Presentation on theme: "GRH and Health Care MA, GAMC and Waivers. Automatic Eligibility Receiving GRH payment MA—must have MA basis MA with waiver –Eligible for MA payment."— Presentation transcript:
GRH and Health Care MA, GAMC and Waivers
Automatic Eligibility Receiving GRH payment MA—must have MA basis MA with waiver –Eligible for MA payment of LTC services –EW exception: Must do EW calculation GAMC—no MA basis –May or may not receive GA grant
MA Spenddown Income over $867 (100% FPG) Spend down to $650 (75% FPG) What bills can be used? –Medicare premiums paid by enrollee –Remedial Care –Waiver services What can’t be used? –GRH room and board costs
Remedial Care Special deduction for GRH Fixed amount updated twice yearly Allowed for anyone in a facility where county has a GRH agreement Applied against spenddown, or Deducted from income (EW)
Spenddown Example 1 Client age 34, single, residing in rate 1 GRH facility (cost $776) Eligible for CADI waiver Receives RSDI of $1070 Pays Medicare Part B premium of $96 Eligible for GRH? No. $ $20 general deduction and $96 ($84 + $12) PN > $776 ($84 + $12) PN > $776 What is his spenddown?
Example 1 Calculation Income exceeds $867 $1070 – 650 = $420 spenddown Can he meet his spenddown? H bill (Medicare) $96 P bill (remedial care) $210 $ = $113 spenddown balance (MMIS recipient amount) Met with R bill (CADI services)
Spenddown Example 2 Client age 50, single, residing in a board and lodge with $1183 GRH rate Receives RSDI of $1571 Not yet Medicare eligible Gets TCM services costing $286 Not eligible for GRH grant What is his spenddown?
Example 2 Calculation Income exceeds $867 $ $650 = $921 spenddown Can he meet his spenddown? P bill (remedial care) $210 $921 - $210 = $711 spenddown balance (MMIS recipient amount) R bill (TCM) $286 $ = $425 remaining balance Not enough bills at this time—can’t meet spenddown
EW Eligibility EW Eligibility Income under the SIS? Compute waiver obligation I ncome over the SIS? No community spouse: Spenddown Community spouse: LTC budget
Example 3: SIS-EW Single client resides in GRH with assisted living Receives RSDI and pension of $1816 Pays Medicare Part B of $96 Has $15 Part D copays (initial month) Not eligible for GRH grant Does she have a waiver obligation?
Example 3 Calculation Income is less than SIS of $1911 Income deductions: –Medicare premium $96 –Maintenance needs allowance $860 –Remedial care $210 –Copays $15 (initial month only) $1816 – 1181 = $635 waiver obligation
Example 4: SIS-EW and GRH Single client resides in adult foster care GRH rate 1 ($776) Receives RSDI of $850 QMB pays Medicare Is there a waiver obligation?
Example 4 Calculation GRH $850 RSDI - 20 general personal needs $776 GRH rate GRH grant 42 GRH grantSIS-EW $850 RSDI -860 maintenance needs 0 waiver obligation 0 waiver obligation
Example 5: Income Above SIS Single client resides in assisted living Receives RSDI and VA of $2075 Pays Medicare Part B of $96 Waiver obligation? Spenddown?
Example 5 Calculation Income exceeds SIS of $1911 $ =$1425 spenddown H bill $96 (Medicare) P bill $210 (remedial care) Spenddown balance $1119 Must meet with waiver services and other bills
Example 6: SIS-EW with Community Spouse Wife resides in GRH with assisted living Receives RSDI and pension of $1816 Pays Medicare Part B of $96 Husband resides in their home Calculated spousal allocation $800 Does she have a waiver obligation?
Example 6 Calculation Income less than SIS Income deductions: –Medicare premium $96 –Maintenance needs allowance $860 $1816 – 956 = $860 available to allocate -Calculated allocation $800 -Remedial care $210 No waiver obligation
Example 7: Income Over SIS with Community Spouse Husband resides in assisted living Receives RSDI and VA of $2075 Pays Medicare Part B of $96 Wife resides in independent apartment Calculated spousal allocation $800 What is the spenddown amount?
Example 7 Calculation Use LTC calculation Income deductions -$96 Medicare premium -$84 personal needs -$800 spousal allocation -$210 remedial care $2075 – 1190 = $885 spenddown
Example 8: Both Spouses on EW and in GRH Couple resides in apartment and both receive assisted living services through EW Husband receives $2000 RSDI and pension Wife receives $1200 RSDI Both pay Medicare Part B of $96 Spenddown? Waiver obligation?
Example 8 Calculation Husband Income exceeds SIS $ spenddown 1350 spenddown H bill $96 (Medicare) P bill $210 (remedial) $1044 spenddown bal. Wife Income under SIS $ Medicare Maint. Needs remedial care $ 34 waiver obligation $ 34 waiver obligation