WSR 97-13-057

PROPOSED RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES

(Medical Assistance Administration)

(Public Assistance)

[Filed June 16, 1997, 4:25 p.m.]

Original Notice.

Exempt from preproposal statement of inquiry under RCW 34.05.310(4).

Title of Rule: WAC 388-508-0805, 388-509-0920, 388-509-0960, 388-513-1380, 388-517-1720, 388-517-1740, and 388-517-1760.

Purpose: Implement increased federal poverty levels.

Other Identifying Information: CR-103 filed as an emergency rule effective April 1, 1997 (WSR 97-08-031 filed March 27, 1997).

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

Statute Being Implemented: Social Security Act-Federal Register, March 10, 1997, pages 10856 - 10859, 42 USC 1396 (a), (l), (m) and 42 USC 1396 (d)(p).

Summary: See Purpose above.

Name of Agency Personnel Responsible for Drafting, Implementation and Enforcement: Joanie Scotson, Medical Assistance Administration, 617 8th S.E., Olympia, WA 98504, (360) 753-7462.

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

Rule is necessary because of federal law, 42 USC 1396 (a), (l), (m) and 42 USC 1396 (d)(p).

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

Proposal Changes the Following Existing Rules: See Purpose above.

No small business economic impact statement has been prepared under chapter 19.85 RCW. This rule does not have an economic impact on small businesses. It concerns eligibility policy and affects only clients and staff.

Section 201, chapter 403, Laws of 1995, does not apply to this rule adoption. This section (RCW 34.05.328) does not currently apply to the Department of Social and Health Services.

Hearing Location: Lacey Government Center (behind Tokyo Bento restaurant), 1009 College Street S.E., Room 104-A, Lacey, WA 98503, on July 22, 1997, at 10:00 a.m.

Assistance for Persons with Disabilities: Contact Leslie Baldwin, Rules Coordinator, by July 13, 1997, TTY (360) 902-8324, phone (360) 902-7540, e-mail lbaldwin@dshs.wa.gov.

Submit Written Comments to and Identify WAC Numbers: Leslie Baldwin, Rules Coordinator, Rules and Policies Assistance Unit, P.O. Box 45850, Olympia, WA 98504-5850, FAX (360) 902-8292, by July 22, 1997.

Date of Intended Adoption: No sooner than July 23, 1997.

June 16, 1997

Merry A. Kogut, Manager

Rules and Policies Assistance Unit

AMENDATORY SECTION (Amending WSR 96-15-029, filed 7/10/96, effective 7/10/96)

WAC 388-508-0805 Pregnant woman--Income standards. (1) The department shall find a pregnant woman eligible for Medicaid as categorically needy when the pregnant woman meets the income requirements of this section.

(2) The department shall ensure total family income will not exceed one hundred eighty-five percent of the Federal Poverty Level (FPL). One hundred eighty-five percent of the current FPL is:

Family Size Monthly Income

(a) One (($1,194)) $1,217

(b) Two (($1,598)) $1,636

(c) Three (($2,002)) $2,056

(d) Four (($2,405)) $2,475

(e) Five (($2,809)) $2,894

(f) Six (($3,213)) $3,314

(g) Seven (($3,617)) $3,733

(h) Eight (($4,021)) $4,152

(i) Nine (($4,425)) $4,572

(j) Ten (($4,829)) $4,991

(k) For family units with more than ten members, add (($404)) $420 to the monthly income for each additional member.

[Statutory Authority: RCW 74.08.090. 96-15-029, 388-508-0805, filed 7/10/96, effective 7/10/96; 95-11-045 (Order 3848), 388-508-0805, filed 5/10/95, effective 6/10/95; 94-10-065 (Order 3732), 388-508-0805, filed 5/3/94, effective 6/3/94. Formerly WAC 388-83-032 (part).]

AMENDATORY SECTION (Amending WSR 96-15-029, filed 7/10/96, effective 7/10/96)

WAC 388-509-0920 Children's health program. (1) The department shall consider a child seventeen years of age or younger, eligible for state-funded medical services with the same coverage as categorically needy, when:

(a) The child is not eligible for a federally-funded Medicaid program; and

(b) The child's nonexempt family income does not exceed one hundred percent of the current federal poverty level (FPL). See income guidelines as described under subsection (4) of this section.

