Participation

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Participation

Revised May 13, 2013

Long-term care

Purpose: Describes the post-eligibility process for individuals residing in a medical institution and meet institutional status. The post eligibility process determines how much the individual must pay toward the cost of their institutional care. For rules on determining participation for Waiver programs, see chapter 388-515.

WAC 182-513-1380

Determining a client's financial participation in the cost of care for long-term care (LTC) services

WAC 182-513-1380

Effective January 1, 2013

WAC 182-513-1380 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 (in 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.

For a client receiving institutional or hospice services in a medical institution, the department applies all subsections of this rule.
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.
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 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.)
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):
1. A personal needs allowance (PNA) of:
  1. 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:
    1. A veteran without a spouse or dependent child.
    2. A veteran's surviving spouse with no dependent children
  2. 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;
  3. One hundred sixty dollars for a client living in a state veterans' home who does not receive a needs based veteran's pension;
  4. Forty-one dollars and sixty-two cents for all clients in a medical institution receiving ABD cash assistance.
  5. For all other clients in a medical institution the PNA is fifty-seven dollars and twenty-eight cents.
  6. Current PNA and long-term care standards can be found at http://www.dshs.wa.gov/manuals/eaz/sections/LongTermCare/LTCstandardspna.shtml
2. Mandatory federal, state, or local income taxes owed by the client.
3. Wages for a client who:
  1. Is related to the supplemental security income (SSI) program as described in WAC 182-512-0050 (1) ; and
  2. 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.
4. 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.
The department allocates nonexcluded income after deducting amounts described in subsection (4) in the following order:
1. Current or back child support garnished or withheld from income according to a child support order in the month of the garnishment if it is for the current month:
  1. For the time period covered by the PNA; and
  2. Is not counted as the dependent member's income when determining the family allocation amount.
2. 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 may change each January based on the consumer price index. Starting January 1, 2008 and each year thereafter the community spouse maintenance allocation can be found in the long-term care standards chart. The monthly maintenance needs allowance:
  1. Consists of a combined total of both:
    1. One hundred fifty percent of the two person federal poverty level. This standard may change annually on July 1st; and
    2. Excess shelter expenses as described under subsection (6) of this section; and
  2. Is reduced by the community spouse's gross countable income; and
  3. Is allowed only to the extent the client's income is made available to the community spouse.
3. A monthly maintenance needs amount for each minor or dependent child, dependent parent or dependent sibling of the community spouse or institutionalized person who:
  1. Resides with the community spouse:
    1. 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
    2. 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.
    3. Child support received from noncustodial parent is the child's income.
4. 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.
5. Maintenance of the home of a single institutional client or institutionalized couple:
  1. Up to one hundred percent of the one-person federal poverty level per month;
  2. Limited to a six-month period;
  3. When a physician has certified that the client is likely to return to the home within the six-month period; and
  4. When social services staff documents the need for the income exemption.
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:
1. The standard shelter allocation is five hundred fourteen dollars. This standard is based on thirty percent of one hundred fifty percent of the two person federal poverty level. This standard may change annually on July 1st and is found at http://www.dshs.wa.gov/manuals/eaz/sections/LongTermCare/LTCstandardspna.shtml; and
2. Shelter expenses are the actual required maintenance expenses for the community spouse's principal residence for:
  1. Rent;
  2. Mortgage;
  3. Taxes and insurance;
  4. Any maintenance care for a condominium or cooperative; and
  5. The food stamp standard utility allowance described in WAC 388-450-0195 provided the utilities are not included in the maintenance charges for a condominium or cooperative.
The amount allocated to the community spouse may be greater than the amount in subsection (6)(b) only when:
1. A court enters an order against the client for the support of the community spouse; or
2. A hearings officer determines a greater amount is needed because of exceptional circumstances resulting in extreme financial duress.
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.
Standards described in this section for long-term care can be found at: http://www.dshs.wa.gov/manuals/eaz/sections/LongTermCare/LTCstandardspna.shtml

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

Participation - the post-eligibility determination:

Participation is determined after a client is found eligible for long-term care (LTC) services under the L, C and K track in ACES. (institutional programs, see LTC overview for a description).

