Only applies to nursing home and support living residents
01/31/2020
Policy Memo
Summary:
The additional resource review for Long Term Care Services can occur after the initial Medicaid and admission approval. This is effective immediately for new and pending applications/admissions.
Major Changes Include:
- Determine initial eligibility for Long Term Care Services (LTC Services) without:
- requesting 12 months of bank statements;
- requesting a 3654 form.
- A 3654 form must be sent after initial approval.
Processing New Applications:
Determine eligibility for LTC Services at the same time the Medicaid eligibility is determined.
Individuals Eligible Under the ACA Adult Group
If the individual qualifies to receive coverage under ACA, resource information is not required.
- Approve the individual for ACA and LTC Services by processing the admit in IES, answering "not required" to the 3654 dropdown response and completing the admit in the LTC subsystem.
- After initial approval, send a VCL with a 3654 to the individual and appropriate parties with a 10 day due date.
- The VCL needs to include the following statement, "If the 3654 is not returned, the LTC Services will be terminated."
- If the 3654 is not returned; change the 3654 dropdown response to "no", discharge the individual from the facility, update IES accordingly, and send out notices.
- Reject TAN and update TAN status code.
- Complete and send IL 444-1010 Admit Rejection Letter to the provider and upload a copy to the ECR.
- Only the LTC Services are terminated. Individual may still be eligible for Medicaid.
- If the 3654 is returned, review the form and process accordingly. See PM 07-02-21: LTC Resource Review for additional information.
NOTE: If the 3654 is received prior to approval of the application or determination of LTC Services, review the form and process accordingly before approving LTC Services.
Refer to manual release MR #17.14: ACA Adult Eligibility Group 08/02/2017 for policy guidance.
Individuals Eligible Under AABD Programs
If the individual qualifies to receive coverage under AABD, determine eligibility for LTC Services at the same time.
Current income and current resource verifications will be required for approval of an application. The LTC individual and the community spouse are required to provide essential information regarding the income and resource values owned by either or both spouses. See PM 07-02-00: Aid to the Aged, Blind, and Disabled (AABD) for more information on assets and PM 08-02-00: Aid to the Aged, Blind, and Disabled for information in income.
- If backdating is requested, bank account statements are required for each requested backdated month.
- Use the verified amount of nonexempt resources available on the first day of each individual month that backdating is requested before any income has been added or expenses paid. Refer to PM 15-04-01: Resources (AABD) for additional policy
- Eligibility for each month of medical backdating is determined separately. Do not use the resource amount as of the day of decision for any backdated month. Additionally, excess resources are not reduced in backdated months. Resource reductions start the month following the month in which the application was received.
- For the application month, use the most current verified amount minus any countable net income received for that month.
- If the individual qualifies, approve the individual for AABD and LTC Services by processing the admit in IES, answering "not required" to the 3654 dropdown response and completing the admit in the LTC subsystem.
- After initial approval, send a manual VCL with a 3654 to the individual and appropriate parties with a 10 day due date.
- The VCL needs to include the following statement, "If the 3654 is not returned, the LTC Services will be terminated."
- If the 3654 is not returned; change the 3654 dropdown response to "no", discharge the individual from the facility, update IES accordingly, and send out notices.
- Reject TAN and update TAN status code.
- Complete and send the IL 444-1010 Admit Rejection Letter to the provider and upload a copy to the ECR.
- Only the LTC Services are terminated. Individual may still be eligible for Medicaid.
- If the 3654 is returned, review the form and process accordingly. See PM 07-02-21: LTC Resource Review for additional information.
NOTE: If the 3654 is received prior to approval of the application or determination of LTC Services, review the form and process accordingly before approving LTC Services.
Refer to PM 15-04-01: Resources (AABD) for additional policy on applying resources.
Processing Admits for Individuals Already Receiving Medicaid:
Individual Receiving Medicaid Less Than 6 Consecutive Months Coverage
Determine eligibility for LTC Services by entering the admission information in IES and process admit in the LTC subsystem.
- After approval of LTC Services; send a VCL with a 3654 to the individual and appropriate parties with a 10 day due date.
- The VCL needs to include the following statement, "If the 3654 is not returned, the LTC Services will be terminated."
- If the 3654 is not returned, discharge the individual from the facility, update IES accordingly, and send out notices.
