Home and Community Based Medicaid (HCB Medicaid)

HCB Medicaid eligibility rules provide for a higher income threshold for individuals who meet the requirements for and have a need for Aged and Disabled Waiver (ADW) services. Determination of HCB Medicaid eligibility requires coordination between FSD and DSDS. The FSD HCB Medicaid Referral (IM54a) shall be used as communication between the agencies regarding HCB Medicaid eligibility requirements. The IM-54a shall be uploaded into the participant’s electronic case record. DSDS staff shall review HCB Medicaid eligibility during the initial assessment, reassessment and PCCP maintenance process.

Spenddown Coverage

Individuals who meet Medicaid eligibility requirements, but have income over the monthly limit, may meet eligibility for spenddown coverage [Needs Link]. A spenddown is a monthly premium payment that participants must meet before Medicaid benefits become active.

At Initial Assessment

The spenddown liability must be met for the current date before a referral for HCBS can be processed except for a participant that appears to be HCB Medicaid eligible. Upon receipt of a referral for a potential participant that is not HCB Medicaid eligible with an unmet spenddown, DSDS staff shall inform the individual:

• A referral cannot be completed because the spenddown liability has not been met for the current date
• To contact FSD for information on Medicaid benefits
• To contact the HCBS Intake Customer Service Center to initiate a referral once Medicaid benefits are active

Upon receipt of a referral for a potential participant that has met the spenddown for the current date, DSDS staff shall complete the initial assessment in the participant’s electronic case record.

• If LOC is met, DSDS staff shall proceed with developing a PCCP and coordinating with the selected HCBS provider. DSDS staff shall inform the participant that Medicaid will only reimburse for HCBS during periods when the monthly spenddown liability has been met. The participant will be responsible to pay for the cost of any HCBS provided during periods when the monthly spenddown liability has not been met.
• If LOC is not met, DSDS staff shall proceed with the adverse action [Needs Link] process.

At Reassessment

A participant with spenddown coverage must have met the spenddown liability at least once within the previous three (3) months to continue with the reassessment process. DSDS staff shall:

• Review the Medicaid eligibility within the participant’s electronic case record and/or DSS systems to verify that Medicaid benefits are currently active.
  • If the spenddown liability has been met at least once within the previous three (3) months, DSDS Staff or designee shall complete the reassessment process within the participant’s electronic case record.
  • If the spenddown liability has not been met for the current date and has not been met at least once within the previous three (3) months, DSDS Staff shall initiate the adverse action process.

NOTE: At the time of reassessment, DSDS staff shall determine if a participant with spenddown coverage meets the eligibility criteria for HCB Medicaid. If a participant meets HCB Medicaid eligibility criteria, DSDS staff should initiate the FSD HCBFSD HCB Medicaid Referral (IM-54a).

Unmet Spenddown HCB Referral

Potential or current participants must meet the age, income and ADW criteria, as outlined in Missouri’s Medicaid Program policy.

Initial Referral

If a potential participant has not met spenddown at initial referral, they are referred to FSD.

• FSD will initiate HCBS referrals for participants who have not met their spenddown but meet the HCB criteria.

If LOC and/or ADW eligibility is not met, DSDS staff shall:

• Proceed with the adverse action process
• Complete and upload an IM-54a into the participant’s electronic case record
• If FSD initiated the IM-54a, submit the IM-54 to FSD HCB Processing Center

NOTE: If FSD initiated the IM-54a and DSDS staff did not conduct the initial assessment, DSDS staff shall return the original IM54a to the FSD HCB Processing Center, explaining why an assessment was not completed. The updated form should be uploaded into the electronic case record system.

Reassessment and PCCP Maintenance

At reassessment or PCCP maintenance if DSDS staff or its designee identifies that a current participant with spenddown coverage meets HCB Medicaid eligibility criteria outlined in HCB Medicaid policy, DSDS staff shall:

• Initiate the FSD HCB referral (IM-54a)
• Upload the IM-54a
• Submit the IM-54a to the FSD HCB Processing Center

When DSDS staff or its designee identifies that a current participant with HCB Medicaid no longer meets criteria or requires an ADW, DSDS staff shall:

• Proceed with the adverse action [Needs Link] process if appropriate
• Complete and upload the IM-54a into the participant’s electronic case record
• Submit the IM-54a to the FSD HCB Processing Center

Qualified Income Trust (QIT)

Individuals with income more than HCB Medicaid requirements may still qualify for HCB Medicaid by diverting a portion of their income into a QIT (a.k.a. Miller Trust). QIT is limited to persons needing Medicaid for nursing facility care or for services provided through the ADW.