(2) The department shall determine nonexempt family income by:

(a) Following AFDC methodology; and

(b) Applying the medical income rules as described under WAC 388-506-0610.

(3) The department shall not require a child to meet the following eligibility factors:

(a) Citizenship;

(b) Social Security number; or

(c) Resources limits.

(4) The department shall find that one hundred percent of the current FPL equals:

Family Size Monthly Income

(a) One (($645)) $658

(b) Two (($864)) $885

(c) Three (($1,082)) $1,111

(d) Four (($1,300)) $1,338

(e) Five (($1,519)) $1,565

(f) Six (($1,737)) $1,791

(g) Seven (($1,955)) $2,018

(h) Eight (($2,174)) $2,245

(i) Nine (($2,392)) $2,471

(j) Ten (($2,610)) $2,698

(k) For family units with more than ten members, add (($219)) $227 to the monthly income for each additional member.

(5) For a child determined eligible under this section, the department shall not consider a change in family income during the certification period.

[Statutory Authority: RCW 74.08.090. 96-15-029, 388-509-0920, filed 7/10/96, effective 7/10/96; 95-11-056 (Order 3848A), 388-509-0920, filed 5/11/95, effective 6/11/95; 94-17-036 (Order 3769), 388-509-0920, filed 8/10/94, effective 9/10/94; 94-10-065 (Order 3732), 388-509-0920, filed 5/3/94, effective 6/3/94. Formerly WAC 388-83-033 (part).]

AMENDATORY SECTION (Amending 96-15-029, filed 7/10/96, effective 7/10/96)

WAC 388-509-0960 Children's income standards. (1) The department shall determine a child meeting the eligibility requirements under WAC 388-509-0910 eligible as categorically needy when the total family countable income does not exceed two hundred percent of the federal poverty level (FPL). The department shall find that two hundred percent of the current FPL equals:

Family Size Monthly Income

(a) One (($1,290)) $1,315

(b) Two (($1,727)) $1,769

(c) Three (($2,164)) $2,222

(d) Four (($2,600)) $2,675

(e) Five (($3,037)) $3,129

(f) Six (($3,474)) $3,582

(g) Seven (($3,910)) $4,035

(h) Eight (($4,347)) $4,489

(i) Nine (($4,784)) $4,942

(j) Ten (($5,220)) $5,395

(k) For family units with more than ten members, add (($437)) $454 to the monthly income for each additional member.

(2) For a child determined eligible under WAC 388-509-0910, the department shall not consider a change in family income during the certification period.

[Statutory Authority: RCW 74.08.090. 96-15-029, 388-509-0960, filed 7/10/96, effective 7/10/96; 95-11-056 (Order 3848A), 388-509-0960, filed 5/11/95, effective 6/11/95. Statutory Authority: RCW 74.08.090 and Letter from HCFA approving State Plan Transmittal 94-21. 95-05-023 (Order 3833), 388-509-0960, filed 2/8/95, effective 3/11/95. Statutory Authority: RCW 74.08.090. 94-17-036 (Order 3769), 388-509-0960, filed 8/10/94, effective 9/10/94; 94-10-065 (Order 3732), 388-509-0960, filed 5/3/94, effective 6/3/94. Formerly WAC 388-83-033 (part).]

AMENDATORY SECTION (Amending Order 3963, filed 4/10/96, effective 5/11/96 WAC 388-513-1380 Institutional--Participation. (1) In reducing payment to the institution, the department shall consider the institutionalized client's:

(a) Income under WAC 388-513-1330 (3)(a), (b), (c), and (d); and

(b) Resources under WAC 388-513-1350, 388-513-1360, and 388-513-1365.

(2) In reducing payment to the institution, the department shall consider the eligible institutionalized client's excess resources available to meet the cost of care after the following allocations:

(a) Health insurance and Medicare premiums, deductions, and co-insurance not paid by a third party; and

(b) Noncovered medical bills which are the liability of the client and not paid by a third party.

(3) The department shall not use allocations used to reduce excess resources under subsection (2) of this section to reduce income under subsection (4) of this section.

