PERMANENT RULES
SOCIAL AND HEALTH SERVICES
(Aging and Disability Services Administration)
Effective Date of Rule: Thirty-one days after filing.
Purpose: The department is amending WAC 388-515-1505 Financial eligibility requirements for long-term care services under COPES, New Freedom, PACE, MMIP, and WMIP:
| &sqbul; | Increasing the personal needs allowance (PNA) 3.3% for clients residing in alternate living facilities. This change is due to the Washington state 2007-09 operating budget (SHB 1128). |
| &sqbul; | Making changes to the language, clarifying rules, and updating WAC references. |
| &sqbul; | Clarifying the community spouse allowance computation. |
| &sqbul; | Clarifying excess nonexcluded resources above the standard are reduced in an amount equal to necessary medical care and not incurred by a transfer penalty. |
| &sqbul; | Clarifying the allowances for a General assistance -- Expedited medicaid (GA-X) client receiving earned income in an alternate living facility (ALF) on the home and community services (HCS) waiver. |
| &sqbul; | Clarifying and adding hospice service eligibility for clients not in a medical institution with gross income at or below the special income level (SIL – 300% of the federal benefit rate) and not eligible for another categorically needy (CN) or medically needy (MN) medicaid program. |
| &sqbul; | Clarifying that clients deemed "SSI eligible" do not participate in the cost of personal care, but may pay up to the room and board amount of the federal benefit rate (FBR) minus $60.78 if residing in an alternate living facility (ALF). |
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, 74.09.575, 74.09.500, and 74.09.530.
Other Authority: Chapter 522, Laws of 2007 (SHB 1128).
Adopted under notice filed as WSR 07-16-094 on July 30, 2007.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 1, Repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.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 1, Repealed 0.
Date Adopted: September 19, 2007.
Stephanie E. Schiller
Rules Coordinator
3883.3(a) Community options program entry system (COPES);
(b) Program of all-inclusive care for the elderly (PACE);
(c) Medicare/Medicaid integration project (MMIP);
(d) Washington Medicaid integration partnership (WMIP);
((and))
(e) New Freedom consumer directed services (New Freedom); and
(f) Hospice services for clients not in a medical institution with gross income at or below the SIL and not eligible for another CN or MN medicaid program.
(2) To be eligible, a client must:
(a) 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;
(iii) MMIP waiver services, per WAC 388-106-0725;
(iv) WMIP waiver services, per WAC 388-106-0750; ((or))
(v) New Freedom, per WAC 388-106-1410; or
(vi) Hospice, per chapter 388-551 WAC.
(b) Meet the aged, blind or disability criteria of the
Supplemental Security Income (SSI) program as described in WAC
((388-511-1105(1))) 388-475-0050(1);
(c) Require the level of care provided in a nursing facility as described in WAC 388-106-0355;
(d) Be residing in a medical facility as defined in WAC 388-500-0005, or likely to be placed in one within the next thirty days in the absence of home or community-based LTC services 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 home or community-based LTC
services and be approved for a plan of care as described in
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 388-513-1363, 388-513-1364, 388-513-1365 and 388-513-1366; and
(i) Meet the resource and income requirements described in subsections (3), (4), and (5) or be an SSI beneficiary not subject to a penalty period as described in subsection (2)(h).
(3) Refer to WAC 388-513-1315 for rules used to determine
((nonexcluded)) countable resources ((and)), income and
eligibility standards.
(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 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. If excess resources are not allocated to participation, then the client is ineligible)) Excess resources are reduced in an amount equal to medical expenses incurred by the institutional client as described in WAC 388-513-1350 and:
(a) Must result in countable resources being at or below the resource standard in WAC 388-513-1350(1).
(b) If remaining resources are over the standard, the client is ineligible.
(5) Nonexcluded income must be at or below the SIL (300% of the federal benefit rate (FBR)) 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 (7), (8), ((and)) (9), (10, and (11)
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)) garnished for child support or
withheld according to a child support order in the month of
the garnishment (for current and back support):
(i) For the time period covered by the ((maintenance
amount)) PNA; and
(ii) ((Not deducted under another provision in the
post-eligibility process)) Is not counted as the child's
income when determining the family allocation amount.
