PROPOSED RULES
SOCIAL AND HEALTH SERVICES
(Aging and Disability Services Administration)
Original Notice.
Preproposal statement of inquiry was filed as WSR 11-24-093.
Title of Rule and Other Identifying Information: Chapter 388-513 WAC, Client not in own home, institutional medical and chapter 388-515 WAC, Alternative living, institutional medical.
Hearing Location(s): Office Building 2, Lookout Room, DSHS Headquarters, 1115 Washington, Olympia, WA 98504 (public parking at 11th and Jefferson. A map is available at http://www1.dshs.wa.gov/msa/rpau/RPAU-OB-2directions.html), on September 25, 2012, at 10:00 a.m.
Date of Intended Adoption: Not earlier than September 26, 2012.
Submit Written Comments to: DSHS Rules Coordinator, P.O. Box 45850, Olympia, WA 98504, e-mail DSHSRPAURulesCoordinator@dshs.wa.gov, fax (360) 664-6185, by 5 p.m. on September 25, 2012.
Assistance for Persons with Disabilities: Contact Jennisha Johnson, DSHS rules consultant, by September 4, 2012, TTY (360) 664-6178 or (360) 664-6094 or by e-mail at jennisha.johnson@dshs.wa.gov.
Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules:
| • | Combine categorically needy (CN) and medically needy (MN) home and community-based waiver eligibility based on approval by Centers for Medicare and Medicaid Services. |
| • | Update excess home equity standard and add formula for increase based on federal standards for January 2011, and ongoing. |
| • | Update federal utility standard used in spousal deeming. |
| • | Clarifying reasonable limits for qualifying medical deductions. |
| • | Update links and references based on program changes made by economic services administration (ESA) and health care authority (HCA). |
| • | Update links and references based on HB 1738 and HCA medicaid WACs recodified under TITLE 182 WAC. |
| • | Correction of language allowing the federal poverty level (FPL) as a personal needs allowance (PNA) for a married individual receiving a home and community-based waiver, living at home but apart from the community spouse. |
| • | Add language to the hardship waiver WAC to include transfers between registered domestic partners or legally married same sex couples up to the resource amount a married [couple] is allowed for transfer of resources. |
| • | Updating references and adding clarifying language. |
Reasons Supporting Proposal: See above.
Statutory Authority for Adoption: RCW 74.04.050, 74.04.057, 74.08.090, and 74.09.530.
Statute Being Implemented: RCW 74.04.050, 74.04.057, 74.08.090, and 74.09.530.
Rule is necessary because of federal law, C.F.R. Title 42: 435.725; 435.217; 435.733. Section 6014 of the Deficit Reduction Act of 2005.
Name of Proponent: Department of social and health services, governmental.
Name of Agency Personnel Responsible for Drafting, Implementation and Enforcement: Lori Rolley, P.O. Box 45600, Olympia, WA 98504-5600, (360) 725-2271.
No small business economic impact statement has been prepared under chapter 19.85 RCW. The preparation of a small business impact statement is not required, as no new costs will be imposed on small businesses or nonprofits as a result of this rule amendment.
A cost-benefit analysis is not required under RCW 34.05.328. [Rules] are exempt per RCW 34.05.328 (5)(b)(v), rules the content of which is explicitly and specifically dictated by statute.
July 19, 2012
Katherine I. Vasquez
Rules Coordinator
4264.13Additional medical definitions that are not specific to LTC services can be found in WAC 182-500-0005 through 182-500-0110 Medical definitions.
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.))
"Adequate consideration" means the reasonable value of the goods or services received in exchange for transferred property approximates the reasonable value of the property transferred.
"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), 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. Licensed as an adult family home under chapter 70.128 RCW.
(2) Adult residential care facility (ARC) (formerly known as a CCF) is a licensed facility that provides its residents with shelter, food, household maintenance, personal care and supervision. Licensed as an assisted living under chapter 18.20 RCW.
(3) Adult residential rehabilitation center (ARRC)
described in WAC 388-865-0235 or adult residential treatment
facility (ARTF)((, a)) described in WAC 388-865-0465 are
licensed ((facility)) facilities that provides ((its)) their
residents with twenty-four hour residential care for
impairments related to mental illness.
(4) Assisted living facility (AL), a licensed facility for aged and disabled low-income persons with functional disabilities. COPES eligible clients are often placed in assisted living. Licensed as an assisted living facility under chapter 18.20 RCW.
(5) Division of developmental disabilities (DDD) group home (GH), a licensed facility that provides its residents with twenty-four hour supervision. Depending on the size, a DDD group home may be licensed as an adult family home under chapter 70.128 RCW or an assisted living facility under chapter 18.20 RCW. Group homes provide community residential instruction, supports, and services to two or more clients who are unrelated to the provider.
(6) Enhanced adult residential care facility (EARC), 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. Licensed as an assisted living facility under chapter 18.20 RCW.
"Authorization date" means the date payment begins for long-term care services described in WAC 388-106-0045.
"CARE assessment" means the evaluation process defined in chapter 388-106 WAC used by a department designated social services worker or a case manager to determine the client's need for long-term care services.
"Clothing and personal incidentals (CPI)" means the
((same as personal needs allowance (PNA) which is defined
later in this section)) cash payment issued by the department
for clothing and personal items for individuals living in an
ALF described in WAC 388-478-0045 or medical institution
described in WAC 388-478-0040.
"Community options program entry system (COPES)" means a medicaid waiver program described in chapter 388-106 WAC 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 (ALF).
"Community spouse (CS)" means a person who ((does not
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)):
(1) Does not reside in a medical institution; and
(2) Is legally married to a client who resides in a medical institution or receives services from a home and community-based (HCB) waiver program. A person is considered married if not divorced, even when physically or legally separated from his or her spouse.
"Community spouse excess shelter" means the excess shelter standard is used to calculate whether a community spouse qualifies for the community spouse maintenance allowance because of high shelter costs. The federal maximum standard that is used to calculate the amount is found at: http://www.dshs.wa.gov/manuals/eaz/sections/LongTermCare/LTCstandardspna.shtml.
"Community spouse income and family allocation" means:
(1) The community spouse income standard is used when there is a community spouse. It is used when determining the total allocation for the community spouse from the institutional spouse's income.
(2) The family allocation income standard is used when a dependent resides with the community spouse. This amount is deducted from an institutional spouse's payment for their cost of care to help support the dependent. The federal maximum standard that is used to calculate the amount can be found at: http://www.dshs.wa.gov/manuals/eaz/sections/LongTermCare/LTCstandardspna.shtml.
"Community spouse maintenance allocation" means an amount deducted from an institutional spouse's payment toward their cost of care in order for the community spouse to have enough income to pay their shelter costs. This is a combination of the community spouse income allocation and the community spouse excess shelter calculation. The federal maximum standard that is used to calculate the amount can be found at:
"Community spouse resource allocation (CSRA)" means the resource amount the community spouse is allowed. A community spouse resource evaluation is completed to determine if the standard is more than the state standard up to the federal community spouse transfer maximum standard.
"Community spouse resource evaluation" means a review of the couple owned at the start of the current period of institutional status. This review may result in a resource standard for the community spouse that is higher than the state standard.
"Community spouse transfer maximum" means the federal maximum standard that is used to determine the community spouse resource allocation (CSRA). This standard is found at: http://www.dshs.wa.gov/manuals/eaz/sections/LongTermCare/LTCstandardspna.shtml.
"DDD waiver" means medicaid waiver programs described in
chapter 388-845 WAC that provide home and community-based
services as an alternative to an intermediate care facility
for the ((mentally retarded (ICF-MR))) intellectually disabled
(ICF-ID) to persons determined eligible for services from DDD.
((There are four waivers administered by DDD: Basic, Basic
Plus, Core and Community Protection.))
"Dependent" means an individual who is financially dependent upon another for his well being as defined by financial responsibility regulations for the program. For the purposes of long-term care, rules allow allocation in post eligibility to a dependent. If the dependent is eighteen years or older and being claimed as a dependent for income tax purposes, a dependent allocation can be considered. This can include an adult child, a dependent parent or a dependent sibling.
"Equity" means the equity of real or personal property is the fair market value (see definition below) less any encumbrances (mortgages, liens, or judgments) on the property.
"Exception to rule (ETR)" means a waiver by the secretary's designee to a department policy for a specific client experiencing an undue hardship because of the policy. The waiver may not be contrary to law.
"Fair market value (FMV)" means the price an asset may
reasonably be expected to sell for on the ((local)) open
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.
"Home and community based services" (HCBS) means services provided in the home or a residential setting to individuals assessed by the department.
"Home and community based (HCB) waiver programs" means section 1915(c) of the social security act enables states to request a waiver of applicable federal medicaid requirements to provide enhanced community support services to those medicaid beneficiaries who would otherwise require the level of care provided in a hospital, nursing facility or intermediate care facility for the intellectually disabled (ICF-ID).
"Initial eligibility" means part one of institutional medical eligibility for long-term care services. Once resource and general eligibility is met, the gross nonexcluded income is compared to three hundred percent of the federal benefit rate (FBR) for a determination of CN or MN coverage.
"Institutional services" means services paid for by
medicaid or state ((payment)) funds and provided in a
((nursing facility or equivalent care provided in a medical
facility)) medical institution, through a home and community
based (HCB) waiver or program of all-inclusive care for the
elderly (PACE).
"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 person who has
attained institutional status as described in chapter 388-513 WAC, and receives services in a medical institution or from a
home and community based waiver program described in chapter
388-513 and 388-515 WAC. A person is considered married if
not divorced, even when physically or legally separated from
his or her spouse.
"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.
"Likely to reside" means a determination by the
department that a client is reasonably expected to remain in a
medical ((facility)) institution 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.
"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 as a personal needs allowance or that is allocated to a spouse or dependent family member who lives in the client's home. (See community spouse maintenance allocation and community spouse income and family allocation).
(("Medically intensive children (MIC)" program means a
medicaid waiver 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)) "Medicaid personal
care (MPC)" means a medicaid state plan program authorized
under RCW 74.09.520. Clients eligible for this program may
receive personal care in their own home or in a residential
facility. Financial eligibility is based on a client
receiving a noninstitutional categorically needy (CN) medical
program.
"Noninstitutional medical assistance" means any medical
benefits ((provided by medicaid or state-funded programs that
do not include LTC services)) or programs not authorized under
chapter 388-513 or 388-515 WAC. The exception is WAC 388-513-1305 noninstitutional SSI related clients living in an
ALF.
(("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 waiver 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. Individuals receiving services in an ALF pay room and board in addition to calculated participation. Participation is the result of the post-eligibility process used in institutional and HCB waiver eligibility.
"Penalty period" means a period of time for which a client is not eligible to receive LTC services due to asset transfers.
"Personal needs allowance (PNA)" means a standard
allowance for clothing and other personal needs for long-term
care clients who live in a medical institution or alternate
living facility, or at home. ((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)) institution 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).
"Spousal impoverishment" means financial provisions to protect income and assets of the noninstitutional (community spouse) through income and resource allowances. The spousal allocation process is used to discourage the impoverishment of a spouse due to the need for LTC services by their husband or wife. That law and those that have extended and/or amended it are referred to as spousal impoverishment legislation. (Section 1924 of the Social Security Act).
"State spousal resource standard" means minimum resource standard allowed for a community spouse. (See community spouse resource transfer maximum).
"Swing bed" means a bed in a ((medical facility))
critical access hospital that is contracted to be used as
((both)) either a hospital ((and)) or a nursing facility bed
based on the need of the individual.
"Third party resource (TPR)" means a resource where the purpose of the payment is for payment of assistance of daily living or medical services or personal care. Third party resources are described in WAC 182-501-0200. The department is considered the payer of last resort as described in WAC 182-502-0100.
"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)) changing ownership or title of an asset such as
income, real property, or personal property by one of the
following:
(1) An intentional act that changes ownership or title; or
(2) A failure to act that results in a change of ownership or title.
"Transfer date for real property or interest in real property" means:
(1) The date of transfer for real property is the day the deed is signed by the grantor if the deed is recorded; or
(2) The date of transfer for real property is the day the signed deed is delivered to the grantee.
"Transfer month" means the calendar month in which resources were legally transferred.
"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. Clients who are denied or terminated from LTC services due to a transfer of asset penalty or having excess home equity may apply for an undue hardship waiver based on criteria described in WAC 388-513-1367.
"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, the newest type of VA disability
pension, 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), 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;
(5) Dependent allowance veteran's payments made to, or on behalf of, spouses of veterans or children regardless of their ages or marital status. Any portion of a veteran's payment that is designated as the dependent's income is countable income to the dependent; or
(6) Special monthly compensation (SMC). Extra benefit paid to a veteran in addition to the regular disability compensation to a veteran who, as a result of military service, incurred the loss or loss of use of specific organs or extremities.
"Waiver programs/services" means programs for which the
federal government authorizes exceptions to federal medicaid
rules. Such programs provide to an eligible client a variety
of services not normally covered under medicaid. In
Washington State, home and community based (HCB) waiver
programs are ((DDD waivers, COPES, MIC, and OBRA)) authorized
by the division of developmental disabilities (DDD), or home
and community services (HCS).
[Statutory Authority: RCW 71A.12.030, 71A.10.020, chapters 71A.10 and 71A.12 RCW, 2004 c 276. 04-18-054, § 388-513-1301, filed 8/27/04, effective 9/27/04. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and 74.09.575. 02-09-052, § 388-513-1301, filed 4/12/02, effective 5/13/02. 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.]
(1) The eligibility criteria for noninstitutional medical assistance in an ALF follows SSI-related medical rule described in WAC 182-512-0050 through 182-512-0960 with the exception of the higher medical standard based on the daily rate described in subsection (3).
(2) Alternate living facilities (AFH) include the following:
(a) An adult family home (AFH), 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. Licensed as an adult family home under chapter 70.128 RCW and chapter 388-76 WAC;
(b) An adult residential care facility (ARC)(formally known as a CCF) is a licensed facility that provides its residents with shelter, food, household maintenance, personal care and supervision. Licensed as an assisted living facility under chapter 18.20 RCW and chapter 388-78A WAC;
(c) An adult residential rehabilitation center (ARRC) described in WAC 388-865-0235 or adult residential treatment facility (ARTF) described in WAC 388-865-0465. These are licensed facilities that provide its residents with twenty-four hour residential care for impairments related to mental illness;
(d) ((An adult residential treatment facility (ARTF)))
Assisted living facility (AL), a licensed facility for aged
and disabled low-income persons with functional disabilities.
COPES eligible clients are often placed in assisted living.
Licensed as an assisted living facility under chapter 18.20 RCW and chapter 388-78A WAC;
(e) ((An assisted living facility (AL))) Division of
developmental disabilities (DDD) group home (GH), a licensed
facility that provides its residents with twenty-four hour
supervision. Depending on size of a DDD group home may be
licensed as an adult family home under chapter 70.128 RCW or a
boarding home under chapter 18.20 RCW. Group home means a
residence that is licensed as either an assisted living
facility or an adult family home by the department under
chapters 388-78A or 388-76 WAC. Group homes provide community
residential instruction, supports, and services to two or more
clients who are unrelated to the provider; and
(f) ((A division of developmental disabilities (DDD)
group home (GH); and
(g) An enhanced adult residential care facility (EARC).
(2))) Enhanced adult residential care facility (EARC), 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. Licensed as an assisted living facility under chapter 18.20 RCW.
(3) The monthly income standard for noninstitutional
medical assistance under the categorically needy (CN) program
((that cannot exceed the special income level (SIL) equals the
following amounts. For a client who lives in:
(a) An ARC, an ARRC, an ARTF, an AL, a DDD GH, or an EARC, the department-contracted rate based on a thirty-one day month plus the PNA; or
(b) An AFH, the department-contracted rate based on a thirty-one day month plus the PNA plus the cost of any add-on hours authorized by the department.
(3))) has two steps:
(a) The gross nonexcluded monthly income cannot exceed the special income level (SIL) which is three hundred percent of the federal benefit rate (FBR); and
(b) The countable income cannot be greater than the department contracted daily rate times thirty-one days, plus the thirty-eight dollars and eighty-four cents PNA/CPI described in WAC 388-478-0045.
(4) The monthly income standard for noninstitutional
medical assistance under the medically needy (MN) program
equals the private facility daily rate ((based on a
thirty-one-day month)) times thirty one days, plus the
thirty-eight dollars and eight-four cents PNA/CPI described in
WAC 388-478-0045. Follow MN rules described in chapter 388-519 WAC.
(((4) The monthly income standard for noninstitutional
medical assistance under the general assistance (GA) program
equals the GA grant standard described in WAC 388-478-0045.))
