WAC 388-515-1505 Long-term care home and community based services and hospice

Emergency WAC effective 4/1/2012

1. This chapter describes the general and financial eligibility requirements for categorically needy (CN) home and community based (HCB) services administered by home and community services (HCS) and hospice services administered by the health care authority (HCA).
2. The HCB service programs are:
   
        (a) Community options program entry system  (COPES);
   
        (b) Program of all-inclusive care for the elderly  (PACE);
   
        (c) Washington medicaid integration partnership  (WMIP); or
   
        (d) New Freedom  consumer directed services (New Freedom).
3. Roads to community living (RCL) services. For RCL services this chapter is used only to determine your cost of care. Medicaid eligibility is guaranteed for three hundred sixty-five days upon discharge from a medical institution.
4. Hospice  services if you don't reside in a medical institution and:
   
        (a) Have gross income at or below the special income level  (SIL); and
   
        (b) Aren't eligible for another CN or medically needy (MN) medicaid program.
5. WAC 388-515-1506 describes the general eligibility requirements for HCS CN waivers.
6. WAC 388-515-1507 describes eligibility for waiver services when you are eligible for medicaid using noninstitutional CN rules.
7. WAC 388-515-1508 describes the initial financial eligibility requirements for waiver services when you are not eligible for noninstitutional CN medicaid described in WAC 388-515-1507     (1).
8. WAC  388-515-1509 describes the rules used to determine your responsibility in the cost of care for waiver services if you are not eligible for medicaid under a CN program listed in WAC 388-515-1507(1). This is also called client participation or post eligibility.
   

WAC 388-515-1506 What are the general eligibility requirements for home and community based (HCB) services and hospice?

Emergency WAC effective 4/1/2012

1. To be eligible for home and community based (HCB) services and hospice you must:
   1. Meet the program and age requirements for the specific program:
      1. COPES, per WAC 388-106-0310;
      2. PACE, per WAC 388-106-0705;
      3. WMIP waiver services, per WAC 388-106-0750;
      4. New Freedom, per WAC 388-106-1410;
      5. Hospice, per chapter 182-551 WAC; or
      6. Roads to community living (RCL), per WAC 388-106-0250, 388-106-0255 and 388-106-0260.
   2. Meet the disability criteria for the supplemental security income (SSI) program as described in WAC 388-475-0050;
   3. Require the level of care provided in a nursing facility described in WAC 388-106-0355;
   4. Be residing in a medical institution as defined in WAC 182-500-0005, or likely to be placed in one within the next thirty days without HCB services provided under one of the programs listed in subsection (1)(a);
   5. Have attained institutional status as described in WAC 388-513-1320;
   6. Be determined in need of services and be approved for a plan of care as described in subsection (1)(a);
   7. Be able to live at home with community support services and choose to remain at home, or live in a department-contracted:
      1. Enhanced adult residential care (EARC) facility;
      2. Licensed adult family home  (AFH); or
      3. Assisted living (AL) facility.
   8. Not be subject to a penalty period of ineligibility for the transfer of an asset as described in WAC 388-513-1363 through 388-513-1366;
   9. Not have a home with equity in excess of the requirements described in WAC 388-513-1350.
2. Refer to WAC 388-513-1315 for rules used to determine countable resources, income, and eligibility standards for long-term care services.
3. Current income and resource standard charts are located at: http://www.dshs.wa.gov/manuals/eaz/sections/LongTermCare/LTCstandardspna.html.
   

WAC 388-515-1507 What are the financial requirements for home and community based (HCB) services when you are eligible for a non institutional categorically needy (CN) medicaid program?