Division of Assets

Division of Assets may be used to prevent spousal impoverishment. Federal law provides a way to protect a portion of assets and income for a “community spouse” whose spouse is receiving vendor nursing care or HCBS.

Specified Low Income Medicare Beneficiary 2 (SLMB2)

SLMB2 is a program that can aid with Medicare premiums, co-insurance and deductibles for qualifying individuals. SLMB2 beneficiaries may be HCB Medicaid eligible if all requirements are met, however, the participant must choose which coverage (HCB Medicaid or SLMB coverage) to have.

QIT, Division of Assets, or SLMB2 Referral Process

The HCB referral process may be initiated for potential participants pursuing QIT, Division of Assets, or SLMB2.

At initial assessment, if the participant meets LOC and ADW requirements, DSDS shall:

• Complete and return the IM-54a to the FSD HCB Processing Center
• If FSD returns the IM-54a approving HCB Medicaid benefits:
  • Enter all assessment and authorization activity into the participant’s electronic case record
  • Coordinate service delivery with the selected HCBS provider(s)
• If FSD returns the IM-54a denying HCB Medicaid benefits:
  • Proceed with the adverse action process
• If LOC and/or ADW eligibility is not met:
  • Proceed with the adverse action process
  • Complete and return the IM-54a to FSD HCB Processing Center

NOTE: If an initial assessment was not conducted, DSDS staff shall explain why there was not an assessment completed on the original IM-54a, upload the updated form and submit the form to FSD HCB Processing Center.

At reassessment or PCCP maintenance, if DSDS staff or its designee identifies that a current participant with HCB Medicaid no longer meets criteria or refuses an ADW, DSDS staff shall proceed with the adverse action [Needs Link] process to close HCB Medicaid.

• DSDS staff shall complete and upload the IM54a regarding ineligibility for HCB Medicaid and send to the FSD HCB Processing Center.

Blind Pension (ME Code 02)

Blind Pension provides assistance to blind individuals who do not qualify under the Supplemental Aid to the Blind law and who are not eligible for Supplemental Security Income benefits. Eligible individuals receive a monthly cash grant, as well as MO HealthNet coverage. ME Code 02 [Needs Link] will only reimburse for state plan services. Participants with ME Code 02 are not eligible for any waivered services. The electronic case record will only display the services the participant is eligible for.

If a participant has a waivered service that was previously authorized, but Medicaid eligibility changes to ME Code 02, DSDS staff shall:

• Initiate the adverse action [Needs Link] process to close the waiver service
• Close all prior authorized waivered services

Ticket to Work Health Assurance (ME Code 85)

The Ticket to Work Health Assurance (TWHA) program provides Medicaid coverage, including HCBS, for persons with disabilities ages 16 through 64 who are employed. Like spenddown coverage, TWHA coverage has a monthly premium payment that participants must meet before Medicaid benefits become active.

At Initial Assessment

The TWHA premium liability must be met for the current date before a referral for HCBS can be processed. Upon receipt of a referral for a potential participant with an unmet TWHA premium liability, DSDS staff shall inform the participant:

• A referral cannot be completed because the TWHA premium has not been met for the current date
• To contact FSD for information on Medicaid benefits
• To contact the HCBS Customer Service Center to initiate a referral once Medicaid benefits are active

Upon receipt of a referral for a potential participant that has met the TWHA premium for the current date, DSDS staff shall complete the initial assessment in the participant’s electronic case record.

• If LOC is met, DSDS staff shall proceed with developing a PCCP and coordinating with the selected HCBS provider(s). DSDS staff shall inform the participant that Medicaid will only reimburse for HCBS during periods when the monthly TWHA premium liability has been met. The participant will be responsible to pay for the cost of any HCBS provided during periods when the monthly liability has not been met.
• If LOC is not met, DSDS staff shall proceed with the adverse action [Needs Link] process.

At Reassessment

A participant with TWHA coverage must have met the TWHA premium liability at least once within the previous three (3) months to continue with the reassessment process. DSDS staff shall review Medicaid eligibility within the participant’s electronic case record and/or DSS systems to verify that Medicaid benefits are currently active.

• If the TWHA premium has been met for the current date or has been met at least once within the previous three (3) months, DSDS Staff or designee shall complete the reassessment process within the participant’s electronic case record.
• If the TWHA premium has not been met for the current date and has not been met at least once within the previous three (3) months, DSDS Staff shall initiate the adverse action [Needs Link] process.

