WSR 00-19-071

EXPEDITED ADOPTION

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)

[ Filed September 19, 2000, 3:16 p.m. ]

Title of Rule: WAC 388-515-1505 Community options program entry system (COPES), 388-515-1510 Community alternatives program and outward bound residential alternatives, and 388-515-1530 Coordinated community AIDS services alternatives.

Purpose: Correcting cross references that are now outdated due to the recent amendment of WAC 388-513-1380 Institutional -- Participation -- Client cost of care.

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

Statute Being Implemented: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500.

Summary: This is a housekeeping action to correct the cross references to WAC 388-513-1380 in chapter 388-513 WAC. This is necessary because of the recent amendment to WAC 388-513-1380.

Name of Agency Personnel Responsible for Drafting, Implementation and Enforcement: Stephen Kozak, MAA, 617 8th Avenue S.E., Olympia, WA 98504, (360) 725-1321.

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 Summary above.

Proposal Changes the Following Existing Rules: The cross references to WAC 388-513-1380 will be changed.

NOTICE

THIS RULE IS BEING PROPOSED TO BE ADOPTED USING AN EXPEDITED RULE-MAKING PROCESS THAT WILL ELIMINATE THE NEED FOR THE AGENCY TO HOLD PUBLIC HEARINGS, PREPARE A SMALL BUSINESS ECONOMIC IMPACT STATEMENT, OR PROVIDE RESPONSES TO THE CRITERIA FOR A SIGNIFICANT LEGISLATIVE RULE. IF YOU OBJECT TO THIS RULE BEING ADOPTED USING THE EXPEDITED RULE-MAKING PROCESS, YOU MUST EXPRESS YOUR OBJECTIONS IN WRITING AND THEY MUST BE SENT TO Kelly Cooper, Rules Coordinator, Department of Social and Health Services, P.O. Box 45850, Olympia, WA 98503-5850, fax (360) 664-6185 , AND RECEIVED BY November 20, 2000.


September 14, 2000

Marie Myerchin-Redifer, Manager

Rules and Policies Assistance Unit

2856.1
AMENDATORY SECTION(Amending WSR 00-01-087, filed 12/14/99, effective 1/14/00)

WAC 388-515-1505
Community options program entry system (COPES).

This section describes the financial eligibility requirements for waivered services under the COPES program and the rules used to determine a client's participation in the cost of care.

(1) The department establishes eligibility for COPES for a client who:

(a) Is eighteen years of age or older;

(b) Meets the disability criteria of the Supplemental Security Income (SSI) program as described in WAC ((388-503-0501(1))) 388-503-0510(1);

(c) Requires the level of care provided in a nursing facility;

(d) Is in a medical facility, or will likely be placed in one within the next thirty days in the absence of waivered services described in WAC ((388-15-620)) 388-71-0510;

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

(f) Has been determined to be in need of waivered services and is approved for a plan of care as described in WAC ((388-15-610)) 388-71-0435;

(g) Is able to live at home with community support services and chooses to do so, or in a department-contracted:

(i) Adult residential care (ARC) facility;

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

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

(iv) Assisted living (AL) facility.

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

(i) Meets the income and resource requirements described in subsection (2).

(2) The department allows a client to have nonexcluded resources in excess of the standard described in WAC 388-513-1350(1) during the month of either an application or eligibility review if, when excess resources are added to nonexcluded income, the combined total does not exceed the special income level (SIL). Refer to WAC 388-513-1315 for rules used to determine nonexcluded income and resources. During other months, financial requirements include the following:

(a) Nonexcluded income must be at or below the SIL; and

(b) Nonexcluded resources not allocated to participation in a prior month must be at or below the resource standard.

(3) A client who is eligible for SSI does not participate SSI income in the cost of care. Such a client who is:

(a) Living at home, retains a maintenance needs amount as described in subsection (5); or

(b) Living in an ARC, EARC, AFH, or AL:

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

(ii) Pays remaining SSI income to the facility for the cost of board and room.

(4) A client who is eligible for the general assistance expedited Medicaid disability (GAX) program does not participate in the cost of care. Such a client who is:

(a) Living at home, retains a maintenance needs amount as described in subsection (5); or

(b) Living in an ARC, EARC, AFH, or AL:

(i) Retains a PNA of thirty-eight dollars and eighty-four cents; and

(ii) Pays remaining income and GAX grant to the facility for the cost of board and room.

