PROPOSED RULES
SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)
Original Notice.
Preproposal statement of inquiry was filed as WSR 00-01-106.
Title of Rule: WAC 388-513-1380 Determining a client's participation in the cost of care for long-term care (LTC) services.
Purpose: To adopt changes in the federal standards for community spouses, family maintenance needs amount and excess shelter allowances that are based on the federal poverty level for which an increase took effect on April 4, 2000.
Statutory Authority for Adoption: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500.
Statute Being Implemented: Section 1924(g) of the Social Security Act.
Summary: See Purpose above.
Reasons Supporting Proposal: An increase in these standards are beneficial to clients receiving LTC services. Other changes made are to simplify language and clarify current policy.
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 necessary because of federal law, Section 1924(g) of the Social Security Act.
Explanation of Rule, its Purpose, and Anticipated Effects: See Purpose above.
Proposal Changes the Following Existing Rules: Changes standards and makes minor wording changes.
No small business economic impact statement has been prepared under chapter 19.85 RCW. Does not impact small businesses.
RCW 34.05.328 applies to this rule adoption. RCW 34.05.328 (5)(b)(vii) exempts DSHS rules that apply to client medical eligibility.
Hearing Location: Lacey Government Center (behind Tokyo Bento Restaurant), 1009 College Street S.E., Room 104-B, Lacey, WA 98503, on July 25, 2000, at 10:00 a.m.
Assistance for Persons with Disabilities: Contact Kelly Cooper by July 14, 2000, phone (360) 664-6094, TTY (360) 664-6178, e-mail coopekd@dshs.wa.gov.
Submit Written Comments to: Identify WAC Numbers, DSHS Rules Coordinator, Rules and Policies Assistance Unit, P.O. Box 45850, Olympia, WA 98504-5850, fax (360) 664-6185, by July 25, 2000.
Date of Intended Adoption: Not sooner than July 26, 2000.
June 15, 2000
Marie Myerchin-Redifer, Manager
Rules and Policies Assistance Unit
2719.3
This section describes ((allocations of)) how
the department allocates income and excess resources ((used to
determine a person's)) when determining participation in the cost
of care ((for institutional services in a medical facility.
Income allocations described in this section are used to reduce
countable income that remains after exclusions described in WAC 388-513-1340)) (in the post-eligibility process). The department
applies rules described in WAC 388-513-1315 to define what income
and resources must be used in this process.
(1) ((Allocations used to reduce excess resources are
amounts for incurred medical expenses, not subject to third-party
payment, for which the person is liable, including:
(a) Health insurance and Medicare premiums, deductions, and co-insurance charges; and
(b) Necessary medical care recognized under state law, but not covered under the state's Medicaid plan.
(2) Allocations used to reduce countable income are made in the following order:
(a) Amounts described in subsection (2)(a) may not total more than the one-person medically needy income level (MNIL):
(i) A personal needs allowance (PNA) as follows:
(A) One hundred sixty dollars for a person living in a state veterans' home;
(B) Ninety dollars for a veteran or a veteran's surviving spouse, who receives an improved pension and does not live in a state veterans' home; or
(C) Forty-one dollars and sixty-two cents for all other persons in a medical facility.
(ii) Federal, state, or local income taxes:
(A) Mandatorily withheld from earned or unearned income for income tax purposes before receipt by the person; or
(B) Not covered by withholding, but are owed, become an obligation, or have been paid by the person during the time period covered by the PNA.
(iii) Wages for a person who:
(A) Is SSI-related; and
(B) Receives the wages as part of a department-approved training or rehabilitative program designed to prepare the person for a less restrictive placement. When determining this deduction employment expenses are not deducted.
(iv) Guardianship fees and administrative costs including any attorney fees paid by the guardian, after June 15, 1998, only as allowed by chapter 388-79 WAC.
(b) Income garnisheed for child support:
(i) For the time period covered by the PNA; and
(ii) Not deducted under another provision in the post-eligibility process.
(c) A monthly needs allowance for the community spouse not to exceed, effective January 1, 1999, two thousand forty-nine dollars, unless a greater amount is allocated as described in subsection (4) of this section. The monthly needs allowance:
(i) Consists of a combined total of both:
(A) An amount added to the community spouse's gross income to provide a total of one thousand three hundred fifty-eight dollars; and
(B) Excess shelter expenses as specified under subsection (3) of this section; and
(ii) Is allowed only to the extent the person's income is made available to the community spouse.
(d) A monthly maintenance needs amount for each dependent or minor child, dependent parent or dependent sibling:
(i) Residing with the community spouse, equal to one-third of the amount that one thousand three hundred fifty-seven dollars exceeds the family member's income. Child support received from an absent parent is the child's income.
(ii) Not residing with the community spouse, equal to the MNIL for the number of family members in the home less the income of the family members.
(e) Incurred medical expenses described in subsections (1)(a) and (b) not used to reduce excess resources.
(f) Maintenance of the home of a single person or institutionalized couple:
(i) Up to one hundred percent of the one-person federal poverty level per month;
(ii) Limited to a six-month period;
(iii) When a physician has certified that the person 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.
