Preproposal statement of inquiry was filed as WSR 97-20-120.

Title of Rule: WAC 388-86-005 Services available to recipients of categorically needy medical, 388-506-0620 SSI-related medical clients, and 388-511-1105 SSI-related eligibility requirements.

Purpose: To amend the medical assistance administration rules that have been partially incorporated into the proposed rules filed as WSR 98-11-084 in order to avoid duplication.

Statutory Authority for Adoption: RCW 74.04.050, 74.04.055, 74.04.057, and 74.08.090.

Statute Being Implemented: RCW 74.04.050, 74.04.055, 74.04.057, and 74.08.090.

Summary: See Purpose above.

Reasons Supporting Proposal: If current rules are not amended at the same time the new rules, filed as WSR 98-11-084, become effective, then two sets of rules will exist in conflict with one another.

Name of Agency Personnel Responsible for Drafting, Implementation and Enforcement: Kevin Sullivan, Medical Assistance Administration, 617 8th S.E., Olympia, WA 98504, (360) 664-2314.

Name of Proponent: Department of Social and Health Services, Medical Assistance Administration, governmental.

Rule is not necessitated by federal law, federal or state court decision.

Explanation of Rule, its Purpose, and Anticipated Effects: See Purpose above.

Proposal Changes the Following Existing Rules: WAC 388-86-005, subsections (1), (2), (8) and (11) are being incorporated into WAC 388-529-0100 and 388-529-0200. Subsection (4) is unnecessary because it is addressed in WAC 388-540-010. Subsections (6) and (7) are unnecessary because they are addressed in chapter 388-240 WAC.

WAC 388-506-0620, subsections (1) and (2) are being incorporated into WAC 388-408-0055; adding cross reference to WAC 388-408-0055 in new subsection (7).

WAC 388-511-1105, replacing outdated WAC cross reference with current one in subsection (4).

No small business economic impact statement has been prepared under chapter 19.85 RCW. These rules do not affect businesses.

RCW 34.05.328 does not apply to this rule adoption. These rules are not considered significant rules because they do not change existing policy.

Hearing Location: Lacey Government Center (behind Tokyo Bento Restaurant), 1009 College Street S.E., Room 104-B, Lacey, WA 98503, on August 25, 1998, at 10:00 a.m.

Assistance for Persons with Disabilities: Contact Paige Wall by August 14, 1998, phone (360) 902-7540, TTY (360) 902-8324, e-mail pwall@dshs.wa.gov.

Submit Written Comments to: Identify WAC Numbers, Paige Wall, Acting Rules Coordinator, Rules and Policies Assistance Unit, P.O. Box 45850, Olympia, WA 98504-5850, fax (360) 902-8292, by August 25, 1998.

Date of Intended Adoption: September 1, 1998.

July 21, 1998

Edith M. Rice, Chief

Office of Legal Affairs

AMENDATORY SECTION (Amending Order 3913, #100246, filed 10/25/95, effective 10/28/95)

WAC 388-86-005  Limitations on services available to recipients of categorically needy medical assistance. (1) ((The department shall provide the following Title XIX mandatory services:

(a) Early and periodic screening diagnosis and treatment services to an eligible person twenty years of age or under;

(b) Family planning services;

(c) Federally qualified health center services;

(d) Home health agency services;

(e) Inpatient and outpatient hospital care;

(f) Medicare certified rural health clinic services;

(g) Other laboratory and x-ray services;

(h) Skilled nursing home care;

(i) Certified registered nurse practitioner services; and

(j) Physicians' services in the office or away from the office as needed for necessary and essential medical care.

(2) The department shall provide the following Title XIX optional services:

(a) Anesthesia services;

(b) Blood;

(c) Chiropractic services;

(d) Drugs and pharmaceutical supplies;

(e) Eyeglasses and examination;

(f) Hearing aids and examinations;

(g) Hospice services;

(h) Licensed midwife services;

(i) Maternity support services;

(j) Oxygen;

(k) Personal care services;

(l) Physical therapy services;

(m) Private duty nursing services;

(n) Surgical appliances;

(o) Prosthetic devices and certain other aids to mobility; and

(p) Dental services.

(3) The department shall limit)) Organ transplants are limited to the cornea, heart, heart-lung, kidney, kidney-pancreas, liver, pancreas, single lung, and bone marrow.

(((4) The department shall provide treatment, dialysis, equipment, and supplies for acute and chronic nonfunctioning kidneys when the client is in the home, hospital, or kidney center as described under WAC 388-86-050(12).

