If someone is interested in the MFP program, who do they contact and who will contact them with a response?

If an individual is interested in the program they may send an email via our website contact page or call our toll free line at 1-877-546-3407.

How does the program determine qualified days of care when an individual enters a nursing facility but is then discharged to a hospital and then readmitted to a nursing facility?

Individuals who have qualifying days of care three months or more with long term care, meet the requirement of “Have resided in a NF three months or more.” The days in the hospital count as qualified days if an individual is readmitted to the nursing facility

What is Cost-Sharing?

The Social Security Act permits the State to require certain recipients to share some of the costs of Medicaid by imposing upon them such payments as enrollment fees, premiums, deductibles, coinsurance, co-payments, or similar cost sharing charges. The Transition Specialist will be responsible for explaining cost sharing responsibilities associated with the transition from the nursing facility to the community.

Can Community Transittion funds be utilized to maintain housing during a hospitalization or a re-admittance back to a facility setting?

No. Community Transittion funds are to be used only for the set up of housing and active transition to a home-and-community-based setting.

If the participant loses Medicaid eligibility or decides to move to a residence not qualified, will they still be eligible for the program?

No. An Individual must remain under Medicaid and choose a qualified residence to reside in to participate in the program. A qualified community based setting is a home owned or leased by the individual or the Individual's family member or an apartment with an individual lease, with lockable access and egress, which includes living, sleeping, bathing, and cooking areas over which the individual or the individual's family has domain and control. Qualified community based settings include apartments available in HUD subsidized housing complexes or congregate housing complexes that accommodate elders and individuals with special needs; or a residence, in a community-based residential setting in which no more than (4) four unrelated individuals reside, and Adult Foster Care.

Who is eligible to participate in the MFP Program?

To participate in the MFP Program, the individual must:

• Have lived in a nursing facility for at least 90 consecutive days (short-term rehab stays do not count towards the 90 days, must meet long term level of care)
• Be Medicaid eligible for 1 day prior to discharge
• Have health needs that can be met through services available in the community
• Voluntarily consent to participation by signing a consent form
• Be eligible for either the Aged & Disabled (A/D) or Traumatic Brain Injury (TBI) waiver, or Developmental Disabilities (DD) waiver

How does the MFP Program Work?

The MFP Program will assist Hoosiers transitioning from a nursing facility or by providing:

• Information to help participants make informed choices regarding transition and participation in the MFP Program and waivers
• Assessment by a nurse indicating that the individual can safely move and live independently
• Access to transition services and assistance from a transition nurse and transition specialist (case manager) through the local Area Agency on Aging
• Post-discharge follow-up by a transition specialist and case manager to ensure the move is satisfactory and the individual’s community-based needs are being met

In what areas of the state will the MFP Program Operate?

The MFP Program will operate throughout the state

What are Home and Community Services (HCBS)?

HCBS are services that are available to individuals who move from nursing facilities or hospitals into the community. These services are provided in addition to medical services that may be needed, to help recipients live independently in the community.

Who is eligible for the A/D and TBI, DD Waivers?

Applicants may choose the waiver that will best serve their individual needs, as long as the following eligibility requirements are met:

• A/D Waiver: Individuals who meet nursing facility level of care and Medicaid eligibility requirements and who are aged (age 65 or older) or disabled may be eligible for the A/D waiver.
• TBI Waiver: Individuals who meet nursing facility level of care and Medicaid eligibility requirements and who are disabled and have traumatic brain injuries may be eligible for the TBI waiver.
• DD Waiver: Individuals who meet the level of care for an intermediate care facility for the mentally retarded (ICF/MR) and Medicaid eligibility requirements may be eligible for the DD waiver

Who will make the final decision related to enrolling in MFP?

This program is person-centered, meaning that the participant or responsible representative will be the decision maker related to care and service type. All home and community-based waiver services require that services be provided to support the health and safety of the participant. Ultimately, it will be the Transition Specialist, Transition Nurse in consultation with the person transitioning that will determine that the program is a good match, and by enrolling the person into the appropriate waiver, assures that all requirements of the home and community-based waiver will be provided to the person.

Who are the cross-agencies that will be working alongside ADVANTAGE?

The Family and Social Services Administration (FSSA) consisting of the Office of Medicaid Policy and Planning (OMPP) and the Division of Aging (DA) have had much input with the Indiana MFP Program details and will work with ADVANTAGE on the program. Additionally, Advantage will coordinate with the Bureau of Developmental Disabilities (BDDS)

What is the difference between services provided through MFP and the current waivers as it relates to case management?

When an individual decides to participate in the MFP Program, the Case Manager will perform the basic functions of the case manager for the first six weeks, after their reentry to the community. The case manager will follow up within 24 hours of discharge, and weekly thereafter. After the first 6 weeks, the participant may transition to a new ongoing case manager, depending on location throughout the state. The Transition Specialist/Case Manager with follow-up at a minimum, quarterly, until the 365 day period is completed. With the traditional waiver, a case manager will follow up within one month of discharge and then every month thereafter.

Medicaid

How will the Transition Specialist verify Medicaid eligibility for the participant?

The State’s billing system, IndianaAIM, is the best source for determining eligibility for Medicaid.

If the participant loses Medicaid eligibility or decides to move to a residence not qualified, will they still be eligible for the program?

No. An Individual must remain under Medicaid and choose a qualified residence to reside in to participate in the program. A qualified community based setting is a home owned or leased by the individual or the Individual's family member or an apartment with an individual lease, with lockable access and egress, which includes living, sleeping, bathing, and cooking areas over which the individual or the individual's family has domain and control. Qualified community based settings include apartments available in HUD subsidized housing complexes or congregate housing complexes that accommodate elders and individuals with special needs; or a residence, in a community-based residential setting in which no more than (4) four unrelated individuals reside, and Adult Foster Care.

Transitioning

Once a participant is transferred home, how do they access transportation services?

The Transition Specialist will give the participant the Medicaid transportation pick list to choose a provider. All participants should have regular Medicaid transportation for medical appointments and then waiver/MFP transportation for all other kinds of transportation such as to the grocery store, shopping and visiting friends. The enhanced transportation should be added to the POC, except for adult foster care situations. This will be billed once the monthly amount of the regular waiver transportation has been met.

There is a 12-month limit to Transition Coordination case management. What will happen to those individuals in the community once the 12-month limit has been reached?

They will be referred to the local Area Agency on Aging (AAA) or Bureau for Developmental Disabilities (BDDS) for continued eligibility for one of the Home and Community Based Waivers or other eligible supportive services.