(4) The department shall deduct the following amounts, in the following order, from the institutionalized client's total income, including amounts disregarded in determining eligibility:

(a) Specified personal needs allowance as follows:

(i) One hundred sixty dollars for a veteran living in a Medicaid-certified state veteran's home nursing facility;

(ii) Ninety dollars for a single veteran receiving an improved veteran's pension; or

(iii) Forty-one dollars and sixty-two cents for all other clients in medical institutions.

(b) Federal, state, or local income taxes:

(i) Mandatorily withheld from earned or unearned income for income tax purposes before receipt by the client;

(ii) Not covered by withholding, but are owed or have been paid by the client; and

(iii) Does not exceed the one-person medically needy income level less the client's personal needs allowance.

(c) Wages not to exceed the one-person medically needy income level (MNIL) less the client's personal needs allowance for a client who:

(i) Is SSI-related; and

(ii) Receives the wages as part of a department-approved training or rehabilitative program designed to prepare the client for a less restrictive placement. When determining this deduction, the department shall:

(A) Not allow a deduction for employment expenses; and

(B) Apply the client's wages not deducted under this subsection to the client's cost of care.

(d) The total amounts deducted under subsection (4)(a), (b), and (c) of this section shall not exceed the one-person MNIL.

(e) A monthly needs allowance for the community spouse not to exceed, effective January 1, ((1996)) 1997, one thousand nine hundred ((nineteen)) seventy-six dollars, unless specified in subsection (6) of this section. The department shall ensure the monthly needs allowance is:

(i) An amount added to the community spouse's gross income to provide a total community spouse's income of one thousand ((two)) three hundred ((ninety-five)) twenty-seven dollars;

(ii) Excess shelter expenses as specified under subsection (5) of this section; and

(iii) Allowed only to the extent income of the institutionalized spouse is made available to the community spouse.

(f) An amount for the maintenance needs of each dependent family member residing with the community spouse:

(i) Equal to one-third of the amount one thousand ((two)) three hundred ((ninety-five)) twenty-seven dollars exceeds the family member's income. Child support received from an absent parent is the child's income.

(ii) "Family member" means a:

(A) Dependent or minor child;

(B) Dependent parent; or

(C) Dependent sibling of the institutionalized or community spouse.

(g) When an institutional client does not have a community spouse, an amount for the maintenance needs of family members residing in the client's home equal to the medically needy income level for the number of legal dependents in the home less the income of the dependents.

(h) Amounts for incurred medical expenses not subject to third-party payment which are the current liability of the client including, but not limited to:

(i) Health insurance premiums, coinsurance, or deductible charges; and

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

(i) Maintenance of the home of a single person or couple:

(i) Up to one hundred percent of the one-person federal poverty level per month;

(ii) Limited to a six-month period; and

(iii) When a physician has certified that the client is likely to return to the home within the six-month period; and

(iv) When social service staff documents initial need for the income exemption and reviews the person's circumstances after ninety days.

(5) For the purposes of this section, the department shall:

(a) Determine shelter expenses to be the actual required maintenance expenses for the community spouse's principal residence for:

(i) Rent;

(ii) Mortgage;

(iii) Taxes and insurance;

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

(v) The food stamp standard allowance for utilities, provided the utilities are not included in the maintenance charges for a condominium or cooperative.

(b) Consider the standard shelter allocation to be three hundred ((eighty-nine)) ninety-nine dollars, effective April 1, ((1996)) 1997.

(c) Consider as "excess shelter expenses" an amount equal to the actual expenses under subsection (5)(a) of this section less the standard shelter allocation under subsection (5)(b) of this section.

(6) The department shall determine the amount the institutional spouse allocates to the community spouse may only be greater than the amount in subsection (4)(e)(i) of this section when:

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

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

(7) The client shall use the income remaining after allocations specified in subsection (4) of this section toward payment of the client's cost of care at the department rate.

(8) SSI-related clients.

(a) SSI-related clients shall continue to receive total payment under 1611 (b)(1) of the Social Security Act for the first three full calendar months of institutionalization in a public or Medicaid-approved medical institution or facility when the:

(i) Stay in the institution or facility is not expected to exceed three months; and

(ii) SSI-related clients plan to return to former living arrangements.

