Waiver While Waiting

Key Points:

Service Coordinator responsibilities:

  1. Receive a referral for an adult with disabilities or aged person who is in need of immediate AD waiver services. For example, a hospital patient returning home; a person exploring nursing facility admission due to declining health; or a person privately paying for home and community-based services whose resources have been depleted.
  2.  Verify the Medicaid pending status on N-FOCUS.
  3. Notify the Medicaid eligibility worker that the waiver referral has been received and Waiver While Waiting may be an option. Begin to gather information about the status of the Medicaid application.
  4. Complete the functional criteria, assessment, and planning process, as usual.
  5. Determine that all points of waiver eligibility are met, including a safe and cost-effective Plan of Services and Supports. Note: A Plan that requires Medicaid payment for personal care aide or home health cannot be implemented under Waiver While Waiting.
  6. Discuss the progress of the Medicaid application with the eligibility worker. If he/she indicates that eligibility is likely, arrange for AD program case to be added to N-FOCUS.

  7. Explain the Waiver While Waiting option to the client/guardian, including -

    1. This option provides temporary waiver services.
    2. Share of Cost might be applied to waiver services.
    3. If Medicaid is denied, services will end without notice.
    4. Assisted Living clients must pay their own room and board. The client and facility should discuss paying anticipated Share of Cost during this period.

  8. Discuss the Waiver While Waiting option with the provider(s), including -

    1. Payment will be made for authorized services during the pending time.
    2. If Medicaid is denied, authorization will end without notice.
    3. Possible Share of Cost.
    4. For Assisted Living, Board and Room payment must be collected during this period.
    5. For Assisted Living, Payment will be made regardless of the final Medicaid decision, but payment will be delayed until after the decision is made.
  9. Complete a Consent Form (revision planned) with the client/guardian. If Waiver While Waiting is chosen, mark the corresponding box.

  10. Authorize services

    1. For in-home: Authorize services on N-FOCUS, as usual.
    2. For assisted living: Complete Form MC-9AD to lock in the payment effective date. Hold onto the form until a Medicaid decision has been made. Share information with the AL facility. Notify DHHS Central Office that Waiver While Waiting is being used for an AL client.
  11. Continue to monitor the progress of the Medicaid application.

  12. When notified that the Medicaid application is approved and case opened:

    1. Document the decision and date in the case record (Functional Criteria Part A).
    2. Notify the client and provider(s) that services are no longer in temporary status.
    3. In-home: The N-FOCUS service authorization requires no action. (When CONNECT is in place, remove the WWW status.)
    4. Assisted living: Submit Form MC-9AD to DHHS Central Office.

  13. Medicaid is approved with a Share of Cost (SOC)

    1. In-home: If a Share of Cost is assigned by Medicaid staff, the SC must know the amount and effective date to apply it to future waiver service billing(s) until the obligation is met. For example, the client learns on 6/22 that Medicaid eligibility is approved with $300 share of cost, effective 5/1. All Home Care Chore costs for May were paid by Medicaid through the AD waiver. The June bill for chore is $750. The client must pay $600 (that is, $300 each for May and for June) with the balance to Medicaid via N-FOCUS billing.
    2. Assisted Living: If a Share of Cost is assigned by Medicaid staff, the SOC will be processed in the usual way, once the MC-9AD is submitted.

  14. Medicaid application is denied

    1. Document the date you learn of this decision and actions taken. If it is in-home waiver, use the most timely method (telephone, if possible) to notify the client and provider(s) that service authorization will end effective the same day. If you are unable to contact the client that day, send a note to the client to advise them their services will end effective with the date you anticipate they will receive the note in the mail. Also notify the provider that the service payment will stop. If it is Assisted Living Waiver, contact the client and the Assisted Living staff to advise the last date of service payment would be that same day (the day you were notified of the Medicaid denial.
    2. Provide information and referral.
    3. In-home: Close the N-FOCUS service authorization(s) See Change a Service Authorizations and Renew a Service Authorization
    4. Assisted Living: Submit Form MC-9AD to DHHS Central Office to address facility payment.· Provide the client's name, SSN, provider name(s),EIN/SSN, Medicaid eligibility worker name and office, reason for Medicaid denial, and effective dates to Central Office.

 Medicaid Social Service Worker responsibilities:

  1. Add an AD Waiver program case (or reopen an existing one) when notified by the Service Coordinator and leave both the Medicaid and AD program cases pending until eligibility for Medicaid can be established. The Waiver Service Coordinator will set up any necessary Service Authorizations on the pending AD program case.
  2. Advise a pending client that they are responsible to pay their monthly income toward their expenses while Medicaid eligibility is being determined. A facility may require the pending client to pay all of their income while they are pending. An actual Share of Cost will not be determined until the Medicaid case is approved.
  3. Notify the Waiver Service Coordinator when eligibility for Medicaid is determined. Also notify of the actual amount of the Share of Cost.

(11-2011)