Transfer of Property Penalty

Participants with a transfer of property penalty have limited Medicaid benefits and are not entitled to ADW services. FSD determines the length of the penalty if a participant has sold, traded, or given away property for which fair and valuable consideration was not received.

The transfer of property penalty does not apply to State Plan, Independent Living Waiver (ILW), Structured Family Caregiving Waiver (SFCW) or Adult Day Care Waiver (ADCW) services; therefore, Medicaid eligible participants may be authorized for those services as identified through the assessment and PCCP.

NOTE: Transferring of income into a QIT does not constitute a Transfer of Property Penalty.

Managed Care

Individuals enrolled in certain Managed Care Health Plans are ineligible to receive HCBS except for State Plan Consumer Directed Services (CDS). Upon receipt of a referral for an individual enrolled in a Managed Care Health Plan where requested services cannot be authorized, DSDS staff shall refer the individual to the Managed Care Health Plan via the Notice of Closure form.

When an individual displays as having dual codes and one is Managed Care, DSDS staff needs to determine if the individual is “opted in” or “locked in” with a Managed Care provider before proceeding with any assessment, authorization or adverse action.

ME CODE 05 (Adult Family): Individual cannot receive HCBS. The participant will need to contact FSD to “opt out” of Managed Care Medicaid or change their Medicaid eligibility code altogether to request or receive HCBS.

Participants may “opt out” of Adult Family Medicaid (ME 05) if they meet one of the following criteria:

• Eligible for Supplemental Security Income (SSI)
• Enrolled in Special Health Care Needs Program
• Disabled and 18 years of age or younger

NOTE: This information also pertains to the ME Codes of 10, 18, 19, 21, 24, 26, 36, 37, 38, 43, 44, 45, 56, 61, 73, 74, & 75

NOTE: The electronic case record system will not allow further action on individuals who receive Managed Care on the date of request.

ME Code E2 (Medicaid Expansion) – Individual can only receive CDS. The participant will need to contact FSD to un-enroll from E2 in situations where there are dual codes and one code is E2, and the participant is requesting or authorized for services that E2 restricts.

Individuals with the following criteria are restricted to receive E2:

• Have active Medicare
• Age 65 or greater
• Eligible for non-spenddown Medicaid (ME codes: 05, 11, 12, 13, or 18)
• Determined as disabled through FSD Medical Review Team or Social Security Administration

Participants may “opt out” of Medicaid Expansion (ME 02) if they meet one of the following criteria:

• Eligible for SSI
• Enrolled in Special Health Care Needs Program
• Disabled and 18 years in age or younger

Electronic Case Record

The participant’s Electronic Case Record provides information to assist with Medicaid eligibility status determination. The eligibility status will display in the participant’s electronic case record. It may take up to 48 hours for the latest information to display. DSDS staff or designee shall utilize the appropriate DSS eligibility systems to verify Medicaid benefits when questions arise regarding the messages displayed within the electronic case record.

HCBS Eligibility

• Medicaid Eligibility (ME) Code [Needs Link]
  • Prior to all HCBS (re)authorizations, the ME Code shall be reviewed to ensure the participant is eligible for specific service(s).
• Spenddown Indicator
  • The spenddown indicator only displays for spenddown participants.
    • If no is displayed, the participant has not met the monthly liability amount and is not currently eligible for Medicaid benefits.
    • If yes is displayed, the participant has met their spenddown liability amount and is currently eligible for Medicaid benefits.
    • MMIS tab and will eligibility period
• Transfer of Property
  • This field is not functional in the electronic case record. Staff shall review the LXIX screen in the DSS Network to determine Transfer of Property.
• Gross Income
  • This data is not consistently updated in the electronic case record. Staff shall access the DSS Network to determine a participant’s income when needed.
• Ticket to Work Premium
  • This field will display only for ME Code 85 participants and will show either paid or not paid.
• Participant Age
• Date of Death

Missouri’s Medicaid program, also known as MO HealthNet, provides health care access to low income individuals who are elderly, disabled, members of families with dependent children, low-income children, uninsured children, pregnant women, refugees, or children in state custody. Missouri Medicaid determinations are made by the Department of Social Services (DSS), Family Support Division (FSD). Complete information regarding eligibility and how to apply for benefits can be obtained by accessing the following web site https://mydss.mo.gov/healthcare . In addition, this web site provides a link to locate a specific Resource Center and FSD’s Information Call Center.

