Purpose: This section will assist in determining whether individuals are eligible for the Community Choices Home & Community Based Waiver while residing in the community or in an Assisted Living Facility.

Current Policy Effective Date: August 1, 2025

Date Last Reviewed:

Previous Policy: January 1, 2022

POL 1002A: DETERMINING ELIGIBILITY FOR COMMUNITY CHOICES HOME & COMMUNITY BASED WAIVER

1. Applicants Must Meet Basic Eligibility Factors

Refer to Section M600 for a description of all basic eligibility factors.

2. Applicants Must Meet Medical Necessity Requirement

Applicants must meet medical necessity. Medical necessity is verified through an LT 101 and stored on the Medicaid Waiver system. Upload the Medicaid Activation Waiver Screen showing the applicant has received a funding opportunity and a Plan of Care has been approved. This verifies the applicant has met the medical necessity requirement.

3. Applicants Must Be Aged, Blind Or Disabled

Applicants must meet one of the following factors:

Age – 65 or older. Blind – legally blind based on Social Security standards. Disabled – person who receives disability benefits from SSA, or is determined disabled by WDH.

4. Applicants Must Be Age 19 Or Older

5. SSI Eligibles Do Not Need To Submit Application

If the client becomes ineligible for SSI, an application will be required to determine continued eligibility.

6. Applicants Must Meet Income Requirements

Require the countable income to be within the maximum income standard. Refer to Medicaid Table 1A for the income standards. Refer to Section M901 to determine if income is countable. Provide an Income Trust Packet when the countable income is above the maximum income standard.

7. Applicants Must Meet Resource Requirements

Require the countable resources to be within the maximum resource standards. Refer to Medicaid Table 7 for the resource standards. Refer to Section M801 to determine if resources are countable.

8. Services Withheld For Resource Transfers

Resources cannot be transferred for less than fair market value during the look-back period prior to application or when clients are receiving benefits.

Refer to Section M803 for information on transferred resources and Section M804 for information on transfer penalties.

9. Clients Must Have Approved Plan Of Care

10. Benefits Begin First Day of Month Plan Of Care Is Approved

Benefits begin the first day of the month the plan of care is approved by WDH.

11. Clients May Enter Nursing Homes

Clients entering a nursing home and remaining for 30 days must have their coverage changed to Nursing Home Care. Refer to Section M1001A for additional eligibility information.

12. Clients Must Be Reviewed

Clients must be periodically reviewed every 12 months to determine continued eligibility. Refer to Section M1403 for information on reviewing eligibility.

A review is not required for SSI clients.

Clients must be reviewed for other Medicaid program eligibility before closing cases.

13. Clients May Lose Benefits

The case will close when any of the following occur:

Client is discharged from the the Community Choices Home & Community Based Waiver. Client does not complete a review. Client dies. Client determined no longer eligible.