(5) The department shall provide))

(2) Detoxification and medical stabilization are provided to chemically-using pregnant women in a hospital.

(((6) The department shall provide detoxification of acute alcohol or other drug intoxication only in a certified detoxification center or in a general hospital having a detoxification provider agreement with the department.

(7) The department shall provide outpatient chemical dependency treatment in programs qualified under chapter 275-25 WAC and certified under chapter 275-19 WAC or its successor.

(8) For services available under the:

(a) Limited casualty program-medically needy, see chapter 388-529 WAC; and

(b) Limited casualty program-medically indigent, see chapter 388-529 WAC.

(9))) (3) The department may require a second opinion and/or consultation before the approval of any elective surgical procedure.

(((10))) (4) The department ((shall)) designates diagnoses that may require surgical intervention:

(a) Performed in other than a hospital in-patient setting; and

(b) Requiring prior approval by the department for a hospital admission.

(((11) The department shall assure the availability of necessary transportation to and from medical services covered under a client's medical program.))

[Statutory Authority: RCW 74.08.090. 95-22-039 (Order 3913, #100246), § 388-86-005, filed 10/25/95, effective 10/28/95; 93-17-038 (Order 3620), § 388-86-005, filed 8/11/93, effective 9/11/93; 92-03-084 (Order 3309), § 388-86-005, filed 1/15/92, effective 2/15/92; 90-17-122 (Order 3056), § 388-86-005, filed 8/21/90, effective 9/21/90; 90-12-051 (Order 3009), § 388-86-005, filed 5/31/90, effective 7/1/90; 89-18-033 (Order 2860), § 388-86-005, filed 8/29/89, effective 9/29/89; 89-13-005 (Order 2811), § 388-86-005, filed 6/8/89; 88-06-083 (Order 2600), § 388-86-005, filed 3/2/88. Statutory Authority: 1987 1st ex.s. c 7. 88-02-034 (Order 2580), § 388-86-005, filed 12/31/87. Statutory Authority: RCW 74.08.090. 87-12-050 (Order 2495), § 388-86-005, filed 6/1/87; 84-02-052 (Order 2060), § 388-86-005, filed 1/4/84; 83-17-073 (Order 2011), § 388-86-005, filed 8/19/83; 83-01-056 (Order 1923), § 388-86-005, filed 12/15/82; 82-10-062 (Order 1801), § 388-86-005, filed 5/5/82; 82-01-001 (Order 1725), § 388-86-005, filed 12/3/81; 81-16-033 (Order 1685), § 388-86-005, filed 7/29/81; 81-10-015 (Order 1647), § 388-86-005, filed 4/27/81; 80-15-034 (Order 1554), § 388-86-005, filed 10/9/80; 78-06-081 (Order 1299), § 388-86-005, filed 6/1/78; 78-02-024 (Order 1265), § 388-86-005, filed 1/13/78; Order 994, § 388-86-005, filed 12/31/74; Order 970, § 388-86-005, filed 9/13/74; Order 911, § 388-86-005, filed 3/1/74; Order 858, § 388-86-005, filed 9/27/73; Order 781, § 388-86-005, filed 3/16/73; Order 738, § 388-86-005, filed 11/22/72; Order 680, § 388-86-005, filed 5/10/72; Order 630, § 388-86-005, filed 11/24/71; Order 581, § 388-86-005, filed 7/20/71; Order 549, § 388-86-005, filed 3/31/71, effective 5/1/71; Order 453, § 388-86-005, filed 5/20/70, effective 6/20/70; Order 419, § 388-86-005, filed 12/31/69; Order 264 (part); § 388-86-005, filed 11/24/67.]

AMENDATORY SECTION (Amending Order 3732, filed 5/3/94, effective 6/3/94)

WAC 388-506-0620  SSI-related medical clients. (1) ((When determining program eligibility for medical care, the department shall limit relative financial responsibility from:

(a) The natural or adoptive parent or stepparent to a child seventeen years of age or younger living in the same household; and

(b) Spouse to spouse living in the same household.

(2) The department shall consider income and resources jointly for spouses when both spouses are SSI-related and live in the same household.

(3))) The department shall consider income and resources for an institutionalized:

(a) Child as described under WAC 388-513-1315(6); or

(b) Spouse as described under WAC 388-513-1330 and 388-513-1350.

(((4))) (2) The department shall consider the income and resources of spouses as available to each other through the month in which the spouses stopped living together. See WAC 388-513-1330 and 388-513-1350 when a spouse is institutionalized.

