State of Wisconsin Department of Health Services

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The policy on this page is from a previous version of the handbook. 

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21-02 Version of 28.6 HCBWLTC Eligibility Groups and Cost Sharing

28.6.1 Home and Community-Based Waivers Long-Term Care Instructions Introduction

Financial eligibility for home and community-based waivers cases is determined in CARES.

Although Katie Beckett cases are Group A, these cases are processed manually outside of CARES by Katie Beckett staff.

28.6.2 Group A

Group A members are waiver functionally eligible and Medicaid eligible via any full-benefit Medicaid subprogram other than HCBW Medicaid.

• Group A members may be eligible for any of the full-benefit Medicaid programs, as listed in Section 21.2 Full-Benefit Medicaid, including those eligible for Special Status MA (see Section 25.0 Special Status Medicaid Introduction).
• Group A does not include someone solely eligible for any of the limited benefit Medicaid subprograms listed in Section 21.3 Limited Benefit Medicaid.

Group A members do not have a cost share.

Members who have met a deductible are eligible for community waivers as a Group A. The member remains eligible as a Group A until the end of the deductible period. At the next review the member will be able to make a choice between meeting the deductible to receive Medicaid (remaining a Group A) or becoming eligible for community waivers as a Group B or B Plus with a potential cost share.

Group A members are financially eligible with no cost share. They are only subject to the asset limit and any premiums associated with the full-benefit Medicaid source, if applicable. For example, if the member’s Medicaid source is MAPP, s/he would be subject to the MAPP asset limit and premium calculated. If the member’s Medicaid source is BadgerCare Plus, the member would not have an asset limit, but may still have a premium calculated.

Note:

Group A members do not have an asset limit if they are Group A eligible via BadgerCare Plus, Adoption Assistance Medicaid, Foster Care Medicaid, Katie Beckett Medicaid, or Wisconsin Well Woman Medicaid since these programs do not have an asset test. All Group A members, including those who are eligible for Group A through BadgerCare Plus eligibility, are subject to the divestment policy described in Chapter 17 Divestment.

28.6.3 Group B and B Plus

Group B members are defined as those not in Group A, but who have gross income at or below the nursing home institutions categorically needy income limit (see Section 39.4 Elderly, Blind, or Disabled Assets and Income Tables).

Group B Plus members are defined as those not in Group A, who have gross income above the nursing home institutions categorically needy income limit, but whose income does not exceed the cost of the appropriate institutional care by more than the medically needy income limit (see Section 39.4 Elderly, Blind, or Disabled Assets and Income Tables).

28.6.4 Cost Share Amount

The cost share amount is the monthly amount Group B and B Plus members must pay toward the cost of their waiver services. The cost share amount is calculated in CARES by applying the cost share deductions to Group B and B Plus members’ gross income. For former SSI members who are not eligible for Special Status Medicaid (Section 25.0 Special Status Medicaid Introduction) special status disregards are not used in the Cost Share calculation. Members who owe a cost share must pay one in the month that they enroll in a community waiver program, even if they only receive services for part of a month. If the member changes from one MCO to another MCO in the same month after paying a cost share to the original MCO, they do not owe a cost share to the new MCO that month.

Family Care, Family Care Partnership, or PACE members institutionalized in a medical institution pay a patient liability calculated according to Chapter 27 Institutional Long-Term Care rather than cost share under this section.

Cost Share or Patient Liability Effective Dates

Income changes which are reported timely and result in an increased patient liability or cost share have the following effective dates:

• Before adverse action: Effective the first of the following month.
• After adverse action: Effective the first of the month after the following month.

Decreases in patient liability or cost share are always effective the first of the month in which the decrease in income occurs or the decrease is reported, whichever is later.

28.6.4.1 Personal Maintenance Allowance

A personal maintenance allowance for room, board, and personal expenses must be deducted from income when calculating cost share. Do not give the special housing amount to waiver participants under age 18.

The personal maintenance allowance (Line 6 and Page 2 of the worksheet) is the total of the following:

1. Community Waivers Basic Needs Allowance (see Section 39.4.2 Elderly, Blind, or Disabled Deductions and Allowances).
2. Sixty-five dollars and ½ earned income deduction (see Section 15.7.5 $65 and ½ Earned Income Deduction).
3. Special housing amount equal to monthly housing costs over $350. If the waiver applicant's housing costs are over $350, add together the following costs and subtract $350 to get the special housing amount:
   1. Rent.
   2. Home or renters insurance.
   3. Mortgage.
   4. Property tax (including special assessments).
   5. Utilities (heat, water, sewer, electricity).
   6. "Room” amount for members in a CBRF, Residential Care Apartment Complex, or an Adult Family Home. The case manager determines and provides this amount.

If both spouses are applying and both have income, divide the special housing amount in whatever way results in the lowest total cost share for the members. See Process Help 11.5.3.3.

If only one spouseA spouse is that person recognized by Wisconsin law as another person's legal husband or wife. Wisconsin does not recognize common law marriage. has income and both spouses are applying, allocate the full special housing amount to the spouse with income.

When one spouse has income and both are applying:

1. And they reside together in the same residence, allocate the full special housing amount to the spouse with income.
2. And they reside in separate rooms in a substitute care facility, but there is only one room and board contract for both, allocate the full housing amount to the spouse with income.
3. And they reside in separate rooms in a substitute care facility, but each has an individual room and board contract, only the spouse with income gets a deduction for the special housing amount, and it is based on their individual "rent” costs that are obtained from the care manager.