Emergency WAC effective 04/01/2012

1. You are eligible for medicaid under one of the following programs:
   1. Supplemental security income (SSI) eligibility described in WAC 388-474-0001. This includes SSI clients under 1619B status;
   2. SSI-related CN medicaid described in WAC 388-475-0100 (2)(a) and (b);
   3. SSI-related healthcare for workers with disabilities program (HWD) described in WAC 388-475-1000.  If you are receiving HWD you are responsible to pay your HWD premium as described in WAC 388-475-1250.  This change is effective 4/1/2009;
   4. Aged, blind or disabled (ABD) cash assistance described in WAC 388-400-0060 and are receiving CN medicaid.
2. You do not have a penalty period of ineligibility for the transfer of an asset as described in WAC 388-513-1363 through 388-513-1366. This does not apply to PACE or hospice services.
3. You do not have a home with equity in excess of the requirements described in WAC 388-513-1350.
4. You do not have to meet the initial eligibility income test of having gross income at or below the special income level  (SIL).
5. You do not pay (participate) toward the cost of your personal care services.
6. If you live in a department contracted facility listed in WAC 388-515-1506 (1)(g), you pay room and board up to the ADSA room and board standard. The ADSA room and board standard is based on the federal benefit rate (FBR) minus the current personal needs allowance (PNA) for HCS CN waivers in an alternate living facility.
   1. If you live in an assisted living (AL) facility, enhanced adult residential center (EARC), or adult family home (AFH) you keep a PNA of sixty-two dollars and seventy-nine cents and use your income to pay up to the room and board standard.
   2. If subsection (6) (a) applies and you are receiving HWD described in WAC 388-475-1000 you are responsible to pay your HWD premium as described in WAC 388-475-1250  in addition to the room and board standard. 
7. If you are eligible for aged, blind or disabled (ABD) cash assistance program described in WAC 388-400-0060  you do not participate in the cost of personal care and you may keep the following:
   1. When you live at home, you keep the cash grant amount  authorized under WAC 388-478-0033;
   2. When you live in an AFH, you keep a PNA of thirty-eight dollars and eighty-four cents, and pay any remaining income and ABD cash grant to the facility for the cost of room and board up to the ADSA room and board  standard;
   3. When you live in an assisted living facility or enhanced adult residential center, you are only eligible to receive a cash grant of thirty-eight dollars and eighty-four cents, which you keep for your PNA.
8. Current resource and income standards are located at: http://www.dshs.wa.gov/manuals/eaz/sections/LongTermCare/LTCstandardspna.shtml.
9. Current PNA and ADSA room and board standards are located at: http://www.dshs.wa.gov/manuals/eaz/sections/LongTermCare/ltcstandardsPNAchartsubfile.shtml.
   

WAC 388-515-1508 How does the department determine if you are financially eligible for home and community based (HCB) services authorized by HCS and hospice if you are not eligible for Medicaid under a categorically needy (CN) program listed in WAC 388-515-1507(1) ?

Emergency WAC effective 4/1/2012

1. If you are not eligible for medicaid under a categorically needy (CN) program listed in WAC 388-515-1507(1), the department must determine your eligibility using institutional medicaid rules. This section explains how you may qualify using institutional medicaid rules.
2. You must meet the general eligibility requirements described in WAC388-513-1315 and 388-515-1506.
3. You must meet the following resource requirements:
   1. Resource limits described in WAC 388-513-1350.
   2. If you have resources over the standard allowed in WAC 388-513-1350, the department reduces resources over the standard by your unpaid medical expenses described in WAC 388-513-1350 (d), (e) and (f) if you verify these expenses.
4. You must meet the following requirements:
   1. Your gross nonexcluded income must be at or below the special income level  (SIL) which is three hundred percent of the federal benefit rate  (FBR); or
   2. For home and community based (HCB) service programs authorized by HCS your gross nonexcluded income is:
      1. Above the special income level  (SIL) which is three hundred percent of the federal benefit rate (FBR); and
      2. Net income is no greater than the medically needy income level  (MNIL).  Net income is calculated by reducing gross nonexcluded income by:
         1. Medically Needy (MN) disregards found in WAC 388-513-1345;
         2. The average monthly nursing facility state rate  is five thousand six hundred and twenty six dollars.  This rate will be updated annually starting October 1, 2012 and each year thereafter on October 1.  This standard will be updated annually in the long-term care section of the EAZ manual  described at http://www.dshs.wa.gov/manuals/eaz/sections/LongTermCare/LTCstandardspna.shtml
5. The department follows the rules in WAC 388-515-1325, 388-513-1330 and 388-513-1340  to determine available income exclusions. 
6. Current resource and income standards (including the SIL, MNIL  and FBR) for long-term care are found at: http://www.dshs.wa.gov/manuals/eaz/sections/LongTermCare/LTCstandardspna.shtml.

WAC 388-515-1509 How does the department determine how much of my income I must pay towards the cost of my care if I am only eligible for home and community based (HCB) services under WAC 388-515-1508?