(((5))) (3) The department shall follow WAC 388-515-1505, 388-515-1510, or 388-515-1530 when one or both spouses are receiving community options program entry system (COPES), community alternatives program (CAP), outward bound residential alternatives (OBRA), or coordinated community aids service alternatives (CASA) waivered service program.

(((6))) (4) The department shall allow a community spouse applying for medically needy a spousal deduction equal to the one-person medically needy income level (MNIL) less the spouse's income when:

(a) The community spouse is living in the same household as the spouse; and

(b) The spouse is receiving home-based and community-based services.

(((7))) (5) The department shall consider income and resources separately as of the first day of the month following the month of separation when spouses stop living together because of placement into a congregate care facility (CCF), adult family home (AFH), adult residential rehabilitation center/adult residential treatment facility (ARRC/ARTF), or division of developmental disability-group home (DDD-GH) facility when:

(a) Only one spouse enters the facility;

(b) Both spouses enter the same facility but have separate rooms; or

(c) Both spouses enter separate facilities.

(((8))) (6) The department shall consider income and resources jointly when spouses are placed in a CCF, AFH, ARRC/ARTF, or DDD-GH facility and share a room.

(7) See Wac 388-408-0055 for rules on medical assistance units that include SSI-related persons.

[Statutory Authority: RCW 74.08.090. 94-10-065 (Order 3732), § 388-506-0620, filed 5/3/94, effective 6/3/94. Formerly WAC 388-92-025.]

AMENDATORY SECTION (Amending WSR 97-03-036, filed 1/9/97, effective 2/9/97)

WAC 388-511-1105  SSI-related eligibility requirements. (1) For the purposes of SSI-related medical assistance, the client shall be:

(a) Sixty-five years of age or over; or

(b) Blind with:

(i) Central visual acuity of 20/200 or less in the better eye with the use of a correcting lens; or

(ii) A limitation in the fields of vision so the widest diameter of the visual field subtends an angle no greater than twenty degrees; or

(c) Disabled.

(i) Decisions on SSI-related disability are the responsibility of the medical assistance administration (MAA) and shall be subject to the authority of:

(A) Federal statutes and regulations codified at 42 U.S.C. Sec 1382c and 20 C.F.R. Parts 404 and 416, as amended; or

(B) Controlling federal court decisions which define the OASDI and SSI disability standard and determination process.

(ii) For MAA's purposes, "disabled" means unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which:

(A) Can be expected to result in death; or

(B) Has lasted or can be expected to last for a continuous period of not less than twelve months.

(iii) In the case of a child seventeen years of age or younger, if the child suffers from any medically determinable physical or mental impairment of comparable severity.

(2) When a person has applied for Title II or Title XVI benefits and the SSA has denied the person's application solely because of a failure to meet Title II and Title XVI blindness or disability criteria, the SSA denial shall be binding on the department, unless the applicant's:

(a) SSA denial is under appeals in the reconsideration stage, the SSA's administrative hearing process, or the SSA's appeals council; or

(b) Medical condition has changed since the SSA denial was issued.

(3) The ineligible spouse, of an SSI beneficiary receiving a state supplement payment for the ineligible spouse, shall not be eligible for Medicaid as noninstitutional categorically needy. Such ineligible spouse may be eligible for noninstitutional medically needy.

(4) The client shall be resource eligible under WAC ((388-511-1110)) 388-478-0080 on the first day of the month to be eligible for any day or days of that month. The department shall make a resource determination of the first moment of the first day of the month. The department shall determine changes in the amount of a client's countable resources during a month do not affect eligibility or ineligibility for that month. Refer to WAC 388-513-1395 for an institutionalized client.

(5) The department shall consider a client under 1619(b) of the Social Security Act as eligible for SSI.

(6) The department shall provide a resident of Washington requiring medical assistance outside the United States care according to WAC 388-501-0180.

[Statutory Authority: RCW 74.08.090 and 74.04.050. 97-03-036, § 388-511-1105, filed 1/9/97, effective 2/9/97. Statutory Authority: RCW 74.08.090, P.L. 100-383, AFDC Transmittal Memo, POMS 830.100, 830.115, 830.725 and 1130.605. 95-08-070 (Order 3845), § 388-511-1105, filed 4/5/95, effective 5/6/95. Statutory Authority: RCW 74.08.090. 94-10-065 (Order 3732), § 388-511-1105, filed 5/3/94, effective 6/3/94. Formerly parts of WAC 388-85-115 and 388-92-015.]