This determination sets the amount the client must contribute toward the cost of care. For a client who is married or has dependent family members, this process determines how much of the client's income is allocated to the spouse and/or family members.

For a client who lives in a medical institution, the department allocates nonexcluded income according to this chapter ( WAC 182-513-1380).

Income that remains after deductions for the personal needs allowance and other allocations are taken is the amount the client must participate in the cost of care in the medical institution.

For a client who lives at home or in an alternate living facility (ALF) and receives waiver services, the department allocates nonexcluded income and participation according to the rules of that specific program. For instructions on participation including room and board costs for Waivers see:

WAC 182-515-1505 (HCS CN Waivers) This is commonly referred to as the COPES program.
WAC 182-515-1510 (DDD CN Waivers).
HCS Medically Needy in home Waiver (MNIW ) for MN in home.
HCS Medically Needy Residential Waiver (MNRW ) for MN residential services.

Long Term Care Medical Standards and Personal Needs Allowance (PNA) Charts.

Institutional standards used in determining initial and post eligibility (participation) in long term care change annually. This chart indicates the formula for the standard and when the standard last changed.

Effective 4/10/2009 client's receiving the $90 from veteran's administration are allowed to keep the $90 plus their personal needs allowance of $57.28 (or $62.79 if residing in a residential setting).

The $90 is to be coded as VZ on the ACES UNER screen.

SSI income:

Typically, when an individual enters a medical facility, the Social Security Administration (SSA) reduces the SSI cash payment to $30 per month. The full SSI benefit is continued, if SSA determines the individual's stay in the facility is not likely to exceed three months and the individual has expenses for maintaining a home. When SSA has made such a determination, the full SSI benefit/State supplementary payment (SSP) is continued and is excluded in the post-eligibility process. The SSI/SSP benefit is not excluded, however, when determining the amount a client must contribute toward the cost of room and board when living in an alternate living facility (ALF). Room and board is discussed under the Waiver and MPC chapters.

Personal needs allowance (PNA) for clothing, personal items and incidentals (CPI):

Personal needs allowance (PNA) for clothing, personal items and incidentals (CPI). Client's are allowed the highest personal needs allowance in a given month based on living arrangement, authorized service and marital status. If a client resided at home the first day of the month and went into a nursing home the same day, we would allow the in home PNA because they were residing in a home setting at least one moment during that given month. If a client went from a nursing home to an adult family home on COPES services the first day of the month, we would allow the COPES ALF PNA as it is the highest allowed. If that client were then discharged home on COPES from the ALF on the last day of the month, the benefit would be recalculated allowing the COPES in home PNA.

Mandatory taxes, department approved wages and guardianship fees

Mandatory taxes, department approved wages and Guardianship fees are allowed as a post eligibility deduction when determining participation for long-term care Medicaid programs. The combination of PNA, mandatory taxes, department approved wages, guardianship fees and administrative costs cannot exceed the MNIL for clients in a medical institution. (WAC 182-513-1380 (4) ). There are times when the guardianship and/or administrative fees are over the amount allowed in a month (MNIL). It may take 2 or more months to allow for the administrative cost and guardianship fee. The correct order of deductions that cannot exceed the MNIL are:

PNA
Mandatory Taxes
Wages from approved employment
Guardianship/Attorney fees

Note: 65 and 1/2 deduction is not allowed for earnings in a Medical institution, however a wage deduction is allowed dollar for dollar up to the MNIL after allowing the PNA and mandatory tax deduction.

Approved wages need to be coded as RH ACES on the EARN screen.

An ACES change was promoted in 7/08 to match this policy. See ACES instructions below for the text describing these changes and how to code these fees.

Dependent and Family Allocation used in CN Waiver or Institutional Participation Calculation.

