1. Sequential Evaluation
The Highs and Lows
BPRO Conference
May 2019

2. Review of eligibility requirements Hierarchy of covered groups
We will cover…
The eligibility path
Review of eligibility requirements
Hierarchy of covered groups 2

3. Eligibility Determination Process
The eligibility determination process consists of an evaluation of the individual’s situation by comparing each of his or her circumstances to an established standard or definition.
The applicant must be informed of all known factors that affect eligibility.
M A 3

4. The Eligibility Path Long Term Care
Eligibility determinations follow a prescribed sequence.
The applicant must meet:
All non-financial eligibility requirements
A covered group
The resource limit for the covered group, if any
The income limit for the covered group
Certain other resource requirements, if seeking long-term care.
M A
Long Term Care 4

5. Non-Financial Review Long Term Care
The general non-financial requirements:
Legal presence in the United States
Citizenship and alien status
Virginia residency
Social security number provisions met
Assignment of rights
Application for other benefits
Institutional status requirements met M 5

6. Financial Review Long Term Care
Resource evaluation, if the covered group has a resource test.
Income evaluation
Unearned income
Earned income
Individuals seeking Medicaid payment of long-term services and supports (LTSS) are subject to additional financial requirements.
Asset transfer
Home equity M 6

7. Resource Test Long Term Care
Covered groups/individuals with no resource test
Groups subject to Modified Adjusted Gross Income (MAGI) methodology
Non-MAGI Families & Children (F&C) groups, other than Medically Needy (MN)
Individuals under age 18 F&C 300% SSI covered group
Covered groups/individuals with a resource test:
Aged, Blind or Disabled (ABD)
ABD and F&C MN covered groups
Individuals age 18 and over in the Families & Children (F&C) 300% SSI covered group M 7

8. Covered Group
Although the business rules are programmed into VaCMS, the eligibility worker (EW) is the ultimate line of defense for whether or not an individual’s covered group and AC were determined correctly. 8

9. Covered Groups Long Term Care Divided into two classifications:
Categorically Needy (CN)
Some federally mandated and some optional
Medically Needy (MN)
Fall under one of two main policy umbrellas
Families & Children (F&C)
Aged, Blind, or Disabled (ABD)
Each group is defined by a specific set of criteria
age, disability status, parental status, Medicare entitlement, etc. M
Long Term Care 9

10. Hierarchy of Covered Groups
Long Term Care
An applicant must be evaluated for eligibility in all potential covered groups and enrolled in the group that is the most beneficial to the applicant.
Groups without a separate Medicaid financial evaluation
Groups with a financial evaluation offering full coverage
Groups offering limited coverage
The goal of sequential processing is to provide “the strongest and longest” coverage for which an individual qualifies.
M A
M B 10

11. List of Covered Groups M0310.002
Long Term Care
Group and Description
Mandatory = required under federal regulations
Optional = State Plan Option
Categorically Needy (CN)
Medically Needy(MN)
Aged, Blind, or Disabled (ABD)
SSI – mandatory X
AG – mandatory
Protected – mandatory
≤ 80% FPL – optional
≤ 300% of SSI – optional
(institutionalized only)
Medicaid Works – optional
Medicare Savings Programs (QMB, SLMB, QI, QDWI)
--all mandatory
Aged
Blind
Disabled
--all optional
Families & Children (F&C) `
IV-E Foster Care or Adoption Assistance - mandatory
LIFC Parent/Caretaker Relatives - mandatory
Pregnant woman/newborn child – mandatory
mandatory
optional
Child under age 19 – mandatory
BCCPTA – optional
Plan First – optional
Child under 18 – optional
Individuals under age 21, Special Medical Needs Adoption Assistance
Former Virginia Foster Care Children under age 26 – mandatory
(effective January 1, 2014)
MAGI Adults – optional
(effective January 1, 2019) 11

12. Children 12

13. Who Is A Child? Long Term Care
For the purposes of meeting his own covered group, a child might mean
Under age 18
Under age 19
Foster Care, Adoption Assistance and institutionalized individuals under 21
Note that the term “living with a dependent child” under 18 is used when evaluating an adult for the Low-income Families with Children (LIFC) covered group. 13

14. F&C – Child Long Term Care
Does the child meet the definition of a foster care child, adoption assistance child, special medical needs adoption assistance child or an individual under age 21? If so, evaluate in the appropriate covered group for these individuals.
No resource test
Title IV-E children have no separate income test
Does the child meets the definition of a newborn child? If so, evaluate in the pregnant women/newborn child covered group. 14

15. F&C - Child Long Term Care
If the child is under age 18 or is an individual under age 21 who meets the adoption assistance or foster care definition or is under age 21 in an intermediate care facility (ICF) or facility for individuals with intellectual disabilities (ICF-ID), AND is in a medical institution or has been screened and approved for Home and Community Based Services (HCBS) or has elected hospice, evaluate in the appropriate F&C 300% of SSI covered group.
Long Term Care 15

16. F&C - Child Long Term Care
If a child is under the age of 19, evaluate for Medicaid in this group.
If a child is a former foster care child under age 26 years, evaluate for coverage in this group
If a child has income in excess of the Medicaid limit for children under 19, evaluate for the Family Access to Medical Insurance Security Plan (FAMIS) eligibility (chapter M21). 16

