Overview of the MLTSS / HealthChoice Illinois Program
The Illinois Managed Long Term Services and Supports (MLTSS) Medicaid Waiver provides a variety of home and community-based services (HCBS) for elderly and disabled “dual eligible” residents who are at risk of being institutionalized (being placed in a nursing home). “Dual eligible” means eligible for both Medicaid and Medicare. HCBS are intended to assist program participants in maintaining independence at home, the home of a relative, or a supportive living setting, such as an assisted living residence. Benefits might include help with daily living activities, such as basic housecleaning, meal preparation, grocery shopping, bathing, and transportation for medical appointments. Adult day care is another potential benefit and can serve as respite care for program participants who have family caregivers.
Beneficiaries of the Managed Long Term Services and Supports Program receive their long-term care benefits via a single Medicaid plan provided by a managed care organization (MCO). A MCO is essentially a private healthcare company. The MCO has a network of care providers and program participants receive services via these providers. Within each county of Illinois, there are several managed care plans from which to choose. As a side note, many long-term care Medicaid programs allow program participants the option of self-directing their own care, specifically hiring the caregiver of their choosing. Unfortunately, this is not an option through the MLTSS program.
MLTSS is a mandatory statewide program for eligible persons who choose not to participate in the Medicare-Medicaid Alignment Initiative (MMAI). MMAI is also for persons who are “dual eligible”. However, with MMAI, program participants receive their Medicaid, Medicare, and prescription drug benefits via one healthcare plan, while only Medicaid benefits are received via MLTSS.
Both MLTSS and MMAI are entitlement programs, which means meeting eligibility requirements equates to immediate receipt of program benefits. Put differently, the programs do not limit the number of participant enrollment slots and there is never a waitlist for program participation.
The Medicaid Managed Long Term Services and Supports (MLTSS) Waiver Program is a 1915(b) Managed Care Waiver. It is part of the state’s managed care program, HealthChoice Illinois. To avoid confusion, the MLTSS Waiver may be referred interchangeably with HealthChoice Illinois. Illinois’ Family Health Program (FHP) and Integrated Care Program (ICP) are also part of the HealthChoice Illinois Program.
Medicaid pays doctors, hospitals, and other providers in one of two ways, either “Fee-For Service” or “Managed Care”. Under Fee-For Service, Medicaid pays providers directly for each service they provide. Beneficiaries can receive services from any Medicaid-certified provider. Under Managed Care, Medicaid contracts with a Managed Care Organization (MCO). Medicaid pays the MCO a set amount for each beneficiary, rather than for each service provided. The MCO has a network of doctors, hospitals, and other providers and the MCO pays them. Beneficiaries must use providers within the network.
Benefits of the MLTSS / HealthChoice Illinois Program
The following care services and supports may be available via the Managed Long Term Services and Supports Waiver / HealthChoice Illinois Program. An individual care plan will determine which benefits a program participant will receive.
– Adult Day Health Care – also called adult day service. Provides daytime supervision and assistance in a community-based group setting. Transportation to / from one’s home and adult day health facility may be provided.