(5) The department ((determines a client's nonexcluded
resources for noninstitutional medical assistance under the:
(a) General assistance (GA) and temporary assistance for needy families (TANF) programs as described in chapter 388-470 WAC; and
(b) SSI-related medical program as described in chapter 388-475 WAC)) approves CN noninstitutional medical assistance for a period of up to twelve months for a client who is SSI-related as described in WAC 182-512-0050, if:
(a) The client's nonexcluded resources do not exceed the standard described in WAC 388-513-1350(1); and
(b) The client's nonexcluded income does not exceed the CN standard described in subsection (3) of this section. SSI related program as described in chapter 182-512 WAC.
(6) The department ((determines a client's nonexcluded
income for noninstitutional medical assistance as described
in:
(a) Chapter 388-450 WAC for GA and TANF programs; and
(b) Chapter 388-475 WAC and WAC 388-506-0620 for SSI-related medical programs)) approves MN noninstitutional medical assistance for a period of months described in chapter 182-504 WAC for an SSI-related client, if:
(a) The client's nonexcluded resources do not exceed the standard described in WAC 388-513-1350(1); and
(b) The client satisfies any spenddown liability as described in chapter 182-519 WAC.
(7) The department ((approves CN noninstitutional medical
assistance for a period of up to twelve months for a client
who receives Supplemental Security Income (SSI) or who is
SSI-related as described in WAC 388-475-0050, if:
(a) The client's nonexcluded resources described in subsection (5) do not exceed the standard described in WAC 388-513-1350(1); and
(b) The client's nonexcluded income described in subsection (6) does not exceed the CN standard described in subsection (2))) determines eligibility for a cash grant for individuals residing in an alternate living facility using the following program rules:
(a) WAC 388-400-0005 temporary assistance for needy families (TANF);
(b) WAC 388-400-0060 aged, blind, disabled (ABD) cash benefit;
(c) WAC 388-400-0030 refugee assistance.
(8) The ((department approves MN noninstitutional medical
assistance for a period of months described in chapter 388-416 WAC for an SSI-related client, if:
(a) The client's nonexcluded resources described in subsection (5) do not exceed the standard described in WAC 388-513-1350(1); and
(b) The client satisfies any spenddown liability as described in chapter 388-519 WAC)) client described in subsection (7) residing in an adult family home (AFH) receives a grant based on a payment standard described in WAC 388-478-0033 due to an obligation to pay shelter costs to the adult family home. The client keeps a CPI in the amount of thirty-eight dollars and eighty-four cents described in WAC 388-478-0045 and pays the remainder of the grant to the adult family home as room and board.
(9) The ((department approves GA and TANF
noninstitutional medical assistance for a period of months
described in chapter 388-416 WAC)) client described in
subsection (7) residing in an ALF described in subsections
(2)(b), (c), (d), (e), (f) or (g) (all nonadult family home
residential settings) keeps the thirty-eight dollars and
eighty-four cents CPI amount based on WAC 388-478-0045.
(10) The client described in ((subsections (7) and (9)
keeps the PNA amount and pays remaining income to the facility
for board and room)) (3) and receiving medicaid personal care
(MPC) from the department keeps sixty-two dollars and
seventy-nine cents as a PNA and pays the remainder of their
income to the ALF for room and board and personal care.
[Statutory Authority: RCW 74.08.090. 06-07-077, § 388-513-1305, filed 3/13/06, effective 4/13/06. 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, § 388-513-1305, filed 12/8/99, effective 1/8/00. Statutory Authority: RCW 74.08.090 and 74.09.500. 99-06-045, § 388-513-1305, filed 2/26/99, effective 3/29/99. Statutory Authority: RCW 74.08.090. 94-10-065 (Order 3732), § 388-513-1305, filed 5/3/94, effective 6/3/94. Formerly parts of WAC 388-83-036 and 388-99-036.]
Reviser's note: The typographical error in the above section occurred in the copy filed by the agency and appears in the Register pursuant to the requirements of RCW 34.08.040.
AMENDATORY SECTION(Amending WSR 10-01-158, filed 12/22/09,
effective 1/22/10)
WAC 388-513-1315
Eligibility for long-term care
(institutional, waiver, and hospice) services.
This section
describes how the department determines a client's eligibility
for medical for clients residing in a medical institution, on
a waiver, or receiving hospice services under the
categorically needy (CN) or medically needy (MN) programs. Also described are the eligibility requirements for these
services under the ((general assistance (GA) program in
subsection (12))) aged, blind, or disabled (ABD) cash
assistance, medical care services (MCS) and the state funded
((nursing facility)) long-term care services program described
in subsection (11).
(1) To be eligible for long-term care (LTC) services described in this section, a client must:
(a) Meet the general eligibility requirements for medical
programs described in WAC ((388-503-0505)) 182-503-0505 (2)
and (3)(a) through (((f))) (g);
(b) Attain institutional status as described in WAC 388-513-1320;
(c) Meet functional eligibility described in chapter 388-106 WAC for home and community services (HCS) waiver and nursing facility coverage; or
(d) Meet criteria for division of developmental disabilities (DDD) assessment under chapter 388-828 WAC for DDD waiver or institutional services;
(e) Not have a penalty period of ineligibility as
described in WAC 388-513-1363, 388-513-1364, or 388-513-1365
((or 388-513-1366));
(((e))) (f) Not have equity interest in their primary
residence greater than ((five hundred thousand dollars in
their primary residence as)) the home equity standard
described in WAC 388-513-1350; and
(((f))) (g) Must disclose to the state any interest the
applicant or spouse has in an annuity and meet annuity
requirements described in chapter 388-561 WAC:
(i) This is required for all institutional or waiver services and includes those individuals receiving Supplemental Security Income (SSI).
(ii) A signed and completed eligibility review for long term care benefits or application for benefits form can be accepted for SSI individuals applying for long-term care services.
(2) To be eligible for institutional, waiver, or hospice services under the CN program, a client must either:
(a) Be related to the Supplemental Security Income (SSI)
program as described in WAC ((388-475-0050)) 182-512-0050 (1),
(2) and (3) and meet the following financial requirements, by
having:
(i) Gross nonexcluded income described in subsection (8)(a) that does not exceed the special income level (SIL) (three hundred percent of the federal benefit rate (FBR)); and
(ii) Countable resources described in subsection (7) that do not exceed the resource standard described in WAC 388-513-1350; or
(b) Be approved and receiving ((the general assistance
expedited medicaid disability (GA-X) or general assistance
aged (GA-A) or general assistance disabled (GA-D) described in
WAC 388-505-0110(6))) aged, blind, or disabled cash assistance
described in WAC 388-400-0060 and meet citizenship
requirements for federally funded medicaid described in WAC 388-424-0010; or
(c) Be eligible for CN apple health for kids described in
WAC ((388-505-0210)) 182-505-0210; or CN family medical
described in WAC ((388-505-0220)) 182-505-0240; or family and
children's institutional medical described in WAC
((388-505-0230)) 182-514-0230 through ((388-505-0260))
182-514-0260. Clients not meeting the citizenship
requirements for federally funded medicaid described in WAC 388-424-0010 are not eligible to receive waiver services. Nursing facility services for noncitizen children require
prior approval ((for)) by aging and disability services
administration (ADSA) under the state funded nursing facility
program described in WAC ((388-438-0125 for noncitizen
children)) 182-507-0125; or
(d) Be eligible for the temporary assistance for needy
families (TANF) program as described in WAC 388-400-0005. Clients not meeting disability or blind criteria described in
WAC ((388-475-0050)) 182-512-0050 are not eligible for waiver
services.
(3) The department allows a client to reduce countable resources in excess of the standard. This is described in WAC 388-513-1350.
(4) To be eligible for waiver services, a client must meet the program requirements described in:
(a) WAC 388-515-1505 through 388-515-1509 for COPES, New Freedom, PACE, and WMIP services; or
(b) WAC 388-515-1510 through 388-515-1514 for DDD
waivers((; or
(c) WAC 388-515-1540 for the medically needy residential waiver (MNRW); or
(d) WAC 388-515-1550 for the medically needy in-home waiver (MNIW))).
(5) To be eligible for hospice services under the CN program, a client must:
(a) Meet the program requirements described in chapter
((388-551)) 182-551 WAC; and
(b) Be eligible for a noninstitutional categorically
needy program (((CN-P))) (CN) if not residing in a medical
institution thirty days or more; or
(c) Reside at home and benefit by using home and community based waiver rules described in WAC 388-515-1505 through 388-515-1509 (SSI related clients with income over the effective one-person MNIL and gross income at or below the 300 percent of the FBR or clients with a community spouse); or
(d) Receive home and community waiver (HCS) or DDD waiver services in addition to hospice services. The client's responsibility to pay toward the cost of care (participation) is applied to the waiver service provider first; or
(e) Be eligible for institutional CN if residing in a medical institution thirty days or more.
(6) To be eligible for institutional or hospice services under the MN program, a client must be:
(a) Eligible for MN children's medical program described
in WAC ((388-505-0210, 388-505-0255, or 388-505-0260))
182-514-0230, 182-514-0255, or 182-514-0260; or
(b) Related to the SSI program as described in WAC
((388-475-0050)) 182-512-0050 and meet all requirements
described in WAC 388-513-1395; or
(c) Eligible for the MN SSI related program described in
WAC ((388-475-0150)) 182-512-0150 for hospice clients residing
in a home setting; or
(d) Eligible for the MN SSI related program described in WAC 388-513-1305 for hospice clients not on a medically needy waiver and residing in an alternate living facility.
(e) Be eligible for institutional MN if residing in a medical institution thirty days or more described in WAC 388-513-1395.
(7) To determine resource eligibility for an SSI-related client under the CN or MN program, the department:
(a) Considers resource eligibility and standards described in WAC 388-513-1350; and
(b) Evaluates the transfer of assets as described in WAC 388-513-1363, 388-513-1364, or 388-513-1365 ((or
388-513-1366)).
(8) To determine income eligibility for an SSI-related client under the CN or MN program, the department:
(a) Considers income available as described in WAC 388-513-1325 and 388-513-1330;
(b) Excludes income for CN and MN programs as described in WAC 388-513-1340;
(c) Disregards income for the MN program as described in WAC 388-513-1345; and
(d) Follows program rules for the MN program as described in WAC 388-513-1395.
(9) A client who meets the requirements of the CN program is approved for a period of up to twelve months.
(10) A client who meets the requirements of the MN
program is approved for a period of months described in WAC 388-513-1395(((6))) for:
(a) Institutional services in a medical institution; or
(b) Hospice services in a medical institution.
(11) The department determines eligibility for ((the))
state funded ((nursing facility program described in WAC 388-438-0110 and 388-438-0125. Nursing facility services
under the state funded nursing facility program must be
preapproved by aging and disability services administration
(ADSA).
(12) The department determines eligibility for institutional services under the GA program described in WAC 388-448-0001 for a client who meets all other requirements for such services but is not eligible for programs described in subsections (9) through (11).
(13))) programs under the following rules:
(a) A client who is eligible for ABD cash assistance program described in WAC 388-400-0060 but is not eligible for federally funded medicaid due to citizenship requirements receives MCS medical described in WAC 182-508-0005. A client who is eligible for MCS may receive institutional services but is not eligible for hospice or HCB waiver services.
(b) A client who is not eligible for ABD cash assistance but is eligible for MCS coverage only described in WAC 182-508-0005 may receive institutional services but is not eligible for hospice or HCB waiver services.
(c) A noncitizen client who is not eligible under subsections (11)(a) or (b) and needs long-term care services may be eligible under WAC 182-507-0110 and WAC 182-507-0125. This program must be pre-approved by aging and disability services administration (ADSA).
(12) A client is eligible for medicaid as a resident in a psychiatric facility, if the client:
(a) Has attained institutional status as described in WAC 388-513-1320; and
(b) Is under the age of twenty-one at the time of application; or
(c) Is receiving active psychiatric treatment just prior to their twenty-first birthday and the services extend beyond this date and the client has not yet reached age twenty-two; or
(d) Is at least sixty-five years old.
(((14))) (13) The department determines a client's
eligibility as it does for a single person when the client's
spouse has already been determined eligible for LTC services.
(((15))) (14) If an individual under age twenty one is
not eligible for medicaid under SSI related in WAC
((388-475-0050)) 182-512-0050 or ((general assistance (GA)
described in WAC 388-448-0001 and 388-505-0110(6))) ABD cash
assistance described in WAC 388-400-0060 or MCS described in
182-508-0005, consider eligibility under WAC ((388-505-0255))
182-514-0255 or ((388-505-0260)) 182-514-0260.
(((16))) (15) Noncitizen ((individuals)) clients under
age nineteen can be considered for the apple health for kids
program described in WAC ((388-505-0210)) 182-505-0210 if they
are admitted to a medical institution for less than thirty
days. Once ((an individual)) a client resides or is likely to
reside in a medical institution for thirty days or more, the
department determines eligibility under WAC ((388-505-0260))
182-514-0260 and must be preapproved for coverage by ADSA as
described in WAC ((388-438-0125)) 182-507-0125.
(16) Noncitizen clients not eligible under subsection (15) of this section can be considered for LTC services under WAC 182-507-0125. These clients must be pre-approved by ADSA.
(17) The department determines a client's total responsibility to pay toward the cost of care for LTC services as follows:
(a) For SSI-related clients residing in a medical institution see WAC 388-513-1380;
(b) For clients receiving HCS CN waiver services see WAC 388-515-1509;
(c) For clients receiving DDD CN waiver services see WAC 388-515-1514; or
(d) ((For clients receiving HCS MN waiver services see
WAC 388-515-1540 or 388-515-1550; or
(e))) For TANF related clients residing in a medical
institution see WAC ((388-505-0265)) 182-514-0265.
(18) Clients not living in a medical institution who are
considered to be receiving SSI benefits for the purposes of
medicaid do not pay service participation toward their cost of
care. Clients living in a residential setting do pay room and
board as described in WAC 388-515-1505 through 388-515-1509 or
WAC 388-515-1514. Groups deemed to be receiving SSI and for
medicaid purposes are eligible to receive ((CN-P)) CN
medicaid. These groups are described in WAC ((388-475-0880))
182-512-0880.
[Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530. 10-01-158, § 388-513-1315, filed 12/22/09, effective 1/22/10. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, 74.09.575, and Deficit Reduction Act of 2005, 42 C.F.R. Section 435. 09-07-036, § 388-513-1315, filed 3/10/09, effective 4/10/09. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, 74.39.010. 07-19-129, § 388-513-1315, filed 9/19/07, effective 10/20/07. Statutory Authority: RCW 74.08.090. 06-07-077, § 388-513-1315, filed 3/13/06, effective 4/13/06. Statutory Authority: RCW 71A.12.030, 71A.10.020, chapters 71A.10 and 71A.12 RCW, 2004 c 276. 04-18-054, § 388-513-1315, filed 8/27/04, effective 9/27/04. 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, § 388-513-1315, filed 12/8/99, effective 1/8/00. Statutory Authority: RCW 74.08.090 and 74.09.500. 99-06-045, § 388-513-1315, filed 2/26/99, effective 3/29/99. Statutory Authority: RCW 74.04.050, 74.08.090 and 42 CFR 435.1005. 98-04-003, § 388-513-1315, filed 1/22/98, effective 2/22/98. Statutory Authority: RCW 74.08.090. 96-11-072 (Order 3980), § 388-513-1315, filed 5/10/96, effective 6/10/96. Statutory Authority: RCW 74.08.090 and 1995 c 312 § 48. 95-19-007 (Order 3895), § 388-513-1315, filed 9/6/95, effective 10/7/95. Statutory Authority: RCW 74.08.090. 94-10-065 (Order 3732), § 388-513-1315, filed 5/3/94, effective 6/3/94.]
(a) Be approved for and receiving home and community based waiver services or hospice services; or
(b) Reside or ((be)) based on a department assessment is
likely to reside in a medical institution, institution for
((medical)) mental diseases (IMD) or inpatient psychiatric
facility for a continuous period of:
(i) Thirty days if you are an adult eighteen and older;
(ii) Thirty days if you are a child seventeen years of age or younger admitted to a medical institution; or
(iii) Ninety days if you are a child seventeen years of age or younger receiving inpatient chemical dependency or inpatient psychiatric treatment.
(2) Once the department has determined that you meet institutional status, your status is not affected by:
(a) Transfers between medical facilities; or
(b) Changes from one kind of long-term care services (waiver, hospice or medical institutional services) to another.
(3) If you are absent from the medical institution or you do not receive waiver or hospice services for at least thirty consecutive days, you lose institutional status.
[Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, 74.09.575, and Deficit Reduction Act of 2005, 42 C.F.R. Section 435. 09-07-036, § 388-513-1320, filed 3/10/09, effective 4/10/09. Statutory Authority: RCW 74.08.090. 06-07-077, § 388-513-1320, filed 3/13/06, effective 4/13/06. 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, § 388-513-1320, filed 12/8/99, effective 1/8/00. Statutory Authority: RCW 74.08.090 and 74.09.500. 99-06-045, § 388-513-1320, filed 2/26/99, effective 3/29/99. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090 and 42 C.F.R. 435.403 (j)(2). 97-15-025, § 388-513-1320, filed 7/8/97, effective 8/8/97. Statutory Authority: RCW 74.08.090. 96-11-072 (Order 3980), § 388-513-1320, filed 5/10/96, effective 6/10/96; 94-10-065 (Order 3732), § 388-513-1320, filed 5/3/94, effective 6/3/94.]
