WSR 06-03-079

PERMANENT RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Health and Recovery Services Administration)

[ Filed January 12, 2006, 4:24 p.m. , effective February 12, 2006 ]


Effective Date of Rule: Thirty-one days after filing.

Purpose: The department of social and health services (DSHS) is adding program of all-inclusive care for the elderly (PACE), and Medicare-Medicaid integration project (MMIP) eligibility rules to this WAC section. DSHS is also changing language to make the rule clearer.

Citation of Existing Rules Affected by this Order: Amending WAC 388-515-1505.

Statutory Authority for Adoption: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 74.09.530.

Adopted under notice filed as WSR 05-23-163 on November 23, 2005.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 1, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 1, Repealed 0.

Date Adopted: January 11, 2006.

Andy Fernando, Manager

Rules and Policies Assistance Unit

3621.3
AMENDATORY SECTION(Amending WSR 05-03-077, filed 1/17/05, effective 2/17/05)

WAC 388-515-1505   ((Community options program entry system (COPES))) Financial eligibility requirements for long-term care services under COPES, PACE, and MMIP.   (1) This section describes the financial eligibility requirements and the rules used to determine a client's participation in the total cost of care for ((waiver)) home or community-based long-term care (LTC) services provided under the following programs:

(a) Community options program entry system (COPES) ((and the rules used to determine a client's participation in the total cost of care.

(1))) (b) Program of all-inclusive care for the elderly (PACE); and

(c) Medicare/Medicaid integration project (MMIP).

(2) To be eligible ((for COPES)), a client must:

(a) ((Be eighteen years of age or older;)) Meet the program and age requirements for the specific program, as follows:

(i) COPES, per WAC 388-106-0310;

(ii) PACE, per WAC 388-106-0705; or

(iii) MMIP waiver services, per WAC 388-106-0725.

(b) Meet the aged, blind or disability criteria of the Supplemental Security Income (SSI) program as described in WAC ((388-503-0510(1))) 388-511-1105(1);

(c) Require the level of care provided in a nursing facility as described in WAC ((388-72A-0055)) 388-106-0355;

(d) Be residing in a medical facility as defined in WAC ((388-513-1301)) 388-500-0005, or likely to be placed in one within the next thirty days in the absence of ((waiver)) home or community-based LTC services ((described in WAC 388-71-0410 and 388-71-0415)) provided under one of the programs listed in subsection (1) of this section;

(e) Have attained institutional status as described in WAC 388-513-1320;

(f) Be determined in need of ((waivered)) home or community based LTC services and be approved for a plan of care as described in ((WAC 388-72A-0055)) subsection (2)(a)(i), (ii), or (iii);

(g) Be able to live at home with community support services and choose to remain at home, or live in a department-contracted:

(i) Enhanced adult residential care (EARC) facility;

(ii) Licensed adult family home (AFH); or

(iii) Assisted living (AL) facility.

(h) Not be subject to a penalty period of ineligibility for the transfer of an asset as described in WAC 388-513-1364, 388-513-1365 and 388-513-1366; and

(i) Meet the resource and income requirements described in subsections (((2),)) (3) ((and)), (4), and (5) or be an SSI beneficiary not subject to a penalty period as described in subsection (2)(h).

(((2))) (3) Refer to WAC 388-513-1315 for rules used to determine nonexcluded resources and income.

(((3))) (4) Nonexcluded resources above the standard described in WAC 388-513-1350(1):

(a) Are allowed during the month of an application or eligibility review, when the combined total of excess resources and nonexcluded income does not exceed the special income level (SIL).

(b) Are reduced by ((incurred)) medical expenses incurred by the client (for definition, see WAC 388-519-0110(10)) that are not subject to third-party payment and for which the client is liable, including:

(i) Health insurance and Medicare premiums, deductions, and co-insurance charges; and

(ii) Necessary medical care recognized under state law, but not covered under the state's Medicaid plan.

(c) Not allocated to participation must be at or below the resource standard((, otherwise)). If excess resources are not allocated to participation, then the client is ineligible.

(((4))) (5) Nonexcluded income must be at or below the SIL and is allocated in the following order:

(a) An earned income deduction of the first sixty-five dollars plus one-half of the remaining earned income;

(b) Maintenance and personal needs allowances as described in subsection (((6),)) (7), ((and)) (8), and (9) of this section;

(c) Guardianship fees and administrative costs including any attorney fees paid by the guardian only as allowed by chapter 388-79 WAC;

(d) Income garnisheed for child support or withheld ((pursuant)) according to a child support order:

(i) For the time period covered by the maintenance amount; and

(ii) Not deducted under another provision in the post-eligibility process.

(e) Monthly maintenance needs allowance for the community spouse not to exceed that in WAC 388-513-1380 (6)(b) unless a greater amount is allocated as described in subsection (((5))) (6) of this section. This amount:

(i) Is allowed only to the extent that the client's income is made available to the community spouse; and

(ii) Consists of a combined total of both:

(A) An amount added to the community spouse's gross income to provide ((a total equal to)) the amount ((allocated)) described in WAC 388-513-1380 (6)(b)(i)(A); and

(B) Excess shelter expenses. For the purposes of this section, excess shelter expenses are the actual required maintenance expenses for the community spouse's principal residence. These expenses are:

(I) Rent;

(II) Mortgage;

(III) Taxes and insurance;

(IV) Any maintenance care for a condominium or cooperative; and

(V) The food assistance standard utility allowance (for LTC services this is set at the standard utility allowance (SUA) for a four-person household), provided the utilities are not included in the maintenance charges for a condominium or cooperative;

(VI) LESS the standard shelter allocation listed in WAC 388-513-1380 (7)(a).