– Assisted Living / Memory Care Services
– Behavioral Health
– Care Coordination
– Automated Medication Dispenser (AMD) – includes installation and monthly service fees
– Emergency Home Response – includes installation and monthly service fees
– Home Modifications – for safety and accessibility
– Homemaker Services –planning and preparation of meals, light housecleaning, and shopping for essentials
– Non-Emergency Transportation – to medical appointments
– Nursing Facility Care
– Personal Care Assistance – assistance with bathing, personal hygiene, eating, mobility, and self-administration of medications
Eligibility Requirements for MLTSS / HealthChoice Illinois Program
The Managed Long Term Services and Supports Waiver is a mandatory Medicaid program for Illinois residents who are elderly (60+ years old) or disabled (21+ years old), enrolled in Medicaid and Medicare, and either reside in a nursing home or receive long-term services and supports via a Medicaid Waiver, such as the HCBS Waiver for Persons who are Elderly and the Supportive Living Program. Remember, while MLTSS is a mandatory program for eligible persons, they do still have the option of enrolling in the Medicare-Medicaid Alignment Initiative instead. Additional eligibility criteria are as follows:
Financial Criteria: Income, Assets & Home Ownership
The applicant income limit is equivalent to 100% of the Federal Poverty Level (FPL), which increases on an annual basis in January. In 2021, an applicant, regardless of marital status, can have a monthly income up to $1,073. When both spouses are applicants, the monthly income limit for the couple is $1,452. When only one spouse is an applicant, the income of the non-applicant spouse is not counted towards the income eligibility of his/her spouse. Only the applicant spouse’s income is considered, which is limited to $1,073 / month. Furthermore, monthly income from the applicant spouse can be transferred to the non-applicant spouse as a spousal income allowance, also called a monthly maintenance needs allowance. The maximum amount that can be transferred in 2021 is $2,739 / month. This spousal allowance is intended to ensure the non-applicant spouse has a minimum monthly income of this amount. Non-applicant spouses who have their own income equal to or greater than $2,739 / month are not entitled to a spousal income allowance.
In 2021, the asset limit is $2,000 for a single applicant. For married couples, with both spouses as applicants, the asset limit is $3,000. When only one spouse is an applicant, the assets of both the applicant and non-applicant spouse are limited, though the non-applicant spouse is allocated a larger portion of the assets to prevent spousal impoverishment. (Unlike with income, Medicaid considers the assets of a married couple to be jointly owned). In this case, the applicant spouse can retain up to $2,000 in assets and the non-applicant spouse can keep up to $109,560. This larger allocation of assets to the non-applicant spouse is called a community spouse resource allowance.
Some assets are not counted towards Medicaid’s asset limit. These generally include an applicant’s primary home, household furnishings and appliances, personal effects, and a vehicle.
Assets should not be given away or sold under fair market value within 60-months of long-term care Medicaid application. This is because Medicaid has a look back rule and violating it results in a penalty period of Medicaid ineligibility.
The home is often the highest valued asset a Medicaid applicant owns, and many persons worry that Medicaid will take their home. Fortunately, for eligibility purposes, Illinois Medicaid considers the home exempt (non-countable) in the following circumstances.
– The applicant lives in the home or has “intent” to return to the home and his / her home equity interest is no greater than $603,000. Home equity interest is the current value of the home minus any outstanding mortgage.
– The applicant has a spouse that lives in the home.
– The applicant has a disabled or blind adult child that lives in the home.
– The applicant has a child under 21 years old that lives in the home.
To learn more about the potential of Medicaid taking the home, click here.
Medical Criteria: Functional Need
An applicant must require a nursing facility level of care (NFLOC). For the Managed Long Term Services and Supports Program, a needs assessment to determine one’s level of care requirement is completed by a Community Care Unit (CCU) contracted by the state. The tool used is the Determination of Need (DON). To assess functional needs, one’s ability / inability to independently complete the activities of daily living (i.e., transferring from the bed to a chair, mobility, eating, toileting, eating) and instrumental activities of daily living (i.e., housework, laundry, preparing meals) is considered. A Mini-Mental Status Examination (MMSE) considers one’s cognitive functioning, such as sense of awareness and memory, which is relevant for persons with Alzheimer’s disease or a related dementia. A diagnosis of dementia in and of itself does not mean one will meet a NFLOC.
Qualifying When Over the Limits
Having income and / or assets over Medicaid’s limit(s) does not mean an applicant cannot still qualify for Illinois Medicaid. There are a variety of planning strategies that can be used to help persons who would otherwise be ineligible to become eligible. Some of these strategies are fairly easy to implement, and others, exceedingly complex. Below are the most common.
