Medicaid Personal Care (MPC)
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Medicaid Personal Care (MPC)


Revised September 8, 2014



Purpose: To explain a Medicaid program called Medicaid Personal Care (MPC) for individuals eligible for a non institutional CN program and meeting the functional criteria for personal care services.

What is Medicaid Personal Care (MPC)

A Medicaid program that is allowed under Washington State’s Medicaid State Plan, that provides assistance with activities of daily living to individuals who are eligible for non-institutional categorically needy (CN) or Alternative Benefit Plan (ABP) medical programs. 

Functional eligibility for this program is based on Chapter 388-106 WAC.

MPC services are available in the client’s own home, adult family homes (AFH) , or Adult Residential Center (ARC).

MPC is authorized by Home and Community Services (HCS) and Developmental Disabilities  (DDA) administrations.

A CARE assessment is done by a case manager, nurse or social service specialist from DDA, HCS or Area Agency on Aging  (AAA). 

Clients must meet the functional criteria based on the social service assessment and financial eligibility based on eligibility for a non-institutional CN or ABP Medicaid program. 

The only exception is the Alien Emergent Medical (AEM) Modified Adjusted Gross Income (MAGI) medical program under N21 and N25.  AEM programs do not cover Medicaid Personal Care (MPC) services.  Consult the medical program chart desk tool. 

MPC clients pay room and board if living in a adult family home, adult residential center (ARC) or DDA group home. 

What is room and board?  

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. In other words, room and board is considered "rent". 

There is also a term used by ALTSA and DDA called the room and board rate.  This rate is based on the FBR minus the HCS/COPES Waiver PNA in an ALF.   

Most MPC clients pay the ALTSA standard room and board rate for their rent.

The exception is clients receiving medical under the G03 program. This is because the standard that is used to make them eligible for a CN program has been raised based on having to pay all of their countable income minus the PNA to the provider.  This rate for the purpose of the G03 program is called the client's total responsibility.

Additional manual material: 

Room and board.  

G03 program called Non-institutional SSI related clients living in an adult family home or boarding home

LTC PNA chart and room and board

Definitions


Medical eligibility chart desk tool

Desk tools have been issued to field staff during ACA and MAGI training to determine if a medical coverage group can authorize a service (MPC, HCB Waiver and Institutional).

Current desk tools can be found at the HCS financial sharepoint site. 


What is Classic Medicaid?

Classic medicaid are programs for clients that are Aged, Blind or Disabled (ABD)

The ABD classic medical programs are also called SSI related programs. In order to receive one of these medical programs, you must be age 65 or over, or considered disabled or blind by Social Security criteria.  All individuals age 65 or over or on Medicare must be considered for a Classic program unless they do not meet citizenship requirements for federal medicaid. 

Classic medicaid included the institutional group (ABD clients living in a medical institution 30 days or more) and Home and Community Based (HCB) Waiver programs.  (L track).

What is the basic difference between "institutional" and "non-institutional"

Institutional medicaid has different income standards and rules for initial eligibility and higher resource standards for a couple when only one needs institutional services. 

Institutional also has a 2nd eligibility component called "post-eligibility treatment of income".  This 2nd eligibility computation determines the amount the client must pay toward their cost of care to the medical institution or to the HCB Waiver provider.  This is called "participation".

Non-institutional medicaid does not have a "post eligibility" component, therefore individuals living in the community on non-institutional medicaid do not "participate" toward the cost of their personal care. 

All MPC clients must be eligible for a non-institutional CN/ABP medical program.  

MPC clients do not pay "participation" but they are responsible to pay room and board (their rent) when living in an alternate living facility.  

Classic Institutional ABD Medicaid programs are:

  • CN residing in a medical institution 30 days or more (L01, L02)
  • MN residing in a medical institutional 30 days or more (L95, L99)
  • State funded 45 slot program for non citizens.  Nursing facility coverage only and must be pre-approved (L04)
  • Home and Community Based  (HCB) Waivers and Hospice (L21, L22)
  • State funded 45 slot program for non citizens.  In home or state residential and must be pre approved (L24)

Classic Non-institutional ABD Medicaid programs are: 

  • Medicare Savings Programs (MSP).  These programs pay for medicare A and B related premiums and expenses. (S03, S04 S05, S06)
  • SSI clients receives medicaid automatically based on criteria sent by social security.  Washington is a 1634 State which is a section in the Social Security Act that describes this agreement with the State and Social Security (S01)
  • SSI related clients with countable income at or below the SSI standard (S02)
  • SSI related clients living in a contracted alternate living facility (G03)
  • SSI related Medically Needy and Spenddown (S95 and S99)
  • Healthcare for Workers with Disabilities (HWD) (S08)
  • Undocumented Alien, Emergency related services (AEM) (S07) does not cover NF or personal care.  It is used for hospitalization, kidney dialysis and cancer treatment.  This program must be pre-approved by the Health Care Authority (HCA).

Classic Programs that do not fall into the Aged/Blind/Disabled group:

  • Foster care medical authorized and maintained by the Health Care Authority.  Some foster care children may be disabled, but disability is not a requirement for this program that can be authorized up to age 26.  (D01, D02 , D26)
  • Institutional children (K01, K95, K99) This program uses Modified Adjusted Gross Income (MAGI) income methodology to determine initial eligibility but the eligibility is not done by the Health Benefit Exchange.  The eligibility is determined by the DDA LTC specialty unit and is primarily used for children's mental health facilities (CLIP) and children needing hospitalization that are not eligible for medical under a N track MAGI program. 