(3) For the purposes of this section, "excess shelter expenses" equal the actual expenses under subsection (3)(a) less the standard shelter allocation under subsection (3)(b):
(a) Shelter expenses are 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 utility allowance, provided the utilities are not included in the maintenance charges for a condominium or cooperative.
(b) The standard shelter allocation is four hundred seven dollars, effective April 1, 1998.
(4) The amount allocated to the community spouse may be greater than the amount in subsection (2)(c) only when:
(a) A court enters an order against the person 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.
(5) A person receiving SSI 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:
(a) Stay in the institution or facility is not expected to exceed three months; and
(b) The person plans to return to former living arrangements)) For a client receiving institutional or hospice services in a medical facility, the department applies all subsections of this rule.
(2) For a client receiving waivered services at home or in an alternate living facility, the department applies only those subsections of this rule that are cited in the rules for those programs.
(3) For a client receiving hospice services at home, the department applies rules used for the community options program entry system (COPES).
(4) The department allocates excess resources in an amount equal to incurred medical expenses that are not subject to third-party payment and for which the client is liable, including:
(a) Health insurance and Medicare premiums, deductions, and co-insurance charges; and
(b) Necessary medical care recognized under state law, but not covered under the state's Medicaid plan.
(5) The amount of excess resources described in subsection (4) is limited to the following amounts:
(a) For LTC services provided under the categorically needy (CN) program, the amount described in WAC 388-513-1315(3); or
(b) For LTC services provided under the medically needy (MN) program, the amount described in WAC 388-513-1395(2)(a) or (b).
(6) The department allocates nonexcluded income up to a total of the medically needy income level (MNIL) in the following order:
(a) A personal needs allowance (PNA) of:
(i) One hundred sixty dollars for a client living in a state veterans' home;
(ii) Ninety dollars for a veteran or a veteran's surviving spouse, who receives an improved pension and does not live in a state veterans' home; or
(iii) Forty-one dollars and sixty-two cents for all other clients in a medical facility.
(b) Federal, state, or local income taxes:
(i) Mandatorily withheld from earned or unearned income for income tax purposes before receipt by the client; or
(ii) Not covered by withholding, but are owed, become an obligation, or have been paid by the client during the time period covered by the PNA.
(c) Wages for a client who:
(i) Is related to the supplemental security income (SSI) program as described in WAC 388-503-0510 (1); 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 employment expenses are not deducted.
(d) Guardianship fees and administrative costs including any attorney fees paid by the guardian, after June 15, 1998, only as allowed by chapter 388-79 WAC.
(7) The department allocates nonexcluded income after deducting amounts described in subsection (6) in the following order:
(a) Income garnisheed for child support:
(i) For the time period covered by the PNA; and
(ii) Not deducted under another provision in the post-eligibility process.
(b) A monthly needs allowance for the community spouse not to exceed, effective January 1, 2000, two thousand one hundred three dollars, unless a greater amount is allocated as described in subsection (9) of this section. The monthly needs allowance:
(i) Consists of a combined total of both:
(A) An amount added to the community spouse's gross income to provide a total of one thousand four hundred seven dollars; and
(B) Excess shelter expenses as specified under subsection (8) of this section; and
(ii) Is allowed only to the extent the client's income is made available to the community spouse.
(c) A monthly maintenance needs amount for each minor or dependent child, dependent parent or dependent sibling of the community or institutionalized spouse who:
(i) Resides with the community spouse, equal to one-third of the amount that one thousand four hundred seven dollars exceeds the dependent family member's income.
(ii) Does not reside with the community spouse, 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.
(d) Incurred medical expenses described in subsections (4)(a) and (b) not used to reduce excess resources.
(e) Maintenance of the home of a single client or institutionalized couple:
(i) Up to one hundred percent of the one-person federal poverty level per month;
(ii) Limited to a six-month period;
(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 client's circumstances after ninety days.
(8) For the purposes of this section, "excess shelter expenses" equal the actual expenses under subsection (8)(b) less the standard shelter allocation under subsection (8)(a). For the purposes of this rule:
(a) The standard shelter allocation is four hundred twenty-two dollars, effective April 1, 2000; and
(b) Shelter expenses are 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 utility allowance, provided the utilities are not included in the maintenance charges for a condominium or cooperative.
(9) The amount allocated to the community spouse may be greater than the amount in subsection (7)(b) 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.
(10) A client who continues to receive SSI in a medical facility does not participate the SSI income in the cost of care for medical services.
[Statutory Authority: RCW 72.36.160, 74.04.050, 74.04.057, 74.08.090, 74.09.500 and Section 1924(g) of the Social Security Act, Section 4715 of the BBA of 1997 (Public Law 105-33, HR 2015). 99-11-017, § 388-513-1380, filed 5/10/99, effective 6/10/99. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 43.20B.460, 11.92.180, and Section 1924 (42 USC 396r-5). 98-08-077, § 388-513-1380, filed 3/31/98, effective 4/1/98. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530 and Social Security Act, Federal Register, March 10, 1997, pgs. 10856 - 10859, 42 U.S.C. 1396 (a)(l)(m). 97-16-008, § 388-513-1380, filed 7/24/97, effective 7/24/97. 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.]