WAC 388-515-1505 Financial eligibility requirements for long-term care services under COPES, New Freedom, PACE, MMIP and WMIP
Emergency July 1, 2008
This section describes the financial eligibility requirements and the rules used to determine a client’s participation in the total cost of care for home or community based long-term care (LTC) services provided under the following programs:
Program of all-inclusive care for the elderly (PACE);
Medicare/Medicaid integration project (MMIP);
Washington Medicaid Integration partnership (WMIP); and
New Freedom consumer directed services (New Freedom).
Hospice services for clients not in a medical institution with gross income at or below the SIL and not eligible for another CN or MN Medicaid program.
To be eligible for COPES a client must:
Meet the program and age requirements for the specific program, as follows:
Meet the aged, blind or disability criteria of the Supplemental Security Income (SSI) program as described in WAC 388-475-0050 (1);
Require the level of care provided in a nursing facility as described in WAC 388-106-0355;
Be residing in a medical facility as defined in WAC 388-500-0005, or likely to be placed in one within the next thirty days in the absence of home or community-based LTC services provided under one of the programs listed in subsection (1) of this section;
Have attained institutional status as described in WAC 388-513-1320;
Be determined in need of home or community-based LTC services and be approved for a plan of care as described in subsection (2) (a) (i), (ii), or (iii);
Be able to live at home with community support services and chooses to remain at home, or live in a department-contracted:
Meet the resource and income requirements described in subsections (3), (4) and (5) or be an SSI beneficiary not subject to a penalty period as described in subsection (2) (h).
Refer to WAC 388-513-1315 for rules used to determine countable resources and eligibility standards.
Excess resources are reduced in an amount equal to medical expenses incurred by the institutional client as described in WAC 388-513-1350; and
Must result in countable resources being at or below the resource standard in WAC 388-513-1350(1)
If remaining resources are over the standard, the client is ineligible.
Nonexcluded income must be at or below the SIL (300% of the federal benefit rate (FBR)) and is allocated in the following order:
An earned income deduction of the first sixty-five dollars plus one-half of the remaining earned income;
Maintenance and personal needs allowances as described in subsection (7), (8), (9), (10) and (11) of this section ;
Guardianship fees and administrative costs including any attorney fees paid by the guardian only as allowed by chapter 388-79 WAC;
Income garnished for child support or withheld according to a child support order in the month of the garnishment (for current and back support);
Is not counted as the child's income when determining the family allocation amount.
Monthly maintenance needs allowance for the community spouse not to exceed that in WAC 388-513-1380 (5)(b) unless greater amount is allocated as described in subsection (6) of this section. This amount: ;
Is allowed only to the extent that the client's income is made available to the community spouse; and
Excess shelter expenses. For the purposes of this section, excess shelter expenses are the actual required maintenance expenses for the community spouse's principal residence. These expenses are:
Rent;
Mortgage;
Taxes and insurance;
Any maintenance care for a condominium or cooperative; and
The food assistance standard utility allowance (for LTC Services this is set at the standard utility allowance (SUA) for a four-person household), provided the utilities are not included in the maintenance charges for a condominium or cooperative;
Is reduced by the community spouse's gross countable income.
A Monthly maintenance needs amount for each minor or dependent child, dependent parent or dependent sibling of the community or institutionalized spouse based on the living arrangement of the dependent. If the dependent:
Resides with the community spouse, the amount is equal to one-third of the community spouse income allocation as described in WAC 388-513-1380 (6) (b) (i) (A) that exceeds the dependent family member’s income;
Does not reside with the community spouse, the amount is equal to the MNIL for the number of dependent family members in the home less the income of the dependent family members.
Child support received from a non-custodial is the child’s income;
Medical expenses incurred by the client and not used to reduce excess resources. Allowable medical expenses and reducing excess resources are described in WAC 388-513-1350.
The amount allocated to the community spouse may be greater than the amount in subsection (5) (e) only when:
A court enters an order against the client for the support of the community spouse; or
A hearings officer determines a greater amount is needed because of exceptional circumstances resulting in extreme financial duress.
A client who receives SSI and lives at home as defined in WAC 388-106-0010 does not use income to participate in the cost of personal care.
Retains a personal needs allowance (PNA) of sixty two dollars and seventy-nine cents; and
Uses income to pay the facility for the cost of room and board.
Room and board is the SSI FBR minus sixty two dollars and seventy-nine cents.
A client who is eligible to receive CN-P Medicaid described in WAC 388-475-0100 (2)(a) and (b) and lives at home , defined in WAC 388-106-0010, does not use income to participate in the cost of personal care.