Medicaid (non-spenddown)

Medicaid benefits are available to persons who:

• Are United States citizens or eligible qualified non-citizen;
• Are residents of Missouri and intend to maintain residency in Missouri;
• Provide (or apply for) a Social Security Number (SSN);
• Are determined medically eligible based on:
  • Age (65 years of age), or
  • Disabled (determined to be permanently and totally disabled), or
  • Blind; and
• Do not own resources which exceed the Medicaid limit:
  • $5,000 for an individual; or
  • $10,000 for a couple; and
    • Married couples who have resources exceeding the $10,000 maximum may be eligible for a Division of Assets - when only one of the couple needs Medicaid funded Home and Community Based Services (HCBS) through a Home and Community Based Waiver i.e., Aged and Disabled Waiver (ADW) or is institutionalized.
  • Have monthly income which does not exceed the non-spenddown income limit (Medicaid Income Information [Needs Link]). Participants whose adjusted income exceeds the established guidelines as determined by FSD may be eligible for Medicaid benefits with a spenddown (see information included in this policy), and/or if age 63 or older, may be eligible for HCB Medicaid or Miller Trust benefits (see information included in this policy).

Medicaid (spenddown)

Benefit eligibility is the same as above for non-spenddown Medicaid except participants with income in excess of the income limit will have an amount of monthly medical expenses, similar to an insurance premium or deductible, that are the participant’s financial responsibility before Medicaid benefits are active. The spenddown liability is the amount by which an individual's or couple's net income exceeds the non-spenddown income limit (Medicaid Income Information [Needs Link]). Medicaid spenddown eligibility is determined initially by FSD. Upon determination of eligibility, the participant shall continue to be Medicaid eligible until a change in the participant’s situation causes ineligibility. The participant does not have to make reapplication. Active Medicaid coverage, however, is determined on a monthly basis.

• Participants may meet their spenddown obligation by:
  • Paying the spenddown liability directly to the MO HealthNet Division (MHD) on a monthly basis which will provide active coverage for the entire month. A timely monthly payment provides the participant with ongoing Medicaid coverage; or
  • Submitting medical bills that reach the participant’s spenddown liability, to the local FSD office. Active coverage will start the day the participant meets the spenddown liability and continue during the remainder of that month. On the day that the participant reaches their spenddown liability, MHD will only pay for medical services over the spenddown liability. Individuals do NOT have to pay their medical expenses before being considered as meeting their spenddown liability.
• Once determined eligible for Medicaid spenddown, a participant will be “locked-in” to receive Medicaid coverage.

Blind Pension

The Blind Pension (BP) program was established in 1921 and is financed entirely by state funds. This program provides assistance for blind persons who do not qualify under the Supplemental Aid to the Blind (SAB) law and who are not eligible for Supplemental Security Income (SSI) benefits. Each eligible person receives a monthly cash grant as well as state funded, rather than federally funded, Medicaid coverage. Additional information regarding the BP program can be found by accessing the following link: http://dss.mo.gov/fsd/blind-pension.htm.

Benefits are available under the BP program to persons who:

• Are 18 years of age or older;
• Are living in Missouri and intends to remain;
• Are United States citizens or eligible non-citizens;
• Have not given away, sold, or transferred real or personal property in order to be eligible for BP;
• Are single, or married and living with spouse, and do not own real or personal property worth more than $20,000. In determining the value of real or personal property, the real estate occupied by the blind person or spouse as the home shall be excluded;
• Is of good moral character;
• Have no sighted spouse living in Missouri who can provide support;
• Do not publicly solicit alms;
• Are determined to be totally blind as defined by law (up to 5/200 or visual field of less than 5 degrees);
• Are found to be ineligible for SAB (http://dss.mo.gov/fsd/sblind.htm);
• Are willing to have a medical treatment or an operation to cure their blindness, unless they are 75 years old or older;
• Are not a resident of a public, private, or endowed institution except a public medical institution; and
• Are found ineligible to receive federal SSI benefits.

Home and Community Based (HCB) Medicaid

Medicaid eligibility rules provide for a higher income threshold for individuals who meet the requirements for and have a need for services in the ADW (HCBS Introduction). A determination must be made for need and the availability of ADW services before FSD can apply the higher HCB income. Therefore determination of HCB Medicaid requires the inter-agency cooperation between FSD and the Department of Health and Senior Services (DHSS), Division of Senior and Disability Services (DSDS) or its designee. HCB Medicaid coverage does not have any direct cash benefits.

