GRH and Health CareGRH and Health Care

MA, GAMC and WaiversMA, GAMC and Waivers

Automatic EligibilityAutomatic Eligibility

Receiving GRH paymentReceiving GRH payment MA—must have MA basisMA—must have MA basis MA with waiverMA with waiver

– Eligible for MA payment of LTC servicesEligible for MA payment of LTC services– EW exception: Must do EW calculationEW exception: Must do EW calculation

GAMC—no MA basisGAMC—no MA basis– May or may not receive GA grantMay or may not receive GA grant

MA SpenddownMA Spenddown

Income over $867 (100% FPG)Income over $867 (100% FPG) Spend down to $650 (75% FPG)Spend down to $650 (75% FPG) What bills can be used?What bills can be used?

– Medicare premiums paid by enrolleeMedicare premiums paid by enrollee– Remedial CareRemedial Care– Waiver servicesWaiver services

What can’t be used?What can’t be used?– GRH room and board costs GRH room and board costs

Remedial CareRemedial Care

Special deduction for GRHSpecial deduction for GRH

Fixed amount updated twice yearlyFixed amount updated twice yearly

Allowed for anyone in a facility where Allowed for anyone in a facility where county has a GRH agreementcounty has a GRH agreement

Applied against spenddown, orApplied against spenddown, or Deducted from income (EW)Deducted from income (EW)

Spenddown Example 1Spenddown Example 1

Client age 34, single, residing in rate 1 Client age 34, single, residing in rate 1 GRH facility (cost $776)GRH facility (cost $776)

Eligible for CADI waiverEligible for CADI waiver Receives RSDI of $1070Receives RSDI of $1070 Pays Medicare Part B premium of $96Pays Medicare Part B premium of $96

Eligible for GRH? Eligible for GRH? No. $1070 - $20 general deduction and $96 No. $1070 - $20 general deduction and $96

($84 + $12) PN > $776($84 + $12) PN > $776

What is his spenddown?What is his spenddown?

Example 1 CalculationExample 1 Calculation

Income exceeds $867Income exceeds $867 $1070 – 650 = $420 spenddown$1070 – 650 = $420 spenddownCan he meet his spenddown?Can he meet his spenddown? H bill (Medicare) $96H bill (Medicare) $96 P bill (remedial care) $210P bill (remedial care) $210 $420- 306 = $113 spenddown $420- 306 = $113 spenddown

balance balance (MMIS recipient amount)(MMIS recipient amount)

Met with R bill (CADI services)Met with R bill (CADI services)

Spenddown Example 2Spenddown Example 2

Client age 50, single, residing in a Client age 50, single, residing in a board and lodge with $1183 GRH rateboard and lodge with $1183 GRH rate

Receives RSDI of $1571Receives RSDI of $1571 Not yet Medicare eligibleNot yet Medicare eligible Gets TCM services costing $286Gets TCM services costing $286 Not eligible for GRH grantNot eligible for GRH grant What is his spenddown?What is his spenddown?

Example 2 CalculationExample 2 Calculation Income exceeds $867Income exceeds $867 $1571 - $650 = $921 spenddown$1571 - $650 = $921 spenddown Can he meet his spenddown?Can he meet his spenddown? P bill (remedial care) $210P bill (remedial care) $210 $921 - $210 = $711 spenddown balance$921 - $210 = $711 spenddown balance

(MMIS recipient amount)(MMIS recipient amount) R bill (TCM) $286R bill (TCM) $286 $711- 286 = $425 remaining balance$711- 286 = $425 remaining balance

Not enough bills at this time—can’t meet Not enough bills at this time—can’t meet spenddownspenddown

EW Eligibility EW Eligibility

Income under the SIS?Income under the SIS?

Compute waiver obligationCompute waiver obligation

IIncome over the SIS?ncome over the SIS?No community spouse: SpenddownNo community spouse: Spenddown

Community spouse: LTC budget Community spouse: LTC budget

Example 3: SIS-EWExample 3: SIS-EW

Single client resides in GRH with Single client resides in GRH with assisted livingassisted living

Receives RSDI and pension of $1816Receives RSDI and pension of $1816 Pays Medicare Part B of $96Pays Medicare Part B of $96 Has $15 Part D copays (initial month)Has $15 Part D copays (initial month) Not eligible for GRH grantNot eligible for GRH grant

Does she have a waiver obligation? Does she have a waiver obligation?