(5) An SSI-related client living at home retains a maintenance needs amount equal to the following:

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

(i) Single; or

(ii) Married, and is:

(A) Not living with the community spouse; or

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

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

(c) 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.

(6) An SSI-related client living in an ARC, EARC, AFH, or AL receives a maintenance needs amount equal to the one-person MNIL and:

(a) Retains a PNA taken from the MNIL of fifty-eight dollars and eighty-four cents; and

(b) Pays the remainder of the MNIL to the facility for the cost of board and room.

(7) The client's income that remains:

(a) After allocations described in subsection (5) or (6) is allocated as described in WAC 388-513-1380 (((1), (2)(b) through (e), (3) and (4))) (7)(a) through (d), (8) and (9); and

(b) After allocations described in subsection (7)(a) is the client's participation in the cost of care.

[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.]


AMENDATORY SECTION(Amending WSR 00-01-051, filed 12/8/99, effective 1/8/00)

WAC 388-515-1510
Community alternatives program (CAP) and outward bound residential alternatives (OBRA).

This section describes the eligibility requirements for waivered services under the CAP and OBRA programs and the rules used to determine a client's participation in the cost of care.

(1) The department establishes eligibility for CAP and OBRA services for a client who:

(a) Is both Medicaid eligible under the categorically needy (CN) program and meets the requirements for services provided by the division of developmental disabilities (DDD);

(b) Has attained institutional status as described in WAC 388-513-1320;

(c) Has been assessed as requiring the level of care provided in an intermediate care facility for the mentally retarded (IMR);

(d) Has a department-approved plan of care that includes support services to be provided in the community;

(e) Is able to reside in the community according to the plan of care and chooses to do so;

(f) Meets the income and resource requirements described in subsection (2); and

(g) For the OBRA program only, the client must be a medical facility resident at the time of application.

(2) The department allows a client to have nonexcluded resources in excess of the standard described in WAC 388-513-1350(1) during the month of either an application or eligibility review if, when excess resources are added to nonexcluded income, the combined total does not exceed the special income level (SIL). Refer to WAC 388-513-1315 for rules used to determine nonexcluded income and resources. During other months, financial requirements include the following:

(a) Nonexcluded income must be at or below the SIL; and

(b) Nonexcluded resources not allocated to participation in a prior month must be at or below the resource standard.

(3) A client who is eligible for supplemental security income (SSI) does not participate in the cost of care for CAP or OBRA services.

(4) An SSI-related client retains a maintenance needs amount of up to the SIL, who is:

(a) Living at home; or

(b) Living in an alternate living facility described in WAC 388-513-1305(1).

(5) A client described in subsection (4)(b) retains the greater of:

(a) The SSI grant standard; or

(b) An amount equal to a total of the following:

(i) A personal needs allowance (PNA) of thirty-eight dollars and eighty-four cents; plus

(ii) The facility's monthly rate for board and room, which the client pays to the facility; plus

(iii) The first twenty dollars of monthly earned or unearned income; and

(iv) The first sixty-five dollars plus one-half of the remaining earned income not previously excluded.

(6) If a client has a spouse in the home who is not receiving CAP or OBRA services, the department allocates the client's income in excess of the amounts described in subsections (4) and (5) as an additional maintenance needs amount in the following order:

(a) One for the spouse, as described in WAC 388-513-1380 (((2)(c))) (7)(b); and

(b) One for any other dependent family member in the home, as described in WAC 388-513-1380 (((2)(d))) (7)(c).

(7) A client's participation in the cost of care for CAP or OBRA services is the client's income:

(a) That exceeds the amounts described in subsections (4), (5), and (6); and

(b) Remains after deductions for medical expenses not subject to third-party payment for which the client remains liable, included in the following:

(i) Medicare and other health insurance premiums, deductibles, or coinsurance charges; and

(ii) Necessary medical care recognized under state law but not covered by Medicaid.