Emergency WAC effective 04/01/2012

If you are only eligible for Medicaid under WAC 388-515-1508, the department determines how much you must pay based upon the following:

1. If you are single and living at home as defined in WAC 388-106-0010, you keep all your income up to the federal poverty level (FPL) for your personal needs allowance (PNA ).
2. If you are married living at home as defined in WAC 388-106-0010, you keep all your income up to the medically needy income level (MNIL ) for your PNA.
3. If you live in an assisted living (AL) facility, enhanced adult residential center (EARC), or adult family home (AFH), you:
   1. Keep a PNA  from your gross nonexluded income. The PNA is sixty-two dollars and seventy-nine cents effective July 1, 2008; and
   2. Pay for your room and board up to the ADSA room and board standard.
4. In addition to paying room and board, you may also have to pay toward the cost of personal care. This is called your participation. Income that remains after the PNA and any room and board deduction is reduced by allowable deductions in the following order:
   1. If you are working, the department allows an earned income deduction of the first sixty-five dollars plus one-half of the remaining earned income.
   2. Guardianship fees and administrative costs including any attorney fees paid by the guardian only as allowed by chapter 388-79 WAC;
   3. Current or back child support garnished or withheld from your income according to a child support order in the month of the garnishment if it is for the current month. If the department allows this as deduction from your income, the department will not count it as your child's income when determining the family allocation amount;
   4. A monthly maintenance needs allowance for your community spouse not to exceed that in WAC 388-513-1380 (5)(b) unless a greater amount is allocated as described in subsection (e) of this section. This amount:
      1. Is allowed only to the extent that you make your income available to your community spouse; and
      2. Consists of a combined total of both:
         1. One hundred fifty percent of the two person federal poverty level. This standard increases annually on July 1 (http://aspe.hhs.gov/poverty/ ); and
         2. Excess shelter expenses. For the purposes of this section, excess shelter expenses are the actual required maintenance expenses for your community spouse's principal residence. These expenses are determined in the following manner:
            1. Rent, including space rent for mobile homes, plus;
            2. Mortgage, plus;
            3. Taxes and insurance, plus;
            4. Any required payments for maintenance care for a condominium or cooperative, minus;
            5. The food assistance standard utility allowance  (SUA) described in WAC 388-450-0195  provided the utilities are not included in the maintenance charges for a condominium or cooperative, minus;
            6. The standard shelter allocation. This standard is based on thirty percent of one hundred fifty percent of the two person federal poverty level. This standard increases annually on July 1 (http://aspe.hhs.gov/poverty).
   5. Is reduced by your community spouse's gross countable income.
   6. The amount allocated to the community spouse may be greater than the amount in subsection (d)(ii) only when:
      1. There is a court order approving the higher amount for the support of your community spouse; or
      2. A hearings officer determines a greater amount is needed because of exceptional circumstances resulting in extreme financial duress.
   7. A monthly maintenance needs amount  for each minor or dependent child, dependent parent, or dependent sibling of your community or institutional spouse. The amount the department allows is based on the living arrangement of the dependent. If the dependent:
      1. Resides with your community spouse, the amount is equal to one-third of the community spouse allocation as described in WAC 388-513-1380 (5)(b)(i)(A) that exceeds the dependent family member's income (child support received from a noncustodial parent is considered the child's income);
      2. Does not reside with the community spouse, the amount is equal to the MNIL  based on the number of dependent family members in the home less their separate income (child support received from a noncustodial parent is considered the child's income).
   8. Your unpaid medical expenses which have not been used to reduce excess resources. Allowable medical expenses are described in WAC 388-513-1350.
   9. The total of the following deductions cannot exceed the SIL (three hundred percent of the FBR):
      1. Personal needs allowance  in subsections (1), (2) and (3)(a) and (b); and
      2. Earned income deduction of the first sixty-five dollars plus one-half of the remaining earned income in subsection (4)(a); and
      3. Guardianship fees and administrative costs  in subsection (4)(b).
   10. You must pay your provider the combination of the room and board amount and the cost of personal care services after all allowable deductions.
   11. You may have to pay third party resources described in WAC 388-501-0200 in addition to the room and board and participation. The combination of room and board, participation, and third party resources is the total amount you must pay.
   12. Current income and resource standards for long-term care (including SIL, MNIL, FPL, FBR) are located at: http://www.dshs.wa.gov/manuals/eaz/sections/LongTermCare/LTCstandardspna.shtml.
   13. If you are in multiple living arrangements in a month (an example is a move from an adult family home to a home setting on HCB services), the department allows you the highest PNA available based on all the living arrangements and services you have in a month.
   14. Current PNA and ADSA room and board standards are located at: http://www.dshs.wa.gov/manuals/eaz/sections/LongTermCare/ltcstandardsPNAchartsubfile.shtml.