Example 3 Calculation Example 3 Calculation

Income is less than SIS of $1911Income is less than SIS of $1911 Income deductions:Income deductions:

– Medicare premium $96Medicare premium $96– Maintenance needs allowance $860Maintenance needs allowance $860– Remedial care $210Remedial care $210– Copays $15 (initial month only)Copays $15 (initial month only)

$1816 – 1181 = $635 waiver $1816 – 1181 = $635 waiver obligationobligation

Example 4: SIS-EW and GRHExample 4: SIS-EW and GRH

Single client resides in adult foster careSingle client resides in adult foster care GRH rate 1 ($776)GRH rate 1 ($776) Receives RSDI of $850Receives RSDI of $850 QMB pays MedicareQMB pays Medicare

Is there a waiver obligation?Is there a waiver obligation?

Example 4 CalculationExample 4 Calculation

GRH GRH

$850 RSDI$850 RSDI- 20 20 generalgeneral

830830- 9696 personal needs personal needs

734734

$776 GRH rate $776 GRH rate

--734734

42 GRH grant42 GRH grant

SIS-EWSIS-EW

$850 RSDI$850 RSDI

--860860 maintenance needs maintenance needs

0 waiver obligation 0 waiver obligation

Example 5: Income Above SISExample 5: Income Above SIS

Single client resides in assisted livingSingle client resides in assisted living Receives RSDI and VA of $2075Receives RSDI and VA of $2075 Pays Medicare Part B of $96Pays Medicare Part B of $96

Waiver obligation? Spenddown?Waiver obligation? Spenddown?

Example 5 CalculationExample 5 Calculation

Income exceeds SIS of $1911Income exceeds SIS of $1911 $2075-650=$1425 spenddown$2075-650=$1425 spenddown H bill $96 (Medicare)H bill $96 (Medicare) P bill $210 (remedial care)P bill $210 (remedial care) Spenddown balance $1119Spenddown balance $1119 Must meet with waiver services and Must meet with waiver services and

other billsother bills

Example 6: SIS-EW with Example 6: SIS-EW with Community SpouseCommunity Spouse

Wife resides in GRH with assisted Wife resides in GRH with assisted living living

Receives RSDI and pension of $1816Receives RSDI and pension of $1816 Pays Medicare Part B of $96Pays Medicare Part B of $96 Husband resides in their homeHusband resides in their home Calculated spousal allocation $800Calculated spousal allocation $800

Does she have a waiver obligation?Does she have a waiver obligation?

Example 6 CalculationExample 6 Calculation

Income less than SISIncome less than SIS Income deductions:Income deductions:

– Medicare premium $96Medicare premium $96– Maintenance needs allowance $860Maintenance needs allowance $860$1816 – 956 = $860 available to allocate$1816 – 956 = $860 available to allocate- Calculated allocation $800Calculated allocation $800- Remedial care $210Remedial care $210

No waiver obligationNo waiver obligation

Example 7: Income Over SIS with Example 7: Income Over SIS with Community SpouseCommunity Spouse

Husband resides in assisted livingHusband resides in assisted living Receives RSDI and VA of $2075Receives RSDI and VA of $2075 Pays Medicare Part B of $96Pays Medicare Part B of $96 Wife resides in independent Wife resides in independent

apartmentapartment Calculated spousal allocation $800Calculated spousal allocation $800

What is the spenddown amount?What is the spenddown amount?

Example 7 CalculationExample 7 Calculation

Use LTC calculationUse LTC calculation Income deductionsIncome deductions

-$96 Medicare premium-$96 Medicare premium

-$84 personal needs-$84 personal needs

-$800 spousal allocation-$800 spousal allocation

-$210 remedial care-$210 remedial care

$2075 – 1190 = $885 spenddown$2075 – 1190 = $885 spenddown

Example 8: Both Spouses on EW Example 8: Both Spouses on EW and in GRH and in GRH

Couple resides in apartment and Couple resides in apartment and both receive assisted living services both receive assisted living services through EWthrough EW

Husband receives $2000 RSDI and Husband receives $2000 RSDI and pensionpension

Wife receives $1200 RSDIWife receives $1200 RSDI Both pay Medicare Part B of $96Both pay Medicare Part B of $96

Spenddown? Waiver obligation?Spenddown? Waiver obligation?

Example 8 CalculationExample 8 Calculation

HusbandHusband

Income exceeds SISIncome exceeds SIS

$2000$2000- 650650

1350 spenddown1350 spenddown

H bill $96 (Medicare)H bill $96 (Medicare)

P bill $210 (remedial)P bill $210 (remedial)

$1044 spenddown $1044 spenddown bal.bal.

WifeWife

Income under SISIncome under SIS

$1200$1200- 96 Medicare96 Medicare- 860 Maint. Needs860 Maint. Needs- 210210 remedial care remedial care

$ 34 waiver $ 34 waiver obligation obligation