(1) Refer to WAC 388-513-1330 for rules related to available income for legally married couples.
(2) The department must apply the following rules when determining income eligibility for SSI-related LTC services:
(a) WAC ((388-475-0600)) 182-512-0600 Definition of
income;
(b) WAC ((388-475-0650)) 182-512-0650 Available income;
(c) WAC ((388-475-0700)) 182-512-0700 Income eligibility;
(d) WAC ((388-475-0750)) 182-512-0750 Countable unearned
income;
(e) WAC ((388-475-0840(3))) 182-514-0840(3) Self
employment income-allowable expenses;
(f) WAC ((388-513-1315(16))) 388-513-1315(15),
Eligibility for long-term care (institutional, waiver, and
hospice) services; and
(g) WAC 388-450-0155, 388-450-0156 ((and)), 388-450-0160
and 182-509-0155 for sponsored immigrants and how to determine
if sponsors' income counts in determining benefits.
[Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530. 07-14-087, § 388-513-1325, filed 6/29/07, effective 7/30/07. 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, § 388-513-1325, filed 12/8/99, effective 1/8/00.]
(1) The department must apply the following rules when determining income eligibility for LTC services:
(a) WAC ((388-475-0600)) 182-512-0600 Definition of
income SSI-related medical;
(b) WAC ((388-475-0650)) 182-512-0650 Available income;
(c) WAC ((388-475-7000)) 182-512-0700 Income eligibility;
(d) WAC ((388-475-0750)) 182-512-0750 Countable unearned
income;
(e) WAC ((388-475-0840(3))) 182-512-0840(3)
Self-employment income-allowance expenses;
(f) WAC ((388-506-0620)) 182-512-0960, SSI-related
medical clients; and
(g) WAC 388-513-1315 (((15) and (16))), Eligibility for
long-term care (institutional, waiver, and hospice) services.
(2) For an institutionalized client married to a community spouse who is not applying or approved for LTC services, the department considers the following income available, unless subsection (4) applies:
(a) Income received in the client's name;
(b) Income paid to a representative on the client's behalf;
(c) One-half of the income received in the names of both spouses; and
(d) Income from a trust as provided by the trust.
(3) The department considers the following income unavailable to an institutionalized client:
(a) Separate or community income received in the name of the community spouse; and
(b) Income established as unavailable through a ((fair
hearing)) court order.
(4) For the determination of eligibility only, if available income described in subsections (2)(a) through (d) minus income exclusions described in WAC 388-513-1340 exceeds the special income level (SIL), then:
(a) The department follows community property law when determining ownership of income;
(b) Presumes all income received after marriage by either or both spouses to be community income; and
(c) Considers one-half of all community income available to the institutionalized client.
(d) If the total of subsection (4)(c) plus the client's own income is over the SIL, follow subsection (2).
(5) ((If both spouses are either applying or approved for
LTC services, then:
(a) The department allocates one-half of all community income described in subsection (4) to each spouse; and
(b) Adds the separate income of each spouse respectively to determine available income for each of them.
(6))) The department considers income generated by a transferred resource to be the separate income of the person or entity to which it is transferred.
(((7))) (6) The department considers income available to
the client not generated by a transferred resource available
to the client, even when the client transfers or assigns the
rights to the stream of income to:
(a) The spouse; or
(b) A trust for the benefit of ((the)) their spouse.
(8) The department evaluates the transfer of a resource
described in subsection (((6))) (5) according to WAC 388-513-1363, 388-513-1364, and 388-513-1365 ((and
388-513-1366)) to determine whether a penalty period of
ineligibility is required.
[Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.575, and 2005 federal Deficit Reduction Act (DRA), Public Law 109-171. 07-17-152, § 388-513-1330, filed 8/21/07, effective 10/1/07. Statutory Authority: RCW 74.08.090. 06-07-077, § 388-513-1330, filed 3/13/06, effective 4/13/06. 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, § 388-513-1330, filed 12/8/99, effective 1/8/00. Statutory Authority: RCW 74.08.090 and 74.09.500. 99-06-045, § 388-513-1330, filed 2/26/99, effective 3/29/99. Statutory Authority: RCW 74.08.090, 74.05.040 and 20 C.F.R. 416.1110-1112, 1123 and 1160. 97-10-022, § 388-513-1330, filed 4/28/97, effective 5/29/97. Statutory Authority: RCW 74.08.090 and Title XIX State Agency Letter #94-33. 95-02-028 (Order 3819), § 388-513-1330, filed 12/28/94, effective 1/28/95. Statutory Authority: RCW 74.08.090. 94-10-065 (Order 3732), § 388-513-1330, filed 5/3/94, effective 6/3/94. Formerly parts of WAC 388-95-335 and 388-95-340.]
Reviser's note: The typographical error in the above section occurred in the copy filed by the agency and appears in the Register pursuant to the requirements of RCW 34.08.040.
AMENDATORY SECTION(Amending WSR 09-09-101, filed 4/20/09,
effective 5/21/09)
WAC 388-513-1340
Determining excluded income for
long-term care (LTC) services.
This section describes income
the department excludes when determining a client's
eligibility and participation in the cost of care for LTC
services with the exception described in subsection (31).
(1) Crime victim's compensation;
(2) Earned income tax credit (EITC) for twelve months after the month of receipt;
(3) Native American benefits excluded by federal statute (refer to WAC 388-450-0040);
(4) Tax rebates or special payments excluded by other statutes;
(5) Any public agency's refund of taxes paid on real property and/or on food;
(6) Supplemental security income (SSI) and certain state public assistance based on financial need;
(7) The amount a representative payee charges to provide services when the services are a requirement for the client to receive the income;
(8) The amount of expenses necessary for a client to receive compensation, e.g., legal fees necessary to obtain settlement funds;
(9) Any portion of a grant, scholarship, or fellowship used to pay tuition, fees, and/or other necessary educational expenses at any educational institution;
(10) Child support payments received from an absent parent for a child living in the home are considered the income of the child;
(11) Self-employment income allowed as a deduction by the Internal Revenue Service (IRS);
(12) Payments to prevent fuel cut-offs and to promote energy efficiency that are excluded by federal statute;
(13) Assistance (other than wages or salary) received under the Older Americans Act;
(14) Assistance (other than wages or salary) received under the foster grandparent program;
(15) Certain cash payments a client receives from a governmental or nongovernmental medical or social service agency to pay for medical or social services;
(16) Interest earned on excluded burial funds and any appreciation in the value of an excluded burial arrangement that are left to accumulate and become part of the separately identified burial funds set aside;
(17) Tax exempt payments received by Alaska natives under the Alaska Native Settlement Act established by P.L. 100-241;
(18) Compensation provided to volunteers in ACTION programs under the Domestic Volunteer Service Act of 1973 established by P.L. 93-113;
(19) Payments made from the Agent Orange Settlement Fund or any other funds to settle Agent Orange liability claims established by P.L. 101-201;
(20) Payments made under section six of the Radiation Exposure Compensation Act established by P.L. 101-426;
(21) Payments made under the Energy Employee Occupational Compensation Program Act of 2000, (EEOICPA) Pub. L. 106-398;
(22) Restitution payment, and interest earned on such payment to a civilian of Japanese or Aleut ancestry established by P.L. 100-383;
(((22))) (23) Payments made under sections 500 through
506 of the Austrian General Social Insurance Act;
(((23))) (24) Payments made from Susan Walker v. Bayer
Corporation, et, al., 95-C-5024 (N.D. Ill.) (May 8, 1997)
settlement funds;
(((24))) (25) Payments made from the Ricky Ray Hemophilia
Relief Fund Act of 1998 established by P.L. 105-369;
(((25))) (26) Payments made under the Disaster Relief and
Emergency Assistance Act established by P.L. 100-387;
(((26))) (27) Payments made under the Netherlands' Act on
Benefits for Victims of Persecution (WUV);
(((27))) (28) Payments made to certain survivors of the
Holocaust under the Federal Republic of Germany's Law for
Compensation of National Socialist Persecution or German
Restitution Act;
(((28))) (29) Interest or dividends received by the
client is excluded as income. Interest or dividends received
by the community spouse of an institutional individual is
counted as income of the community spouse. Dividends and
interest are returns on capital investments such as stocks,
bond, or savings accounts. Institutional status is defined in
WAC 388-513-1320;
(((29))) (30) Income received by an ineligible or
nonapplying spouse from a governmental agency for services
provided to an eligible client, e.g., chore services;
(((30))) (31) Department of Veterans Affairs benefits
designated for:
(a) The veteran's dependent when determining LTC eligibility for the veteran. The VA dependent allowance is considered countable income to the dependent unless it is paid due to unusual medical expenses (UME);
(b) Unusual medical expenses, aid and attendance
allowance, special monthly compensation (SMC) and housebound
allowance, with the exception described in subsection (((31)))
(32);
(((31))) (32) Benefits described in subsection
(((30)(b))) (31)(b) for a client who ((resides in a state
veterans' home and has no dependents)) receives long-term care
services are excluded when determining eligibility, but are
considered available as a third-party resource (TPR) when
determining ((participation)) the amount the client
contributes in the cost of care.
[Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, Social Security Act § 1611, 1902, and C.F.R. 435.725. 09-09-101, § 388-513-1340, filed 4/20/09, effective 5/21/09. 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, § 388-513-1340, filed 12/14/99, effective 1/14/00. Statutory Authority: RCW 74.08.090 and Title XIX State Agency Letter #94-33. 95-02-028 (Order 3819), § 388-513-1340, filed 12/28/94, effective 1/28/95. Statutory Authority: RCW 74.08.090. 94-10-065 (Order 3732), § 388-513-1340, filed 5/3/94, effective 6/3/94. Formerly WAC 388-95-340 (part).]
(1) The department disregards the following income amounts in the following order:
(a) Income that is not reasonably anticipated, or is received infrequently or irregularly, when such income does not exceed:
(i) Twenty dollars per month if unearned; or
(ii) Ten dollars per month if earned.
(b) The first twenty dollars per month of earned or unearned income, unless the income paid to a client is:
(i) Based on need; and
(ii) Totally or partially funded by the federal government or a private agency.
(2) For a client who is related to the supplemental
security income (SSI) program as described in WAC
((388-475-0050(1))) 182-512-0050(1), the first sixty-five
dollars per month of earned income not excluded under WAC 388-513-1340, plus one-half of the remainder.
(3) ((For a TANF/SFA-related client, fifty percent of
gross earned income.
(4) Department of Veterans Affairs benefits if:
(a) Those benefits are designated for:
(i) Unusual medical expenses;
(ii) Aid and attendance allowance; or
(iii) Housebound allowance; and
(b) The client:
(i) Resides in a state veterans' home; and
(ii) Has no dependents)) Department of Veterans Affairs benefits designated for:
(a) The veteran's dependent when determining LTC eligibility for the veteran. The VA dependent allowance is considered countable income to the dependent unless it is paid due to unusual medical expenses (UME);
(b) Unusual medical expenses, aid and attendance allowance, special monthly compensation (SMC) and housebound allowance, with the exception described in subsection (4).
(4) Benefits described in subsection (3)(b) for a client who receives long-term care services are excluded when determining eligibility, but are considered available as a third-party resource (TPR) when determining the amount the client contributes in the cost of care.
(5) Income the Social Security Administration (SSA) withholds from SSA Title II benefits for the recovery of an SSI overpayment.
[Statutory Authority: RCW 74.08.090. 06-07-077, § 388-513-1345, filed 3/13/06, effective 4/13/06. 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, § 388-513-1345, filed 12/14/99, effective 1/14/00. Statutory Authority: RCW 74.08.090 and Title XIX State Agency Letter #94-33. 95-02-028 (Order 3819), § 388-513-1345, filed 12/28/94, effective 1/28/95. Statutory Authority: RCW 74.08.090. 94-10-065 (Order 3732), § 388-513-1345, filed 5/3/94, effective 6/3/94. Formerly WAC 388-95-340 (part).]
(1) The resource standard used to determine eligibility for LTC services equals:
(a) Two thousand dollars for:
(i) A single client; or
(ii) A legally married client with a community spouse,
subject to the provisions described in subsections (((8))) (9)
through (((11))) (12) of this section; or
(b) Three thousand dollars for a legally married couple,
unless subsection (((3))) (4) of this section applies.
(2) Effective January 1, 2012 if an individual purchases a qualified long-term care partnership policy approved by the Washington Insurance Commissioner under the Washington long-term care partnership program, the department allows the individual with the long-term care partnership policy to retain a higher resource amount based on the dollar amount paid out by a partnership policy. This is described in WAC 388-513-1400.
(3) When both spouses apply for LTC services the department considers the resources of both spouses as available to each other through the month in which the spouses stopped living together.
(((3))) (4) When both spouses are institutionalized, the
department will determine the eligibility of each spouse as a
single client the month following the month of separation.
(((4))) (5) If the department has already established
eligibility and authorized services for one spouse, and the
community spouse needs LTC services in the same month, (but
after eligibility has been established and services authorized
for the institutional spouse), then the department applies the
standard described in subsection (1)(a) of this section to
each spouse. If doing this would make one of the spouses
ineligible, then the department applies (1)(b) of this section
for a couple.
(((5))) (6) When a single institutionalized individual
marries, the department will redetermine eligibility applying
the rules for a legally married couple.
(((6))) (7) The department applies the following rules
when determining available resources for LTC services:
(a) WAC ((388-475-0300)) 182-512-0300, Resource
eligibility;
(b) WAC ((388-475-0250)) 182-512-0250, How to determine
who owns a resource; and
(c) WAC 388-470-0060(6), Resources of an alien's sponsor.
(((7))) (8) For LTC services the department determines a
client's countable resources as follows:
(a) The department determines countable resources for
SSI-related clients as described in WAC ((388-475-0350))
182-512-0350 through ((388-475-0550)) 182-512-0550 and
resources excluded by federal law with the exception of:
(i) WAC ((388-475-0550(16);)) 182-512-0550 pension funds
owned by an:
(I) Ineligible spouse. Pension funds are defined as funds held in an individual retirement account (IRA) as described by the IRS code; or
(II) Work-related pension plan (including plans for self-employed individuals, known as Keogh plans).
(ii) WAC ((388-475-0350)) 182-512-0350 (1)(b) clients who
have submitted an application for LTC services on or after May
1, 2006 and have an equity interest greater than five hundred
thousand dollars in their primary residence are ineligible for
LTC services. This exception does not apply if a spouse or
blind, disabled or dependent child under age twenty-one is
lawfully residing in the primary residence. Clients denied or
terminated LTC services due to excess home equity may apply
for an undue hardship waiver described in WAC 388-513-1367.
Effective January 1, 2011, the excess home equity limits
increase to five hundred six thousand dollars. On January 1,
2012 and on January 1 of each year thereafter, this standard
may be increased or decreased by the percentage increased or
decreased in the consumer price index-urban (CPIU). For
current excess home equity standard starting January 1, 2011
and each year thereafter, see
http://www.dshs.wa.gov/manuals/eaz/sections/LongTermCare/LTCstandardspna.shtml.
(b) For an SSI-related client one automobile per household is excluded regardless of value if it is used for transportation of the eligible individual/couple.
(i) For an SSI-related client with a community spouse, the value of one automobile is excluded regardless of its use or value.
(ii) A vehicle not meeting the definition of automobile is a vehicle that has been junked or a vehicle that is used only as a recreational vehicle.
(c) For an SSI-related client, the department adds
together the countable resources of both spouses if
subsections (((2))) (3), (((5))) (6) and (((8)(a))) (9)(a) or
(b) apply, but not if subsection (((3) or)) (4) or (5) apply.
(d) For an SSI-related client, excess resources are reduced:
(i) In an amount equal to incurred medical expenses such as:
(A) Premiums, deductibles, and coinsurance/copayment charges for health insurance and medicare;
(B) Necessary medical care recognized under state law, but not covered under the state's medicaid plan;
(C) Necessary medical care covered under the state's medicaid plan incurred prior to medicaid eligibility. Expenses for nursing facility care are reduced at the state rate for the facility that the client owes the expense to.
(ii) As long as the incurred medical expenses:
(A) Were not incurred more than three months before the month of the medicaid application;
(B) Are not subject to third-party payment or reimbursement;
(((B))) (C) Have not been used to satisfy a previous
spend down liability;
(((C))) (D) Have not previously been used to reduce
excess resources;
(((D))) (E) Have not been used to reduce client
responsibility toward cost of care;
(((E))) (F) Were not incurred during a transfer of asset
penalty described in WAC 388-513-1363, 388-513-1364, and
388-513-1365 ((and 388-513-1366)); and
(((F))) (G) Are amounts for which the client remains
liable.
