Adult Medicaid Manual MA-2280 COMMUNITY ALTERNATIVES PROGRAM (CAP)

II. POLICY PRINCIPLES - APPLICABLE TO ALL PROGRAMS

A. General Policy Rules

1. To receive CAP, the a/r must request CAP and be eligible in the Aged, Blind, and Disabled (MAABD) aid program/categories, EXCEPT:

a. Children in CAP/C may also be in I-AS or H-SF,

b. Children in CAP-MR/DD may also be in I-AS or H-SF, and

c. Adults in CAP-MR/DD may also be in S-AAD.

2. Individuals in Family and Children's (FC) Medicaid aid program/categories must be deleted from that coverage and be determined eligible under M-AABD in order to be eligible for CAP services, except as noted in II.A.1.a.,b., and c., above.

3. Recipients with living arrangement codes of 16 (incarcerated) or 17 (Institution for Mental Disease) who are in suspension status for Medicaid are not eligible for CAP.

4. All application processing requirements and time frames for the appropriate aid program/category apply.

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(II.A.)

5. The CAP effective date for all CAP programs is the latest of the following:

a. The date of the Medicaid application,

b. The date of FL-2/MR-2 approval,

or

c. The date of deinstitutionalization for an institutionalized a/r.

6. All CAP recipients are exempt from Medicaid co payments, and the annual physician visit limit. Refer to MA-2905 and MA-3540, Medicaid Covered Services.

7. The agency designated the responsibility for approving specific CAP programs will consider the following in determining CAP participation (the approving authority differs for each CAP program):

a. Medicaid eligibility,

b. The risk of institutionalization,

c. The type of institutional care appropriate for the CAP Program.

d. The need for CAP services,

e. The resources available to meet the a/r’s home care needs, and

f. Whether the needed community care can be provided and the a/r can be maintained safely in the home and within the monthly CAP cost limit.

8. The CAP a/r must have an assessment to determine the need for services appropriate to the particular CAP program. The CAP Assessment is used to start this process.

9. Certification Periods

a. CAP a/r’s have 6 or 12 months certification periods (c.p.’s). Refer to MA-2350, Certification and Authorization, for instructions on establishing the c.p.

b. SSI CAP certification periods are controlled by the SSA. Refer to MA-2350, Certification and Authorization.

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(II.A.)

10. Budgeting

a. Financial Responsibility

(1) There is no spouse-for-spouse or parent-for-child financial responsibility in the CAP programs.

(2) Only the a/r’s income is used to determine financial eligibility and spousal income protection does not usually apply in CAP cases. However, if one spouse is in a nursing facility or other medical institution, the at home CAP spouse is entitled to spousal income protection.

(3) The income of the CAP a/r is not considered available to a spouse/dependent who is also a Medicaid recipient.

(4) All assets of a couple owned jointly or individually must be considered when one spouse is in CAP or long-term care (ltc). However, an amount can be protected for the other spouse under the spousal protection reserve regulations. Refer to MA-2231, Community Spouse Resource Protection.

(5) If both spouses are CAP, each is in a separate budget unit (b.u.) of one.

b. One-Third Reduction

Do not apply one-third reduction in CAP, even if applied by SSI.

c. Budget Unit

Always use one for CAP b.u., beginning with the month of approval for CAP.

d. Deductible Cases

(1) All CAP deductibles are calculated monthly. The 6 month deductible calculations are waived for all CAP cases.

(2) Never apply a deductible to an SSI individual or an SSI individual in Special Assistance for the Aged or Disabled (S-AAD) who is eligible for CAP, even if there is other countable income. Refer to MA-1100, SSI Medicaid-County DSS Responsibility.

(3) Use MA-2360, Medicaid Deductible, for deductible requirements, procedures, and regular allowable expenses

REVISED 11/01/11-CHANGE NO. 17-11

(II.A.10.d.)

(4) If an individual has a deductible, a copy of the current CAP Plan of Care (POC) must be maintained in the eligibility record. Some expenses which would not be allowed toward a regular Medicaid deductible may be allowed for a CAP deductible only if they are included in the Medicaid column on the CAP Plan of Care (POC) Cost Summary. See Plan of Care. If the a/r is responsible for payment of the charge, apply the expense to the CAP deductible.

(a) To be listed in the Medicaid column, the medical service or costs are expected to be paid by Medicaid, except for when the CAP recipient is in deductible status. Since Medicaid requires the provider to be licensed, only licensed provider services can be placed in the Medicaid column. This includes private sitters.

