GRH and Health Care MA, GAMC and Waivers

Automatic Eligibility  Receiving GRH payment  MA—must have MA basis  MA with waiver –Eligible for MA payment of LTC services –EW exception: Must do EW calculation  GAMC—no MA basis –May or may not receive GA grant

MA Spenddown  Income over $867 (100% FPG)  Spend down to $650 (75% FPG)  What bills can be used? –Medicare premiums paid by enrollee –Remedial Care –Waiver services  What can’t be used? –GRH room and board costs

Remedial Care  Special deduction for GRH  Fixed amount updated twice yearly  Allowed for anyone in a facility where county has a GRH agreement  Applied against spenddown, or  Deducted from income (EW)

Spenddown Example 1  Client age 34, single, residing in rate 1 GRH facility (cost $776)  Eligible for CADI waiver  Receives RSDI of $1070  Pays Medicare Part B premium of $96 Eligible for GRH? No. $ $20 general deduction and $96 ($84 + $12) PN > $776 ($84 + $12) PN > $776 What is his spenddown?

Example 1 Calculation  Income exceeds $867  $1070 – 650 = $420 spenddown Can he meet his spenddown?  H bill (Medicare) $96  P bill (remedial care) $210  $ = $113 spenddown balance (MMIS recipient amount)  Met with R bill (CADI services)

Spenddown Example 2  Client age 50, single, residing in a board and lodge with $1183 GRH rate  Receives RSDI of $1571  Not yet Medicare eligible  Gets TCM services costing $286  Not eligible for GRH grant  What is his spenddown?

Example 2 Calculation  Income exceeds $867  $ $650 = $921 spenddown  Can he meet his spenddown?  P bill (remedial care) $210  $921 - $210 = $711 spenddown balance (MMIS recipient amount)  R bill (TCM) $286  $ = $425 remaining balance  Not enough bills at this time—can’t meet spenddown

EW Eligibility EW Eligibility  Income under the SIS? Compute waiver obligation  I ncome over the SIS? No community spouse: Spenddown Community spouse: LTC budget

Example 3: SIS-EW  Single client resides in GRH with assisted living  Receives RSDI and pension of $1816  Pays Medicare Part B of $96  Has $15 Part D copays (initial month)  Not eligible for GRH grant Does she have a waiver obligation?

Example 3 Calculation  Income is less than SIS of $1911  Income deductions: –Medicare premium $96 –Maintenance needs allowance $860 –Remedial care $210 –Copays $15 (initial month only)  $1816 – 1181 = $635 waiver obligation

Example 4: SIS-EW and GRH  Single client resides in adult foster care  GRH rate 1 ($776)  Receives RSDI of $850  QMB pays Medicare Is there a waiver obligation?

Example 4 Calculation GRH $850 RSDI - 20 general personal needs $776 GRH rate GRH grant 42 GRH grantSIS-EW $850 RSDI -860 maintenance needs 0 waiver obligation 0 waiver obligation

Example 5: Income Above SIS  Single client resides in assisted living  Receives RSDI and VA of $2075  Pays Medicare Part B of $96 Waiver obligation? Spenddown?

Example 5 Calculation  Income exceeds SIS of $1911  $ =$1425 spenddown  H bill $96 (Medicare)  P bill $210 (remedial care)  Spenddown balance $1119  Must meet with waiver services and other bills

Example 6: SIS-EW with Community Spouse  Wife resides in GRH with assisted living  Receives RSDI and pension of $1816  Pays Medicare Part B of $96  Husband resides in their home  Calculated spousal allocation $800 Does she have a waiver obligation?

Example 6 Calculation  Income less than SIS  Income deductions: –Medicare premium $96 –Maintenance needs allowance $860 $1816 – 956 = $860 available to allocate -Calculated allocation $800 -Remedial care $210 No waiver obligation

Example 7: Income Over SIS with Community Spouse  Husband resides in assisted living  Receives RSDI and VA of $2075  Pays Medicare Part B of $96  Wife resides in independent apartment  Calculated spousal allocation $800 What is the spenddown amount?

Example 7 Calculation  Use LTC calculation  Income deductions -$96 Medicare premium -$84 personal needs -$800 spousal allocation -$210 remedial care  $2075 – 1190 = $885 spenddown

Example 8: Both Spouses on EW and in GRH  Couple resides in apartment and both receive assisted living services through EW  Husband receives $2000 RSDI and pension  Wife receives $1200 RSDI  Both pay Medicare Part B of $96 Spenddown? Waiver obligation?

Example 8 Calculation Husband Income exceeds SIS $ spenddown 1350 spenddown H bill $96 (Medicare) P bill $210 (remedial) $1044 spenddown bal. Wife Income under SIS $ Medicare Maint. Needs remedial care $ 34 waiver obligation $ 34 waiver obligation