(e) Expenses not allowed to reduce excess resources or participation in personal care:
(i) Unpaid expense(s) prior to waiver eligibility to an
adult family home (AFH) or ((boarding home)) assisted living
facility is not a medical expense.
(ii) Personal care cost in excess of approved hours determined by the CARE assessment described in chapter 388-106 WAC is not a medical expense.
(f) The amount of excess resources is limited to the following amounts:
(i) For LTC services provided under the categorically needy (CN) program:
(A) Gross income must be at or below the special income level (SIL), 300% of the federal benefit rate (FBR).
(B) In a medical institution, excess resources and income must be under the state medicaid rate based on the number of days in the medical institution in the month.
(C) For CN waiver eligibility, incurred medical expenses must reduce resources within allowable resource limits for CN-waiver eligibility. The cost of care for the waiver services cannot be allowed as a projected expense.
(ii) For LTC services provided under the medically needy
(MN) program when excess resources are added to
((nonexcluded)) countable income, the combined total is less
than the:
(A) ((Private)) State medical institution rate based on
the number of days in the medical institution in the month,
plus the amount of recurring medical expenses ((for
institutional services)); or
(B) ((Private)) State hospice rate based on the number of
days in the medical institution in the month plus the amount
of recurring medical expenses, ((for hospice services)) in a
medical institution.
(C) For MN waiver eligibility, incurred medical expenses must reduce resources within allowable resource limits for MN-waiver eligibility. The cost of care for the waiver services cannot be allowed as a projected expense.
(g) For a client not related to SSI, the department applies the resource rules of the program used to relate the client to medical eligibility.
(((8))) (9) For legally married clients when only one
spouse meets institutional status, the following rules apply. If the client's current period of institutional status began:
(a) Before October 1, 1989, the department adds together one-half the total amount of countable resources held in the name of:
(i) The institutionalized spouse; or
(ii) Both spouses.
(b) On or after October 1, 1989, the department adds together the total amount of nonexcluded resources held in the name of:
(i) Either spouse; or
(ii) Both spouses.
(((9))) (10) If subsection (((8)(b))) (9)(b) of this
section applies, the department determines the amount of
resources that are allocated to the community spouse before
determining countable resources used to establish eligibility
for the institutionalized spouse, as follows:
(a) If the client's current period of institutional
status began on or after October 1, 1989 and before August 1,
2003, the department allocates the maximum amount of resources
ordinarily allowed by law. Effective January 1, 2009, the
maximum allocation is one hundred and nine thousand five
hundred and sixty dollars. This standard ((increases)) may
change annually on January 1st based on the consumer price
index. (For the current standard starting January 2009 and
each year thereafter, see long-term care standards at
http://www1.dshs.wa.gov/manuals/eaz/sections/LongTermCare/LTCstandardspna.shtml); or
(b) If the client's current period of institutional status began on or after August 1, 2003, the department allocates the greater of:
(i) A spousal share equal to one-half of the couple's
combined countable resources as of the ((beginning)) first day
of the month of the current period of institutional status, up
to the amount described in subsection (((9)(a))) (10)(a) of
this section; or
(ii) The state spousal resource standard of ((forty-five
thousand one hundred four dollars effective July 1, 2007
through June 30, 2009. Effective July 1, 2009 this standard
increases to)) forty-eight thousand six hundred thirty-nine
dollars (this standard ((increases)) may change every odd year
on July 1st). This ((increase)) standard is based on the
consumer price index published by the federal bureau of labor
statistics. For the current standard starting July 2009 and
each year thereafter, see long-term care standards at
http://www1.dshs.wa.gov/manuals/eaz/sections/LongTermCare/LTCstandardspna.shtml.
(((10))) (c) Resources are verified on the first moment
of the first day of the month institutionalization began as
described in WAC 182-512-0300(1).
(11) The amount of the spousal share described in
(((9)(b)(i))) (10)(b)(i) can be determined anytime between the
date that the current period of institutional status began and
the date that eligibility for LTC services is determined. The
following rules apply to the determination of the spousal
share:
(a) Prior to an application for LTC services, the couple's combined countable resources are evaluated from the date of the current period of institutional status at the request of either member of the couple. The determination of the spousal share is completed when necessary documentation and/or verification is provided; or
(b) The determination of the spousal share is completed as part of the application for LTC services if the client was institutionalized prior to the month of application, and declares the spousal share exceeds the state spousal resource standard. The client is required to provide verification of the couple's combined countable resources held at the beginning of the current period of institutional status.
(((11))) (12) The amount of allocated resources described
in subsection (((9))) (10) of this section can be increased,
only if:
(a) A court transfers additional resources to the community spouse; or
(b) An administrative law judge establishes in a fair hearing described in chapter 388-02 WAC, that the amount is inadequate to provide a minimum monthly maintenance needs amount for the community spouse.
(((12))) (13) The department considers resources of the
community spouse unavailable to the institutionalized spouse
the month after eligibility for LTC services is established,
unless subsection (((5))) (6) or (((13)(a))) (14)(a), (b), or
(c) of this section applies.
(((13))) (14) A redetermination of the couple's resources
as described in subsection (((7))) (8) is required, if:
(a) The institutionalized spouse has a break of at least thirty consecutive days in a period of institutional status; or
(b) The institutionalized spouse's countable resources
exceed the standard described in subsection (1)(a), if
subsection (((8)(b))) (9)(b) applies; or
(c) The institutionalized spouse does not transfer the
amount described in subsections (((9))) (10) or (((11))) (12)
to the community spouse ((or to another person for the sole
benefit of the community spouse as described in WAC 388-513-1365(4))) by either:
(i) The end of the month of the first regularly scheduled eligibility review; or
(ii) The reasonable amount of additional time necessary to obtain a court order for the support of the community spouse.
[Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, and 74.09.575. 09-12-058, § 388-513-1350, filed 5/28/09, effective 7/1/09. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 74.09.530. 08-13-072, § 388-513-1350, filed 6/16/08, effective 7/17/08. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.575, 74.09.500, and 74.09.530. 07-19-128, § 388-513-1350, filed 9/19/07, effective 10/20/07. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, 74.09.575, 2005 Federal Deficit Reduction Act (DRA) Public Law 109-171, and Section 1924 of the Social Security Act (42 U.S.C. 1396r-5). 07-01-073, § 388-513-1350, filed 12/18/06, effective 1/18/07. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 42 U.S.C. 9902(2). 05-07-033, § 388-513-1350, filed 3/9/05, effective 4/9/05. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.575; 2003 1st sp.s. c 28, and section 1924 of the Social Security Act (42 U.S.C. 1396R-5). 04-04-072, § 388-513-1350, filed 2/2/04, effective 3/4/04. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500 and Section 1924 (42 U.S.C. 1396R-5). 01-18-055, § 388-513-1350, filed 8/30/01, effective 9/30/01. 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, § 388-513-1350, filed 12/8/99, effective 1/8/00. Statutory Authority: RCW 74.08.090 and 74.09.500. 99-06-045, § 388-513-1350, filed 2/26/99, effective 3/29/99. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, 74.09.575 and Section 1924 (42 USC 1396r-5). 98-11-033, § 388-513-1350, filed 5/14/98, effective 6/14/98. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090 and 74.09.575. 97-09-112, § 388-513-1350, filed 4/23/97, effective 5/24/97. Statutory Authority: RCW 74.08.090 and Title XIX State Agency Letter 95-44. 96-09-033 (Order 3963), § 388-513-1350, filed 4/10/96, effective 5/11/96. 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), § 388-513-1350, filed 2/8/95, effective 3/11/95. Statutory Authority: RCW 74.08.090. 94-23-129 (Order 3808), § 388-513-1350, filed 11/23/94, effective 12/24/94; 94-10-065 (Order 3732), § 388-513-1350, filed 5/3/94, effective 6/3/94. Formerly parts of WAC 388-95-337 and 388-95-340.]
• Refer to WAC 388-513-1364 for rules used to evaluate asset transfers made on or after April 1, 2003 and before May 1, 2006.
• Refer to WAC 388-513-1365 for rules used to evaluate asset transfer made prior to April 1, 2003.
(1) When evaluating the effect of the transfer of asset made on or after May 1, 2006 on the client's eligibility for LTC services the department counts sixty months before the month of application to establish what is referred to as the "look-back" period.
(2) The department does not apply a penalty period to transfers meeting the following conditions:
(a) The total of all gifts or donations transferred do not exceed the average daily private nursing facility rate in any month;
(b) The transfer is an excluded resource described in WAC 388-513-1350 with the exception of the client's home, unless the transfer of the home meets the conditions described in subsection (2)(d);
(c) The asset is transferred for less than fair market value (FMV), if the client can provide evidence to the department of one of the following:
(i) An intent to transfer the asset at FMV or other adequate compensation. To establish such an intent, the department must be provided with written evidence of attempts to dispose of the asset for fair market value as well as evidence to support the value (if any) of the disposed asset.
(ii) The transfer is not made to qualify for LTC services, continue to qualify, or avoid Estate Recovery. Convincing evidence must be presented regarding the specific purpose of the transfer.
(iii) All assets transferred for less than fair market value have been returned to the client.
(iv) The denial of eligibility would result in an undue hardship as described in WAC 388-513-1367.
(d) The transfer of ownership of the client's home, if it is transferred to the client's:
(i) Spouse; or
(ii) Child, who:
(A) Meets the disability criteria described in WAC
((388-475-0050)) 182-512-0050 (1)(b) or (c); or
(B) Is less than twenty-one years old; or
(C) Lived in the home for at least two years immediately before the client's current period of institutional status, and provided verifiable care that enabled the individual to remain in the home. A physician's statement of needed care is required; or
(iii) Brother or sister, who has:
(A) Equity in the home, and
(B) Lived in the home for at least one year immediately before the client's current period of institutional status.
(e) The asset is transferred to the client's spouse or to
the client's child, if the child meets the disability criteria
described in WAC ((388-475-0050)) 182-512-0050 (1)(b) or (c);
(f) The transfer meets the conditions described in subsection (3), and the asset is transferred:
(i) To another person for the sole benefit of the spouse;
(ii) From the client's spouse to another person for the sole benefit of the spouse;
(iii) To trust established for the sole benefit of the
individual's child who meets the disability criteria described
in WAC ((388-475-0050)) 182-512-0050 (1)(b) or (c);
(iv) To a trust established for the sole benefit of a
person who is sixty-four years old or younger and meets the
disability criteria described in WAC ((388-475-0050))
182-512-0050 (1)(b) or (c); or
(3) The department considers the transfer of an asset or
the establishment of a trust to be for the sole benefit of a
person described in subsection (((1)(f))) (2)(f), if the
transfer or trust:
(a) Is established by a legal document that makes the transfer irrevocable;
(b) Provides that no individual or entity except the spouse, blind or disabled child, or disabled individual can benefit from the assets transferred in any way, whether at the time of the transfer or at any time during the life of the primary beneficiary; and
(c) Provides for spending all assets involved for the sole benefit of the individual on a basis that is actuarially sound based on the life expectancy of that individual or the term of the trust, whichever is less; and
(d) The requirements in subsection (2)(c) of this section do not apply to trusts described in WAC 388-561-0100 (6)(a) and (b) and (7)(a) and (b).
(4) The department does not establish a period of ineligibility for the transfer of an asset to a family member prior to the current period of long-term care service if:
(a) The transfer is in exchange for care services the family member provided the client;
(b) The client has a documented need for the care services provided by the family member;
(c) The care services provided by the family member are allowed under the medicaid state plan or the department's waiver services;
(d) The care services provided by the family member do not duplicate those that another party is being paid to provide;
(e) The FMV of the asset transferred is comparable to the FMV of the care services provided;
(f) The time for which care services are claimed is reasonable based on the kind of services provided; and
(g) Compensation has been paid as the care services were performed or with no more time delay than one month between the provision of the service and payment.
(5) The department considers the transfer of an asset in exchange for care services given by a family member that does not meet the criteria as described under subsection (4) as the transfer of an asset without adequate consideration.
(6) If a client or the client's spouse transfers an asset within the look-back period without receiving adequate compensation, the result is a penalty period in which the individual is not eligible for LTC services.
(7) If a client or the client's spouse transfers an asset on or after May 1, 2006, the department must establish a penalty period by adding together the total uncompensated value of all transfers made on or after May 1, 2006. The penalty period:
(a) For a LTC services applicant, begins on the date the client would be otherwise eligible for LTC services based on an approved application for LTC services or the first day after any previous penalty period has ended; or
(b) For a LTC services recipient, begins the first of the month following ten-day advance notice of the penalty period, but no later than the first day of the month that follows three full calendar months from the date of the report or discovery of the transfer; or the first day after any previous penalty period has ended; and
(c) Ends on the last day of the number of whole days found by dividing the total uncompensated value of the assets by the statewide average daily private cost for nursing facilities at the time of application or the date of transfer, whichever is later.
(8) If an asset is sold, transferred, or exchanged, the portion of the proceeds:
(a) That is used within the same month to acquire an excluded resource described in WAC 388-513-1350 does not affect the client's eligibility;
(b) That remain after an acquisition described in subsection (8)(a) becomes an available resource as of the first day of the following month.
(9) If the transfer of an asset to the client's spouse
includes the right to receive a stream of income not generated
by a transferred resource, the department must apply rules
described in WAC 388-513-1330 (((6))) (5) through (((8))) (7).
(10) If the transfer of an asset for which adequate compensation is not received is made to a person other than the client's spouse and includes the right to receive a stream of income not generated by a transferred resource, the length of the penalty period is determined and applied in the following way:
(a) The total amount of income that reflects a time frame based on the actuarial life expectancy of the client who transfers the income is added together;
(b) The amount described in subsection (10)(a) is divided by the statewide average daily private cost for nursing facilities at the time of application; and
(c) A penalty period equal to the number of whole days found by following subsections (7)(a), (b), and (c).
(11) A penalty period for the transfer of an asset that is applied to one spouse is not applied to the other spouse, unless both spouses are receiving LTC services. When both spouses are receiving LTC services;
(a) We divide the penalty between the two spouses.
(b) If one spouse is no longer subject to a penalty (e.g. the spouse is no longer receiving institutional services or is deceased) any remaining penalty that applies to both spouses must be served by the remaining spouse.
(12) If a client or the client's spouse disagrees with the determination or application of a penalty period, that person may request a hearing as described in chapter 388-02 WAC.
(13) Additional statutes which apply to transfer of asset penalties, real property transfer for inadequate consideration, disposal of realty penalties, and transfers to qualify for assistance can be found at:
(a) RCW 74.08.331 Unlawful practices -- Obtaining assistance -- Disposal of realty;
(b) RCW 74.08.338 Real property transfers for inadequate consideration;
(c) RCW 74.08.335 Transfers of property to qualify for assistance; and
(d) RCW 74.39A.160 Transfer of assets--Penalties.
[Statutory Authority: RCW 34.05.353 (2)(d), 74.08.090, and chapters 74.09, 74.04 RCW. 08-11-047, § 388-513-1363, filed 5/15/08, effective 6/15/08. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.575, and 2005 federal Deficit Reduction Act (DRA), Public Law 109-171. 07-17-152, § 388-513-1363, filed 8/21/07, effective 10/1/07.]
(1) The department does not apply a penalty period to the following transfers by the client, if they meet the conditions described:
(a) Gifts or donations totaling one thousand dollars or less in any month;
(b) The transfer of an excluded resource described in WAC 388-513-1350 with the exception of the client's home, unless the transfer of the client's home meets the conditions described in subsection (1)(d);
(c) The transfer of an asset for less than fair market value (FMV), if the client can provide evidence to the department of one of the following:
(i) An intent to transfer the asset at FMV or other adequate compensation;
(ii) The transfer is not made to qualify for LTC services;
(iii) The client is given back ownership of the asset;
(iv) The denial of eligibility would result in an undue hardship.
(d) The transfer of ownership of the client's home, if it is transferred to the client's:
(i) Spouse; or
(ii) Child, who:
(A) Meets the disability criteria described in WAC
((388-475-0050)) 182-512-0050 (1)(b) or (c); or
(B) Is less than twenty-one years old; or
(C) Lived in the home for at least two years immediately before the client's current period of institutional status, and provided care that enabled the client to remain in the home; or
(iii) Brother or sister, who has:
(A) Equity in the home; and
(B) Lived in the home for at least one year immediately before the client's current period of institutional status.
(e) The transfer of an asset, if the transfer meets the conditions described in subsection (4), and the asset is transferred:
(i) To another person for the sole benefit of the spouse;
(ii) From the client's spouse to another person for the sole benefit of the spouse;
(iii) To trust established for the sole benefit of the
client's child who meets the disability criteria described in
WAC ((388-475-0050)) 182-512-0050 (1)(b) or (c);
(iv) To a trust established for the sole benefit of a
person who is sixty-four years old or younger and meets the
disability criteria described in WAC ((388-475-0050))
182-512-0050 (1)(b) or (c); or
(f) The asset is transferred to the client's spouse or to
the client's child, if the child meets the disability criteria
described in WAC ((388-475-0050)) 182-512-0050 (1)(b) or (c).