(b) The CAP recipient must be responsible for payment of the charge, in order to apply the charge toward the deductible. This charge must be included in the Medicaid column on the cost summary in the POC.

For example: Adult Day Health services can be applied to the deductible as long as the a/r is responsible for the charge and Adult Day Health services are included in the Medicaid column of the Plan of Care.

(c) Items listed in the “Other” column on the cost summary are expected to be paid for by a third party or provided at no charge, and cannot be used toward meeting a deductible. This includes services provided by a non-licensed person.

(5) There are some services (e.g.. DME’s, home modifications and etc.) that can be used toward a deductible for other Medicaid recipients, but must be included in the Medicaid column on the cost summary in the POC for CAP.

(6) A provider may not inflate charges to the a/r to assist the a/r in meeting a deductible, i.e., charge the a/r more than the provider's usual and customary charge.

(7) Expenses in Excess of the Deductible Amount:

(a) Current c.p.

1) Non-covered expenses applicable to the deductible that meet the requirements in a current c.p. (paid or unpaid) and are in excess of the amount of the monthly deductible may be "rolled over" to a subsequent month in the same c.p.

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(II.A.10.d.(7))

2) Non-covered expenses must be applied to the deductible before applying expenses that may be covered.

3) Expenses in a current c.p. that may be covered by Medicaid must be applied only after applying all non-covered expenses.

(b) Prior c.p.

The unpaid portion of medical bills from a prior c.p. in excess of the amount of the deductible may be "rolled over" to a subsequent c.p. if the bills:

1) Remain unpaid,

2) Have not been applied to a deductible that was met, and

3) Meet the other requirements of MA-2360, Medicaid Deductible.

(c) Refer to MA-2360, Medicaid Deductible, for deductible policy.

11. Retroactive Eligibility

There is no retroactive coverage for CAP services; however there is retroactive coverage for regular Medicaid services, if eligibility requirements are met in the retroactive period,

12. Reserve

a. The reserve limit is for a b.u. of one in all CAP cases. Refer to MA-2230 Financial Resources, for instructions regarding reserve requirements and procedures.

b. Spousal resource protection applies in CAP. The at home CAP spouse is entitled to resource protection. Refer to MA-2231, Community Spouse Resource Protection.

13. Transfer of Assets

Transfer of assets sanctions apply to all CAP programs, including CAP-MR/DD. Refer to MA-2240, Transfer of Resources.

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(II.A.)

14. Eligibility Information System (EIS) Entries

a. A CAP indicator code in EIS controls the payment for CAP services and the various exemptions for the CAP a/r, such as the exemption from prescription limits and co payments.

b. Failure to enter the CAP "indicator code" will result in denied claims.

c. Failure to enter the CAP "end date" when CAP services are terminated may result in payment errors, which will be the financial responsibility of the county department of social services (dss).

(1) If the a/r becomes institutionalized (placement in a nursing facility) a ltc living arrangement code or a patient monthly liability (pml) amount automatically closes CAP without the CAP termination information having to be entered by the county dss.

(2) When the entire case is closed, entering the termination code automatically closes CAP without the CAP termination information having to be entered by the county dss.

d. EIS instructions are found in EIS-3101.

15. Notices

a. Automated and manual notices are used for CAP cases. When using an “other code” you must key the notice text on page two of the DSS-8125.

b. Send the CAP Case Manager a copy of the notices sent to the a/r.

Examples: DSS-8108, Notice of Benefits, DSS-8109, Your Application for Benefits Is Being Denied Or Withdrawn, DSS-8110, Your Benefits Are Changing.

c. Refer to MA-2420, Notice and Hearings Process.

16. Appeals

Appeal requirements apply to CAP.

a. CAP/C and CAP/MR/DD appeals go directly to the DMA Hearing Office/Office of Administrative Hearings (OAH).

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(II.A.16.)

b. For appeals regarding CAP/DA hold a local hearing at the county dss. If further appeal is required, hold a state appeal through the Division of Social Services Hearing and Appeals. See MA-2420, Notice and Hearings Process.

17. Transfers

When a CAP recipient moves to another county, it does not affect his eligibility for CAP services. CAP coverage continues in the new county. Refer to IV, V, VI and VII for transfer instructions for specific CAP programs.

18. Estate recovery applies to CAP cases. Refer to MA-2285, Estate Recovery.

B. Policy Principles and Services for Specific CAP Programs

1. CAP/C - See IV.

2. CAP/DA - See V.

3. CAP/Choice – See VI.

4. CAP-MR/DD - See VII.