• HCB Medicaid application requirements are:
  • 63 years of age or older;
  • Monthly income at or below the current HCB income standard (Medicaid Income Information [Needs Link]).
  • Meet nursing facility level of care;
  • Is eligible to be authorized for an ADW service;
  • Meets the other eligibility requirements as outlined under Medicaid for the Aged, Blind, and Disabled.

Qualified Income Trust (i.e., Miller Trust)

A qualifying income trust, such as a Miller Trust, allows an individual to place income into a trust in order to meet income eligibility guidelines for Medicaid. The trust must consist solely of the individual’s income, such as monthly Social Security or pension benefits, but not resources, and must be used solely for the benefit of the individual. There are no limits on how much income can be placed in the qualifying trust. However, if amounts paid out of the trust exceed the fair market value of goods and services on behalf of the individual, then the individual may be at risk of a penalty for an uncompensated asset transfer, resulting in loss of Medicaid coverage for needed services. Additionally, amounts paid out of the trust may count as income – whether paid directly to the beneficiary or paid to purchase something on their behalf (other than medical care). This “income” must be under the eligibility level in the state and is subject to post-eligibility share-of-cost rules. Finally, the trust must specify the state will receive any amounts remaining in the trust, after the person no longer receives Medicaid benefits; up to the amount the state paid in Medicaid benefits for the Miller Trust owner.

Ticket to Work Health Assurance (TWHA)

• The Ticket to Work Health Assurance (TWHA) program provides Medicaid coverage, including some HCBS, for persons with disabilities, age 16 through 64, who are employed. Resource limits are the same as for Medicaid coverage. However, the TWHA Program allows earnings.
• Participants with income above 100% of the Federal Poverty Level (FPL) will pay a premium to receive coverage. The income of the spouse is included when determining eligibility for the TWHA program. A participant whose computed gross income exceeds 100% of the Federal Poverty Level (FPL) must pay a monthly premium to participate in the TWHA program.
• TWHA eligible participants will be locked into eligibility when all requirements have been met for Medicaid coverage.
• TWHA has two components, a Basic Coverage Group and a Medically Improved Group. The Basic Coverage Group is for persons who have earnings but are determined to be permanently and totally disabled. The Medically Improved Group is for persons who have lost their eligibility for the Basic Coverage Group solely due to medical improvement. Both groups provide full Medicaid benefits.
• Upon approval, MHD will send an Initial Invoice letter, billing the participant for the premium amount for any past coverage selected through the month following approval. Coverage will not begin until the premium payment is received. If the participant does not send in the complete amount, they will be credited for any full month premium amount received starting with the month after approval and going back as far as the amount of premium paid allows.
• MHD will send a Recurring Invoice on the second working day of each month for the next month's premium. If the premium is not received prior to the beginning of the new month, the person's coverage ends on the day of the last paid month.
• MHD will not send a recurring invoice to the participant after six months of nonpayment of premium. The participant's eligibility for TWHA will remain open but the individual will not receive coverage until the premium is paid.

MO HealthNet Managed Care

• MO HealthNet Managed Care refers to the statewide medical assistance program for low-income families, pregnant women, and children under the age of 19 or, in some cases, until the age of 21. Managed Care participants receive their health care through either the Fee-for-Service delivery system or the Managed Care Health Plan delivery system, depending on where the individual lives. For Managed Care participants who are enrolled in a MO HealthNet Managed Care Health Plan, the health plan is responsible for meeting their personal care needs. These services are not prior authorized within the electronic case record. The electronic case record will provide contact information for the MO HealthNet Managed Care Health Plan. Although Missouri’s managed care system has expanded statewide, Missourians who receive aged, blind, or disabled Medicaid benefits will not be included in the managed care system and will continue to receive services through the traditional Fee-for-Service delivery system.

Supplemental Nursing Care (SNC)

• The Supplemental Nursing Care (SNC) program is available primarily for residents of licensed residential care facilities (RCF) and assisted living facilities (ALF). The SNC program provides an actual cash payment to the resident of up to $156 per month for RCF residents and $292 per month for ALF residents. SNC recipients also get a $50 personal needs allowance.

Eligibility for:

* Participants enrolled in a Managed Care Health Plan are not eligible to receive services authorized by the Division of Senior and Disability Services (DSDS) and need to be directed to their health plan.

** PC in RCF/ALF authorizations only.

*** Participants with an ME code E2 are only eligible for Consumer-Directed Services authorized by DSDS.