Accessnebraska Waiver Process Guide for Adult Populations

ACCESSNebraska Waiver Process Guide For Adult Populations

Aged and Disabled (AD) Waiver and Traumatic Brain Injury (TBI) Waiver

October 2010

Revised 10-15-10

Background……………………………………………………………………………………….2

1. Waiver Referral Process – SSW Role…………………………………..3

1. Waiver Office Receives Waiver Referral – SC Role………………4

II-A. Medicaid is Pending……………………………………………………5

II-B. Medicaid is Active……………………………………………………….5

II-C. No Medicaid Case……………………………………………………….5

1. Outcome of Waiver Referral………………………………………………6

III-A. Waiver Criteria is Met………………………………………………..6

III-B. Waiver is Denied………………………………………………………..7

1. Ongoing Communication……………………………………………………8

IV-A. Medicaid Eligibility Review…………………………………………8

IV-B. Waiver Eligibility Review…………………………………………….9

IV-C. Changes in Client Situation…………………………………………10

1. Appeal Process…………………………………………………………………..11

V-A. Appeal of Medicaid Action………………………………………….11

V-B. Appeal of Waiver Action……………………………………………..12

Appendix

Advantages of Receiving Waiver Services

Assisted Living Waiver Services Process

Waiver Referral Chart – Nebraska by City

Waiver Referral Chart – Nebraska by County

Senior Care Options (SCO) Process

Assistive Technology Partnership (ATP)

Disabled Persons and Family Support (DPFS)

1. A need for AD Waiver or TBI Waiver is identified.
2. Contact the Waiver Office serving the area where the client resides.
3. For clients age 18 through age 64, refer to the Waiver Services Contractor Chart, by City or by County, for where the client is located. See Table Key for contact information. For map, see for contact information.
4. For clients age 65 or over, refer to the Waiver Services Contractor Chart, by City or by County, for where the client is located. See Table Key for contact information. For map, see contact information.
5. Complete Referral, providing client’s contact information and the reason for the referral.

1. Referral from any source for a request for Waiver Services through the AD Waiver or the TBI Waiver is received.
2. Identify if the person currently has Medicaid
3. If Medicaid is open, determine if the individual is receiving full Medicaid.
4. If so, continue to Step 3, below.
5. If not, create Worker Alert for Medicaid case to determine if the client could qualify for full Medicaid if they would qualify for Waiver.
6. If Medicaid is not open, determine if Medicaid is pending. If so, continue to Step 3, below.
7. If there is no Active or Pending Medicaid case, the referral is not accepted. Continue to Steps 4 and 6.
8. Determine if the referral is accepted.
9. Inform the referral source of the outcome of the referral.
10. If referral is accepted, send a Worker Alert to the Medicaid case to pend an AD/TBI Waiver case and who to assign as the worker for that case.
11. If referral is not accepted, refer the individual to appropriate resources or services.

1. Review N-FOCUS Narrative.
2. If indicated, send Worker Alert for Medicaid eligibility issues, such as:
3. Share of Cost (SOC)
4. Resource Spenddown
5. Living Arrangement
6. Household Status
7. If Waiver referral is accepted, send Worker Alert on the Medicaid case to pend the Waiver case and to assign SC as worker for that case.

1. Review N-FOCUS Narrative.
2. Check Medicaid category to determine if individual is receiving full Medicaid.
3. If individual is not receiving full Medicaid, send Worker Alert to determine if the individual could qualify for full Medicaid if they were approved for AD or TBI Waiver.
4. If Waiver referral is accepted, send Worker Alert on the Medicaid case to pend the Waiver case and to assign SC as worker for that case.

1. Inform the individual they must first apply for Medicaid, and
2. If they choose to apply for Medicaid, to indicate on the application that they were directed to apply by the Waiver SC.

1. Check the status of the individual’s Medicaid Case
2. Check for a reply for any Worker Alert requests for information, including that the individual will qualify for full Medicaid, if needed.
3. Send Worker Alert to Medicaid case, indicating
4. The individual has been determined to meet the AD or TBI Waiver level of care,
5. The living arrangement, and
6. The effective date of Waiver eligibility.
7. If Medicaid is in Pending status, wait until Worker Alert is received on the AD or TBI case that Medicaid eligibility has been determined.
8. If Medicaid is Active, send Worker Alert requesting budgeting be processed to activate the AD or TBI case.
9. If individual is not eligible for full Medicaid, check that the AD or TBI case has been denied.

