WSR 02-09-052

PERMANENT RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)

[ Filed April 12, 2002, 4:03 p.m. ]

Date of Adoption: April 9, 2002.

Purpose: Amending WAC 388-513-1301, to remove the definitions of "annuity" and "life estate"; add a reference to chapter 388-561 WAC, Trusts, annuities, and life estates, which includes these definitions; clarify other definitions in this WAC; and remove duplicated definitions of terms defined in WAC 388-500-0005.

Citation of Existing Rules Affected by this Order: Amending WAC 388-513-1301.

Statutory Authority for Adoption: RCW 74.04.050, 74.04.057, 74.08.090, and 74.09.575.

Adopted under notice filed as WSR 01-21-098 on October 23, 2001.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 1, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 1, Repealed 0.
Effective Date of Rule: Thirty-one days after filing.

April 9, 2002

Brian H. Lindgren, Manager

Rules and Policies Assistance Unit

2971.4
AMENDATORY SECTION(Amending WSR 00-01-051, filed 12/8/99, effective 1/8/00)

WAC 388-513-1301   Definitions related to long-term care (LTC) services.   This section defines the meaning of certain terms used in chapters 388-513 and 388-515 WAC. Within these chapters, institutional, waivered, and hospice services are referred to collectively as LTC services. Other terms related to LTC services that also apply to other programs are found in the sections in which they are used. Definitions of terms used in certain rules that regulate LTC programs are as follows:

"Add-on hours" means additional hours the department purchases from providers to perform medically-oriented tasks for clients who require extra help because of a handicapping condition.

"Alternate living facility (ALF)" means one of the following community residential facilities that are contracted with the department to provide certain services:

(1) Adult family home (AFH) ((is)), a licensed family home that provides its residents with personal care and board and room for two to six adults unrelated to the person(s) providing the care.

(2) Adult residential care facility (ARC) (((formally know)) formerly known as a CCF) is a licensed facility that provides its residents with shelter, food, household maintenance, personal care and supervision.

(3) Adult residential rehabilitation center (ARRC) or Adult residential treatment facility (ARTF) ((is)), a licensed facility that provides its residents with twenty-four hour residential care for impairments related to mental illness.

(4) Assisted living facility (AL) ((is)), a licensed facility for aged and disabled low-income persons with functional disabilities. COPES eligible clients are often placed in assisted living.

(5) Division of developmental disabilities (DDD) group home (GH) ((is)), a licensed facility that provides its residents with twenty-four hour supervision.

(6) Enhanced adult residential care facility (EARC) ((is)), a licensed facility that provides its residents with those services provided in an ARC, in addition to those required because of the client's special needs.

(("Annuity" means a policy, certificate, or contract that is an agreement between two or more parties to purchase a right to receive periodic income of a specified amount for a specified period of time.

"Assets" means all the income and resources of the client and the client's spouse. This includes any income and resources they are entitled to but do not receive because of action by:

(1) The client or the spouse;

(2) An individual, court or administrative body, with legal authority to act in place of or on behalf of the client or the spouse; or

(3) An individual, court or administrative body, acting at the direction or upon the request of the client or the spouse.))

"Clothing and personal incidentals (CPI)" means ((a standard allowance intended for clothing and other personal expenses for clients who live in a medical or alternate living facility. This allowance is sometimes referred to as the client's)) the same as personal needs allowance (PNA) later in this section.

"Community alternatives program (CAP)" means a Medicaid-waivered program that provides home and community-based services as an alternative to an institution for the mentally retarded (ICF-MR) to persons determined eligible for services from DDD.

"Community options program entry system (COPES)" means a Medicaid-waivered program that provides an aged or disabled person assessed as needing nursing facility care with the option to remain at home or in an alternate living facility.

"Community spouse (CS)" means a person who does not ((receive institutional, waivered, or hospice services)) live in a medical institution or nursing facility, and who is legally married to an institutionalized client or to a person receiving services from home and community-based waiver programs.

"Comprehensive assessment (CA)" means the evaluation process used by a department designated social services worker to determine the client's need for long-term care services.

"Coordinated community AIDS service alternative (CASA)" means a Medicaid-waivered program that provides a person with Acquired Immune Deficiency Syndrome (AIDS) or Disabled Class IV Human Immunodeficiency Virus (HIV) and at risk of hospitalization with the option to remain at home or in an alternate living facility.

"Fair market value (FMV)" means the price an asset may reasonably be expected to sell for on the local market at the time of transfer or assignment. A transfer of assets for love and affection is not considered a transfer for FMV.

"Federal benefit rate (FBR)" means the basic benefit amount the Social Security Administration (SSA) pays to clients who are eligible for the Supplemental Security Income (SSI) program.

(("Hospice" means a Medicaid program that provides a client with a terminal illness a variety of treatment alternatives that can be received either at home or in a nursing facility.))

"Institutional services" means services paid for by Medicaid or state payment and provided in a nursing facility or equivalent care provided in a medical facility.

"Institutional status" means what is described in WAC 388-513-1320.

"Institutionalized client" means a client who has attained institutional status as described in WAC 388-513-1320.

"Institutionalized spouse" means a client who has attained institutional status as described in WAC 388-513-1320 and is legally married to a person who is not an institutionalized client.

"Legally married" means persons legally married to each other under provision of Washington state law. Washington recognizes other states' legal and common-law marriages. Persons are considered married if they are not divorced, even when they are physically or legally separated.