Dependent allocation

Medical Institution Income Exemption (MIIE) (Housing exemption)

The MIIE is income, up to 100% of the Federal Poverty Level, that the client can keep in order to maintain his/her residence during his/her NF or institutional stay. The MIIE is approved by the social worker/case manager. Instructions are in the ADSA LTC manual.

MIIE can be approved for up to 6 months when it is determined the client is likely to return home within 6 months.

The Social Worker/Case manager submits a communication to the financial worker showing the MIIE was approved or denied and indicating the amount of shelter costs approved up to the FPL.

MIIE eligibility is determined with each nursing home admission by the HCS SW. There is no limit to MIIE for multiple admissions and discharges to a facility other than it is not allowed for more than 6 consecutive months.

Hospice

Hospice program

Participation in the cost of care for hospice services received in a medical facility is determined according to WAC 182-513-1380. The client pays their participation amount to the hospice agency.

Veterans benefits: VA Benefits chart and clarifying information.

Change of circumstances The reporting requirements for LTC clients are described in WAC 388-418-0005. See CHANGE OF CIRCUMSTANCES for additional information. When taking action on a change in the client's circumstances, advance notice is not required with participation changes, but adequate notice is always required.

WORKER RESPONSIBILITIES

Deduct from the client's nonexcluded income the appropriate amount for the client's personal needs allowance or maintenance needs amount. Use rules that apply to the specific program for which the client is approved when determining the appropriate amount:
1. WAC 182-513-1380 is used to determine participation for SSI related individuals in a medical institution including Hospice in a medical institution.
2. WAC 182-514-0230 is used to determine participation for long term care for families and children.
3. WAC 182-515-1509 is used to determine participation for HCS CN Waiver (COPES) and Hospice outside of a medical institution.
4. WAC 182-515-1514 is used to determine participation for DDD CN Waivers
5. WAC 182-515-1550 is used to determine participation for HCS Medically Needy in Home Waiver (MNIW)
6. WAC 182-515-1540 is used to determine participation for HCS Medically Needy Residential Waiver (MNRW)
To reduce excess resources, deduct amounts for medical expenses for which the client is liable. WAC 182-513-1350. See allowable medical services and expenses used to reduce participation.
To reduce participation, deduct medical expenses not already used to reduce excess resources as described in WAC 182-513-1350. See allowable medical services and expenses used to reduce participation.

NOTE:

A client must receive continued assistance, if all of the following conditions apply:

Advance notice is not required.

Adequate notice is mailed less than ten days before the effective date.

A fair hearing is requested within ten days of the date the letter is mailed.

Advance notice is not required to change a client's participation in the cost of care, since no reduction, suspension, or termination of services will result. A change in the participation amount is not considered an adverse action.

Allocate the income of a client who is married to a community spouse as described in WAC 182-513-1380 . Always request an exception to rule (ETR) for allocating the client's income to a former spouse when the Court has ordered a spousal maintenance amount to be paid. For Waiver programs (COPES) see WAC 182-515-1509 for instructions.
When both spouses are receiving LTC services, allocate the income according to the maintenance needs amount provided under the program from which services are received. Note: WAC 182-513-1315 (14) states: The department determine's a client's eligibility as it does for a single person when the client's spouse has already been determined eligible for LTC services.

EXAMPLE

Mr. Jones is on COPES at home. Mrs. Jones fell and broke her hip and now needs services too. Mrs. Jones has been determined financially and functionally eligible for COPES. Since they are both institutionalized they are treated as a single individual. Each is allowed the 1 person FPL as a PNA.

EXAMPLE

The amount of nonexcluded income that is allocated from a client in a medical facility who is married to a spouse receiving COPES in the home is limited to the maintenance needs amount provided under the COPES program.

NOTE:

The maximum community spouse maintenance allowance includes any excess shelter costs.

Scenario: Community Spouse (CS) paying privately in a residential setting, usually an assisted living facility. Institutionalized spouse is in the nursing home or receiving COPES.

For this scenario the department is counting the private pay in the residential setting minus the 4 person SUA/LTC utility standard as the shelter cost for the purposes of determining excess shelter for the CS.

