CLARIFYING INFORMATION This program is used for clients who have countable income over the CNIL and living in a licensed, department contracted alternate living facility (ALF).
Non institutional Medicaid in an ALF (ACES medical coverage group; G03, G95 and G99) has the same program rules as SSI related Medicaid, but with a higher income standard. Institutional Medicaid is under the L, C and K track series.
For SSI-related clients who are eligible to receive CN coverage because they are on SSI (S01) or are SSI related with income at or below the CNIL (S02), the higher standard used for non institutional Medicaid in an ALF is not needed because they already meet CN-P eligibility.
Special income disregards for SSI-related programs such as disabled adult child (DAC) and COLA/Pickle are described in WAC 388-475-0880 and Clarifying Information, Special Income Disregards.
The G03/G95/G99 medical coverage group is used for eligibility when a client resides in an alternate living facility. The daily rate is what drives the eligibility. The difference in eligibility between the SSI related series (S02, S95, S99) and non institutional in an ALF (G03, G95, G99) is the income standard. The standard is the daily rate x 31 days plus the general assistance personal needs allowance (PNA) of $38.84 rather than the CNIL standard. For clients receiving Home & Community Services (HCS), Division of Developmental Disabilities (DDD), or Regional Support Network/Mental health (RSN) services with income under the Medicaid Special Income Level (SIL) use the state daily rate authorized for that client. For private pay clients in a state contracted/licensed facility, use the private daily rate the client is charged by the facility.
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Categorically Needy (CN-P) G03
To be eligible for CN benefits, a client must have non-excluded income at or below both the CN standard and the SIL and resources at or below the resource standard for SSI related clients.
There are 2 tests for CN-P eligibility under the G03 program:
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Is the client's gross income under the Medicaid SIL? And;
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Is the client's countable income under the state contracted daily rate x 31 days plus the general assistance PNA?
If the answer to both (a) and (b) are yes, the client is income eligible for CN-P G03. If one or both are answered no, the case will trickle to a medically needy program.
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Medically Needy (G95/G99)
The income standard used to determine eligibility for these benefits under the medically needy (MN) program is based on the private facility rate based on a thirty-one day month plus the general assistance PNA.
If the income exceeds the MN standard, the excess is used to determine the client's spenddown liability. Refer to SPENDDOWN for procedures to be followed.
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What is a department contracted/licensed alternate living facility?
Department contracted facility means a licensed facility such as an adult family home or boarding home that is contracted with DSHS to provide services such as Medicaid Personal Care (MPC) or Developmental Disability Division (DDD) or Home & Community Services (HCS) Waiver services. It also applies to facilities that are contracted with the Regional Support Network (RSN) to provide services. The RSN provides Mental Health services. If the facility does not accept a client with the RSN, DDD or HCS services it is not considered a department contracted facility. A facility can be licensed, but not contracted with DSHS or Mental Health. Eligibility for client's living in a licensed but not contracted facility is done as if the client is in their own home.
Facility rates can vary from one facility to another. The facility rate must be updated in ACES at each eligibility review and documented as to how the rate was verified. Another term used to describe these facilities is an alternate living facility (ALF).
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The state rate is used for CN eligibility.
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The private rate is used for MN eligibility.
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The state and private rate could be the same, or the private rate could be lower than the state rate based on providing a client with personal care services.
Some facilities that hold a contract with the department also have private-pay beds. Clients not eligible for Medicaid or state payment for the cost of care in a department-contracted facility pay the private rate established by the facility. These clients may still be eligible for non-institutional medical assistance using the rules for the G03 program.
To search for Adult family Home or Boarding Homes contracted with DSHS: http://adsaweb/afhbh/
The list on the Adult family home/Boarding Home indicates if the facility is not contracted for Medicaid or mental health.
EXAMPLES 1 through 5 how to determine if the facility is contracted for the purposes of G03.
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Medicaid Personal Care (MPC)
The department authorizes personal care services for a client assessed as requiring assistance with daily living. This assessment is done by a case manager (CM), nurse or social worker (SW) from the Division of Developmental Disabilities (DDD), Home and Community Services (HCS) or Area Agency on Aging (AAA). This service is called Medicaid Personal Care or (MPC). Clients must meet the functional criteria based on the social service assessment AND the financial eligibility based on eligibility for a non institutional CN-P Medicaid program. The department establishes and pays a daily rate to the adult family home or boarding home provider.
Clients do not have to be on MPC services with the department to use rules for the G03 program, but they do need to reside in a facility contracted to provide services by DSHS or the RSN. Clients are either on MPC on a Waiver program or paying the facility privately. Clients on MPC have part of the cost of the facility paid by the Department.
In order to receive MPC, clients must be eligible for a non-institutional CN-P Medicaid program. Examples of non-institutional CN-P programs are S01, S02, S08/HWD, G02, G03, F06, F01, F04, R01. Medically Needy clients are not eligible for MPC services.
Since G03 is not an institutional Medicaid program, HCS and DDD can authorize MPC services for those who have been assessed by HCS and DDD to need the services. There is no post eligibility in the G03 program as there is in institutional Medicaid, but clients do need to pay income to the facility after the allowable SSI related deductions and $38.84 personal needs allowance. Effective 7/1/2007 the MPC PNA was raised 3.3% by the legislature to $40.12. Even though MPC clients with HCS or DDD have a higher PNA standard effective 7/1/2007, it did not change the ELIGIBILITY standard for the G03 program which is based on the General Assistance standard of $38.84. This amount was not raised by the legislature. Effective 7/1/2008, the MPC PNA standard will increase to $41.44.
G01/GA-U clients are not eligible for MPC, but they may be receiving state funded services through HCS or DDD.
MPC services can only be approved for clients in a Adult Residential Center (ARC) or Adult Family Home (AFH). MPC services cannot be authorized in an Assisted Living facility.
MPC services are not subject to transfer of asset or excess home equity rules that affect institutional programs. (institutional programs or under a Waiver or residing in a medical institution 30 days or more).
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Room and Board, what does this mean?
Throughout the manual both terms, room and board and board and room are used to describe a living arrangement in which an individual purchases food, shelter, and household maintenance requirements from one vendor. There is also a term used by ADSA called the room and board rate. This rate is based on the FBR minus the current PNA in an ALF used in the Home and Community Service Waiver program.
For client's receiving MPC through the G03 program, the rate they have to pay to the facility is higher than the standard room and board rate used by ADSA.
The rate clients on G03 pay the facility is their countable income after SSI related deductions and disregards minus $40.12 PNA. This rate for the purpose of the G03 program is called the client's total responsibility. All other ADSA clients on MPC pay the standard room and board rate established by ADSA with the exception of G03 clients. We are using a higher standard than the FBR to determine eligibility for G03, therefore the client is paying all of their available income to the facility after keeping the PNA, the $20 disregard and any other allowed SSI related disregards.
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