(2) The department does not establish a period of ineligibility for the transfer of an asset to a family member prior to the current period of institutional status, if:
(a) The transfer is in exchange for care services the family member provided the client;
(b) The client has a documented need for the care services provided by the family member;
(c) The care services provided by the family member are allowed under the medicaid state plan or the department's waivered services;
(d) The care services provided by the family member do not duplicate those that another party is being paid to provide;
(e) The FMV of the asset transferred is comparable to the FMV of the care services provided;
(f) The time for which care services are claimed is reasonable based on the kind of services provided; and
(g) Compensation has been paid as the care services were performed or with no more time delay than one month between the provision of the service and payment.
(3) The department considers the transfer of an asset in exchange for care services given by a family member that does not meet the criteria as described under subsection (2) as the transfer of an asset without adequate consideration.
(4) The department considers the transfer of an asset or the establishment of a trust to be for the sole benefit of a person described in subsection (1)(e), if the transfer or trust:
(a) Is established by a legal document that makes the transfer irrevocable;
(b) Provides that no individual or entity except the spouse, blind or disabled child, or disabled individual can benefit from the assets transferred in any way, whether at the time of the transfer or at any time during the life of the primary beneficiary; and
(c) Provides for spending all assets involved for the sole benefit of the individual on a basis that is actuarially sound based on the life expectancy of that individual or the term or the trust, whichever is less; and
(d) The requirements in subsection (4)(c) of this section do not apply to trusts described in WAC 388-561-0100 (6)(a) and (b).
(5) If a client or the client's spouse transfers an asset within the look-back period described in WAC 388-513-1365 without receiving adequate compensation, the result is a penalty period in which the client is not eligible for LTC services. If a client or the client's spouse transfers an asset on or after April 1, 2003, the department must establish a penalty period as follows:
(a) If a single or multiple transfers are made within a single month, then the penalty period:
(i) Begins on the first day of the month in which the transfer is made; and
(ii) Ends on the last day of the number of whole days found by dividing the total uncompensated value of the assets by the statewide average daily private cost for nursing facilities at the time of application.
(b) If multiple transfers are made during multiple months, then the transfers are treated as separate events and multiple penalty periods are established that begin on the latter of:
(i) The first day of the month in which the transfer is made; or
(ii) The first day after any previous penalty period has ended and end on the last day of the whole number of days as described in subsection (5)(a)(ii).
(6) If an asset is sold, transferred, or exchanged, the portion of the proceeds:
(a) That is used within the same month to acquire an excluded resource described in WAC 388-513-1350 does not affect the client's eligibility;
(b) That remain after an acquisition described in subsection (6)(a) becomes an available resource as of the first day of the following month.
(7) If the transfer of an asset to the client's spouse
includes the right to receive a stream of income not generated
by a transferred resource, the department must apply rules
described in WAC 388-513-1330 (((6))) (5) through (((8))) (7).
(8) If the transfer of an asset for which adequate compensation is not received is made to a person other than the client's spouse and includes the right to receive a stream of income not generated by a transferred resource, the length of the penalty period is determined and applied in the following way:
(a) The total amount of income that reflects a time frame based on the actuarial life expectancy of the client who transfers the income is added together;
(b) The amount described in subsection (8)(a) is divided by the statewide average daily private cost for nursing facilities at the time of application; and
(c) A penalty period equal to the number of whole days found by following subsections (5)(a) and (b) and (8)(a) and (b) is applied that begins on the latter of:
(i) The first day of the month in which the client transfers the income; or
(ii) The first day of the month after any previous penalty period has ended.
(9) A penalty period for the transfer of an asset that is applied to one spouse is not applied to the other spouse, unless:
(a) Both spouses are receiving LTC services; and
(b) A division of the penalty period between the spouses is requested.
(10) If a client or the client's spouse disagrees with the determination or application of a penalty period, that person may request a hearing as described in chapter 388-02 WAC.
[Statutory Authority: RCW 34.05.353 (2)(d), 74.08.090, and chapters 74.09, 74.04 RCW. 08-11-047, § 388-513-1364, filed 5/15/08, effective 6/15/08. Statutory Authority: RCW 74.08.090. 03-20-059, § 388-513-1364, filed 9/26/03, effective 10/27/03. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and 74.09.575. 03-06-048, § 388-513-1364, filed 2/28/03, effective 4/1/03.]
(1) The department disregards the following transfers by the client, if they meet the conditions described:
(a) Gifts or donations totaling one thousand dollars or less in any month;
(b) The transfer of an excluded resource described in WAC 388-513-1350 with the exception of the client's home, unless the transfer meets the conditions described in subsection (1)(d);
(c) The transfer of an asset for less than fair market value (FMV), if the client can provide evidence to the department that satisfies one of the following:
(i) An intent to transfer the asset at FMV or other adequate compensation;
(ii) The transfer is not made to qualify for LTC services;
(iii) The client is given back ownership of the asset;
(iv) The denial of eligibility would result in an undue hardship.
(d) The transfer of ownership of the client's home, if it is transferred to the client's:
(i) Spouse; or
(ii) Child, who:
(A) Meets the disability criteria described in WAC
((388-475-0050)) 182-512-0050 (1)(b) or (c); or
(B) Is less than twenty-one years old; or
(iii) A son or daughter, who:
(A) Lived in the home for at least two years immediately before the client's current period of institutional status; and
(B) Provided care that enabled the client to remain in the home; or
(iv) A brother or sister, who has:
(A) Equity in the home, and
(B) Lived in the home for at least one year immediately before the client's current period of institutional status.
(e) The transfer of an asset other than the home, if the transfer meets the conditions described in subsection (4), and the asset is transferred:
(i) To the client's spouse or to another person for the sole benefit of the spouse;
(ii) From the client's spouse to another person for the sole benefit of the spouse;
(iii) To the client's child who meets the disability
criteria described in WAC ((388-475-0050)) 182-512-0050 (1)(b)
or (c) or to a trust established for the sole benefit of this
child; or
(iv) To a trust established for the sole benefit of a
person who is ((sixty-fours)) sixty-four years old or
younger and meets the disability criteria described in WAC
((388-475-0050)) 182-512-0050 (1)(b) or (c).
(f) The transfer of an asset to a member of the client's family in exchange for care the family member provided the client before the current period of institutional status, if a written agreement that describes the terms of the exchange:
(i) Was established at the time the care began;
(ii) Defines a reasonable FMV for the care provided that reflects a time frame based on the actuarial life expectancy of the client who transfers the asset; and
(iii) States that the transferred asset is considered payment for the care provided.
(2) When the fair market value of the care described in subsection (1)(f) is less than the value of the transferred asset, the department considers the difference the transfer of an asset without adequate consideration.
(3) The department considers the transfer of an asset in exchange for care given by a family member without a written agreement as described under subsection (1)(f) as the transfer of an asset without adequate consideration.
(4) The transfer of an asset or the establishment of a trust is considered to be for the sole benefit of a person described in subsection (1)(e), if the transfer or trust:
(a) Is established by a legal document that makes the transfer irrevocable; and
(b) Provides for spending all funds involved for the benefit of the person for whom the transfer is made within a time frame based on the actuarial life expectancy of that person.
(5) When evaluating the effect of the transfer of an asset on a client's eligibility for LTC services received on or after October 1, 1993, the department counts the number of months before the month of application to establish what is referred to as the "look-back" period. The following number of months apply as described:
(a) Thirty-six months, if all or part of the assets were transferred on or after August 11, 1993; and
(b) Sixty months, if all or part of the assets were transferred into a trust as described in WAC 388-561-0100.
(6) If a client or the client's spouse transfers an asset within the look-back period without receiving adequate compensation, the result is a penalty period in which the client is not eligible for LTC services. If a client or the client's spouse transfers an asset on or after March 1, 1997 and before April 1, 2003, the department must establish a penalty period as follows:
(a) If a single or multiple transfers are made within a single month, then the penalty period:
(i) Begins on the first day of the month in which the transfer is made; and
(ii) Ends on the last day of the number of whole months found by dividing the total uncompensated value of the assets by the statewide average monthly private cost for nursing facilities at the time of application.
(b) If multiple transfers are made during multiple months, then the transfers are treated as separate events and multiple penalty periods are established that:
(i) Begin on the latter of:
(A) The first day of the month in which the transfer is made; or
(B) The first day after any previous penalty period has ended; and
(ii) End on the last day of the whole number of months as described in subsection (6)(a)(ii).
(7) If an asset is sold, transferred, or exchanged, the portion of the proceeds:
(a) That is used within the same month to acquire an excluded resource described in WAC 388-513-1350 does not affect the client's eligibility;
(b) That remains after an acquisition described in subsection (7)(a) becomes an available resource as of the first day of the following month.
(8) If the transfer of an asset to the client's spouse
includes the right to receive a stream of income not generated
by a transferred resource, the department must apply rules
described in WAC 388-513-1330 (((6))) (5) through (((8))) (7).
(9) If the transfer of an asset for which adequate compensation is not received is made to a person other than the client's spouse and includes the right to receive a stream not generated by a transferred resource, the length of the penalty period is determined and applied in the following way:
(a) The total amount of income that reflects a time frame based on the actuarial life expectancy of the client who transfers the income is added together;
(b) The amount described in (9)(a) is divided by the statewide average monthly private cost for nursing facilities at the time of application; and
(c) A penalty period equal to the number of whole months found by following subsections (9)(a) and (b) is applied that begins on the latter of:
(i) The first day of the month in which the client transfers the income; or
(ii) The first day of the month after any previous penalty period has ended.
(10) A penalty period for the transfer of an asset that is applied to one spouse is not applied to the other spouse, unless:
(a) Both spouses are receiving LTC services; and
(b) A division of the penalty period between the spouses is requested.
(11) If a client or the client's spouse disagrees with the determination or application of a penalty period, that person may request a hearing as described in chapter 388-02 WAC.
[Statutory Authority: RCW 34.05.353 (2)(d), 74.08.090, and chapters 74.09, 74.04 RCW. 08-11-047, § 388-513-1365, filed 5/15/08, effective 6/15/08. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and 74.09.575. 03-14-038, § 388-513-1365, filed 6/23/03, effective 8/1/03. Statutory Authority: RCW 74.08.090. 01-02-076, § 388-513-1365, filed 12/29/00, effective 1/29/01. 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, § 388-513-1365, filed 12/8/99, effective 1/8/00. Statutory Authority: RCW 74.08.090 and 74.09.500. 99-06-045, § 388-513-1365, filed 2/26/99, effective 3/29/99. Statutory Authority: RCW 74.08.090, 74.04.050, 74.04.057, 74.09.585 and § 17 of the Social Security Act. 97-05-040, § 388-513-1365, filed 2/14/97, effective 3/17/97. Statutory Authority: RCW 74.08.090. 95-02-027 (Order 3818), § 388-513-1365, filed 12/28/94, effective 1/28/95; 94-10-065 (Order 3732), § 388-513-1365, filed 5/3/94, effective 6/3/94. Formerly WAC 388-95-395.]
• Defines undue hardship;
• Specifies the approval criteria for an undue hardship request;
• Establishes the process the department follows for determining undue hardship; and
• Establishes the appeal process for a client whose request for an undue hardship is denied.
(1) When does undue hardship exist?
(a) Undue hardship may exist:
(i) When a transfer of an asset occurs between:
(A) Registered domestic partners as described in chapter 26.60 RCW; or
(B) Same-sex couples who were married in states and the District of Columbia where same-sex marriages are legal; and
(C) The transfer would not have caused a period of ineligibility if made between an opposite sex married couple under WAC 388-513-1363.
(ii) When a client who transferred the assets or income, or on whose behalf the assets or income were transferred, either personally or through a spouse, guardian or attorney-in-fact, has exhausted all reasonable means including legal remedies to recover the assets or income or the value of the transferred assets or income that have caused a penalty period; and
(((ii))) (iii) The client provides sufficient
documentation to support their efforts to recover the assets
or income; or
(((iii))) (iv) The client is unable to access home equity
in excess of ((five hundred thousand dollars due to a lien or
legal impediment)) the standard described in WAC 388-513-1350;
and
(((iv))) (v) When, without LTC benefits, the client is
unable to obtain:
(A) Medical care to the extent that his or her health or life is endangered; or
(B) Food, clothing, shelter or other basic necessities of life.
(b) Undue hardship can be approved for an interim period while the client is pursuing recovery of the assets or income.
(2) Undue hardship does not exist:
(a) When the transfer of asset penalty period or excess home equity provision inconveniences a client or restricts their lifestyle but does not seriously deprive him or her as defined in subsection (1)(a)(iii) of this section;
(b) When the resource is transferred to a person who is handling the financial affairs of the client; or
(c) When the resource is transferred to another person by the individual that handles the financial affairs of the client.
(d) Undue hardship may exist under (b) and (c) if DSHS has found evidence of financial exploitation.
(3) How is an undue hardship waiver requested?
(a) An undue hardship waiver may be requested by:
(i) The client;
(ii) The client's spouse;
(iii) The client's authorized representative;
(iv) The client's power of attorney; or
(v) With the consent of the client or their guardian, a
medical institution, as defined in WAC ((388-500-0005))
182-500-0005, in which an institutionalized client resides.
(b) Request must:
(i) Be in writing;
(ii) State the reason for requesting the hardship waiver;
(iii) Be signed by the requestor and include the requestor's name, address and telephone number. If the request is being made on behalf of a client, then the client's name, address and telephone number must be included;
(iv) Be made within thirty days of the date of denial or termination of LTC services; and
(v) Returned to the originating address on the denial/termination letter.
(4) What if additional information is needed to determine a hardship waiver?
(a) A written notice to the client is sent requesting additional information within fifteen days of the request for an undue hardship waiver. Additional time to provide the information can be requested by the client.
(5) What happens if my hardship waiver is approved?
(a) The department sends a notice within fifteen days of receiving all information needed to determine a hardship waiver. The approval notice specifies a time period the undue hardship waiver is approved.
(b) Any changes in a client's situation that led to the approval of a hardship must be reported to the department by the tenth of the month following the change per WAC 388-418-0007.
(6) What happens if my hardship waiver is denied?
(a) The department sends a denial notice within fifteen days of receiving the requested information. The letter will state the reason it was not approved.
(b) The denial notice will have instructions on how to request an administrative hearing. The department must receive an administrative hearing request within ninety days of the date of the adverse action or denial.
(7) What statute or rules govern administrative hearings?
(a) An administrative hearing held under this section is governed by chapters 34.05 RCW and chapter 388-02 WAC and this section. If a provision in this section conflicts with a provision in chapter 388-02 WAC, the provision in this section governs.
(8) Can the department revoke an approved undue hardship waiver?
(a) The department may revoke approval of an undue hardship waiver if any of the following occur:
(i) A client, or his or her authorized representative, fails to provide timely information and/or resource verifications as it applies to the hardship waiver when requested by the department per WAC 388-490-0005 and 388-418-0007 or 182-504-0125;
(ii) The lien or legal impediment that restricted access to home equity in excess of five hundred thousand dollars is removed; or
(iii) Circumstances for which the undue hardship was approved have changed.
[Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, Section 1917 (c)(2)(D) of the Social Security Act (42 U.S.C. 1396p (c)(2)(D), and Section 6011(d) of the federal Deficit Reduction Act of 2005. 07-17-005, § 388-513-1367, filed 8/2/07, effective 9/2/07.]
Reviser's note: The typographical error in the above section occurred in the copy filed by the agency and appears in the Register pursuant to the requirements of RCW 34.08.040.
AMENDATORY SECTION(Amending WSR 09-07-037, filed 3/10/09,
effective 4/10/09)
WAC 388-513-1380
Determining a client's financial
participation in the cost of care for long-term care (LTC)
services.
This rule describes how the department allocates
income and excess resources when determining participation in
the cost of care (the post-eligibility process). The
department applies rules described in WAC 388-513-1315 to
define which income and resources must be used in this
process.
(1) For a client receiving institutional or hospice services in a medical institution, the department applies all subsections of this rule.
(2) For a client receiving waiver 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, or in an alternate living facility, the department applies rules used for the community options program entry system (COPES) for hospice applicants with gross income under the medicaid special income level (SIL) (300% of the federal benefit rate (FBR)), if the client is not otherwise eligible for another noninstitutional categorically needy medicaid program. (Note: For hospice applicants with income over the medicaid SIL, medically needy medicaid rules apply.)
(4) The department allocates nonexcluded income in the following order and the combined total of (4)(a), (b), (c), and (d) cannot exceed the effective one-person medically needy income level (MNIL):
(a) A personal needs allowance (PNA) of:
(i) Seventy dollars for the following clients who live in a state veteran's home and receive a needs based veteran's pension in excess of ninety dollars:
(A) A veteran without a spouse or dependent child.
(B) A veteran's surviving spouse with no dependent children.
