Long Term Care (LTC): ADvantage Review Process

An annual review, redetermination of financial eligibility, is required for the continuation of benefits. The current income and resources of the individual receiving ADvantage Waiver benefits must be verified. The resources of the spouse, if any, must be reviewed to verify whether or not a transfer of assets has occurred. See article entitled LTC: Transfer of Assets (Community Spouse) – After Certification.

All current income and resource information of client should be entered in the appropriate FACS blocks and FACS case notes must be entered.

If client continues to be financially eligible the Social Services Specialist must update the “Type Action Taken” block in the Medical General Tab with CHANGE OF INFORMATION WHICH DOES NOT AFFECT SECTION STATUS and the “Date of Last Redetermination” block with the next effective date. No change is made to the authorization.

If it is determined that client is no longer financially eligible the nurse must be notified by email, with supervisor and area nurse copied as soon as possible. The nurse will have the responsibility of closing the ADvantage Waiver authorization. NOTE: If the case is not closed on or before the first deadline, the nurse cannot close the case until after the first day of the next month.

Only after receiving notification from the nurse that the ADvantage Waiver authorization is closed should the Social Services Specialist update the “Type Action Taken” block in the Medical General Tab with CLOSED and enter the appropriate reason for closure, if the client is not eligible for Medicaid coverage without ADvantage Waiver.

Unable to Locate: The Social Services Specialist should make every attempt to contact/locate the client before requesting the nurse to close the ADvantage Waiver authorization. Attempts should include sending an ADM-92, making phone calls to client or their representative, making a home visit and/or requesting the nurse’s assistance in locating client.

If the case has a Medicaid Income Pension Trust, refer to article LTC: Medical Income Pension Trust – Review.

The Social Services Specialist must NOT close an ADvantage case for any reason, including death of the client. The nurse must be notified and the authorization closed first.

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