Non-Institutional SSI related clients living in an adult family home or boarding home (G03)
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Non-Institutional SSI related clients living in an adult family home or boarding home (G03)


Revised December 9, 2013



Purpose:

WAC 182-513-1305Determining eligibility for non-institutional medical assistance in an alternate living facility (ALF)

WAC 182-513-1305

WAC 182-513-1305

Effective January 1, 2014

WAC 182-513-1305 Determining eligibility for non-institutional medical assistance in an alternate living facility (ALF)

Emergency WAC effective 1-1-2014

This section describes how the department defines the monthly income standard and uses it to determine eligibility for non-institutional medical assistance for a client who lives in a department-contracted ALF. Refer to WAC 182-515-1500 for the personal needs allowance (PNA) amount that applies in this rule.

  1. The eligibility criteria for non-institutional medical assistance in an ALF follows SSI-related medical rule described in chapter 182-512 WAC with the exception of the higher medical standard based on the daily rate described in subsection (3) of this section..
  2. Alternate living facilities (ALF) include the following:
    1. 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) provider the care. Licensed as an adult family home under chapter 70.128 RCW and chapter 388-76 WAC;
    2. 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 a boarding home under chapter 18.20 RCW and chapter 388-78A WAC;
    3. 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;
    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 a boarding home under chapter 18.20 RCW and chapter 388-78A WAC;
    5. Developmentally disabilities administration (DDA) group home (GH), a licensed facility that provides its residents with twenty-four hour supervision. Depending on the size of a DDA 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 a boarding home 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
    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 a boarding home under chapter 18.20 RCW.
  3. The monthly income standard for non-institutional medical assistance under the categorically needy (CN) program has two steps:
    1. The gross non-excluded monthly income cannot exceed the special income level (SIL) which is three hundred percent of the federal benefit rate (FBR); and
    2. The countable income cannot be greater than the department contracted daily rate times thirty one days, plus the PNA/CPI described in WAC 182-513-1300.
  4. The monthly income standard for non-institutional medical assistance under the medically needy (MN) program equals the private facility daily rate times thirty one days, plus the thirty-eight dollars and eighty- four cents PNA/CPI described in WAC 182-513-1300. Follow MN rules described in chapter 182-519 WAC.
  5. The department approves CN non-institutional 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:
    1. The client’s non-excluded resources do not exceed the standard described in WAC 182-513-1350 (1); and
    2. The client’s non-excluded income does not exceed the CN standard described in chapter 182-512 WAC.
  6. The department approves MN non-institutional medical assistance for a period of months described in chapter 182-504 WAC  for an SSI- related client, if:
    1. The client’s non-excluded resources do not exceed the standard described in WAC 182-513-1350 (1); and
    2. The client satisfies any spenddown liability as described in chapter 182-519 WAC.
  7. A client  residing in an adult family home (AFH) receiving a grant based on a payment standard 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 182-515-1500 and pays the remainder of the grant to the adult family home as room and board.
  8. The client described in subsection  (3) of this section 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.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

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 eligibility.

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 ABD cash standard of $38.84.   

 For clients receiving Home & Community Services (HCS), Developmental Disabilities Administration (DDA), or Regional Support Network/Mental health (RSN) services with income at or below 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.

  1. 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:

  1. Is the client's gross income under the Medicaid SIL? And;

  2. Is the client's countable income under the state contracted daily rate x 31 days plus $38.84?

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.

  1. 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 $38.84.

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.

  1. 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 Administration (DDA) 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, DDA 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).

  • The state rate is used for CN eligibility.

  • The private rate is used for MN eligibility.

  • 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.

  1. 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 service specialist from the Developmental Disabilities Administration (DDA), 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 Medicaid program..  Medically Needy clients are not eligible for MPC services.  Institutional programs are under the K and L track in ACES. 

Since G03 is not an institutional Medicaid program, HCS and DDA can authorize MPC services for those who have been assessed by HCS and DDA 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 the allowable PNA.   Effective 7/1/2007 the MPC PNA was raised by the legislature to match the PNA allowed for Waiver programs.    Even though MPC clients with HCS or DDA have a higher PNA standard , it did not change the ELIGIBILITY standard for the G03 program which is based on the state-funded cash PNA of $38.84.     This amount was not raised by the legislature.  G01 clients are not eligible for MPC, but they may be receiving state funded services through HCS or DDA.

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).

  1. 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/MPC pay the facility is their countable income after SSI related deductions and disregards minus $62.79 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. 