(b) The department shall not consider the SSI payment when computing the client's participation amount.

(9) The department shall not consider income from reparation payments made by the Federal Republic of Germany when computing the client's participation amount.

[Statutory Authority: RCW 74.08.090 and Title XIX State Agency Letter 95-44. 96-09-033 (Order 3963), 388-513-1380, filed 4/10/96, effective 5/11/96. Statutory Authority: RCW 74.08.090. 95-11-045 (Order 3848), 388-513-1380, filed 5/10/95, effective 6/10/95. Statutory Authority: RCW 74.08.090 and Title XIX State Agency Letter 94-49, notice of increase in SSI level. 95-05-022 (Order 3832), 388-513-1380, filed 2/8/95, effective 3/11/95. Statutory Authority: RCW 74.08.090. 94-10-065 (Order 3732), 388-513-1380, filed 5/3/94, effective 6/3/94. Formerly WAC 388-95-360.]

AMENDATORY SECTION (Amending WSR 96-15-029, filed 7/10/96, effective 7/10/96)

WAC 388-517-1720 Qualified Medicare beneficiaries--Income and resources. (1) The department shall provide Medicare cost sharing for a qualified medical beneficiary (QMB) client having:

(a) A total countable income, as determined under chapter 388-511 WAC, except as specified in subsection (2) of this section, not exceeding one hundred percent of the current federal poverty level (FPL). One hundred percent of the current FPL is:

Family Size Monthly

(i) One (($645)) $658

(ii) Two (($864)) $885

(b) Resources, as determined under WAC 388-511-1110, not exceeding twice the maximum supplemental security income (SSI) resource limits.

(2) The department shall not consider a person's Social Security cost-of-living increase until April 1 of each year.

[Statutory Authority: RCW 74.08.090. 96-15-029, 388-517-1720, filed 7/10/96, effective 7/10/96; 95-11-056 (Order 3848A), 388-517-1720, filed 5/11/95, effective 6/11/95; 94-10-065 (Order 3732), 388-517-1720, filed 5/3/94, effective 6/3/94. Formerly WAC 388-82-140 (part).]

AMENDATORY SECTION (Amending WSR 96-15-029, filed 7/10/96, effective 7/10/96)

WAC 388-517-1740 Special low-income Medicare beneficiaries (SLMB)--Income and resources. (1) The department shall provide Medicare cost sharing for a SLMB client having:

(a) A total countable income, as determined under chapter 388-511 WAC, over one hundred percent of the current federal poverty level (FPL), but not exceeding one hundred twenty percent of the FPL. One hundred twenty percent of the current FPL is:

Family Size Monthly

(i) One (($774)) $789

(ii) Two (($1,036)) $1,061

(b) Resources, as determined under WAC 388-511-1110, not exceeding twice the maximum supplemental security income (SSI) resource limits.

(2) The department shall not consider a person's Social Security cost-of-living increase until April 1 of each year.

[Statutory Authority: RCW 74.08.090. 96-15-029, 388-517-1740, filed 7/10/96, effective 7/10/96; 95-23-030 (Order 3917, #100251), 388-517-1740, filed 11/8/95, effective 12/9/95; 95-11-056 (Order 3848A), 388-517-1740, filed 5/11/95, effective 6/11/95; 94-10-065 (Order 3732), 388-517-1740, filed 5/3/94, effective 6/3/94. Formerly WAC 388-82-150 (part).]

AMENDATORY SECTION (Amending WSR 96-15-029, filed 7/10/96, effective 7/10/96)

WAC 388-517-1760 Qualified disabled working individuals (QDWI) income and resources. The department shall pay premiums for Medicare Part A for a person having:

(1) A total countable family income, as determined under chapter 388-511 WAC, not exceeding two hundred percent of the current FPL. Two hundred percent of the current FPL is:

Family Size Monthly

(a) One (($1,290)) $1,315

(b) Two (($1,727)) $1,769

(2) Resources, as determined under WAC 388-511-1110, not exceeding twice the maximum supplemental security income (SSI) resource limits.