[Statutory Authority: RCW 11.92.180, 43.20B.460, 48.85.020, 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, 74.[09.]575, 74.09.585; 20 C.F.R. 416.1110-1112, 1123 and 1160; 42 C.F.R. 435.403 (j)(2) and 1005; and Sections 17, 1915(c), and 1924 (42 U.S.C. 1396) of the Social Security Act. 00-01-051, 388-515-1510, filed 12/8/99, effective 1/8/00. Statutory Authority: RCW 74.08.090 and 74.09.500. 99-06-045, 388-515-1510, filed 2/26/99, effective 3/29/99. Statutory Authority: RCW 74.08.090. 94-10-065 (Order 3732), 388-515-1510, filed 5/3/94, effective 6/3/94. Formerly WAC 388-83-210.]


AMENDATORY SECTION(Amending WSR 00-01-051, filed 12/8/99, effective 1/8/00)

WAC 388-515-1530
Coordinated community AIDS services alternatives (CASA) program.

This section describes the eligibility requirements for waivered services under the CASA program and the rules used to determine a client's participation in the cost of care.

(1) The department establishes eligibility for CASA services for a client who:

(a) Meets the disability criteria of the supplemental security income (SSI) program as described in WAC 388-503-0510(1);

(b) Has attained institutional status as described in WAC 388-513-1320;

(c) Has been diagnosed with:

(i) Acquired Immune Deficiency Syndrome (AIDS) or disabling Class IV human immunodeficiency virus disease; or

(ii) P2 HIV/AIDS, if fourteen years old or younger;

(d) Has been certified by the client's physician or nurse practitioner to be in the terminal state of life;

(e) Has been assessed as being medically at risk for needing inpatient care;

(f) Has a plan of care approved by the department and the department of health (DOH);

(g) Does not have private insurance, including a COBRA extension, that covers inpatient hospital care;

(h) Is able to live at home or in an alternate living facility (ALF) described in WAC 388-513-1305(1) and chooses to do so; and

(i) Meets the income and resource requirements described in subsection (2).

(2) The department allows a client to have nonexcluded resources in excess of the standard described in WAC 388-513-1350(1) during the month of either an application or an eligibility review if, when excess resources are added to nonexcluded income, the combined total does not exceed the special income level (SIL). Refer to WAC 388-513-1315 for rules used to determine nonexcluded income and resources. During other months, financial requirements include the following:

(a) Nonexcluded income must be at or below the SIL; and

(b) Nonexcluded resources not allocated to participation in a prior month must be at or below the resource standard.

(3) A client who is eligible for SSI does not participate in the cost of care for CASA services.

(4) An SSI-related client retains a maintenance needs amount, if:

(a) Living at home, of up to the SIL; or

(b) Living in an ALF described in WAC 388-513-1305(1), of thirty-eight dollars and eighty-four cents.

(5) The income of a client described in subsections (4)(a) or (b) that exceeds the maintenance needs amount is allocated as described in WAC 388-513-1380 (((1), (2)(b) through (e), (3), and (4))) (7)(a) through (d), (8) and (9).

(6) The income of a client described in subsection (4)(b) that exceeds the maintenance needs amount and the amount described in subsection (5) is paid to the facility for the cost of board and room up to an amount that is equal to the difference between the:

(a) Amount of the SIL; and

(b) The combined total of amounts described in subsections (4)(b) and (5).

(7) A client's participation in the cost of care for CASA services is the amount of income that remains after allocations described in subsections (4), (5), and (6).

(8) The client must meet any participation obligation, in order to remain eligible.

[Statutory Authority: RCW 11.92.180, 43.20B.460, 48.85.020, 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, 74.[09.]575, 74.09.585; 20 C.F.R. 416.1110-1112, 1123 and 1160; 42 C.F.R. 435.403 (j)(2) and 1005; and Sections 17, 1915(c), and 1924 (42 U.S.C. 1396) of the Social Security Act. 00-01-051, 388-515-1530, filed 12/8/99, effective 1/8/00. Statutory Authority: RCW 74.08.090 and 74.09.500. 99-06-045, 388-515-1530, filed 2/26/99, effective 3/29/99. Statutory Authority: RCW 74.08.090. 95-18-001 (Order 3882), 388-515-1530, filed 8/23/95, effective 9/23/95; 94-10-065 (Order 3732), 388-515-1530, filed 5/3/94, effective 6/3/94. Formerly WAC 388-83-220.]

Washington State Code Reviser's Office