(ii) The difference between one hundred sixty dollars and the needs based veteran's pension amount for persons specified in subsection (4)(a)(i) of this section who receive a veteran's pension less than ninety dollars.
(iii) One hundred sixty dollars for a client living in a state veterans' home who does not receive a needs based veteran's pension;
(iv) Forty-one dollars and sixty-two cents for all
clients in a medical institution receiving ((general
assistance)) ABD cash assistance.
(v) ((Effective July 1, 2007 through June 30, 2008
fifty-five dollars and forty-five cents)) For all other
clients in a medical institution((. Effective July 1, 2008
this)) the PNA ((increases to)) is fifty-seven dollars and
twenty-eight cents.
(vi) Current PNA and long-term care standards can be
found at
((http://www1.dshs.wa.gov/manuals/eaz/sections/LongTermCare/LTCstandardspna.shtml))
http://www.dshs.wa.gov/manuals/eaz/sections/LongTermCare/LTCstandardspna.shtml.
(b) Mandatory federal, state, or local income taxes owed by the client.
(c) Wages for a client who:
(i) Is related to the Supplemental Security Income (SSI)
program as described in WAC ((388-475-0050(1)))
182-512-0050(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.
(5) The department allocates nonexcluded income after deducting amounts described in subsection (4) in the following order:
(a) ((Income)) Current or back child support garnished
((for child support or withheld according to a child support
order in the month of garnishment (for current and back
support))) or withheld from income according to a child
support order in the month of the garnishment if it is for the
current month:
(i) For the time period covered by the PNA; and
(ii) Is not counted as the dependent member's income when determining the family allocation amount.
(b) A monthly maintenance needs allowance for the
community spouse not to exceed, effective January 1, 2008, two
thousand six hundred ten dollars, unless a greater amount is
allocated as described in subsection (7) of this section. The
community spouse maintenance allowance ((is increased)) may
change each January based on the consumer price index
((increase (from September to September,
http://www.bls.gov/cpi/))). Starting January 1, 2008 and each
year thereafter the community spouse maintenance allocation
can be found in the long-term care standards chart at
http://www1.dshs.wa.gov/manuals/eaz/sections/LongTermCare/LTCstandardspna.shtml. The monthly maintenance needs allowance:
(i) Consists of a combined total of both:
(A) One hundred fifty percent of the two person federal
poverty level. This standard ((increases)) may change
annually on July 1st (((http://aspe.os.dhhs.gov/poverty/)));
and
(B) Excess shelter expenses as described under subsection (6) of this section.
(ii) Is reduced by the community spouse's gross countable income; and
(iii) 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 spouse or institutionalized person who:
(i) Resides with the community spouse:
(A) ((In an amount equal to one-third of one hundred
fifty percent of the two person federal poverty level less the
dependent family member's income. This standard increases
annually on July 1st (http://aspe.os.dhhs.gov/poverty/))) For
each child, one hundred and fifty percent of the two-person
FPL minus that child's income and divided by three (child
support received from a noncustodial parent is considered the
child's income). This standard is called the community spouse
(CS) and family maintenance standard and can be found at:
http://www.dshs.wa.gov/manuals/eaz/sections/LongTermCare/LTCstandardspna.shtml.
(ii) Does not reside with the community spouse or institutionalized person, in an amount equal to the effective one-person MNIL for the number of dependent family members in the home less the dependent family member's income.
(iii) Child support received from a noncustodial parent is the child's income.
(d) Medical expenses incurred by the institutional client and not used to reduce excess resources. Allowable medical expenses and reducing excess resources are described in WAC 388-513-1350.
(e) Maintenance of the home of a single institutionalized 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 services staff documents the need for the income exemption.
(6) For the purposes of this section, "excess shelter expenses" means the actual expenses under subsection (6)(b) less the standard shelter allocation under subsection (6)(a). For the purposes of this rule:
(a) The standard shelter allocation is based on thirty
percent of one hundred fifty percent of the two person federal
poverty level. This standard ((increases)) may change
annually on July 1st (((http://aspe.os.dhhs.gov/poverty/)))
and is found at:
http://www.dshs.wa.gov/manuals/eaz/sections/LongTermCare/LTCstandardspna.shtml; 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 ((for four
persons)) described in WAC 388-450-0195, provided the
utilities are not included in the maintenance charges for a
condominium or cooperative.
(7) The amount allocated to the community spouse may be greater than the amount in subsection (6)(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.
(8) A client who is admitted to a medical facility for ninety days or less and continues to receive full SSI benefits is not required to use the SSI income in the cost of care for medical services. Income allocations are allowed as described in this section from non-SSI income.
(9) Standards described in this section for long-term
care can be found at:
((http://www1.dshs.wa.gov/manuals/eaz/sections/LongTermCare/LTCstandardspna.shtml))
http://www.dshs.wa.gov/manuals/eaz/sections/LongTermCare/LTCstandardspna.shtml.
[Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, and Deficit Reduction Act of 2005, 42 C.F.R. Section 435. 09-07-037, § 388-513-1380, filed 3/10/09, effective 4/10/09. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 74.09.530. 08-13-072, § 388-513-1380, filed 6/16/08, effective 7/17/08. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, and 2006 c 372. 07-19-126, § 388-513-1380, filed 9/19/07, effective 10/20/07; 07-01-072, § 388-513-1380, filed 12/18/06, effective 1/18/07. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530 and 2005 c 518 § 207 and Sec. 1924 Social Security Act (42 U.S.C. 1396r-5). 06-07-144, § 388-513-1380, filed 3/21/06, effective 4/21/06. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 42 U.S.C. 9902(2). 05-07-033, § 388-513-1380, filed 3/9/05, effective 4/9/05. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.575; 2003 1st sp.s. c 28, and section 1924 of the Social Security Act (42 U.S.C. 1396R-5). 04-04-072, § 388-513-1380, filed 2/2/04, effective 3/4/04. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500 and Section 1924 (42 U.S.C. 1396R-5). 01-18-055, § 388-513-1380, filed 8/30/01, effective 9/30/01. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and Section 1924(g) of the Social Security Act. 00-17-058, § 388-513-1380, filed 8/9/00, effective 9/9/00. 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.]
(1) To be eligible for institutional or hospice services under the MN program for individuals living in a medical institution, a client must meet the financial requirements described in subsection (5). In addition, a client must meet program requirements described in WAC 388-513-1315; and
(a) Be an SSI-related client with countable income as described in subsection (4)(a) that is more than the special income level (SIL); or
(b) Be a child not described in subsection (1)(a) with countable income as described in subsection (4)(b) that exceeds the categorically needy (CN) standard for the children's medical program.
(2) For an SSI-related client, excess resources ((can
be)) are reduced by medical expenses as described in WAC 388-513-1350 to the resource standard for a single or married
individual.
(3) The department determines a client's countable resources for institutional and hospice services under the MN programs as follows:
(a) For an SSI-related client, the department determines countable resources per WAC 388-513-1350.
(b) For a child not described in subsection (3)(a), no determination of resource eligibility is required.
(4) The department determines a client's countable income for institutional and hospice services under the MN program as follows:
(a) For an SSI-related client, the department reduces available income as described in WAC 388-513-1325 and 388-513-1330 by:
(i) Excluding income described in WAC 388-513-1340;
(ii) Disregarding income described in WAC 388-513-1345; and
(iii) Subtracting previously incurred 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.
(b) For a child not described in subsection (4)(a), the department:
(i) Follows the income rules described in WAC
((388-505-0210)) 182-505-0210 for the children's medical
program; and
(ii) Subtracts the medical expenses described in subsection (4).
(5) If the ((combined total of a client's countable
income, when added to)) income remaining after the allowed
deductions described in WAC 388-513-1380, plus countable
resources in excess of the standard described in WAC 388-513-1350(1), is less than the department-contracted rate
((plus the amount of recurring medical expenses,)) times the
number of days residing in the facility the client:
(a) Is eligible for institutional or hospice services in
a medical institution, and ((noninstitutional)) medical
assistance;
(b) Is approved for twelve months; and
(c) Participates ((in)) income and excess resources
toward the cost of care as described in WAC 388-513-1380.
(6) If the ((combined total of a client's countable))
income((, which when added to countable resources in excess of
the standard described in WAC 388-513-1350(1) is less than the
private nursing facility rate plus the amount of recurring
medical expenses, but more than the department contracted
rate,)) remaining after the allowed deductions described in
WAC 388-513-1380 plus countable resources in excess of the
standard described in WAC 388-513-1350(1) is more than the
department-contracted rate times the number of days residing
in the facility the client:
(a) Is not eligible for ((nursing facility care only and
is approved for a three or six month base period as described
in chapter 388-519 WAC)) payment of institutional services;
and
(((i))) (b) ((Pays the nursing home at the current state
rate)) Eligibility is determined for medical assistance only
as described in chapter 182-519 WAC.
(7) If the income remaining after the allowed deductions described in WAC 388-513-1380 is more than the department contracted nursing facility rate based on the number of days the client is in the facility, but less than the private nursing rate plus the amount of medical expenses not used to reduce excess resources the client:
(a) Is eligible for nursing facility care only and is approved for a three or six month based period as described in chapter 182-519 WAC. This does not include hospice in a nursing facility; and
(i) Pays the nursing home at the current state rate;
(ii) Participates in the cost of care as described in WAC 388-513-1380; and
(iii) Is not eligible for medical assistance or hospice
services unless the requirements in (6)(b) ((or (c) are)) is
met.
(b) Is approved for medical assistance for a three or six
month base period as described in chapter ((388-519)) 182-519
WAC, if:
(i) No income and resources remain after the post eligibility treatment of income process described in WAC 388-513-1380.
(ii) Medicaid certification is approved beginning with the first day of the base period.
(c) Is approved for medical assistance for up to three or
six months when they incur additional medical expenses that
are equal to or more than excess income ((and resources))
remaining after the post eligibility treatment of income
process described in WAC 388-513-1380.
(i) This process is known as spenddown and is described
in WAC ((388-519-0100)) 182-519-0100.
(ii) Medicaid certification is approved on the day the spenddown is met.
(((7))) (8) If the ((combined total of a client's
nonexcluded income, which when added to nonexcluded resources
is above the facility monthly private rate)) income remaining
after the allowed deductions described in WAC 388-513-1380,
plus countable resources in excess of the standard described
in WAC 388-513-1350 is more than the private nursing facility
rate times the number of days in a month residing in the
facility, the client:
(a) ((The client is ineligible using institutional
rules)) Is not eligible for payment of institutional services.
(b) Eligibility is ((considered under a
noninstitutional)) determined for medical assistance
((program)) only as described in chapter ((388-416 and
388-519)) 182-519 WAC.
[Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, 74.39.010. 07-19-129, § 388-513-1395, filed 9/19/07, effective 10/20/07. 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, § 388-513-1395, filed 12/8/99, effective 1/8/00. Statutory Authority: RCW 74.08.090 and 74.09.500. 99-06-045, § 388-513-1395, filed 2/26/99, effective 3/29/99. Statutory Authority: RCW 74.08.090 and Budget Note 17. 96-16-092, § 388-513-1395, filed 8/7/96, effective 8/29/96. Statutory Authority: RCW 74.08.090 and 1995 2nd sp.s. c 18 §§ 2095a and 5b. 95-24-017 (Order 3921, #100267), § 388-513-1395, filed 11/22/95, effective 1/1/96. Statutory Authority: RCW 74.08.090. 94-10-065 (Order 3732), § 388-513-1395, filed 5/3/94, effective 6/3/94. Formerly WAC 388-95-400.]
(1) Treatment of Entrance Fee. An individual's entrance fee in a continuing care retirement community or life care community is considered a resource available to the individual to the extent that:
(a) The individual has the ability to use the entrance fee, or the contract provides that the entrance fee may be used to pay for care should other resources or income of the individual be insufficient to pay for care.
(b) The individual is eligible for a refund of any remaining entrance free when the individual dies or terminates the continuing care retirement community or life care community contract and leaves the community; and
(c) The entrance free does not confer an ownership interest in the continuing care retirement community or life care community.
[]
(2) The HCB service programs are:
(a) Community options program entry system (COPES);
(b) Program of all-inclusive care for the elderly (PACE);
(c) Washington medicaid integration partnership (WMIP); or
(d) New Freedom consumer directed services (New Freedom).
(3) Roads to community living (RCL) services. For RCL services this chapter is used only to determine your cost of care. Medicaid eligibility is guaranteed for three hundred sixty-five days upon discharge from a medical institution.
(4) Hospice services if you don't reside in a medical institution and:
(a) Have gross income at or below the special income level (SIL); and
(b) Aren't eligible for another CN or medically needy (MN) medicaid program.
(5) WAC 388-515-1506 describes the general eligibility requirements for HCS CN waivers.
(6) WAC 388-515-1507 describes eligibility for waiver services when you are eligible for medicaid using noninstitutional CN rules.
(7) WAC 388-515-1508 describes the initial financial eligibility requirements for waiver services when you are not eligible for noninstitutional CN medicaid described in WAC 388-515-1507(1).
(8) WAC 388-515-1509 describes the rules used to determine your responsibility in the cost of care for waiver services if you are not eligible for medicaid under a CN program listed in WAC 388-515-1507(1). This is also called client participation or post eligibility.
[Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 74.09.530 and Washington state 2007-09 operating budget (SHB 1128). 08-22-052, § 388-515-1505, filed 11/3/08, effective 12/4/08. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.575, 74.09.500, 74.09.530, and 2007 c 522. 07-19-127, § 388-515-1505, filed 9/19/07, effective 10/20/07. 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.]
(a) Meet the program and age requirements for the specific program:
(i) COPES, per WAC 388-106-0310;
(ii) PACE, per WAC 388-106-0705;
(iii) WMIP waiver services, per WAC 388-106-0750;
(iv) New Freedom, per WAC 388-106-1410;
(v) Hospice, per chapter ((388-551)) 182-551 WAC; or
(vi) Roads to community living (RCL), per WAC 388-106-0250, 388-106-0255 and 388-106-0260.
(b) Meet the disability criteria for the Supplemental
Security Income (SSI) program as described in WAC
((388-475-0050)) 182-512-0050;
(c) Require the level of care provided in a nursing facility described in WAC 388-106-0355;
(d) Be residing in a medical institution as defined in
WAC ((388-500-0005)) 182-500-0050, or likely to be placed in
one within the next thirty days without HCB services provided
under one of the programs listed in subsection (1)(a);
(e) Have attained institutional status as described in WAC 388-513-1320;
(f) Be determined in need of services and be approved for a plan of care as described in subsection (1)(a);
(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
through ((388-513-1366)) 388-513-1365;
(i) Not have a home with equity in excess of the requirements described in WAC 388-513-1350.
(2) Refer to WAC 388-513-1315 for rules used to determine countable resources, income, and eligibility standards for long-term care services.
(3) Current income and resource standard charts are located at: http://www.dshs.wa.gov/manuals/eaz/sections/LongTermCare/LTCstandardspna.html.
[Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 74.09.530 and Washington state 2007-09 operating budget (SHB 1128). 08-22-052, § 388-515-1506, filed 11/3/08, effective 12/4/08.]
(a) Supplemental Security Income (SSI) eligibility described in WAC 388-474-0001. This includes SSI clients under 1619B status;
(b) SSI-related CN medicaid described in WAC
((388-475-0100)) 182-512-0100 (2)(a) and (b);
(c) SSI-related healthcare for workers with disabilities
program (HWD) described in WAC ((388-475-1000)) 182-511-1000.
If you are receiving HWD, you are responsible to pay your HWD
premium as described in WAC ((388-475-1250)) 182-511-1250.
((This change is effective April 1, 2009));
(d) ((General assistance expedited medicaid disability
(GAX) or general assistance based on aged/blind/disabled
criteria)) Aged, blind, or disabled (ABD) cash assistance
described in WAC ((388-505-0110(6))) 388-400-0060 and are
receiving CN medicaid.
(2) You do not have a penalty period of ineligibility for
the transfer of an asset as described in WAC 388-513-1363
through ((388-513-1366)) 388-513-1365. This does not apply to
PACE or hospice services.
(3) You do not have a home with equity in excess of the requirements described in WAC 388-513-1350.
(4) You do not have to meet the initial eligibility income test of having gross income at or below the special income level (SIL).
(5) You do not pay (participate) toward the cost of your personal care services.
(6) If you live in a department contracted facility listed in WAC 388-515-1506 (1)(g), you pay room and board up to the ADSA room and board standard. The ADSA room and board standard is based on the federal benefit rate (FBR) minus the current personal needs allowance (PNA) for HCS CN waivers in an alternate living facility.
(a) If you live in an assisted living (AL) facility, enhanced adult residential center (EARC), or adult family home (AFH) you keep a PNA of sixty-two dollars and seventy-nine cents and use your income to pay up to the room and board standard.
(b) If subsection (6)(a) applies and you are receiving
HWD described in WAC ((388-475-1000)) 182-511-1000, you are
responsible to pay your HWD premium as described in WAC
((388-475-1250)) 182-511-1250, in addition to the ADSA room
and board standard.
