Medicaid Personal Care (MPC)

Revised April 30, 2013

Clarifying Information

Medicaid Personal Care (MPC): A Medicaid program that is allowed under Washington State’s Medicaid State Plan, this program provides assistance with activities of daily living to individuals who receive SSI or are approved for other CN medical programs.  Functional eligibility for this program requires unmet needs as outlined in WAC 388-106-0210.  Services are available in the client’s own home, adult family homes, and boarding homes with an Adult Residential Care (ARC) contract. The program is administered by Home and Community Services (HCS) and Developmental Disabilities  (DDD) administrations.

An assessment is done by a case manager, nurse or social service specialist from DDD, HCS or Area Agency on Aging (AAA). Clients must meet the functional criteria based on the social service assessment  AND the financial eligibility based on eligibility for a non institutional CN Medicaid program.

• MPC is a state plan entitlement program.  If clients are eligible for CN without using the higher income and resource standards  for institutional  eligibility and meeting the functional eligibility criteria for the program, they are “entitled” to MPC.  (note:  Institutional programs are the K and L track in ACES). This makes MPC the priority medicaid program for personal care services and is usually the first program considered. This is because waiver programs that provide personal care such as HCS Waivers or DDD Waivers  are restricted to a certain number of clients.  MPC services include personal care services and CN medical program. MPC services are authorized by HCS and DDD.  If a MPC client enters a nursing facility  (NF), MPC services are terminated and eligibility must be re-established when the client reenters the community. 
• The concurrent functional (social service) and financial determination process determines program eligibility.
•  If  a TANF client needs waiver services, they must be determined disabled by the Social Security Administration criteria or have an NGMA  determination before you can authorize waiver services.  A TANF client can receive MPC if functionally eligible without a disability determination since they are eligible for CN. 
• MPC is not considered an "institutionalized" program.  An institutionalized program is based on an individual residing in a Medical institution 30 days or more or on a Waiver program with HCS or DDD.  MPC is not subject to transfer of asset penalties  or excess home equity  provisions.  An individual receiving MPC in a community setting (home, adult family home or boarding home ) is already eligible for CN Medicaid without using the "institutional/Waiver" rules.
• MPC is not an "institutional" program, those eligible for non institutional Medicaid do not participate toward the cost of personal care.  If living in an adult family home or assisted living, they do pay room and board.   If receiving Medicaid based on WAC 182-513-1305 (G03), clients pay available income minus the personal needs allowance to the adult family home/boarding home. 

• 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 HCS/COPES Waiver PNA in an ALF.   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 the PNA for MPC in an ALF.  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. LTC standards PNA and Room and Board.

• Those NOT eligible for a non institutional CN program, such as medically needy S95, G95, G99 or S99 in ACES (SSI related medically needy or SSI related medically needy with spenddown) are NOT eligible to receive MPC.  Notify the authorized agency (HCS, DDD or Area Agency on Aging) that the client is not financially eligible for MPC. 

Agency Responsibilities

Financial staff determines financial eligibility for financial and medical assistance programs. The DDD, HCS or AAA case manager responsible for placement and case management services determines functional eligibility, initiates the payment to the provider, 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 assigned case manager/social service specialist determines the functional eligibility for the service and notifies the client and provider of changes in the service including the client responsibility; 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.

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

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

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Worker Responsibilities

Indicate M for MPC service in ACES on the INST screen under the HCBS 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. 

If a client is on services with DDD always indicate the agency name and mailing address on the AREP screen in ACES to receive copies of notices.  HCS social service specialists and case managers receive an automated notification via barcode and not via the AREP screen.

 Services authorized by DDD, HCS and AAA are tied to eligibility for CN Medicaid. If Medicaid closes, the service authorized by the social service specialist/case manager must close.   

If MPC services end per the authorized agency indicate the service end date on the HCBS field in the month services ended.  If in an adult family home or boarding home a discharge date would be required.   Delete the service in the ongoing months.  Delete DDD information on the AREP screen.  No notice regarding the MPC service is required by the financial worker, the authorized agency (DDD, HCS or AAA) is responsible to send the notice  to the client when MPC services end, change or if the amount the client pays to the ALF provider changes.  The financial worker is responsible to send notices on any changes in the Medicaid eligibility. 

Clients residing in an alternate living facility such as an adult family home or DDD group home that have countable income over the CNIL can be considered for Non Institutional SSI related clients living in an Adult Family Home or Boarding Home (G03).   Some clients are put on a HCS Waiver or DDD Waiver program.  These clients are not on MPC, but on an "institutionalized" program.  (ACES code is L22)

If client is not eligible for a non-institutional 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 DDD CN Waivers  for rules describing Waiver services authorized by each agency.  The authorizing agency (DDD, HCS or AAA)  will notify the financial worker of the type of service. 

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 that apply to Waiver/institutional programs.  Some CN programs such as HWD (S08) or Childrens Medical do not have resource requirements, but Waiver programs do have resource requirements.  Breast and Cervical Cancer (S30) program  is determined by the Health Department not DSHS, an application must be submitted for Waiver/LTC services.  Social service specialists and case managers should 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)

Medicaid Personal Care Chart

ACES CN Medical Coverage Group Codes

(Financially eligible for MPC/WPC)

*These are time limited programs. You should be aware that the service will only be available as long as the client is receiving medical under one of these groups and explain this at the time of the assessment.

**Institutional medical (L02), including waiver services (L22), have higher income and resource limits.  The resource limit for G03 is the same as SSI, but the income standard is higher.  Clients may no longer qualify for CN medical programs if those institutional medical or waiver services end.  Before authorizing MPC services, check ACES or contact a financial services worker to ensure that the client will be eligible for CN medical under a non-institutional medical program.

ACES Instructions

ACES instructions for MPC are in the process of being updated.  Please refer to Worker Responsibilities above for current instructions.

ACES instructions for long-term care and Waiver programs