17. F&C - Child Long Term Care
If the child’s parent opted for a Plan First evaluation, evaluate for Plan First. 17

18. F&C – MN Child Long Term Care
If the child meets a category below and has income in excess of the appropriate F&C CN income limit, evaluate as MN.
Under age 1,
Child under age 18,
Individual under age 21 or a special medical needs adoption assistance child 18

19. F&C - Adult 19

20. F&C - Adult Long Term Care
If the individual is a former foster care child under 26 years, evaluate is this covered group.
If the individual meets the definition of a parent/caretaker-relative, evaluate in the Low Income Families with Children (LIFC) covered group.
If the individual meets the definition of a pregnant woman, evaluate in the pregnant woman/newborn child group
Long Term Care 20

21. F&C - Adult Long Term Care
If the individual has been screened and diagnosed with breast or cervical cancer or pre-cancerous conditions by the Every Woman’s Life program and does not meet the definition of for coverage as SSI, LIFC, Pregnant Woman or Child under 19, evaluate in the Breast and Cervical Cancer Prevention and Treatment Act (BCCPTA) covered group.
If the individual is between the ages of 19 and 64 and is not eligible for or entitled to Medicare, evaluate in the MAGI Adults group. 21

22. F&C - Adult Long Term Care
If the individual is in a medical institution, or has been screened and approved for Home and Community Based Services or has elected hospice, evaluate in the appropriate F&C 300 % of SSI covered group.
If the individual has excess income for full coverage in a Medicaid covered group and is under 65, evaluate for Plan First coverage. 22

23. F&C – MN Adult Long Term Care
If the individual is a pregnant woman but has excess income for coverage in a CN group or FAMIS MOMS, evaluate as MN. 23

24. Aged, Blind, or Disabled 24

25. ABD
If the individual is a current SSI/AG recipient, evaluate in this covered group.
If the individual is a former SSI or AG recipient, evaluate first in the protected covered groups.
Exception to above-- if the individual requests MEDICAID WORKS, evaluate for Medicaid Works. 25

26. ABD
If the individual does not meet the criteria for SSI/AG or protected, is between ages 19 and 64, and is not eligible for or enrolled in Medicare, evaluate next in the MAGI Adults covered group
No resource test!
If the individual is aged and/or is eligible for or has Medicare, evaluate next in the ABD with income < 80% FPL covered group. 26

27. ABD
If a disabled individual has income at or below 80% FPL (including SSI recipients and 1619(b) individuals) and is going back to work, evaluate the individual in the Medicaid Workd covered group.
If the individual does not meet the requirements for MAGI Adults, 80% FPL group or Medicaid Works, but meets the definition of an institutionalized individual, evaluate in the 300% of SSI covered groups 27

28. ABD
If the individual is a Medicare beneficiary with income or resources in excess of the full-benefit Medicaid covered groups, evaluate in the Medicare Savings Programs (MSP) groups (QMB, SLMB, QI, QDWI).
If the individual is not eligible for Medicaid coverage in an MSP group AND he is at least age 19 years but under age 65 years or he requests a Plan First evaluation, evaluate in the Plan First covered group. 28

29. ABD – MN
If the individual meets all the requirements, other than income, for coverage in a full benefit Medicaid group, evaluate as MN.
If the person is eligible for an MSP or Plan First, also evaluate for as MN as long as resources are under the MN resource limit. 29

30. Disabled Child Long Term Care
A child receiving SSI should be enrolled in the ABD SSI Medicaid covered group.
Evaluate a disabled teen age 16 or over requesting Medicaid Works in that covered group.
Parental resource deeming applies in the initial eligibility determination.
No parental income deeming. 30

31. Disabled Child Long Term Care
Evaluate a child under 18 receiving LTSS in the 300% SSI covered group
No resource test if under 19, no parental deeming
No disability determination required if under 18; LTSS use level of care criteria
Child must be referred to DDS for a disability determination prior to turning 18, when ABD rules and resource test begin. 31

32. Disabled Child Long Term Care
Evaluate a disabled child who is not receiving LTSS first as a F&C child under 19.
No resource test
MAGI rules, higher income limit
If not eligible as a child under 19, evaluate in the 80% SSI covered group.
Parental resource and income deeming applies to, regardless of what parent may have been told. 32

33. Coverage for Incarcerated Individuals (Offenders)
All individuals eligible in a full-coverage CN covered group are eligible for coverage of inpatient hospital services only while incarcerated.
AC = 108 for MAGI Adults
AC = 109 for all others
Individuals enrolled as MN or on a spenddown when they become incarcerated must be evaluated for possible changes in income as soon as the EW becomes aware of the incarceration.
May meet a full coverage group due to loss of income. 33

34. Coverage for Incarcerated Individuals (Offenders)
When the offender is released, his eligibility must be reviewed.
New or resumed income may result in ineligibility.
Covered group may change.
AC must be changed regardless of covered group. 34

35. DMAS - Eligibility & Enrollment Services Division
Contacts
DMAS - Eligibility & Enrollment Services Division
Cindy Olson
EESD - Director
(804)
Kelly Pauley
EESD - Manager
(804)
Senior Policy Analysts
Susan Hart (804)
Vic Grand (804)
Dana Thierry (804)
Mahalia Arnold (804) 35