Consult the medical program chart desk tool under the MPC column to determine what classic medical programs can authorize MPC. 

Additional manual material on institutional:

LTC Overview


What is Modified Adjusted Gross Income (MAGI) Medicaid

MAGI medicaid eligibility is determined by the Health Benefit Exchange. 

These programs show up as "N" track in ACES and are for children, pregnant woman, and adults under age 65.  In order to be considered for medical under MAGI methodology, you can't be on Medicare.

It is possible for for a disabled individual not on Medicare to qualify under MAGI by the Health Benefit Exchange.

Once an individual is eligible to receive Medicare, the case is redetermined from the MAGI program to a ABD Classic Medicaid program. 

Individuals receiving MAGI programs under "N" track in ACES with the exception of  AEM N21 and N25 are eligible to receive MPC if functionally eligible. 

During the implementation of the provisions of the Affordable Care Act (ACA), some children and families will receive medical under a "F" track ACES program.  At their eligibility review, the case will be converted to a N track MAGI based program through the Health Benefit Exchange.  This conversion will be completed on 8/31/2014. 

Consult the Medical program chart desk tool under the MPC column to determine what programs can authorize MPC. 

Additional information:

Medicaid Expansion 2014

Washington Health Benefit Exchange


What is Medical Care Services (MCS)

MCS is a state funded medical program used for legally admitted non citizens that do no qualify for a Classic or MAGI medicaid program because they are in their 5 year bar for federal medicaid.

MCS covers nursing home and HCS has a state funded residential program for individuals eligible to receive MCS.

MCS does not cover MPC or HCB Waiver. 


Agency Responsibilities

CSD, HCS and DDA LTC specialty unit Financial staff determines eligibility for Classic medical assistance programs.

The Health Benefit Exchange (HBE) determine eligibility for MAGI based medical.

The LTC overview  and includes a chart to indicate which specific agency is responsible to determine financial eligibility for each medical program. 

DDA, HCS or AAA case manager responsible for placement and case management services,  determines functional eligibility, initiates the payment to the provider via SSPS, the amount the client must pay to the facility for their cost of care and notifies the client.

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 financial worker is responsible to determine the financial eligibility for Classic medicaid. Changes need to be reported back and forth between the financial worker and assigned case manager/social service specialist.

HCS social service specialists use the DSHS 14-443 Financial/Social Service communication form. in barcode.

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

.


Worker Responsibilities

HCS financial staff : 

All Classic Medicaid receiving MPC services through HCS: 

Indicate M for MPC service in ACES on the INST screen under the HCB type field. Indicate the start date of the service and the approving agency under the approval source.  Indicate the payment auth date.  For MPC the start date of the service and the payment auth date is the same date.

If the client is living in an alternate living facility, the top line (facility section) of the INST screen must be completed. A provider number is not needed for an alternate living facility, but the entry date, level of care, payment authorization date and state rate are needed. 

DDA Specialty Unit financial staff: 

All Classic Medicaid cases receiving MPC residential services through DDA:

The DDA Specialty unit case manages MPC classic medicaid for DDA clients living in an alternate living facility,

 Indicate M for MPC service in ACES on the INST screen under the HCB type field. Indicate the start date of the service and the approving agency under the approval source.  Indicate the payment auth date.  For MPC the start date of the service and the payment auth date is the same date.

Complete the top line (facility section) of the INST screen.   A provider number is not needed for an alternate living facility, but the entry date, level of care, payment authorization date and state rate are needed. 

DDA and HCS Financial Staff Responsibilities: 

If MPC services end,  indicate the service end date on the HCBS field in the month services ended. 

If in an ALF/residential setting indicate the end date under the facility line.

If client is not eligible for a non-institutional Classic CN program, notify the agency authorizing MPC services that client is not financially eligible for MPC.  Client may be considered for a CN institutional Waiver program such as COPES. 

See HCS CN Waivers or DDA CN Waivers  for rules describing Waiver services authorized by each agency. 

For MPC clients receiving Washington Medicaid Integrated Partnership Managed Care Pilot,   (WMIP) follow the instructions in that section. 

A client going from MPC to Waiver must qualify under the rules for the Waiver program including transfer of asset and excess home equity rules  , income and resource rules that apply to Waiver/institutional programs.  

Social service specialists and case managers must consult financial service staff prior to switching a MPC case to a Waiver case to make sure the client is eligible under Waiver rules. 


WAC references for Medicaid Personal Care (MPC)

388-106-0200 What services may I receive under Medicaid personal care (MPC)?
388-106-0210 Am I eligible for MPC-funded services?
388-106-0213 How are my needs assessed if I am a child applying for MPC services?
388-106-0215 When do MPC services start?
388-106-0220 How do I remain eligible for MPC?
388-106-0225 How do I pay for MPC?
388-106-0230 Can I be employed and receive MPC?
388-106-0235 Are there waiting lists for MPC?
Modification Date: September 8, 2014