1. Upon full Medicaid eligibility determination for the individual, send Worker Alert to SC regarding the status of the Medicaid case.
2. When notified that the individual meets Waiver eligibility criteria, within 5 work days,
3. Complete budgeting process to activate the AD or TBI Waiver case, and
4. Generate a Worker Alert to the Waiver case for further SC processes.

1. The Pending Waiver case needs to be denied,
2. The reason Waiver eligibility is denied,
3. The identified unmet needs indicated in the Waiver Assessment that could be addressed by other DHHS programs, and
4. Other referrals completed by the SC.

1. Deny the AD or TBI program case on N-FOCUS.
2. Explore eligibility for other DHHS programs that could meet the individual’s needs, following program specific guidelines.
3. Consider if additional referrals are indicated.
4. Determine if additional action is needed regarding current Medicaid eligibility.

1. System-generated Medicaid Review letter/application is sent to the client.
2. When Alert is received that review letter has been sent, set a Worker Alert for the AD or TBI program case.
3. If Review Application is not received, close the Medicaid case. An automated alert is generated to the AD or TBI case.
4. If Review Application is received but requested verifications are not received, review the case to determine action to take on the case.
5. If Review Application and requested verifications are received, determine ongoing Medicaid eligibility.
6. If Medicaid eligibility ends, an automated alert is generated to the AD or TBI case.

1. SC receives the Worker Alert that a Medicaid Review is due.
2. Best Practice is to discuss the pending review with the client/representative during the monthly Waiver contact and encourage the client/representative to complete the review timely so benefits do not end.

1. Determine ongoing Waiver eligibility.
2. If AD or TBI eligibility ends, submit electronic Change Report* at for the individual, identifying the SC as the sender, communicating:
3. That AD or TBI is ending and the effective date it will close,
4. The reason AD or TBI Waiver is ending,
5. The identified unmet needs indicated in the Waiver Assessment that could be addressed by other DHHS programs, and
6. Other referrals completed by the SC.

1. Notification from SC is received that AD or TBI Waiver is closing.
2. Close the AD or TBI program case on N-FOCUS, and
3. Explore eligibility for other DHHS programs that could meet the individual’s needs, following program specific guidelines.
4. Consider if additional referrals are indicated. If so, inform the client or representative of other sources to explore for needed services.
5. Determine if additional action is needed regarding current Medicaid eligibility.

1. The primary responsibility for reporting changes in their circumstances to DHHS rests with the client or their legal representative.
2. If you become aware of changes in client’s circumstances that may impact Medicaid or AD/TBI Waiver eligibility or services, communicate it to the other party via Worker Alert or Change Report.
3. Examples of changes to communicate (not all inclusive):
4. Move with no change in living arrangement
5. Move that is a change in the living arrangement
6. Resources/Inheritance/Trust
7. Change in SOC
8. Change in Guardianship/Payee/POA
9. Change in Health Insurance
10. Accidents or injuries that might result in a claim to Third Party Liability (TPL)
11. Change in Household Composition
12. Medicaid and/or Waiver program cases close and reopen for any reason
13. Change in Income
14. Medical deduction amount needed for Medicaid eligibility
15. Death of client

1. Appeal Process

1. Notification of Medicaid appeal is received.
2. If client filed within 10 days:
3. When appropriate, re-pend and activate Medicaid and AD or TBI Waiver program case, if both were closed on the same notice.
4. Notify SC via Worker Alert to the AD or TBI program case that the program case has been reopened.
5. If client didn’t file within 10 days:
6. The Medicaid and AD or TBI program cases remain closed, pending appeal decision.
7. Notify SC via secure e-mail of the receipt of the appeal.
8. If appeal is withdrawn,
9. Close Medicaid and AD or TBI program cases, if activated pending appeal decision.
10. Notify the SC the appeal has been withdrawn, via secure e-mail.
11. When appeal findings are received, take appropriate action on the case and notify SC of the appeal findings.
12. If AD or TBI case is active, notify SC via Worker Alert.
13. If AD or TBI case is not active, notify SC via secure e-mail.

1. Notification of AD or TBI Waiver appeal is received.
2. If client filed within 10 days, when appropriate, create Worker Alert to the Medicaid program case to reopen the AD or TBI program case.
3. If the client didn’t file within 10 days, the AD or TBI program case remains closed, pending appeal decision.
4. If appeal is withdrawn, and AD or TBI program case was activated pending appeal decision, notify the Medicaid program case via Worker Alert to close the AD or TBI program case.
5. When appeal findings are received, if N-FOCUS action needs to be taken, notify the Medicaid program case via Worker Alert.

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