 


EXAMPLE

$750.00   Social Security
-$62.79   PNA for client receiving MPC
= $667.21   MPC Client total responsibility payment to the ALF.
Current MPC PNA standards 


Do not use G03/G95/G99 in the following situations:
  • CN SSI related Medicaid under S01 or S02.

    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 182-512-0880  and Clarifying Information, Special Income Disregards Client's receiving services authorized by DDA or HCS pay the ADSA room and board  amount.

  •  SSI eligibility Medical.

  • Healthcare for workers with disability (HWD)(S08)

    In most cases, client's who are on Healthcare for Worker's with disabilities (HWD/S08) would be better off remaining on HWD if receiving services from HCS or DDA. HWD clients on MPC would pay their HWD premium to financial service administration (FSA) and the ADSA room and board amount  to the ALF provider.

  • Clients receiving Waiver services with DDA or HCS.

    Clients authorized for a Waiver program through DDA (described in WAC 182-515-1510) or HCS (described in WAC 182-515-1505 ) may be living in an ALF. If the client is authorized services through a Waiver program, the L22 medical coverage group is used. There are exceptions to this if the client is eligible for HWD or G02 and receiving Waiver services. The L22 Waiver medical coverage group is an institutional program using post eligibility rules to determine how much the client pays toward their cost of care. The amount the client pays along with the standard room and board amount is called participation. There are allowable deductions that can be used in post eligibility under a Waiver program, but not allowed as a deduction in the SSI related rules used for the G03 program. Some examples of these deductions allowed in the post eligibility process for the Waiver programs are guardianship fees, court ordered child support, health insurance premiums, incurred medical expenses and spousal deeming under the spousal impoverishment act.

    The Hospice program uses institutional rules under the L22 program for client's who would benefit in using institutional rules. For a client electing Hospice and paying private to an ALF, DO use the G03 program as a priority if eligible. If not eligible under G03 rules, consider the L22 program for Hospice elections. Hospice description.

  • Clients residing in a non-contracted alternate living facility. (Private Facilities)

    Some facilities are totally private and do not contract with the department to provide services. Determine eligibility for clients in non contracted facilities as if they are in their own home. Do not use the amount the client pays to the private non contracted facility as a medical expense. Alternate living facilities such as private assisted living, private adult family homes are not medical institutions, therefore the amount the client pays to the facility is not considered a medical expense. The standard used for residents of private non contracted facilities is the MNIL standard.

    Examples of non-contracted and private facilities or home settings:

    1. Residents of veteran's homes who received domiciliary or assisted living care are not eligible for Medicaid. The Department of Veterans Affairs is responsible for meeting the needs of the domiciliary or assisted living residents.

    2. Private boarding home, continuing care retirement center (CCRC), private assisted living facilities. supported living, state operated living alternative (SOLA). Determine eligibility as if they are in their own home. (S02/S95/S99).

  • EXAMPLES 6 through 12 on choosing the correct medical coverage group based on the client's circumstances.

AGENCY RESPONSIBILITIES

Financial staff determines financial eligibility for financial and medical assistance programs. The division or agency responsible for placement and case management services determines the amount the client must pay to the facility for their cost of care and notifies the client.

For clients receiving services from the RSN, HCS or DDA, the assigned case-manager/social service specialist indicates the state daily rate on the financial/social service communication form. If MPC  is authorized, the assigned case-manager/social service specialist indicates MPC service, the date service was authorized along with the daily rate and type of facility.  (For Internal staff)

HCS social service specialists use the DSHS 14-443 Financial/Social Service communication form.  This form is automated through the barcode system. 

DDA case managers use the DSHS 15-345 CSO/DDA Communication

RSN case managers use the DSHS 13-348 RSN/CS0 communication form.


WORKER RESPONSIBILITIES

  1. See CITIZENSHIP/ALIEN STATUS, RESIDENCY, and SSN to determine whether a client meets the general eligibility requirements.

  2. Determine the program to which the client can be related to medical eligibility. See ADULT MEDICAL, FAMILY MEDICAL PROGRAMS, and INCAPACITY.

  3. See  SSI related Medical Income and SSI related RESOURCES  to determine income and resource eligibility as follows:

    1. When a client is placed in a facility on the COPES or a DDA Waiver program, use WAC 182-515-1505 for COPES and WAC 182-515-1510  for DDA Waivers to determine eligibility. Screen in a L02 for these programs. (Effective 1/18/2011 the L02 will trickle to a L22)

    2. When a client is otherwise eligible for a SSI related CN-P program (S01 or S02) the S01/S02 program is a priority program. These clients are usually on MPC with either DDA or HCS. Clients who are on SSI or who are considered to be in the "SSI eligibles" group pay the ADSA room and board standard in living in an ALF.   If an S02 client residing in a contracted ALF has an increase in income that causes the S02 to trickle to a S95, do a redetermination under the G03 program.