(7) If you are eligible for ((general assistance
expedited medicaid disability (GAX) or general assistance
based on aged/blind/disabled criteria described in WAC 388-505-0110(6),)) aged, blind or disabled (ABD) cash
assistance program described in WAC 388-400-0060 you do not
participate in the cost of personal care and you may keep the
following:
(a) When you live at home, you keep the cash grant amount
authorized under ((the general assistance program)) WAC 388-478-0033;
(b) When you live in an AFH, you keep a PNA of
thirty-eight dollars and eighty-four cents, and pay any
remaining income and ((general assistance)) ABD cash grant to
the facility for the cost of room and board up to the ADSA
room and board standard; or
(c) When you live in an assisted living facility or enhanced adult residential center, you are only eligible to receive an ABD cash grant of thirty-eight dollars and eighty-four cents as described in WAC 388-478-0045, which you keep for your PNA.
(8) Current resource and income standards are located at: http://www.dshs.wa.gov/manuals/eaz/sections/LongTermCare/LTCstandardspna.shtml.
(9) Current PNA and ADSA room and board standards are located at: http://www.dshs.wa.gov/manuals/eaz/sections/LongTermCare/ltcstandardsPNAchartsubfile.shtml.
[Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, and section 1915(c) of the Social Security Act. 09-14-043, § 388-515-1507, filed 6/24/09, effective 7/25/09. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 74.09.530 and Washington state 2007-09 operating budget (SHB 1128). 08-22-052, § 388-515-1507, filed 11/3/08, effective 12/4/08.]
(2) You must meet the general eligibility requirements described in WAC 388-513-1315 and 388-515-1506.
(3) You must meet the following resource requirements:
(a) Resource limits described in WAC 388-513-1350.
(b) If you have resources over the standard allowed in
WAC 388-513-1350, the department reduces resources over the
standard by your unpaid medical expenses described in WAC 388-513-1350 (((d), (e) and (f))) if you verify these
expenses.
(4) You must meet the following income requirements:
(a) Your gross nonexcluded income must be at or below the special income level (SIL) which is three hundred percent of the federal benefit rate (FBR); or
(b) For home and community based (HCB) service programs authorized by HCS your gross nonexcluded income is:
(i) Above the special income level (SIL) which is three hundred percent of the federal benefit rate (FBR); and
(ii) Net income is no greater than the effective one-person medically needy income level (MNIL). Net income is calculated by reducing gross nonexcluded income by:
(A) Medically needy (MN) disregards found in WAC 388-513-1345; and
(B) The average monthly nursing facility state rate is five thousand six hundred and twenty six dollars. This rate will be updated annually starting October 1, 2012 and each year thereafter on October 1. This standard will be updated annually in the long-term care standard section of the EAZ manual described at http://www.dshs.wa.gov/manuals/eaz/sections/LongTermCare/LTCstandardspna.shtml.
(5) The department follows the rules in WAC 388-515-1325, 388-513-1330, and 388-513-1340 to determine available income and income exclusions.
(6) Current resource and income standards (including the SIL, MNIL and FBR) for long-term care are found at: http://www.dshs.wa.gov/manuals/eaz/sections/LongTermCare/LTCstandardspna.shtml.
[Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 74.09.530 and Washington state 2007-09 operating budget (SHB 1128). 08-22-052, § 388-515-1508, filed 11/3/08, effective 12/4/08.]
(1) If you are single and living at home as defined in WAC 388-106-0010, you keep all your income up to the federal poverty level (FPL) for your personal needs allowance (PNA).
(2) If you are married living at home as defined in WAC 388-106-0010, you keep all your income up to the effective one-person medically needy income level (MNIL) for your PNA if your spouse lives at home with you. If you are married and living apart from your spouse, you're allowed to keep your income up to the FPL for your PNA.
(3) If you live in an assisted living (AL) facility, enhanced adult residential center (EARC), or adult family home (AFH), you:
(a) Keep a PNA from your gross ((nonexluded)) nonexcluded
income. The PNA is sixty-two dollars and seventy-nine cents
effective July 1, 2008; and
(b) Pay for your room and board up to the ADSA room and board standard.
(4) In addition to paying room and board, you may also have to pay toward the cost of personal care. This is called your participation. Income that remains after the PNA and any room and board deduction is reduced by allowable deductions in the following order:
(a) If you are working, the department allows an earned income deduction of the first sixty-five dollars plus one-half of the remaining earned income.
(b) Guardianship fees and administrative costs including any attorney fees paid by the guardian only as allowed by chapter 388-79 WAC;
(c) Current or back child support garnished or withheld from your income according to a child support order in the month of the garnishment if it is for the current month. If the department allows this as deduction from your income, the department will not count it as your child's income when determining the family allocation amount;
(d) A monthly maintenance needs allowance for your community spouse not to exceed that in WAC 388-513-1380 (5)(b) unless a greater amount is allocated as described in subsection (e) of this section. This amount:
(i) Is allowed only to the extent that ((you make)) your
income is made available to your community spouse; and
(ii) Consists of a combined total of both:
(A) One hundred fifty percent of the two person federal
poverty level. This standard ((increases)) may change
annually on July 1st (((http://aspe.os.dhhs.gov/poverty/)))
and can be found at:
http://www.dshs.wa.gov/manuals/eaz/sections/LongTermCare/LTCstandardspna.shtml; and
(B) Excess shelter expenses. For the purposes of this section, excess shelter expenses are the actual required maintenance expenses for your community spouse's principal residence. These expenses are determined in the following manner:
(I) Rent, including space rent for mobile homes, plus;
(II) Mortgage, plus;
(III) Taxes and insurance, plus;
(IV) Any required payments for maintenance care for a
condominium or cooperative, ((minus)) plus;
(V) The food assistance standard utility allowance (SUA)
(((for long-term care services this is set at the standard
utility allowance for a four-person household),)) described in
WAC 388-450-0195 provided the utilities are not included in
the maintenance charges for a condominium or cooperative,
minus;
(VI) The standard shelter allocation. This standard is
based on thirty percent of one hundred fifty percent of the
two person federal poverty level. This standard ((increases))
may change annually on July 1st
(((http://aspe.os.dhhs.gov/poverty.))) and can be found at:
http://www.dshs.wa.gov/manuals/eaz/sections/LongTermCare/LTCstandardspna.shtml; and
(((e))) (VII) Is reduced by your community spouse's gross
countable income.
(((f))) (iii) The amount allocated to the community
spouse may be greater than the amount in subsection (d)(ii)
only when:
(((i))) (A) There is a court order approving ((the)) a
higher amount for the support of your community spouse; or
(((ii))) (B) A hearings officer determines a greater
amount is needed because of exceptional circumstances
resulting in extreme financial duress.
(((g))) (e) A monthly maintenance needs amount for each
minor or dependent child, dependent parent, or dependent
sibling of your community or institutionalized spouse. The
amount the department allows is based on the living
arrangement of the dependent. If the dependent:
(i) Resides with your community spouse, ((the amount is
equal to one-third of the community spouse allocation as
described in WAC 388-513-1380 (5)(b)(i)(A) that exceeds the
dependent family member's income)) for each child, one hundred
fifty percent of the two-person FPL minus that child's income
and divided by three (child support received from a
noncustodial parent is considered the child's income);
(ii) Does not reside with the community spouse, the amount is equal to the effective one-person MNIL based on the number of dependent family members in the home less their separate income (child support received from a noncustodial parent is considered the child's income).
(((h))) (f) Your unpaid medical expenses which have not
been used to reduce excess resources. Allowable medical
expenses are described in WAC 388-513-1350.
(((i))) (g) The total of the following deductions cannot
exceed the SIL (three hundred percent of the FBR):
(i) Personal needs allowance in subsections (1), (2) and (3)(a) and (b); and
(ii) Earned income deduction of the first sixty-five dollars plus one-half of the remaining earned income in subsection (4)(a); and
(iii) Guardianship fees and administrative costs in subsection (4)(b).
(5) You must pay your provider the combination of the room and board amount and the cost of personal care services after all allowable deductions.
(6) You may have to pay third party resources described
in WAC ((388-501-0200)) 182-501-0200 in addition to the room
and board and participation. The combination of room and
board, participation, and third party resources is the total
amount you must pay.
(7) Current income and resource standards for long-term care (including SIL, MNIL, FPL, FBR) are located at: http://www.dshs.wa.gov/manuals/eaz/sections/LongTermCare/LTCstandardspna.shtml.
(8) If you are in multiple living arrangements in a month (an example is a move from an adult family home to a home setting on HCB services), the department allows you the highest PNA available based on all the living arrangements and services you have in a month.
(9) Current PNA and ADSA room and board standards are located at: http://www.dshs.wa.gov/manuals/eaz/sections/LongTermCare/ltcstandardsPNAchartsubfile.shtml.
[Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 74.09.530 and Washington state 2007-09 operating budget (SHB 1128). 08-22-052, § 388-515-1509, filed 11/3/08, effective 12/4/08.]
(1) WAC 388-515-1511 describes the general eligibility
requirements under the ((four)) DDD HCBS waivers.
(2) WAC 388-515-1512 describes the financial requirements
for the DDD waivers if you are eligible for medicaid under the
noninstitutional categorically needy program (((CN-P))) (CN).
(3) WAC 388-515-1513 describes the initial financial
requirements for the DDD waivers if you are not eligible for
medicaid under a categorically needy program (((CN-P))) (CN)
listed in WAC 388-515-1512(1).
(4) WAC 388-515-1514 describes the post eligibility
financial requirements for the DDD waivers if you are not
eligible for medicaid under a categorically needy program
(((CN-P))) CN listed in WAC 388-515-1512(1).
[Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, and Washington state 2007-09 operating budget (SHB 1128). 08-11-083, § 388-515-1510, filed 5/20/08, effective 6/20/08. Statutory Authority: RCW 71A.12.030, 71A.10.020, chapters 71A.10 and 71A.12 RCW, 2004 c 276. 04-18-054, § 388-515-1510, filed 8/27/04, effective 9/27/04. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and 74.09.500. 01-02-052, § 388-515-1510, filed 12/28/00, effective 1/28/01. 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.]
(((1) The four DDD HCBS waivers are:
(a) Basic;
(b) Basic plus;
(c) Core; and
(d) Community protection.))
(2) The requirements for services for DDD HCBS waivers are described in chapter 388-845 WAC. The department establishes eligibility for DDD HCBS waivers. To be eligible, you must:
(a) Be an eligible client of the division of developmental disabilities (DDD);
(b) Meet the disability criteria for the supplemental
security income (SSI) program as described in WAC
((388-475-0050)) 182-512-0050;
(c) Require the level of care provided in an intermediate
care facility for the ((mentally retarded (ICF/MR)))
intellectually disabled (ICF/ID);
(d) Have attained institutional status as described in WAC 388-513-1320;
(e) Be able to reside in the community and choose to do
so as an alternative to living in an ((ICF/MR)) ICF/ID;
(f) Need waiver services as determined by your plan of care or individual support plan, and:
(i) Be able to live at home with waiver services; or
(ii) Live in a department contracted facility, which includes:
(A) A group home;
(B) Group training home;
(C) Child foster home, group home or staffed residential facility;
(D) Adult family home (AFH); or
(E) Adult residential care (ARC) facility.
(iii) Live in your own home with supported living services from a certified residential provider; or
(iv) Live in the home of a contracted companion home provider; and
(g) Be both medicaid eligible under the categorically
needy program (((CN-P))) (CN) and be approved for services by
the division of developmental disabilities.
[Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, and Washington state 2007-09 operating budget (SHB 1128). 08-11-083, § 388-515-1511, filed 5/20/08, effective 6/20/08.]
(a) Supplemental Security Income (SSI) eligibility described in WAC 388-474-0001. This includes SSI clients under 1619B status. These clients have medicaid eligibility determined and maintained by the Social Security Administration;
(b) Healthcare for workers with disabilities (HWD)
described in WAC ((388-475-1000)) 182-511-1000 through
((388-475-1250)) 182-511-1250;
(c) SSI-related ((CN-P)) (CN) medicaid described in WAC
((388-475-0100)) 182-512-0100 (2)(a) and (b) or meets the
requirements in WAC ((388-475-0880)) 182-512-0880 and is
((CN-P)) (CN) eligible after the income disregards have been
applied;
(d) ((CN-P)) CN medicaid for a child as described in WAC
((388-505-0210)) 182-505-0210 (1), (2), (7) or (8); or
(e) ((General assistance expedited medicaid disability
(GA-X) or general assistance based on aged/blind/disabled
criteria described in WAC 388-505-0110(6))) Aged, blind or
disabled (ABD) cash assistance described in WAC 388-400-0060.
(2) If you are eligible for a ((CN-P)) CN medicaid
program listed in subsection (1) above, you do not have to pay
(participate) toward the cost of your personal care and/or
habilitation services.
(3) If you are eligible for a ((CN-P)) CN medicaid
program listed in subsection (1) above, you do not need to
meet the initial eligibility income test of gross income at or
below the special income level (SIL), which is three hundred
percent of the federal benefit rate (FBR).
(4) If you are eligible for a ((CN-P)) CN medicaid
program listed in subsection (1), you pay up to the ADSA room
and board standard described in WAC 3((88-515-1505))
388-515-1507. Room and board and long-term care standards are
located at
((http://www1.dshs.wa.gov/manuals/eaz/sections/LongTermCare/LTCstandardspna.shtml))
http://www.dshs.wa.gov/manuals/eaz/sections/LongTermCare/LTCstandardspna.shtml.
(a) If you live in an ARC, AFH or DDD group home, you keep a personal needs allowance (PNA) and use your income to pay up to the ADSA room and board standard. Effective January 1, 2009 the PNA is sixty-two dollars and seventy-nine cents.
(5) If you are eligible for a premium based medicaid program such as healthcare for workers with disabilities (HWD), you must continue to pay the medicaid premium to remain eligible for that CN-P program.
[Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.575, 74.09.500, 74.09.530. 08-24-069, § 388-515-1512, filed 12/1/08, effective 1/1/09. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, and Washington state 2007-09 operating budget (SHB 1128). 08-11-083, § 388-515-1512, filed 5/20/08, effective 6/20/08.]
Reviser's note: RCW 34.05.395 requires the use of underlining and deletion marks to indicate amendments to existing rules. The rule published above varies from its predecessor in certain respects not indicated by the use of these markings.
AMENDATORY SECTION(Amending WSR 08-11-083, filed 5/20/08,
effective 6/20/08)
WAC 388-515-1513
How does the department determine if I
am financially eligible for DDD waiver service medical
coverage if I am not eligible for medicaid under a
categorically needy program (((CN-P))) (CN) listed in WAC 388-515-1512(1)?
If you are not eligible for medicaid under a
categorically needy program (((CN-P))) (CN) listed in WAC 388-515-1512(1), we must determine your eligibility using
institutional medicaid rules. This section explains how you
may qualify under this program. You may be required to pay
towards the cost of your care if you are eligible under this
program. The rules explaining how much you have to pay are
listed in WAC 388-515-1514. To qualify, you must meet both
the resource and income requirements.
(1) Resource limits are described in WAC 388-513-1350.
If you have resources which are higher than the standard
allowed ((under WAC 388-515-1350, we may reduce the amount we
are required to count if you have unpaid medical expenses.
(a) We will reduce your resources in an amount equal to the unpaid medical expenses you verify. The anticipated cost of your waiver services cannot be used as a medical expense to qualify for this deduction.
(b) If your remaining resources, after the deduction in section (1)(a) are still over the standard, you are ineligible until your resources are below the standard.
(c))), we may be able to reduce resources by your unpaid medical expenses described in WAC 388-513-1350.
(2) You are not subject to a transfer of asset penalty
described in WAC 388-513-1363 through ((388-513-1366))
388-513-1365.
(d) ((Equity in your home is five hundred thousand
dollars or less as)) Not have a home with equity in excess of
the requirements described in WAC 388-513-1350.
(((2))) (3) Your gross nonexcluded income must be at or
below the special income level (SIL) which is three hundred
percent of the federal benefit level. The department follows
the rules in WAC 388-515-1325, 388-513-1330 and 388-513-1340
to determine available income and income exclusions.
(4) Refer to WAC 388-513-1315 for rules used to determine countable resources, income and eligibility standards for long-term care services.
(5) Current income and resources standards are located at: http://www.dshs.wa.gov/manuals/eaz/sections/LongTermCare/LTCstandardspna.shtml.
[Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, and Washington state 2007-09 operating budget (SHB 1128). 08-11-083, § 388-515-1513, filed 5/20/08, effective 6/20/08.]
Reviser's note: The typographical error in the above section occurred in the copy filed by the agency and appears in the Register pursuant to the requirements of RCW 34.08.040.
AMENDATORY SECTION(Amending WSR 08-24-069, filed 12/1/08,
effective 1/1/09)
WAC 388-515-1514
How does the department determine how
much of my income I must pay towards the cost of my ((care))
DDD waiver services if I am not eligible for medicaid under a
categorically needy program (((CN-P))) (CN) listed in WAC 388-515-1512(1)?