A client who is eligible to receive CN-P Medicaid described in WAC 388-475-0100(2)(a) and (b) and lives in an EARC, AFH or AL does not use income to participate in the cost of personal care; and
Retains a personal needs allowance (PNA) of sixty two dollars and seventy-nine cents; and
Uses income to pay the facility for the cost of room and board.
Room and board is the SSI FBR minus sixty two dollars and seventy-nine cents
An institutionalized SSI-related client living:
At home, retains a maintenance needs amount equal to the following:
Up to one hundred percent of the one-person FPL, if the client is:
Single; or
Married, and is:
Not living with the community spouse; or
Whose spouse is receiving long-term care (LTC) services outside of the home.
Up to one hundred percent of the one-person FPL for each client, if both spouses are receiving COPES, New Freedom, PACE, MMIP, or WMIP services;
Up to the one-person medically needy income level (MNIL) for a married client who is living with a community spouse who is not receiving COPES, New Freedom, PACE, MMIP, or WMIP.
In an EARC, AFH, or AL, retains a maintenance needs amount equal to the SSI FBR and:
Retains a personal needs allowance (PNA) of sixty two dollars and seventy-nine cents from the maintenance needs; and
Pays the remainder of the maintenance needs to the facility for the cost of room and board. (Refer to subsection (14) in this section for allocation of the balance of income remaining over maintenance needs.)
A client who is eligible for the general assistance expedited Medicaid disability (GAX) program does not participate in the cost of personal care. When such a client lives:
At home, the client retains the cash grant amount authorized under the general assistance program;
In an AFH, the client retains a PNA of thirty-eight dollars and eighty-four cents, and pays remaining income and GAX grant to the facility for the cost of board and room; or
In an EARC or AL, the client only receives a PNA of thirty-eight dollars and eighty-four cents and retains it.
The total of the following amounts cannot exceed the SIL:
Maintenance and personal needs allowances as described in subsections (7), (8), (9) (10), (11) and (12);
Earned income deduction of the first sixty-five dollars plus one-half of the remaining earned income in subsection (5)(a); and
The Community Options Program Entry System (COPES) is a categorically needy (CN) waiver program that provides clients described in WAC 388-515-1505 with alternatives to placement in a medical facility. These alternatives include remaining in their home or placement in an alternate living facility (ALF) approved by the Home and Community Services (HCS) division. The goal of this program is to provide a safe level of care with maximum independence.
In addition to the income allocations described in WAC 388-515-1505, an exception to rule can be requested to reduce the client’s participation in the cost of room and board when the client requires the services of a guardian or additional funds for a spousal allocation and lives in an ALF. ETRs are forwarded to the HCS Regional designee.
Follow resource requirements in 388-513-1350 including clarifying information.
The department determines financial eligibility for these services according to WAC 388-513-1315. A client must have nonexcluded income at or below the special income level (SIL), but can reduce excess resources in the initial or review months as described in 388-513-1350
Aging and Disability Service Administration’s (ADSA) delivery of services is implemented through a partnership of the Home and Community Services Division (HCS) and Area Agencies on Aging (AAA/Triple A). ADSA contracts with AAA to case manage, review, and reauthorize clients receiving in-home long-term care services administered by ADSA. HCS completes the initial comprehensive assessment and authorizes services for all new applications. Clients receiving in-home services are then transferred to AAA for continuing case management. HCS maintains the case management for clients in facilities.
A Community Spouse is the legally married spouse of an institutionalized person who is not in a medical facility or nursing facility. Washington recognizes other states’ legal and common-law marriages.
A Comprehensive Assessment, is the functional assessment (also called a CARE assessment) completed by Home and Community Services or AAA staff for all clients to determine initial or ongoing HCS Waiver/COPES eligibility.
A client attains Institutional Status when he/she receives HCS Waiver/COPES services.
Eligibility Determination Process
Determine both financial need and functional need.
Complete both eligibility determinations concurrently.
Both financial and functional eligibility must be determined before you authorize HCS Waiver/COPES.
Staff Who Make Eligibility Determinations
The HCS social service staff assess the client’s HCS Waiver/COPES functional eligibility using the comprehensive assessment, determine functional eligibility, and authorize HCS Waiver/COPES services.
The FSS determines the client’s financial eligibility for medical care and post eligibility (determination of participation) to the HCS Waiver/COPES program.
The ongoing casemanagement (HCS or AAA) must be indicated on the AREP screen in ACES in order for the casemanager to receive notices on the case including changes in participation. The HCS/AAA casemanager adjusts SSPS when notified of participation changes.