    3. HWD  is a priority program for clients on DDA Waiver or MPC when it is beneficial to the client. Clients on HWD pay the HWD premium plus the ADSA room and board standard.

    4. HWD  is a priority program for clients on MPC with HCS when it is beneficial to the client. Clients on HWD/MPC pay the HWD premium plus the ADSA room and board standard.  HWD is not included in HCS waivers and cannot be used for clients on a waiver with HCS.

      Tip: If a client is in a licensed/contracted ALF and receiving S95 or S99, do a program change to G03 that uses the higher standard.

    5. When determining non-excluded income used to establish eligibility for the cost of care in the facility, use the CN income rules for an SSI-related client. Compare the result to the monthly income standard described in WAC 182-513-1305.

    6. If the client's non-excluded gross income is above the SIL and/or the department-contracted rate plus the DL PNA/CPI standard use the private facility rate plus the DL PNA/CPI standard.

    7. To determine the client's spenddown liability for non-institutional medical assistance under the MN program, use the client's non-excluded income in excess of the private rate plus the PNA to determine the client's spenddown liability. Do not use the amount charge by the ALF  to reduce the spenddown amount, however the client may use other incurred medical expenses to meet spenddown. (ALFs are not medical institutions).

  1. The department will consider income and resources separately as of the first day of the month following the month of separation when spouses stop living together because of placement into a boarding home or adult family home when:

    1. Only one spouse enters the facility;

    2. Both spouses enter the same facility but have separate rooms; or

    3. Both spouses enter separate facilities.

  2. The department will consider income and resources jointly when spouses are placed in a boarding home or adult family home and share a room.  See WAC 182-512-0960.

  3. Indicate MPC services in ACES under HCBS/MPC services field on INST with the service start date and the agency authorizing the service (DDA or HCS).

  4. Services authorized by DDA, HCS and the RSN are tied to eligibility for CN-P Medicaid. If Medicaid closes, the service authorized by the social service specialist/case manager must close too. Clients must be eligible for a non institutional CN-P Medicaid program in order to receive MPC. See AREP screens for long-term care  . 

    1. HCS social service specialists use the DSHS 14-443 Financial/Social Service communication form. This form is automated through barcode.  The AREP screen does not need to be completed for HCS clients as the social service specialist receives notification via their barcode To Do list. 

    2. DDA case managers use the DSHS 15-345 CSO/DDA Communication

    3. RSN case managers use the DSHS 13-348 RSN/CS0 communication form.

  5. The assigned case manager/social service specialist indicates what services are authorized with the start date, the state daily rate, the current address and any other pertinent information needed to process the case such as if a payee or power of attorney is involved in the case. The assigned case manager/social service specialist determines the functional eligibility for the service; the financial worker is responsible to determine the financial eligibility for Medicaid. Changes need to be reported back and forth between the financial worker and assigned case manager/social service specialist.

    If G03 eligibility trickles to a G95 or G99 because the income is excess of the SIL or the state daily rate and the client is receiving MPC services, notify the agency approving the MPC service that the client is no longer eligible to receive MPC because of excess income.

  6. Contact the facility for its private rate. Contact the department-designated social service specialist for STATE-contracted daily rates. Document behind the INST screen how the daily rate was verified.

    To search for Adult Family Home or Boarding Homes contracted with DSHS: http://adsaweb/afhbh/

  7. Certify CN or MN benefits according to procedures outlined in CERTIFICATION PERIODS.

  8. When a client receiving these benefits transfers to another alternate living facility or goes home, redetermine eligibility and notify the social service specialist. The social service specialist determines any change in the client's cost toward the care and notifies the client and facility.

  9. If a client dies, discontinue benefits effective the date of death and notify the social service specialist. The social service specialist determines any change in the client cost of care and notifies the facility of any refund amount that is due. Indicate the date of death and closure of any MPC services in ACES.

  10. Follow necessary supplemental accommodation (NSA) procedures described in necessary supplemental accommodation services when appropriate. (note: all clients served by DDA or HCS should have an NSA plan, contact the client case manager for assistance with NSA).


ACES PROCEDURES

See Long Term Care and Waivered Services - Institution - ALF/HCB Screen

Modification Date: December 9, 2013