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Medicaid MO Training
Reassessor Training
| Question | Answer |
|---|---|
| Understanding MO Medicaid Home & Community based services (HCBS) | At it's core, this training is about how people get the care they need to stay in their homes, rather than having to go into a nursing facility. This is called Home and Community based services (HCBS). |
| 1. Here are the key areas: | General Eligibility and Core Concepts |
| State Plan Eligibility Requirements | To even begin, an individual needs to be 18+, have active Medicaid with an approp. ME (Medicaid Eligibility) code & meet nursing facility level of care (LOC). Meaning their health needs meet nursing home level but we want to keep them in their home. |
| HCB Medicaid Eligibility | For specific HCBS programs, there are often additional requirements, such as being 63+ years old, needing at least one ADW service (which we'll get to), and having a monthly income at or below 128% of the Federal Poverty Level. |
| Medicaid Spenddown Program | This helps people who are slightly over the income limit. They can "spend down" their excess income on medical expenses (or pay it directly to MO HealthNet) to qualify for Medicaid services. |
| Blind Pension Program | Important restriction: Individuals receiving the Blind Pension Program cannot also receive waiver services. |
| EMOMED | This is simply the electronic tool used to check a person's Medicaid eligibility. |
| 2. How Services Are Delivered | Two Main Models: Once someone is eligible, how do they get care? There are two primary ways: |
| A): Consumer-Directed Services (CDS) Model | This model empowers the individual (the "consumer") to manage their own care. They hire, train, and supervise their own personal care attendants, who can even be family members (but not spouses or legal guardians). |
| CDS Eligibility Requirements | The person must be physically disabled and have the ability to self-direct their care. If they have a cognitive impairment, it must have started on or after age 22. |
| CDS Cost Max | The cost of services cannot exceed 60% of what it would cost to provide the same care in a nursing facility. |
| CDS Reimbursement Restrictions | Medicaid won't pay for services if the person is also authorized for DMH (Department of Mental Health) services, for tasks household members would typically share, or if the task is performed by a licensed professional (unless specifically authorized). |
| CDS Time Restrictions | Crucially, no time is allotted for things like prompting, cueing, standby assistance, respite care, or waiting for the patient. The attendant is paid for direct, active care. |
| Undue Hardship | This refers to situations where following certain rules (like not being able to hire family) would cause severe problems for the client, such as loss of income, family disintegration, or abuse/neglect. |
| B): PC, APC & RN Agency Model | Services are provided by an agency enrolled w/HCBS. Caregivers are employees of the agency, Family (including spouses) can't be hired. Services are authorized &billed in 15-min. unit Prompting & cueing are NOT authorized tasks in this model either. |
| 3. Types of Personal Care Services | Both models can provide different levels of personal care: |
| Personal Care (PC) | These are medically-oriented tasks to help with Activities of Daily Living (ADLs) like bathing, dressing, eating, and mobility, for people with chronic health conditions. |
| PC Cost Max | Similar to CDS, the cost max is up to 60% of the monthly nursing facility care. |
| Advanced Personal Care (APC) | This is a higher level of personal care for those who need assistance with ADLs that involve devices or procedures related to altered body functions (e.g., ostomy/catheter hygiene, bowel programs, aseptic dressings). |
| General Health Evaluation (GHE) | All individuals receiving PC and APC services must have at least two RN (Registered Nurse) visits per year. |
| RN Visit Documentation | For an RN to justify services, they must document that the patient lives alone, or that family members are unwilling/incapable of providing the care. The maximum number of RN visits allowed every 6 months is 26. |
| 4. Specific Medicaid Waivers (Programs) | These are different programs designed for specific populations, each with its own eligibility, services, and restrictions. |
| Aged & Disabled Waiver (ADW): | Target: Individuals 63+ years old who meet nursing facility LOC, have active Medicaid, and an appropriate ME code. Even those in the spenddown program can receive services during periods of eligibility. |
| ADW Services: | Includes chore services, home-delivered meals, homemaker services, respite care, and adult day care services. |
| ADW Restrictions: | Cannot be used if receiving blind pension, in a property transfer penalty, residing in a nursing or residential facility, or receiving services through another HCBS waiver. |
| Adult Day Care Waiver (ADCW): | Target: Individuals 18-63 years old who need continuous care and supervision in a licensed adult day care setting. This includes medical supervision, medication services, meals, snacks, and transportation. |
| ADCW Restrictions: | Max 10 hours/day, 5 days/week. Not for persons residing in a nursing or residential facility licensed by DMH, or those authorized for DMH services. |
| Independent Living Waiver (ILW): | Target: Individuals 18-64 years old with a physical (and possibly cognitive) disability. |
| ILW Eligibility Requirements: | Must be physically disabled, able to self-direct. If there's a cognitive impairment, it must be on or over age 22. Requires active Medicaid and an appropriate ME code. Spenddown and transfer of property penalty may be eligible. |
| ILW Services: | Personal care (CDS Model), case management, environmental assistance/adaptations, specialized medical equipment & supplies, financial management services. |
| ILW Restrictions: | Similar to ADW, blind pension is not eligible, nor are those residing in RCF (Residential Care Facility), ALF (Assisted Living Facility), or DMH facilities, or those receiving services through any other HCBS waiver. |
| Structured Family Caregiving Waiver (SFCW): | Target: Individuals 21+ years old with Alzheimer's or a related diagnosis, where a primary caregiver resides full-time in the household with the patient. |
| SFCW Restrictions: | Not for patients residing in any kind of facility, those receiving blind pension, or those with more than one primary caregiver. |
| InterRAI HC: | This is a specific, person-centered assessment tool used to gather information and guide comprehensive care and service planning in community-based settings for all these waivers. |
| 5. Administrative ... | & Procedural Details |
| Required forms for Reassessment PCCP: | When reassessing a person's Plan of Care (PCCP), specific forms are always needed: the Participant Choice Statement, Assessment Attestation Form, and Rights & Responsibilities Forms. |
| Examples of Collateral Contacts: | These are external sources of information used during assessments, like medical records, relatives, friends, neighbors, or other agencies (e.g., DMH). |
| Adverse Actions: | These are changes in a patient's care plan that the patient disagrees with and that negatively affect them. |
| Adverse Action Waiting Period: | Any changes in a PCCP require a ten (10) business day notification before the change or service closing takes effect. |
| Adverse Action Appeals Timeframe: | If a patient wants to appeal an adverse action, they have ninety (90) business days to do so. |
| Case Note Structure: | When documenting, it's important to write in the first person, use active voice, and avoid vague pronoun usage for clarity and accuracy. |
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