The client authorized services must pay their responsibility toward the cost of care (service participation and room and board) to the provider or provider agency.
HCS Waivers, Room and Board and Bedholds
HCS authorizes Waiver services for clients residing in contracted alternate living facilities such as Assisted Living or Adult Family Homes. The total responsibility paid by the client to the assisted living or adult family home provider is a combination of the Waiver service participation, room and board and VA third party responsibility. VA third party responsibility is an amount paid to the client by VA for aid and attendance and/or unusual medical expenses or UME.
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 a term used by ADSA called the room and board rate. This rate is based on the FBR minus the COPES/HCS Waiver PNA in an ALF.
Clients who reside in alternate living facilities pay room and board (R & B) in addition to their personal care participation.
R & B is all state-funded; therefore you cannot automatically reduce R &B with the deductions listed under the HCS Waiver/COPES program.
All dedcuctions from room and board require an approved Exception to Rule (ETR)
At HCS, approvals are made by the regional designee.
R & B should only be reduced when all other income has been allocated toward participation and the client does not have enough income available to pay toward the expenses.
Limit requests for reducing R & B to those deductions that are allowed from participation. Don't reduce R & B for expenses that we would not allow from participation.
Before requesting an ETR to reduce R & B, ensure you have factored in other income the client may have available that is not being used to pay toward participation. Ensure the client is allowed to keep the appropriate PNA.
Bedholds
Financial services determines the amount of the client's payment towards room and board and their participation toward the cost of personal care. When determining this payment amount, the goals are to avoid making clients pay room and board/participation to multiple facilities whenever possible, and to preserve funding by keeping room and board/participation at the residential (ALF) facility rather than sending it to the nursing home. Social Service LTC manual Chapter 8 Residential Services/Bedhold for Medical Leave describes this process.
Financial workers will:
Take no action until the bed hold has expired. The maximum length of the bed hold payment is 20 days.
Determine how much the client should pay to the residential facility during the discharge month. Assign any remainder to the new facility. If the client:
Did not return to the residential facility, change the client's medical program to nursing facility coverage or other appropriate program and assign room and board/participation to the new facility after determining how much room and board/participation was used at the residential facility during the month the client left.
Does return to the residential facility either in the same month or the next month, assign room and board/participation to that facility.
Returns to the residential facility, do not reassign any room and board/participation to the nursing home for any bed hold month(s) unless there are not enough days at the residential facility to account for it.
Always let the SW/case manager know if a client appears to be eligible for a non-institutional CN-P program such as HWD so they can consider MPC.
If SW/case manager indicates the clients needs can be met by MPC, contact the client and go over their options. It is their choice. HWD has a monthly premium.
HWD does not cover HCS Waiver services, it does cover MPC.
Each HCS Region has a designated HWD worker.
When can HWD and MPC be better than COPES ?
No asset test for HWD.
May have gross income over the SIL with HWD.
No participation toward personal care. There is a monthly HWD premium.
Earned income can be over the social security substantial gainful activity (SGA). SGA is not a factor for HWD but is a factor for most SSI related medicaid including HCS Waivers.
SGA Amounts for 2008
The monthly SGA amount for statutorily blind individuals is $1,570. For non-blind individuals, the monthly SGA amount for is $940. SGA for the blind does not apply to Supplemental Security Income (SSI) benefits, while SGA for the non-blind disabled applies to Social Security and SSI benefits.
What this means is gross income over the SGA affects the disability criteria for the HCS Waiver program unless the client is considered an SSI client or SSI deemed eligible client by Social Security.
When can COPES be better than HWD and MPC?
There is a need for COPES ancillary services such as lifeline.
Is residing in an assisted living or EARC (not MPC contracted).
Client's income is low enough where there is no participation toward personal care and there is already -0- out of pocket cost under the COPES program.
Spousal impoverishment rules do not apply to HWD. Spousal income follows SSI related rule, but is not used in determing the HWD premium.
1619B and "Deemed SSI eligible" clients
SSI deemed eligible clients (countable income is under the SSI standard after DAC, Pickle/COLA exclusion AND SSI was closed due to the receipt of DAC, COLA income) don’t pay service participation. They DO pay room and board in an ALF
1619B clients are considered the same as an “SSI client” SSI payments have stopped due to earnings. SDX indicates continue Medicaid on SDX 1 in the Med Elig field. 1619B clients don’t pay service participation. They DO pay room and board in an ALF.
Deemed SSI eligible clients. What does that mean?