Whenever we are looking spousal deeming for institutional programs (Waiver or residing in a medical institution) and the CS is paying privately at a residential facility (adult family home, assisted living facility) use this method to determine the community spouse's shelter cost.

Indicate the private pay cost minus the LTC utility standard as the shelter cost on the institutionalized spouse SHEL screen. Since ACES adds the 4 person SUA/LTC utility standard to the shelter cost in the calculation, we need to make sure we have subtracted that amount out from the cost of the private pay to the residential setting.

EXAMPLE

Mrs. Smith is on COPES in an AFH. Her monthly income is $1500 per month. Mr. Smith is paying privately at the same AFH. His income is $2650 per month. The AFH is charging him a private rate of $2600 per month.

Mr. Smith is a community spouse. Although both Mr. and Mrs are residing in the same facility, only Mrs. Smith is considered institutionalized because she is receiving Waiver services.

The department will deem some of Mrs. income to Mr. Smith since he has excess shelter costs and is considered the community spouse.

As of 1/2009 the 4 person SUA-LTC utility standard is $384. $2,600 private rate - $384 = $2,216.00 shelter cost for the community spouse. This is indicated on Mrs. (the one on COPES) SHEL screen.

Allocate the income of a client with a community spouse and a dependent family member by determining the monthly maintenance needs amount in the following way:
1. Subtract nonexcluded income of the dependent from the family allocation standard.
2. Divide that amount by three.
Allocate the income of a client with dependent family members, but no community spouse, by determining the monthly maintenance needs amount in the following way:
1. Subtract the dependents' total nonexcluded income from the MNIL standard for the number of legal dependents living in the home
When a client changes providers or facilities during the month, the participation amount may need to be split between the two. Assign any participation amount the client does not owe the first provider or facility to the second one.
In determining split participation, the department figures the cost based on the day of admit and not the day of discharge. Example. Client discharges from facility A on 8/2 and admits to facility B on 8/2. Participation for 8/2 is assigned to facility B.
Treat hospice revocation or discharge like any other change from one nursing facility to another.See hospice.
When changes in the participation amount are made and confirmed within ACES, the system automatically generates a notice to the client/ representative. Since some notices do not contain enough information, add sufficient freeform text to explain what changes are being made and the reason for them. If appropriate, suppress the notice and generate a letter to replace the notice. Situations for which a new notice and letter are appropriate include, but are not limited to the following:
1. Correct a previous award letter/notice.
2. Make a retroactive change per a fair hearing decision.
3. Make a change in participation per a court order.
4. Make a change in the Health insurance premium that is paid quarterly.
5. The beginning date of hospice care
6. A change in hospice agencies
7. Client chooses to stop receiving hospice services
8. Client enters a medical facility for non-respite care
9. Client leaves a facility or dies
When a client dies, review the participation amount assigned in the current award letter. Determine the actual cost of care for services provided using the daily department-contracted rate. If the client's cost of care is less than the participation amount, send an amended award letter that equates the participation amount with the actual cost of care. If the client's cost of care is more than the participation amount, do not change the amount before closing the case. The date of death is considered a discharge with the exception of Hospice and Waiver in an ALF.
1. When a client loses institutional status e.g., is no longer eligible for COPES, redetermine the client's eligibility for non-institutional medical in the following way:
2. Use information in the case record (ACES) unless you need further verification. If a client was CN eligible before losing COPES eligibility, continue CN until you have redetermined the client's eligibility.
If the client remains eligible for medical care, change the appropriate ACES screens, complete and send the client a new award letter through the ACES system.
Complete AREP screens as directed in AREP screens for long-term care cases.
Follow necessary supplemental accommodation (NSA) procedures.

ACES PROCEDURES

See Long Term Care, Alternate Care and Waivered Services

Code the $90 veteran's payment (received by individuals residing in a nursing home) as VZ. Effective April 2009 individuals receiving the $90 VA payment are allowed to keep the $90 plus their PNA of $57.28 (or $62.79 if residing in a residential facility).