If you are not eligible for medicaid under a
categorically needy program (((CN-P))) (CN) listed in WAC 388-515-1512(1), the department determines how much you must
pay based upon the following:
(1) If you are an SSI-related client living at home as defined in WAC 388-106-0010, you keep all your income up to the SIL (three hundred percent of the FBR) for your personal needs allowance (PNA).
(2) If you are an SSI-related client and you live in an ARC, AFH or DDD group home, you:
(a) Keep a personal needs allowance (PNA) from your gross nonexcluded income. Effective January 1, 2009 the PNA is sixty-two dollars and seventy-nine cents; and
(b) Pay for your room and board up to the ADSA room and
board rate described in
((http://www1.dshs.wa.gov/manuals/eaz/sections/LongTermCare/LTCstandardspna.shtml))
http://www.dshs.wa.gov/manuals/eaz/sections/LongTermCare/LTCstandardspna.shtml.
(3) ((Income that remains after the allocation)) In
addition to paying room and board, you may also have to pay
toward the cost of personal care. This is called your
participation. Income that remains after the PNA and any room
and board deduction described in (2) above, is reduced by
allowable deductions in the following order:
(a) If you are working, we allow an earned income deduction of the first sixty-five dollars plus one-half of the remaining earned income;
(b) Guardianship fees and administrative costs including any attorney fees paid by the guardian only as allowed by chapter 388-79 WAC;
(c) Current or back child support garnished or withheld
from your income ((or withheld)) according to a child support
order in the month of the garnishment if it is for the current
month. If we allow this as deduction from your income, we
will not count it as your child's income when determining the
family allocation amount;
(d) A monthly maintenance needs allowance for your community spouse not to exceed that in WAC 388-513-1380 (5)(b) unless a greater amount is allocated as described in subsection (e) of this section. This amount:
(i) Is allowed only to the extent that your income is made available to your community spouse; and
(ii) Consists of a combined total of both:
(A) One hundred fifty percent of the two person federal
poverty level. This standard ((increases)) may change
annually on July 1st (((http://aspe.os.dhhs.gov/poverty/)))
and can be found at:
http://www.dshs.wa.gov/manuals/eaz/sections/LongTermCare/LTCstandardspna.shtml; and
(B) Excess shelter expenses. For the purposes of this section, excess shelter expenses are the actual required maintenance expenses for your community spouse's principal residence. These expenses are determined in the following manner:
(I) Rent, including space rent for mobile homes, plus;
(II) Mortgage, plus;
(III) Taxes and insurance, plus;
(IV) Any required payments for maintenance care for a
condominium or cooperative ((minus)) plus;
(V) The food assistance standard utility allowance (((for
long term care services this is set at the standard utility
allowance (SUA) for a four-person household),)) (SUA) provided
the utilities are not included in the maintenance charges for
a condominium or cooperative, minus;
(VI) The standard shelter allocation. This standard is
based on thirty percent of one hundred fifty percent of the
two person federal poverty level. This standard ((increases))
may change annually on July 1st
(((http://aspe.os.dhhs.gov/poverty))) and can be found at:
http://www.dshs.wa.gov/manuals/eaz/sections/LongTermCare/LTCstandardspna.shtml; and
(VII) Is reduced by your community spouse's gross countable income.
(iii) May be greater than the amount in subsection (d)(ii) only when:
(A) There is a court order approving a higher amount for the support of your community spouse; or
(B) A hearings officer determines a greater amount is needed because of exceptional circumstances resulting in extreme financial duress.
(e) A monthly maintenance needs amount for each minor or dependent child, dependent parent or dependent sibling of your community or institutionalized spouse. The amount we allow is based on the living arrangement of the dependent. If the dependent:
(i) Resides with your community spouse, ((the amount is
equal to one-third of the community spouse allocation as
described in WAC 388-513-1380 (5)(b)(i)(A) that exceeds the
dependent family member's income)) for each child, one hundred
fifty percent of the two-person FPL minus that child's income
and divided by three (child support received from a
noncustodial parent is considered the child's income);
(ii) Does not reside with the community spouse, the amount is equal to the effective one-person MNIL based on the number of dependent family members in the home less their separate income (child support received from a noncustodial parent is considered the child's income).
(f) Your unpaid medical expenses which have not been used to reduce excess resources. Allowable medical expenses are described in WAC 388-513-1350.
(g) The total of the following deductions cannot exceed the SIL (three hundred percent of the FBR):
(i) Personal needs allowances in subsection (1) for in home or subsection (2)(a) in a residential setting; and
(ii) Earned income deduction of the first sixty-five dollars plus one-half of the remaining earned income in subsection (3)(a); and
(iii) Guardianship fees and administrative costs in subsection (3)(b).
(4) If you are eligible for ((general assistance
expedited medicaid disability (GA-X) or general assistance
based on aged/blind/disabled criteria described in WAC 388-505-0110(6),)) aged, blind or disabled (ABD) cash
assistance described in WAC 388-400-0060 you do not
participate in the cost of personal care and you may keep the
following:
(a) When you live at home, you keep the cash grant amount
authorized under the ((general assistance)) ABD cash program;
(b) When you live in an AFH, you keep a PNA of
thirty-eight dollars and eighty-four cents, and pay any
remaining income and ((general assistance)) ABD cash grant to
the facility for the cost of room and board up to the ADSA
room and board standard described in
((http://www1.dshs.wa.gov/manuals/eaz/sections/LongTermCare/LTCstandardspna.shtml))
http://www.dshs.wa.gov/manuals/eaz/sections/LongTermCare/LTCstandardspna.shtml; or
(c) When you live in an ARC or DDD group home, you are only eligible to receive a cash grant of thirty-eight dollars and eighty-four cents which you keep for your PNA.
(5) ((The combination of the)) You may have to pay third
party resources (TPR) described in WAC 182-501-0200 in
addition to room and board ((amount)) and the cost of personal
care and/or habilitation services (participation) after all
allowable deductions have been considered is called your total
responsibility. You pay this amount to the ARC, AFH or DDD
group home provider.
[Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.575, 74.09.500, 74.09.530. 08-24-069, § 388-515-1514, filed 12/1/08, effective 1/1/09. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, and Washington state 2007-09 operating budget (SHB 1128). 08-11-083, § 388-515-1514, filed 5/20/08, effective 6/20/08.]
This section describes the financial eligibility requirements for waiver services under the medically needy residential waiver (MNRW) and the rules used to determine a client's responsibility in the total cost of care.
(1) To be eligible for MNRW, a client must meet the following conditions:
(a) Does not meet financial eligibility for medicaid personal care or the COPES program;
(b) Is eighteen years of age or older;
(c) Meets the SSI related criteria described in WAC
((388-475-0050)) 182-514-0050;
(d) Requires the level of care provided in a nursing facility as described in WAC 388-106-0355;
(e) In the absence of waiver services described in WAC 388-106-0400, would continue to reside in a medical facility as defined in WAC 388-513-1301, or will likely be placed in one within the next thirty days;
(f) Has attained institutional status as described in WAC 388-513-1320;
(g) Has been determined to be in need of waiver services as described in WAC 388-106-0410;
(h) Lives in one of the following department-contracted residential facilities:
(i) Licensed adult family home (AFH);
(ii) Assisted living (AL) facility; or
(iii) Enhanced adult residential care (EARC) facility.
(i) Is not subject to a penalty period of ineligibility
for the transfer of an asset as described in WAC 388-513-1363,
388-513-1364, and 388-513-1365 ((and 388-513-1366)); and
(j) Meets the resource and income requirements described in subsections (2) through (6).
(2) The department determines a client's nonexcluded resources under MNRW as described in WAC 388-513-1350;
(3) Nonexcluded resources, after disregarding excess resources described in (4), must be at or below the resource standard described in WAC 388-513-1350 (1) and (2).
(4) In determining a client's resource eligibility, the department disregards excess resources above the standard described in subsection (3) of this section:
(a) In an amount equal to incurred medical expenses such as:
(i) Premiums, deductibles, and co-insurance/co-payment charges for health insurance and medicare premiums;
(ii) Necessary medical care recognized under state law, but not covered under the state's medicaid plan; or
(iii) Necessary medical care covered under the state's medicaid plan.
(b) As long as the incurred medical expenses:
(i) Are not subject to third-party payment or reimbursement;
(ii) Have not been used to satisfy a previous spend down liability;
(iii) Have not previously been used to reduce excess resources;
(iv) Have not been used to reduce client responsibility toward cost of care; and
(v) Are amounts for which the client remains liable.
(5) The department determines a client's countable income under MNRW in the following way:
(a) Considers income available described in WAC 388-513-1325 and 388-513-1330 (1), (2), and (3);
(b) Excludes income described in WAC 388-513-1340;
(c) Disregards income described in WAC 388-513-1345;
(d) Deducts monthly health insurance premiums, except medicare premiums.
(6) If the client's countable income is:
(a) Less than the residential facility's department-contracted rate, based on an average of 30.42 days in a month the client may qualify for MNRW subject to availability per WAC 388-106-0435;
(b) More than the residential facility's department-contracted rate, based on an average of 30.42 days in a month the client may qualify for MNRW when they meet the requirements described in subsections (7) through (9), subject to availability per WAC 388-106-0435.
(7) The portion of a client's countable income over the department-contracted rate is called "excess income."
(8) A client who meets the requirements for MNRW chooses a three or six month base period. The months must be consecutive calendar months.
(9) A client who has or will have "excess income" is not eligible for MNRW until the client has medical expenses which are equal in amount to that excess income. This is the process of meeting "spenddown." The excess income from each of the months in the base period is added together to determine the total "spenddown" amount.
(10) Medical expenses described in subsection (4) of this WAC may be used to meet spenddown if not already used in subsection (4) of this WAC to disregard excess resources or to reduce countable income as described in subsection (5)(d).
(11) In cases where spenddown has been met, medical coverage begins the day services are authorized.
(12) The client's income that remains after determining available income in WAC 388-513-1325 and 388-513-1330 (1), (2), (3) and excluded income in WAC 388-513-1340 is paid towards the cost of care after deducting the following amounts in the order listed:
(a) An earned income deduction of the first sixty-five dollars plus one-half of the remaining earned income;
(b) Personal needs allowance (PNA) described in WAC 388-515-1505. (Long-term care standards can be found at http://www1.dshs.wa.gov/manuals/eaz/sections/LongTermCare/LTCstandardspna.shtml);
(c) Medicare and health insurance premiums not used to meet spenddown or reduce excess resources described in WAC 388-513-1350;
(d) Incurred medical expenses described in (4) not used to meet spenddown or reduce excess resources described in WAC 388-513-1350.
[Statutory Authority: RCW 34.05.353 (2)(d), 74.08.090, and chapters 74.09, 74.04 RCW. 08-11-047, § 388-515-1540, filed 5/15/08, effective 6/15/08. Statutory Authority: RCW 74.08.090, 74.09.520. 05-11-082, § 388-515-1540, filed 5/17/05, effective 6/17/05. Statutory Authority: 2001 c 269, RCW 74.09.700, 74.08.090, 74.04.050, 74.09.575 and chapter 74.39 RCW. 03-13-052, § 388-515-1540, filed 6/12/03, effective 7/13/03.]
This section describes the financial eligibility requirements for waiver services under the medically needy in-home waiver (MNIW) and the rules used to determine a client's responsibility in the total cost of care.
(1) To be eligible for MNIW, a client must:
(a) Not meet financial eligibility for medicaid personal care or the COPES program;
(b) Be eighteen years of age or older;
(c) Meet the SSI-related criteria described in WAC
((388-475-0050(1))) 182-512-0050(1);
(d) Require the level of care provided in a nursing facility as described in WAC 388-106-0355;
(e) In the absence of waiver services described in WAC 388-106-0500, continue to reside in a medical facility as defined in WAC 388-513-1301, or will likely be placed in one within the next thirty days;
(f) Have attained institutional status as described in WAC 388-513-1320;
(g) Have been determined to be in need of waiver services as described in WAC 388-106-0510;
(h) Be able to live at home with community support services and choose to remain at home;
(i) 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((,)) and 388-513-1365 ((and 388-513-1366)); and
(j) Meet the resource and income requirements described in subsections (2) through (6) of this section.
(2) The department determines a client's nonexcluded resources under MNIW as described in WAC 388-513-1350.
(3) Nonexcluded resources, after disregarding excess resources described in subsection (4) of this section, must be at or below the resource standard described in WAC 388-513-1350.
(4) In determining a client's resource eligibility, the department disregards excess resources above the standard described in subsection (3) of this section:
(a) In an amount equal to incurred medical expenses such as:
(i) Premiums, deductibles, and co-insurance/co-payment charges for health insurance and medicare premiums;
(ii) Necessary medical care recognized under state law, but not covered under the state's medicaid plan; or
(iii) Necessary medical care covered under the state's medicaid plan.
(b) As long as the incurred medical expenses:
(i) Are not subject to third-party payment or reimbursement;
(ii) Are not the result of medical and remedial care expenses that were incurred as the result of imposition of a transfer of asset penalty described in WAC 388-513-1363, 388-513-1364 and 388-513-1365.
(iii) Have not been used to satisfy a previous spenddown liability;
(iv) Have not previously been used to reduce excess resources;
(v) Have not been used to reduce client responsibility toward cost of care; and
(vi) Are amounts for which the client remains liable.
(5) The department determines a client's countable income under MNIW in the following way:
(a) Considers income available described in WAC 388-513-1325 and 388-513-1330 (1), (2), and (3);
(b) Excludes income described in WAC 388-513-1340;
(c) Disregards income described in WAC 388-513-1345;
(d) Deducts monthly health insurance premiums, except medicare premiums, not used to reduce excess resources in subsection (4) of this section;
(e) Allows an income deduction for a nonapplying spouse, equal to the effective one-person medically needy income level (MNIL) less the nonapplying spouse's income, if the nonapplying spouse is living in the same home as the applying person.
(6) A client whose countable income exceeds the effective one-person MNIL may become eligible for MNIW:
(a) When they have or expect to have medical expenses to offset their income which is over the effective one-person MNIL; and
(b) Subject to availability in WAC 388-106-0535.
(7) The portion of a client's countable income over the effective one-person MNIL is called "excess income."
(8) A client who has or will have "excess income" is not eligible for MNIW until the client has medical expenses which are equal in amount to that excess income. This is the process of meeting "spenddown." The excess income from each of the months in the base period is added together to determine the total "spenddown" amount.
(9) The following medical expenses may be used to meet spenddown if not already used in subsection (4) of this section to disregard excess resources or to reduce countable income as described in subsection (5)(d) of this section:
(a) An amount equal to incurred medical expenses such as:
(i) Premiums, deductibles, and co-insurance/co-payment charges for health insurance and medicare premiums;
(ii) Necessary medical care recognized under state law, but not covered under the state's medicaid plan; and
(iii) Necessary medical care covered under the state's medicaid plan.
(b) The cost of waiver services authorized during the base period.
(c) As long as the incurred medical expenses:
(i) Are not subject to third-party payment or reimbursement;
(ii) Are not the result of medical and remedial care expenses that were incurred as the result of imposition of a transfer of asset penalty described in WAC 388-513-1363, 388-513-1364 and 388-513-1365.
(iii) Have not been used to satisfy a previous spenddown liability;
(iv) Have not been used to reduce client responsibility toward cost of care; and
(v) Are amounts for which the client remains liable.
(10) Eligibility for MNIW is effective the first full month the client has met spenddown.
(11) In cases where spenddown has been met, medical coverage and MNIW begin the day services are authorized.
(12) A client who meets the requirements for MNIW chooses a three or six month base period. The months must be consecutive calendar months.
(13) The client's income that remains after determining available income in WAC 388-513-1325 and 388-513-1330 (1), (2), (3) and excluded income in WAC 388-513-1340 is paid towards the cost of care after deducting the following amounts in the order listed:
(a) An earned income deduction of the first sixty-five dollars plus one-half of the remaining earned income;
(b) Personal needs allowance (PNA) in an amount equal to the one-person federal poverty level (FPL) described in WAC 388-478-0075(4);
(c) Medicare and health insurance premiums not used to meet spenddown or reduce excess resources;
(d) Incurred medical expenses described in subsection (4) of this section not used to meet spenddown or reduce excess resources.
[Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.520, 74.09.530 and 2004 c 276 § 206 (6)(b). 07-03-087, § 388-515-1550, filed 1/18/07, effective 2/18/07. Statutory Authority: RCW 74.08.090, 74.09.520. 05-11-082, § 388-515-1550, filed 5/17/05, effective 6/17/05. Statutory Authority: 2004 c 276 § 206 (6)(b) and Townsend vs. DSHS, U.S. District Court, Western District of Washington, No. C 00-0944Z. 04-16-029, § 388-515-1550, filed 7/26/04, effective 8/26/04.]