(e) Monthly maintenance needs allowance for the community
spouse not to exceed that in WAC 388-513-1380 (((6))) (5)(b)
unless a greater amount is allocated as described in
subsection (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 the amount described in WAC 388-513-1380
(6)(b)(i)(A))) One hundred fifty percent of the two person
federal poverty level. This standard increases annually on
July 1st (http://aspe.os.dhhs.gov/poverty/); 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))). This standard is based on thirty
percent of one hundred fifty percent of the two person federal
poverty level. This standard increases annually on July 1st
(http://aspe.os.dhhs.gov/poverty); and
(VII) Is reduced by the community spouse's gross countable income.
(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))) (5)(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.
(iii) Child support received from ((an absent)) a
noncustodial parent is the child's income;
(g) ((Incurred medical expenses described in subsection
(4)(b) not used to reduce excess resources, with the following
exceptions:
Private health insurance premiums for PACE, MMIP, or WMIP)) Medical expenses incurred by the client and not used to reduce excess resources. Allowable medical expenses and reducing excess resources are described in WAC 388-513-1350.
(6) The amount allocated to the community spouse may be greater than the amount in subsection (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.
(7) A client who receives SSI, and lives at home as
defined in WAC 388-106-0010 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 does not participate in the cost of personal care;
(b) In an 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 board and room. Board and room is the SSI federal benefit rate (FBR) minus fifty-eight dollars and eighty-four cents; and
(iii) Does not participate in the cost of personal care if any income remains)).
(8) A client who receives SSI and lives in an enhanced adult residential center (EARC), adult family home (AFH) or assisted living (AL) does not use income to participate in the cost of personal care and:
(a) Retains a personal needs allowance (PNA) of sixty dollars and seventy-eight cents; and
(b) Uses income to pay the facility for the cost of room and board.
(c) Room and board is the SSI FBR minus sixty dollars and seventy-eight cents.
(9) A client who is eligible to receive CN-P medicaid described in WAC 388-475-0100 (2)(a) and (b) and lives at home, defined in WAC 388-106-0010, does not use income to participate in the cost of personal care.
(10) A client who is eligible to receive CN-P medicaid described in WAC 388-475-0100 (2)(a) and (b) and lives in an EARC, AFH or AL does not use income to participate in the cost of personal care and:
(a) Retains a personal needs allowance (PNA) of sixty dollars and seventy-eight cents; and
(b) Uses income to pay the facility for the cost of room and board.
(c) Room and board is the SSI FBR minus sixty dollars and seventy-eight cents.
(((8))) (11) An institutionalized 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, New Freedom, PACE, MMIP, or WMIP 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, New Freedom, PACE, MMIP, or WMIP.
(b) In an 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)) sixty dollars and
seventy-eight cents from the maintenance needs; and
(ii) Pays the remainder of the maintenance needs to the
facility for the cost of ((board and)) room and board. (Refer
to subsection (((11))) (14) in this section for allocation of
the balance of income remaining over maintenance needs.)
(((9))) (12) 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.
(((10))) (13) The total of the following amounts cannot
exceed the SIL:
(a) Maintenance and personal needs allowances as
described in subsections (7), (8), ((and)) (9), (10), (11),
and (12)((;)).
(b) Earned income deduction of the first sixty-five dollars plus one-half of the remaining earned income in subsection (5)(a); and
(c) Guardianship fees and administrative costs in subsection (5)(c).
(((11))) (14) The client's remaining income after the
allocations described in subsections (5) through (((9))) (12)
is the client's ((participation)) responsibility in the
((total)) cost of care.
[Statutory Authority: RCW 74.08.090, 42 C.F.R. 441.302(a), Social Security Act section 1915(c) waiver rules, 42 C.F.R. 438. 06-18-058, § 388-515-1505, filed 8/31/06, effective 10/1/06. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 74.09.530. 06-03-079, § 388-515-1505, filed 1/12/06, effective 2/12/06. 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.]