Clients who have COUNTABLE income under the SSI standard after allowing the exclusion for Disabled Adult Child (DAC), Pickle/COLA, Widow/Widowers AND their SSI was closed because of the receipt of the DAC/COLA/Widow(er) income. These exclusions are described in the SSI related Medicaid chapter. Clients continue to receive CN-P Medicaid as long as they meet resource criteria. Not every client receiving DAC income is eligible for this exclusion. These are the requirements:
Lost cash payment of SSI after 7/1/88 due to receipt of DAC benefits from SSA or a COLA to those benefits.
Disability onset date prior to age 22
Deemed SSI eligible clients should NOT pay Waiver (COPES) service participation, they do pay room and board if living in an ALF.
If countable income is over the SSI standard after the exclusion then all income is counted in post eligibility in determining participation including DAC income.
Instructions are found in WAC 388-475-0880 Special income disregards for SSI-related medical programs.
In other words, an individual who would be eligible for CN-P/S02 in ACES
A client who would otherwise qualify for S02/CN SSI related medicaid because their countable income is at or below the SSI standard does not participate towards personal care under the Waiver program. (but they are responsible to pay room and board when living in an ALF).
These clients do need to meet the same criteria for long-term care services as other Waiver clients and may be subject to transfer of asset penalties or excess home equity described in WAC 388-513-1350 (7)
Let the SW/Case manager know if client would be eligible for a non institutional CN-P program so MPC can be considered. MPC is considered a priority over the Waiver (COPES) program.
1619B status, what does it mean?
SSI clients whose earnings put them over the SSI cash benefit standard but Social Security continues their SSI eligibility. They are considered a SSI recipient and continue to send in reviews to Social Security. The SDX indicates continued Medicaid when a client is 1619B. 1619B clients don’t pay service participation because they are considered to be an SSI client. Follow the same instructions as SSI clients on COPES for 1619B clients. Code SI on UNER to prevent an eligibility review from being generated for the C01. Clients would pay the ADSA room and board amount if residing in an ALF. Clients can have GROSS income over the SIL and continue to receive COPES as long as Social Security maintains their 1619B status.
How to code ACES for a working COPES/HCS CN Waiver client that would be eligible for S01 or S02.
For a SSI, “Deemed SSI Eligible” or 1619B client receiving COPES at home with no Food Assistance: Code earnings as “ON” other non countable income on the EARN screen.Gross income UNDER the SIL: Put the SIL amount as a “UZ” deduction on LTCX.Gross incomeOVER the SIL: Code the excluded income as “LF” on the UNER screen.
For a SSI or a “Deemed SSI eligible” client receiving COPES with Food Assistance: Code earnings as “FS” other FS countable on the EARN screen. Put the SIL amount as a “UZ” deduction on LTCX. Do not use this work around if gross income is OVER the SIL.
For a case with gross income over the SIL AND food assistance and client would be eligible for S01 or S02, keep the medical coverage group as a S01 or S02 rather than the C01 waiver program. Document that client is receiving C01/Waiver services. Indicate ACES currently does not support C01 eligibility with food assistance when gross income is over the SIL and client would otherwise be eligible for S01 or S02.
If the client becomes ineligible for COPES, DDD Waiver the ending date is the last day of the month in which the plan of care ends or that required by advance notes procedures, whichever is later.
New Freedom instructions (New Freedom Consumer Directed Services (NFCDS))
The eligibility for New Freedom is the same as the COPES program. The program in ACES is C01 and coded on the INST under HCBS as"C" the same as COPES The case management is handled through the New Freedom contractor. Financial will be notified by the case manager/social worker of the change to New Freedom and the start date of the change. Currently New Freedom is available in King County. Information on New Freedom can be found in WAC 388-106-1400 through 388-106-1480. WAC 388-106-1410 explains who may be eligible for New Freedom.
The financial worker will:
Determine financial eligibility for long-term care services under the C01 program;
Remove the HCS or AAA case manager as the authorized representative on the AREP screen;
Add NFP-Sunrise and ACRS as an authorized rep. on the AREP screen;
Create and send a new award letter to NFP-Sunrise informing them of the client’s participation amount and advising the client to continue paying his participation to his provider. (NFP-Sunrise will track to ensure the providers are paid less the participation amount.);
At any time, financial staff will also advise NFP-Sunrise as the authorized representative of any Medicaid eligibility or cost of care changes as they occur. (They will receive the notices of termination, participation changes, eligibility reviews due, etc).
New Freedom Services-Sunrise address:
17962 Midvale Ave N Suite 232
Shoreline, WA 98133
Phone: (866) 533-1486
