SI DEN01310.207 Verifying Medicaid Under a State Home or Community Based Care Plan

A. Background

Sections 1902(e)(3) and 1915(c) of the Social Security Act allow States to develop medical assistance programs for certain groups of individuals to provide them with home or community based care.

In the Denver Region, only South Dakota provides Medicaid assistance to disabled children under the authority of section 1902(e)(3) of the Act. These children are sometimes referred to as TEFRA 134 children, and they receive regular Medicaid services under a provision of the State's Medicaid State Plan (i.e., a waiver is not required). Essentially, section 1902(e)(3) permits States to provide Medicaid assistance to children living at home if it is less expensive than providing similar care in an institution.

In the Denver Region, all six States provide Medicaid to children under 1915(c) home or community based waivers. In addition, there are other 1915(c) waivers that cover disabled and aged individuals. These programs are separate from the normal State Medicaid program and are commonly referred to as "home or community based waivers." Medicaid does not pay for room and board under these waivers. Such programs have been approved by the Center for Medicare and Medicaid Services (formerly Health Care Finance Administration) as a mechanism for States to provide home or community based services, not commonly covered under Medicaid, as an alternative to institutional care. The State can target certain groups such as disabled children. Such home or community based programs are usually limited to a certain number of recipients that can be served at any one time.

The following is a list by State of section 1915(c) home or community based waivers currently in existence in the Denver Region under which an SSI recipient/claimant may qualify:

1. Colorado

  • Home Care Services for Elderly, Blind, and Disabled (waiver #0006.90.R3)

  • Habilitation Services for Developmentally Disabled and Mentally Retarded (waiver #0007.91R3)

  • Home Care Services for Persons Living with AIDS (waiver #0211.90.R1)

  • Home Care Services for Chronically mentally Ill (waiver #0268.90)

  • Personal/Respite Care for Individuals with Brain Injury (waiver #0288.90)

  • Supported Living Services (waiver #0293.90)

  • Habilitation Services for Children with Developmental Disabilities (waiver #0305.90)

  • Case Management for Disabled Children (waiver #4157.90.R1)

  • Case Management for Children with Developmental Disabilities (waiver #40179.90)

  • Personal Assistance for Children Needing Extensive Support (waiver #40180.90)

2. Montana

  • Case Management and Home Care for Elderly and Disabled (waiver #0148.90.R1)

  • Intensive Support/Care for Developmentally Disabled (waiver #0208.90.R1)

  • Community Supports, Personal Care, Transportation, etc. (waiver #03710

3. North Dakota

  • Case Management and Care for Developmentally Disabled and Mentally Retarded (waiver # 0037.90.R3)

  • Case Management and Care for Aged and Disabled (waiver # 0054.90.R2)

  • Case Management and Care for Individuals with Traumatic Brain Injuries (waiver # 0273.90)

4. South Dakota

  • Service Coordination and Habilitation for the Mentally Retarded and Developmentally Disabled (waiver # 0044.90.R3)

  • Home Care and Adult Day Health for the Elderly (waiver #0189.90.R1)

  • Assistive Daily Living Supports for the Severely Disabled (quadriplegic) (waiver #0264.90)

  • Service Coordination for Children with Developmental Disabilities (waiver #0338)

5. Utah

  • Respite, Habilitation, and Support Coordination for the Developmentally Disabled and Mentally Retarded (waiver #0158.90.R2)

  • Case Management and Home Care Services for the Aged (waiver #0247.90.R1)

  • Case Management and Home Care Services for Individuals with Acquired Brain Injury (waiver #0292.90)

  • Attendant Care for Individuals with Physical Disabilities (waiver #0331)

  • In-home Based Treatment for Technology Dependent and Medically Fragile Children (waiver #40183)

6. Wyoming

  • Case Management and Personal Care for the Developmentally Disabled (waiver #0226.90.R1)

  • Case Management and Personal Care for the Elderly and Physically Disabled (waiver #0236.90.R1)

  • Case Management and Personal Care for the Developmentally Disabled and Mentally Retarded up to Age 21 (waiver #0253.90.R1)

  • Case Management to Disabled Individuals under Age 21 Who Require Transplants (waiver #40184.90)

  • Assisted Living, Chore and Attendant Care (waiver #0369)

  • Case Management and Care for Individuals with Acquired Brain Injury (waiver #0370)

B. Policy

  1. Disabled children who are eligible for a Medicaid State home care plan under either a section 1915(c) waiver or section 1902(e)(3) may be eligible for the $30.00 (FLA-D) reduced SSI payment under the parental deeming waiver provision (section 8010 of Public Law 101-239) provided they meet all the requirements described in SI 01310.201.

  2. FLA-D may not be applicable for an individual in an institution where Medicaid pays more than 50 percent of the cost of care if the Medicaid payments are made under a section 1915(c) home or community based services waiver. Under such a waiver, Medicaid does not cover the cost of room and board. (SI 00520.011C.2.)

C. Verification

1. When to Verify

For parental deeming of income development, see SI DEN01310.207.B, item 1 for instructions on when to verify Medicaid eligibility under a State home care plan under either section 1915(c) or 1902(e)(3).

For institutional situations where Medicaid is allegedly being paid under 1915(c), verify per C.2. and 3. in all cases.

2. What to Verify

Verify that the individual is receiving Medicaid under either a 1915(c) home or community services waiver or under 1902(e)(3) Medicaid State plan provision. Since room and board is not paid under either 1915(c) or 1902(e)(3), verifying who pays the cost of room and board further documents that Medicaid is being provided under 1902(e)(3) or 1915(c).

3. How to Verify

To verify Medicaid eligibility under either 1915(c) or 1902(e)(3), obtain from the individual/parent a copy of the Medicaid provider agreement form that was completed with the State agency or the institution. This document provides information on the financial arrangements, and it specifies which State agency (e.g., MHMR) is authorizing the Medicaid coverage.

In developing the parental waiver provision, the period of eligibility for the home or community based services must be established. If the documentation does not clearly provide this information, call the Dallas-Denver SSI Team in the Regional Office (RO) to verify that the individual is eligible for Medicaid under a 1915(c) State home care waiver or under 1902(e)(3). Do not call the local State Medicaid Agency. The telephone number is (214) 767-4224.

The RO staff will contact the State agency to verify Medicaid eligibility and obtain specific coverage periods. This information will be provided to the DO and should be recorded on a Report of Contact.


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http://policy.ssa.gov/poms.nsf/lnx/0501310207DEN
SI DEN01310.207 - Verifying Medicaid Under a State Home or Community Based Care Plan - 11/16/2001
Batch run: 01/27/2009
Rev:11/16/2001