff. 1/06) or increased PNA
  • Deduct the Comm. Spouse Income Allowance
  • Deduct the Family Income Allowance, if appropriate
  • Deduct verified, incurred medical expenses
  • Add any third party payment paid directly to the SCL provider, if appropriate.
  • The result is the individual's patient liability or payment toward cost of care.
children receiving scl
Children Receiving SCL
  • Income and resources of the child’s parent/s are considered in the month of admission.
  • Beginning the month after the month of admission, consider only the child’s income and resources.
  • Because of these rules, many children in LTC are ineligible for month of admission, but are eligible beginning the month after separation.
  • Form PA-1A Supp. D is used for Ineligible Child Allocations and Parental Surplus calculations.
children receiving scl1
Children Receiving SCL

Step I- MA Eligibility:

  • Total gross income of the SCL child, and add the gross income of the parents.
  • If this gross income is equal to or less than the special income standard and the child has been in SCL for 30 full consecutive days, the child is MA eligible. Complete Step III to determine patient liability.
children receiving scl2
Children Receiving SCL

Step II- MA Eligibility:

If there is an excess in Step I or the child in SCL less than 30 days, complete Step II to determine MA eligibility.

  • Use form PA-1A, Supp. D to complete this step, since Step II on PA-1A, pg 4 doesn’t include all needed calculations for children in LTC.
  • Prior to determining MA eligibility in Item II of the Supp. D, you will need to calculate the Ineligible Child Allocation and the Parental Surplus.
  • Obtain PA-1A Supp. D to follow the next few slides.
ineligible child allocation
Ineligible Child Allocation

If the SCL child’s parents have other children in the home that are not eligible for LTC, complete these calculations on PA-1A Supp. D, Page 2:

  • Enter the Ineligible Sibling Allocation ($302 eff. 1/06)
  • Subtract the gross income of the Ineligible child
  • The remainder is a “deduction” allowed from the parent’s income.
  • Enter this amount on Page 1, line 10 of the Supp. D
calculating the parental surplus
Calculating the Parental Surplus

On Page 1 of the PA-1A Supp. D- Item I:

  • Total the Parents’ unearned income, and subtract $20 general exclusion. The result is their countable unearned income.
  • Calculate gross earned income, subtract any remainder of $20 exclusion, and other work-related deductions in Vol. IVA, M.S. 2480, if appropriate The result is the countable earned income.
  • Combine countable earned and unearned income, and subtract the Parental Allocation amount (amounts change yearly in January- See Vol. IVA, M.S. 1760).
  • Subtract the Ineligible Child Allocation, calculated earlier.
  • The result is the Parental Income “deemed” (considered) toward the child’s LTC case.
step ii ma eligibility for scl child
Step II- MA Eligibility for SCL Child

Follow these steps listed on PA-1A, Supp. D, Page 1, Item II:

  • Total unearned income for the child, and subtract the $20 general exclusion. The result is the child’s countable unearned income.
  • Total earned income for the child, subtract any remainder of the $20 exclusion, and work-related deductions in Vol. IVA, M.S. 2480.
  • Combine countable earned and unearned income of the child.
  • Add the parental surplus income from Item I. The result is the countable income for the SCL child.
  • Allow verified, incurred medical exp. of parents, siblings, and child
  • Subtract the MA Scale for 1 ($217).
  • Subtract the SCL Standard. If no excess, child is MA Eligible.
  • If any excess income remains, the child is MA ineligible, explore a spend down for any medical expenses.
children receiving scl3
Children Receiving SCL

Step III - Patient Liability

  • Combine gross income/net profit of the SCL child and excess income of the parent/s. (Income minus MA Scale for the appropriate family size, excluding SCL child)
  • Deduct PNA ($623 eff. 1/06) or increased PNA.
  • Deduct verified incurred medical expenses of SCL child.
  • If income of the parent is considered, deduct verified, incurred medical expenses of the parent.
  • Add any third party payments directly to the SCL provider.
  • Result is Patient Liability or payment toward cost of care.
medicaid recipients admitted to scl
Medicaid Recipients Admitted to SCL

If the SCL individual is already receiving MA through SSI, SSP or Pass through:

  • Authorize vendor payment upon receipt of MH/MR letter of approval and form MAP-24.
  • LTC information is entered on KAMES or PA-62
  • Program code and case status code are not changed.
  • Send MA-105 to recipient and SCL provider if the case is on the PA-62 system. Otherwise KAMES will send notices as required.
ma recipients admitted to scl continued
MA Recipients Admitted to SCL-Continued…
  • Exception: SSP for Caretaker Services can only continue if the Caretaker provides services not included in SCL care.
  • If these individuals are subsequently discharged from SCL, MA eligibility should continue in the original category, if all criteria of that program are still met.
medicaid effective dates
Medicaid Effective Dates
  • The MA effective date is the first day of the month the individual met Kentucky Medicaid Program criteria for SCL as indicated on the DMS letter of approval.

Example: PRO certified that the individual met SCL level of care on May 12th. MA Eligibility should begin May 1st.

conclusion
Conclusion
  • SCL services are provided to prevent institutionalization for an individual who would otherwise be admitted to ICF/MR/DD.
  • The local office will receive an MH/MR letter of approval and form MAP-24 for SCL recipients.
  • AMA Technical and Resource eligibility rules apply.
  • MA Eligibility and Patient Liability calculations are similar to other LTC, and are completed using the PA-1A, Pages 4 and 5.
  • MA Recipients admitted to SCL are eligible for a vendor payment upon receipt of MAP-24 and letter of approval.
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