CurrentDistrict of Columbia Department of Health Care FinancePolicy N/A

Eligibility Determination and Enrollment Process for EPD Waiver

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This policy governs District determinations of EPD Medicaid waiver eligibility and enrollment, including non-financial, income, and resource requirements, and the calculation of beneficiary contributions to care after eligibility is established.

Policy Summary

PayerDistrict of Columbia Department of Health Care Finance

PolicyEligibility Determination and Enrollment Process for EPD Waiver

Policy CodePolicy N/A

Change TypeClarification

Effective DateN/A

Next Review DateN/A

Key ActionFor applications, changes in circumstance, and renewals, evaluate eligibility requirements before determining enrollment or contribution to care.

SourceLink

POLICY UPDATE CHANGES

The policy clarifies the required sequence of eligibility determination and post-eligibility income treatment.

2 stepsEligibility process

$4,000Individual resources

$6,000Couple resources

300% SSI FBRSpecial income standard

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CurrentDistrict of Columbia Department of Health Care FinancePolicy N/A

Eligibility Determination and Enrollment Process for EPD Waiver

Customize your policy alerts

Sign up for all District of Columbia Department of Health Care Finance policy alerts

Know when District of Columbia Department of Health Care Finance releases new policies or updates existing guidance.

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Policy Summary

PayerDistrict of Columbia Department of Health Care Finance

PolicyEligibility Determination and Enrollment Process for EPD Waiver

Policy CodePolicy N/A

Change TypeClarification

Effective DateN/A

Next Review DateN/A

Key ActionFor applications, changes in circumstance, and renewals, evaluate eligibility requirements before determining enrollment or contribution to care.

SourceLink

POLICY UPDATE CHANGES

The policy clarifies the required sequence of eligibility determination and post-eligibility income treatment.

2 stepsEligibility process

$4,000Individual resources

$6,000Couple resources

300% SSI FBRSpecial income standard

$70Personal needs allowance

$0+Patient payability

EPD Waiver Eligibility and Post-Eligibility Income

Step I: EPD Waiver Eligibility and Enrollment

Applicants/beneficiaries must satisfy <strong>all</strong> applicable non-financial and financial requirements under Federal and District regulations to qualify for and enroll in the EPD waiver. Step II applies only after Step I eligibility and enrollment are established.

ALL of the following

Non-financial requirements
- District residency.
- United States citizenship or satisfactory immigration status.
- Valid Social Security Number.
- Applicable age requirement.
- Clinical determination.
Resource requirement
- Countable resources are at or below the applicable Medicaid resource limit.≤ $4,000 for an individual; ≤ $6,000 for a couple
  Under 29 DCMR §§9800 and 9800.6. If resources exceed the applicable limit, the agency does not proceed to financial eligibility based on income.
Meet ONE applicable income pathway
- The applicant/beneficiary receives or is eligible to receive Supplemental Security Income (SSI) as determined by the Social Security Administration and is categorically eligible for Medicaid under a mandatory covered group.
  42 CFR §435.120 and 29 DCMR §9511.13.
- For a non-SSI applicant/beneficiary, countable income is at or below the Special Income Standard (SIS), equal to 300% of the SSI Federal Benefit Rate.≤ 300% of SSI FBR; $2,205.00 in 2017
  Meeting the SIS satisfies the income requirement for LTCSS, including the EPD waiver.
- Medically Needy Spend Down pathway
  - Countable income exceeds 300% of the SSI Federal Benefit Rate and the applicant/beneficiary is evaluated through the Medically Needy Spend Down process.
  - The applicant/beneficiary submits incurred medical bills to the agency for evaluation.

Step II: Post-Eligibility Treatment of Income

After the applicant/beneficiary is determined eligible for and enrolled in the EPD waiver program, ESA calculates the contribution to care, also called the patient payability amount. This post-eligibility treatment of income applies to all individuals approved for LTCSS, regardless of setting, including institutional care and HCBS waiver programs.

ALL of the following steps

Determine the beneficiary's gross countable income.
- Community Maintenance Needs Allowance (CMNA) for HCBS waiver only, equal to 300% of the SSI Federal Benefit Rate ($2,205.00 in 2017).
- Personal Needs Allowance (PNA) for institutional care only: $70.00.
- Dependent family allowance equal to the Medically Needy Income Limit (MNIL) for each dependent ($642.83 in 2017).

