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

     Purpose: To comply with federal rules with regard to copayments, policies, and program eligibility.

     Citation of Existing Rules Affected by this Order: Amending WAC 388-517-0310 and 388-517-0320.

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

     Other Authority: 42 U.S.C. Section 1396a.

      Adopted under notice filed as WSR 07-11-135 on May 22, 2007.

     Changes Other than Editing from Proposed to Adopted Version: WAC 388-517-0310(2), substituted "persons" for the word "individuals"; WAC 388-517-0320(6), added explanation of what is meant by the term "dual-eligible client"; and WAC 388-517-0320 (1) and (6), added reference to the governing rule, WAC 388-502-0110.

     Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 2, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0;      Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 2, Repealed 0.

     Date Adopted: July 6, 2007.

Stephanie E. Schiller

Rules Coordinator

     (a) Be ((eligible for)) entitled to or receiving medicare Part A. Qualified disabled working individuals (QDWI) clients must be under age sixty-five;

     (b) Meet program income standards, see WAC 388-478-0085; and

     (c) Have resources at or below twice the resource standards for SSI and SSI related programs, see WAC ((388-478-0085(6))) 388-478-0080(4).

     (2) MSP follow categorically needy program rules for SSI related ((rules)) persons in chapter 388-475 WAC.

     (3) MSP clients are entitled to a fair hearing when the department takes an adverse action such as denying or terminating MSP benefits.

     (4) The department subtracts the allocations and deductions described under WAC 388-513-1380 from a long-term care client's countable income and resources when determining MSP eligibility:

     (a) Allocations to a spouse and/or dependent family member; and

     (b) Client participation in cost of care.

     (5) Medicaid eligibility may affect MSP eligibility, as follows:

     (a) Qualified medicare beneficiaries (QMB) and specified low income beneficiaries (SLMB) clients can receive medicaid and still be eligible to receive QMB or SLMB benefits.

     (b) Qualified individuals (QI-1) and qualified disabled working individuals (QDWI) clients who begin to receive medicaid are no longer eligible for QI-1 or QDWI benefits.

     (6) Every year, when the federal poverty level changes:

     (a) The department adjusts income standards for MSP and state funded medicare buy-in programs, see WAC 388-478-0085.

     (b) The department begins to count the annual Social Security cost-of-living (COLA) increase on April 1st each year when determining eligibility for MSP and state funded medicaid buy-in programs.

     (7) There is no income limit for the state-funded medicare buy-in program. The state-funded medicare buy-in program is for clients who receive medicaid but do not qualify for the federal MSP.

[Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, and 42 U.S.C. 1396a(a) (Section 1902 (n)(2) of the Social Security Act of 1924). 05-14-125, § 388-517-0310, filed 7/1/05, effective 8/1/05.]

     (a) ((Pays)) Medicare Part A premiums (if any);

     (b) ((Pays)) Medicare Part B premiums;

     (c) ((Pays all)) Coinsurance, deductibles ((as described in subsection (6) of this section;

     (d) May pay Medicare Advantage Part C premiums, if cost effective, for those clients already enrolled in Medicare Advantage Part C at the time of application for Medicare Advantage Part C premium payment. (The department does not select a Medicare Advantage Part C plan for QMB clients);

     (e) Pays all coinsurance deductibles and co-payments for QMB-eligible clients enrolled in Medicare Advantage Part C as described in subsection (6) of this section; and

     (f) Pays QMB premiums the first of the month following the month that QMB eligibility is determined)), and copayments for medicare Part A, Part B, and medicare advantage Part C with the following conditions:

     (i) Only the Part A and Part B deductible, coinsurance, and copayments up to the medicare or medicaid allowed amount, whichever is less (WAC 388-502-0110), if the service is covered by medicare and medicaid.

     (ii) Only the deductible, coinsurance, and copayments up to the medicare allowed amount if the service is covered only by medicare.

     (d) Copayments for QMB-eligible clients enrolled in medicare advantage Part C up to the medicare or medicaid allowed amount whichever is less (WAC 388-502-0110).

     (e) QMB Part A and/or Part B premiums the first of the month following the month the QMB eligibility is determined.

     (2) For specified low-income medicare beneficiary (SLMB) clients, the department pays medicare Part B premiums effective up to three months prior to the certification period if eligible for those months. No other payments are made for SLMBs.

     (3) For qualified individual (QI-1) clients, the department pays medicare Part B premiums effective up to three months prior to the certification period if eligible for those months unless:

     (a) The client receives medicaid categorically needy (CN) or medically needy (MN) benefits; and/or

     (b) The department's annual federal funding allotment is spent. The department resumes QI-1 benefit payments the beginning of the next calendar year.

     (4) For qualified disabled working individual (QDWI) clients, the department pays medicare Part A premiums effective up to three months prior to the certification period if eligible for those months. The department stops paying medicare Part A premiums if the client begins to receive CN or MN medicaid.

     (5) For state-funded medicare buy-in program clients, the department pays ((Medicare)):

     (a) Medicare Part B premiums; and

     (b) Only the Part A and B co-insurance, deductibles, and co-payments ((described in subsection (6) of this section)) up to the medicare or medicaid allowed amount, whichever is less (WAC 388-502-0110), if the service is covered by medicare and medicaid.

     (6) For the dual-eligible client, (a client receiving both medicare and CN or MN medical coverage) the department ((limits payments for certain services, provided to Medicare savings and state-funded Medicare buy-in clients,)) pays as follows:

     (a) If the ((Medicaid payment rate is higher than the amount paid by Medicare, the department pays only the cost-sharing liability of the Medicare co-insurance charge)) service is covered by medicare and medicaid, medicaid pays only the deductible, and coinsurance up to the medicare or medicaid allowed amount, whichever is less (WAC 388-502-0110); and

     (b) ((For Medicaid clients who are entitled to Medicare Part A and/or Medicare Part B (referred to as "dual eligible" clients:

     (i) The department pays the Medicare or Medicaid payment rate, whichever is less, for services covered by both Medicare and Medicaid; and

     (ii) The department pays the Medicare deductibles and co-insurance services only covered by Medicare)) Copayments for medicare advantage Part C up to the medicare or medicaid allowed copayment amount, whichever is less (WAC 388-502-0110);

     (c) If no medicaid rate exists, the department will deny payment unless the client is also QMB then refer to section (1) above.

[Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, and 42 U.S.C. 1396a(a) (Section 1902 (n)(2) of the Social Security Act of 1924). 05-14-125, § 388-517-0320, filed 7/1/05, effective 8/1/05.]

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