When both spouses have income and both are applying:

1. And they reside together in the same residence, divide the special housing amount in whatever way results in the lowest total cost share for the members.
2. And they reside in separate rooms in a substitute care facility, but there is only one room and board contract for both, divide the special housing amount in whatever way results in the lowest total cost share for the members.
3. And they reside in separate living arrangements (e.g., they reside in two different substitute care facilities OR they reside in the same substitute care facility but each has a private room and his or her own individual room and board contract) then calculate a separate special housing amount for each, based on their individual "rent" costs that are obtained from the care manager.

The total of 1, 2, and 3 must not be greater than the EBD Maximum Personal Maintenance Allowance (see Section 39.4.2 Elderly, Blind, or Disabled Deductions and Allowances).

28.6.4.2 Family Maintenance Allowance

A family maintenance allowance, an amount to be used for the support of the applicant’s family members, should only be deducted from income when calculating cost share in certain cases. The family maintenance allowance may not be used for a deduction when spousal impoverishment policies apply or if the member is a disabled child. For spousal cases, the institutionalized person can allocate income to the community spouse and children in the home, see Section 18.6 Spousal Impoverishment Income Allocation.

28.6.4.2.1 Family Maintenance Allowance Calculation - Minor Child

When the waiver participant is the custodial parent of a minorA minor is a person less than age 18. child living in the home, and there’s no spouse in the home, calculate the following:

1. Minor children’s gross earned income.
2. -$65 and ½ of gross earned income (see Section 15.7.5 $65 and ½ Earned Income Deduction).
3. =______________.
4. + Minor Children’s total unearned income.
5.  = __________Add (3) and (4).
6. AFDC Related med needy income limit _______ (see Section 39.3 AFDC-Related Income Table). (Do not include the waiver applicantA person who has submitted a request for coverage for whom no decision has been made regarding eligibility in the group size.)

If (5) is greater than (6), there’s no family maintenance allowance. If (5) is less than (6), the family maintenance allowance is the difference between (5) and (6).

28.6.4.2.2 Family Maintenance Allowance Calculation - EBD-Related

If there are no minor children in the home, and spousal impoverishment policies do not apply, calculate the following:

1. Spouse’s gross earned income.
2. -$65 and ½ of total gross earned income (see Section 15.7.5 $65 and ½ Earned Income Deduction).
3. =__________.
4. +Spouse’s total unearned income.
5. =________________ (3)+(4).
6. -$20 disregard .
7. =_________________(6)-(5).
8. ____________Enter the SSI Payment Level Plus the E Supplement for one person (see Section 39.4 Elderly, Blind, or Disabled Assets and Income Tables).

If (7) is greater than (8), there is no family maintenance allowance. If (7) is less than (8), the family maintenance allowance is the difference between (7) and (8).

28.6.4.3 Special Exempt Income

Special exempt income (see Section 15.7.2 Special Exempt Income) must be deducted from income when calculating cost share.

28.6.4.4 Health Insurance

All health and dental insurance premiums covering the waiver person and for which he or she is responsible and pays a premium must be deducted from income when calculating cost share. This includes any Medicare Premium obligation including Medicare Part D. See Section 9.6.2 Policies Not To Report for a list of insurance types for which premium deductions are not allowed.

If the waiver participant is part of a covered group but not responsible for the premium, find his or her proportionate share by dividing the premium by the number of people covered. If both members of a couple apply, but only one pays the premium, divide the premium equally. Prorate premiums over the months payment covers.

Example 8:

Sally pays a $600 premium quarterly for her Medicare supplement policy. Six hundred dollars divided by three equals $200. Enter $200 as her monthly health insurance premium payment on the Medical Coverage page.

28.6.4.5 Medical/Remedial Expenses

The dollar amount of the applicant’s medical and remedial expenses, as reported by the MCO care manager, ICA, or ADRC, must be deducted from income when calculating cost share. See Section 15.7.3 Medical/Remedial Expenses and Section 20.3.6 Medical or Remedial Expenses.

Note:

Care managers should refer to the limitations associated with allowable medical or remedial expenses that are described in Section 27.7.7 Medical or Remedial Expenses and Payments for Non-Covered Services.

28.6.5 Maximum Cost Share Amount

For Family Care, Family Care Partnership, and PACE, see Section 39.4.4 for maximum cost share amount.

28.6.6 Waiver or Reduction Cost Share

Family Care, Family Care Partnership, or PACE members may request a waiver or reduction of their cost share from the Department. Members indicating that they are having difficulty paying cost share should be informed of this right, directed to complete the Application for Reduction of Cost Share form (F-01827), and referred to the Bureau of Adult Programs and Policy (1-855-885-0287).

 

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The information concerning the Medicaid program provided in this handbook release is published in accordance with: Titles XI and XIX of the Social Security Act; Parts 430 through 481 of Title 42 of the Code of Federal Regulations; Chapters 46 and 49 of the Wisconsin Statutes; and Chapters HA 3, DHS 2, 10 and 101 through 109 of the Wisconsin Administrative Code.

Notice: The content within this manual is the sole responsibility of the State of Wisconsin's Department of Health Services (DHS). This site will link to sites outside of DHS where appropriate. DHS is in no way responsible for the content of sites outside of DHS.

Publication Number: P-10030