(("Life estate" means an ownership interest in property limited to the owner's lifetime or, in some cases, to a lesser period. Its duration depends upon the lifetime of the owner or on the occurrence of some specific event, such as remarriage of the owner. Ordinarily, the owner of a life estate has the right: of possession, to use the property, to sell interest in the life estate, and to any income produced by the life estate. A contract establishing the life estate may restrain one or more rights of the owner.))

"Likely to reside" means there is a reasonable expectation the client will remain in a medical facility for thirty consecutive days. Once made, the determination stands, even if the client does not actually remain in the facility for that length of time.

(("Long-term care (LTC) services" means institutional, waivered, and hospice services.))

"Look-back period" means the number of months prior to the month of application for LTC services that the department will consider for transfer of assets.

"Maintenance needs amount" means a monthly income amount a client keeps or that is allocated to a spouse or dependent family member who lives in the client's home.

(("Medical facility" means an establishment that provides food, shelter, and medical care to four or more persons unrelated to the proprietor. (This definition does not include correctional facilities.) Medical facilities are limited to the following:

(1) A private or public medical facility licensed as a hospital and certified for Medicaid.

(2) Institution for mental disease (IMD), which is a hospital, nursing facility, or other facility of more than sixteen beds that is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases, including medical attention, nursing care, and related services.

(3) Institution for the mentally retarded (IMR), which is an institution that is primarily for the diagnosis, treatment, or rehabilitation of persons with mental retardation and related conditions. It provides, in a protected residential setting, ongoing care, twenty-four hour supervision, evaluation, and planning to help each person function at his/her greatest ability. Includes intermediate care facilities for the mentally retarded (ICF-MR).

(4) Nursing facility (NF), which is an institution or part of an institution licensed as a nursing facility or hospital which has a contract with DSHS to provide care for Medicaid clients.

(5) Residential habilitation center (RHC), which is a state-operated facility certified to provide ICF-MR and/or nursing facility level of care for persons with developmental disabilities.))

"Medically intensive children (MIC)" program means a Medicaid-waivered program that enables medically fragile children under age eighteen to live in the community. The program allows them to obtain medical and support services necessary for them to remain at home or in a home setting instead of in a hospital. Eligibility is included in the OBRA program described in WAC 388-515-1510.

"Noninstitutional medical assistance" means medical benefits provided by Medicaid or state-funded programs that do not include LTC services.

"Nursing facility turnaround document (TAD)" means the billing document nursing facilities use to request payment for institutionalized clients.

"Outward bound residential alternative (OBRA)" means a Medicaid-waivered program that provides a person approved for services from DDD with the option to remain at home or in an alternate living facility.

"Participation" means the amount a client is responsible to pay each month toward the total cost of care they receive each month. It is the amount remaining after subtracting allowable deductions and allocations from available monthly income.

"Penalty period" means a period of time for which a client is not eligible to receive LTC services.

"Personal needs allowance (PNA)" means a standard allowance for clothing and other personal needs for clients who live in a medical or alternate living facility. This allowance is sometimes referred to as "CPI."

"Prouty benefits" means special "age seventy-two" Social Security benefits available to persons born before 1896 who are not otherwise eligible for Social Security.

"Short stay" means a person who has entered a medical facility but is not likely to remain institutionalized for thirty consecutive days.

"Special income level (SIL)" means the monthly income standard for the categorically needy (CN) program that is three hundred percent of the SSI Federal Benefit Rate (FBR).

(("SSI-related" means an aged, blind, or disabled client who meets the requirements described in WAC 388-503-0510(1).))

"Swing bed" means a bed in a medical facility that is contracted as both a hospital and a nursing facility bed.

"Transfer of a resource or asset" means any act or failure to act, by a person or a nonapplying joint tenant, whereby title to or any interest in property is assigned, set over, or otherwise vested or allowed to vest in another person.

"Uncompensated value" means the fair market value (FMV) of an asset at the time of transfer minus the value of compensation the person receives in exchange for the asset.

"Undue hardship" means the person is not able to meet shelter, food, clothing, or health needs.

"Value of compensation received" means the consideration the purchaser pays or agrees to pay. Compensation includes:

(1) All money, real or personal property, food, shelter, or services the person receives under a legally enforceable purchase agreement whereby the person transfers the asset; and

(2) The payment or assumption of a legal debt the seller owes in exchange for the asset.

"Veterans benefits" means different types of benefits paid by the federal Department of Veterans Affairs (VA). Some may include additional allowances for:

(1) Aid and attendance for an individual needing regular help from another person with activities of daily living;

(2) "Housebound" for an individual who, when without assistance from another person, is confined to the home((.));

(3) Improved pension ((is)), the newest type of VA disability pension((. It is)), available to veterans and their survivors whose income from other sources (including service connected disability) is below the improved pension amount((.)); or

(4) Unusual medical expenses (UME) ((are)), determined by the VA based on the amount of unreimbursed medical expenses reported by the person who receives a needs-based benefit. The VA can use UME to reduce countable income to allow the person to receive a higher monthly VA payment, a one-time adjustment payment, or both.

"Waivered programs/services" means programs for which the federal government authorizes exceptions to Medicaid rules. Such programs provide to an eligible client a variety of services not normally covered under Medicaid. In Washington state, waivered programs are CAP, CASA, COPES, MIC, and OBRA.

[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, 388-513-1301, filed 12/8/99, effective 1/8/00.]

Washington State Code Reviser's Office