(f) A monthly maintenance needs amount for each minor or dependent child, dependent parent or dependent sibling of the community or institutionalized spouse based on the living arrangement of the dependent. If the dependent:

(i) Resides with the community spouse, the amount is equal to one-third of the community spouse income allocation as described in WAC 388-513-1380 (((6)(b)(I)(A))) (6)(b)(i)(A) that exceeds the dependent family member's income;

(ii) Does not reside with the community spouse, the amount is equal to the MNIL for the number of dependent family members in the home less the income of the dependent family members. Child support received from an absent parent is the child's income;

(g) Incurred medical expenses described in subsection (((3)(b))) (4)(b) not used to reduce excess resources, with the following exceptions:

(i) Private health insurance premiums for MMIP;

(ii) Medicare advantage plan premiums for PACE.

(((5))) (6) The amount allocated to the community spouse may be greater than the amount in subsection (((4)(e))) (5)(e) only when:

(a) A court enters an order against the client for the support of the community spouse; or

(b) A hearings officer determines a greater amount is needed because of exceptional circumstances resulting in extreme financial duress.

(((6))) (7) A client who receives SSI does not use income to participate in the cost of personal care, but does use SSI income to participate in paying costs of board and room. When such a client lives:

(a) At home, the SSI client ((retains a maintenance needs amount equal to the following:

(i) Up to one hundred percent of the one-person Federal Poverty Level (FPL), if the client is:

(A) Single; or

(B) Married, and is:

(I) Not living with the community spouse; or

(II) Whose spouse is receiving long-term care (LTC) services outside of the home.

(ii) Up to one hundred percent of the one-person FPL for each client, if both spouses are receiving COPES services;

(iii) Up to the one-person MNIL if the client is living with a community spouse who is not receiving LTC services.)) does not participate in the cost of personal care;

(b) In an ((EARC, AFH, or AL)) enhanced adult residential center (EARC), adult family home (AFH), or assisted living (AL), the SSI client:

(i) Retains a personal needs allowance (PNA) of fifty-eight dollars and eighty-four cents;

(ii) Pays the facility for the cost of ((room and)) board and room. ((Room and board)) Board and room is the SSI Federal Benefit Rate (FBR) minus fifty-eight dollars and eighty-four cents((:)); and

(iii) ((Retains the remainder of the)) Does not participate in the cost of personal care if any income remains.

(((7))) (8) An SSI-related client living:

(a) At home, retains a maintenance needs amount equal to the following:

(i) Up to one hundred percent of the one-person FPL, if the client is:

(A) Single; or

(B) Married, and is:

(I) Not living with the community spouse; or

(II) Whose spouse is receiving long-term care (LTC) services outside of the home.

(ii) Up to one hundred percent of the one-person FPL for each client, if both spouses are receiving COPES, PACE, or MMIP services;

(iii) Up to the one-person medically needy income level (MNIL) for a married client who is living with a community spouse who is not receiving COPES, PACE, or MMIP.

(b) In an ((ARC,)) EARC, AFH, or AL, retains a maintenance needs amount equal to the SSI FBR and:

(i) Retains a personal needs allowance (PNA) of fifty-eight dollars and eighty-four cents from the maintenance needs; and

(ii) Pays the remainder of the maintenance needs to the facility for the cost of board and room. (Refer to subsection (11) in this section for allocation of the balance of income remaining over maintenance needs.)

(((8))) (9) A client who is eligible for the general assistance expedited Medicaid disability (GAX) program does not participate in the cost of personal care. When such a client lives:

(a) At home, the client retains the cash grant amount authorized under the general assistance program;

(b) In an AFH, the client retains a PNA of thirty-eight dollars and eighty-four cents, and pays remaining income and GAX grant to the facility for the cost of board and room; or

(c) In an EARC or AL, the client only receives a PNA of thirty-eight dollars and eighty-four cents and retains it.

(((9))) (10) The total of the following amounts cannot exceed the SIL:

(a) Maintenance and personal needs allowances as described in subsections (((6),)) (7), ((and)) (8), and (9);

(b) Earned income deduction of the first sixty-five dollars plus one-half of the remaining earned income in subsection (((4)(a))) (5)(a); and

(c) Guardianship fees and administrative costs in subsection (((4)(c))) (5)(c).

(((10))) (11) The client's remaining income after the allocations described in subsections (((4))) (5) through (((8))) (9) is the client's participation in the total cost of care.

[Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and 74.09.575. 05-03-077, 388-515-1505, filed 1/17/05, effective 2/17/05; 02-05-003, 388-515-1505, filed 2/7/02, effective 3/10/02. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and 74.09.500. 01-02-052, 388-515-1505, filed 12/28/00, effective 1/28/01. Statutory Authority: RCW 74.08.090, 74.04.050, 74.04.057, 42 C.F.R. 435.601, 42 C.F.R. 435.725-726, and Sections 4715 and 4735 of the Federal Balanced Budget Act of 1997 (P.L. 105-33) (H.R. 2015). 00-01-087, 388-515-1505, filed 12/14/99, effective 1/14/00. Statutory Authority: RCW 74.08.090. 96-14-058 (Order 100346), 388-515-1505, filed 6/27/96, effective 7/28/96; 95-20-030 (Order 3899), 388-515-1505, filed 9/27/95, effective 10/28/95; 94-10-065 (Order 3732), 388-515-1505, filed 5/3/94, effective 6/3/94. Formerly WAC 388-83-200.]