While Illinois has a Spenddown Program that permits Medicaid applicants to spend “excess” income on medical expenses in order to meet Medicaid’s income limit, the MLTSS Program prohibits persons from qualifying via this avenue.
When persons have assets over the limits, trusts are an option. Irrevocable Funeral Trusts are pre-paid funeral and burial expense trusts that Medicaid does not count as assets. Medicaid asset protection trusts are another option, given advanced planning is done. With this planning strategy, the Medicaid applicant is no longer considered the owner of the assets. In addition to spending countable assets on non-countable assets, there are many other options when the applicant has assets exceeding the limit.
Inadequate planning or improperly implementing a Medicaid planning strategy can result in a denial or delay of Medicaid benefits. Professional Medicaid planners are educated in the planning strategies available in the state of Illinois to meet Medicaid’s financial eligibility criteria without jeopardizing Medicaid eligibility. Furthermore, there are additional planning strategies that not only help one meet Medicaid’s financial criteria, but can also protect assets from Medicaid’s estate recovery program. These strategies often violate Medicaid’s 60-month look back rule, and therefore, should be implemented well in advance of the need for long-term care. However, there are some workarounds, and Medicaid planners are aware of them. For these reasons, it is highly suggested one consult a Medicaid planner for assistance in qualifying for Medicaid when over the income and / or asset limit(s). Find a Medicaid planner.
How to Apply for the MLTSS / HealthChoice Illinois Program
Before You Apply
Prior to applying for the MLTSS Program / HealthChoice Illinois Program, applicants need to ensure they meet the eligibility criteria. Applying when over the income and / or asset limit(s) will be cause for denial of benefits. The American Council on Aging offers a free Medicaid eligibility test to determine if one might meet Medicaid’s eligibility criteria. Take the Medicaid eligibility test.
As part of the application process, applicants will need to gather documentation for submission. Examples include copies of Social Security and Medicare cards, bank statements up to 60-months prior to application, proof of income, and copies of life insurance policies, property deeds, and pre-need burial contracts. Unfortunately, a common reason applications are delayed is required documentation is missing or not submitted in a timely manner.
To apply for the Managed Long Term Services and Supports Program / HealthChoice Illinios, one must apply for IL Medicaid. This can be done via one’s local Department of Human Services’ Family Community Resource Center (FCRC). Contact information can be found here. Persons can also call the Bureau of Customer Inquiry and Assistance at 1-800-843-6154 to locate their local office. Alternatively, persons can apply online via the ABE (Application for Benefits Eligibility) portal here. As part of the application process, the Department on Aging will arrange an in-person needs assessment to determine if the nursing home level of care need is met.
Persons already enrolled in Medicaid who meet the eligibility criteria for the MLTSS Program can call the Illinois Client Enrollment Broker at 1-877-912-8880 to enroll. Alternatively, persons can enroll online. A MCO health plan must be chosen or one will automatically be assigned. Available health plans by Illinois county can be seen here.
For additional information about the MLTSS Waiver, click here and here. Persons can also call the IL Client Enrollment Broker at 1-877-912-8880 for information or assistance choosing a health plan. Furthermore, the elderly can call the IL Department on Aging at 1-800-252-8966 and the disabled can call the IL Department of Human Services, Division on Rehabilitation Services at 1-800-843-6154 for information. The Illinois Department of Healthcare and Family Services (HFS) administers the Managed Long Term Services and Supports Waiver.
Approval Process & Timing
The Medicaid application process can take up to 3 months, or even longer, from the beginning of the application process through the receipt of the determination letter indicating approval or denial. Generally, it takes one several weeks to complete the application and gather all of the supportive documentation. If the application is not properly completed, or required documentation is missing, the application process will be delayed even further. In most cases, it takes between 45 and 90 days for the Medicaid agency to review and approve or deny one’s application. Based on law, Medicaid offices have up to 45 days to complete this process (up to 90 days for disability applications). However, despite the law, applications are sometimes delayed even further.