- Reject TAN and update TAN status code.
- Complete and send IL 444-1010 Admit Rejection Letter to the provider and upload a copy to the ECR.
- Only the LTC Services are terminated. Individual may still be eligible for Medicaid.
- If the 3654 is returned, review the form and process accordingly. See PM 07-02-21: LTC Resource Review PDF for additional information.
NOTE: If the 3654 is received prior to approval of the application or determination of LTC Services, review the form and process accordingly before approving LTC Services.
Individual Receiving Medicaid 6 months or more
The expedited admit process still applies for individuals who have had 6 months consecutive Medicaid coverage prior to moving to a nursing home or supportive living program facility.
- Determine eligibility for LTC Services by entering the admission information in IES and process admit in the LTC subsystem.
- After approval of LTC Services; send a VCL with a 3654 to the individual and appropriate parties with a 10 day due date.
- If the 3654 is returned, review and process accordingly.
- If the 3654 is not returned, no further action is required.
- Refer to the policy memo: New Procedure Active Community Case to LTC NH/SLP/DOA Case for more information.
Additional LTC Procedures
Resource Reductions
- If excess resources are disclosed or found at initial processing of application, the resource reduction can be applied as usual, based on LTC policy stated above.
- If excess resources are found when the 3654 is returned after approval:
- The resource reduction is applied with the effective month going forward.
- It cannot be applied retroactively.
Asset Verification System (AVS)
- An ad hoc request should be created for all applicable applications.
- If a bank account is reported and no results are found in AVS
- A VCL needs to be sent out requesting verifications based on program eligibility rules.
- If a bank account is reported and results are also found in AVS, a VCL is not needed.
- Use AVS bank balances as statements.
- Refer to MR #19.09 Asset Verification System for more guidance on issuing a VCL for resources.
- Refer to PM 02-7-03-n for additional guidance on AVS.
Penalty Periods
- If an unallowable transfer is found prior to approval of application. The beginning date of the penalty period is the later of:
- the date the person becomes otherwise eligible for NH, SLF, or DoA HCBS waiver services (including meeting any spenddown and following any days fully covered by Medicare);
- the first day of the month during which the transfer for less than FMV is made; or
- the first month that can be affected for an ongoing case allowing for timely notice to be sent to the individual.
- If an unallowable transfer is found after the admit has already been completed, only the remaining portion of the penalty period can be applied.
- Refer to PM 07-02-20-d: Penalty Period Due to Non-Allowable Transfers for more information.
LTC-Asset Discovery Investigation(ADI) Referrals
Allowances
The various allowances that permit income and resources to be diverted or transferred to the community spouse or family still need to be applied if applicable. Continue to follow the guidelines and procedures regarding each program:
- Community Spouse Maintenance Needs Allowance, refer to PM 15-04-04-a.
- Family Maintenance Needs Allowance, refer to PM 15-04-04-b.
- Community Home Maintenance Allowance, refer to PM 15-04-04-d.
- Community Spouse Resource Allowance, refer to PM 07-02-22.
Admissions
- Continue to follow and apply all admission timeliness guidelines and screening requirements.
30 Day VCL Extensions
30 day extensions for VCLs requesting resource verifications can be granted WHEN the 3654 form was received after approval. IES is not currently programmed to allow the 30 day extensions for Approved EDGs so the extension will need to be tracked manually.
A VCL was Sent Requesting the 3654 Prior to the Date of this Memo
If the Form 3654 was requested before this memo, refer to Policy Memo: New Procedure Active Community Case to LTC NH/SLP/DOA Case for additional information.
Reopens
Follow current procedures for reopens when the 3654 is returned after the LTC Services were terminated.
- If the 3654 is returned within 60 days after the date of notice of the denial of a medical application or termination of LTC Services:
- Review eligibility and perform the reopen using existing procedures.
- If the 3654 is not returned within 60 days after the date of notice of denial for a medical application or termination of LTC Services:
- The application and LTC Services remains denied or terminated.
- A new TAN and/or application is needed.
NOTE: Refer to MR #14.09 for additional information on reopening denied medical applications.
Grace B. Hou
Secretary, Illinois Department of Human Services
Theresa Eagleson
Director, Healthcare and Family Services
Forms referenced