Financial Standards and Allowances

Individual Countable Resource Limit

Individual resource limit$4,000 in countable resources

Applies toApplicants and beneficiaries seeking Medicaid, including LTCSS and the EPD waiver

Financial evaluationIf resources are at or below the limit, the agency proceeds to determine financial eligibility based on income

Couple Countable Resource Limit

Couple resource limit$6,000 in countable resources

Applies toApplicants and beneficiaries seeking Medicaid, including LTCSS and the EPD waiver

Financial evaluation

Operational Requirements

Denial Risk

Apply eligibility before post-eligibility income treatment

Follow the District’s eligibility determination process before applying post-eligibility treatment of income. An individual who does not meet Step I eligibility requirements cannot remain eligible for EPD waiver services solely through a post-eligibility contribution-to-care calculation.

Documentation Required

Document the two-step eligibility process

For each initial application, change in circumstance, and renewal, document the two-step process: first evaluate non-financial requirements and financial eligibility, including resources, income, and any applicable Medically Needy Spend Down; only after eligibility and enrollment are established should the beneficiary’s contribution to care be calculated.

Key Eligibility Terms

Eligibility Determination and Enrollment Process

ProcessEligibility determination and enrollment under the EPD waiver is a two-step process

Step 1Meet all applicable non-financial and financial requirements, including income and resource requirements

After enrollmentThe beneficiary’s income is reviewed to determine the contribution to care, also called patient payability

Post-Eligibility Treatment of Income

Starting pointDetermine the beneficiary’s gross countable income

CalculationSubtract allowable deductions prescribed under 42 CFR §435.726

Policy Summary

PayerDistrict of Columbia Department of Health Care Finance

PolicyEligibility Determination and Enrollment Process for EPD Waiver

Policy CodePolicy N/A

Change TypeClarification

Effective DateN/A

Next Review DateN/A

Key ActionFor applications, changes in circumstance, and renewals, evaluate eligibility requirements before determining enrollment or contribution to care.

SourceLink

On This Page

Total incurred medical bills equal or exceed the spend down obligation amount.

If incurred medical bills are below the spend down obligation, the applicant/beneficiary is not financially eligible for LTCSS under the EPD waiver; if they equal or exceed it, the applicant/beneficiary qualifies under the EPD waiver.

Incurred medical expenses not subject to third-party payment, including medical expenses used to meet a spend down obligation when the beneficiary qualified through the Medically Needy Spend Down process.

Remedial care expenses equal to amounts paid to a guardian, conservator, or representative payee.

Additional deductions that may apply to institutional care.

The remaining amount after allowable deductions is the beneficiary's patient payability, or contribution to care.Minimum $0.00

Patient payability may be $0.00 or a higher amount. When the calculated amount is $0.00, the beneficiary has no contribution to care.

ESA sends each LTCSS beneficiary a DHS 1445, Statement of Patient Payability, describing the contribution to care.

If resources are at or below the limit, the agency proceeds to determine financial eligibility based on income

Special Income Standard

Standard300% of the Supplemental Security Income (SSI) Federal Benefit Rate

2017 limit$2,205.00

Applies toNon-SSI applicants and beneficiaries seeking LTCSS, including the EPD waiver

Over-limit optionApplicants or beneficiaries above the standard may qualify through the Medically Needy Spend Down process

Community Maintenance Needs Allowance

Allowance300% of the SSI Federal Benefit Rate

2017 amount$2,205.00

Applies toHome and Community-Based Services (HCBS) waiver programs only

UseAn allowable deduction when calculating the beneficiary’s contribution to care

Personal Needs Allowance

Allowance$70.00

Applies toInstitutional care only

UseAn allowable deduction in the contribution-to-care calculation

Dependent Family Allowance

Amount per dependent$642.83 in 2017

Standard usedThe Medically Needy Income Limit (MNIL)

UseAn allowable deduction for each dependent when calculating the beneficiary’s contribution to care

Examples of deductions

The HCBS Community Maintenance Needs Allowance, institutional Personal Needs Allowance, dependent family allowance, qualifying incurred medical expenses, and remedial care expenses

ApplicabilityThe calculation applies after EPD waiver eligibility is established

Patient Payability

DefinitionThe beneficiary’s required contribution toward the cost of care after allowable deductions are applied

Calculation resultThe remaining amount after allowable deductions are subtracted from gross countable income

Permitted range$0.00 or a higher amount

No contributionIf the calculated patient payability is $0.00, the beneficiary does not have to contribute to care

Medically Needy Spend Down

When it appliesWhen countable income exceeds 300% of the SSI Federal Benefit Rate, the Special Income Standard

Required submissionSubmit incurred medical bills to the agency for evaluation against the spend down obligation

Qualification thresholdTotal incurred medical bills must equal or exceed the spend down obligation amount

If bills are insufficientIf total incurred medical bills are below the spend down obligation, the applicant or beneficiary is not financially eligible for LTCSS under the EPD waiver