Long-term care home and community based services and hospice (CN)
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Long-term care home and community based services and hospice (CN)


Revised September 8, 2014


This section is commonly referred as "The COPES chapter". It is used for the eligibility of the HCS CN waiver programs. The medical coverage group is L22. L21 for SSI recipients


Purpose: 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 Health Care Authority (HCA). These services are administered either in a home or residential (non medical institution) setting.

WAC 182-515-1505 Long-term care home and community based services and hospice
WAC 182-515-1506What are the general eligibility requirements for home and community based (HCB) services authorized by home and community services (HCS) and hospice?
WAC 182-515-1507What are the financial requirements for home and community based (HCB) services authorized by home and community services (HCS) when you are eligible for a non-institutional SSI-related categorically needy (CN) medicaid program?
WAC 182-515-1508How 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 182-515-1507(1)?
WAC 182-515-1509How 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 182-515-1508?

Long-term care home and community based services and hospice. Table of Contents WAC

WAC 182-515-1505

WAC 182-515-1505

Effective January 1, 2013

WAC 182-515-1505 Long-term care home and community based services and hospice



  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.

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.

What are the general eligibility requirements for home and community based (HCB) services and hospice?

WAC 182-515-1506

WAC 182-515-1506

Effective October 1, 2013

WAC 182-515-1506 What are the general eligibility requirements for home and community based (HCB) services authorized by home and community services (HCS) and hospice?

Emergency WAC effective 1/1/2014

  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 182-512-0050;
    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 182-500-0050, or likely to be placed in one within the next thirty days without HCB services provided under one of the programs listed in (a) of this subsection;
    5. Have attained institutional status as described in WAC 182-513-1320;
    6. Be determined in need of services and be approved for a plan of care as described in (a) of this subsection;
    7. Be able to live at home with community support services and choose to remain at home, or live in a department-contracted:
    8. Not be subject to a penalty period of ineligibility for the transfer of an asset as described in WAC 182-513-1363 through 182-513-1365;
    9. Not have a home with equity in excess of the requirements described in WAC 182-513-1350.
  2. Refer to WAC 182-513-1315 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.hca.wa.gov/medicaid/Eligibility/index.aspx.

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.

What are the financial requirements for home and community based (HCB) services when you are eligible for a noninstitutional categorically needy (CN) program?

WAC 182-515-1507

WAC 182-515-1507

Effective January 10, 2013

WAC 182-515-1507 What are the financial requirements for home and community based (HCB) services authorized by home and community services (HCS) when you are eligible for a non-institutional SSI-related categorically needy (CN) medicaid program?

Emergency WAC effective 1/1/2014

  1. You are eligible for medicaid under one of the following programs:
    1. Supplemental security income (SSI) eligibility described in WAC 388-474-0001 and chapter 182-510 WAC.  This includes SSI clients under 1619B status;
    2. SSI-related CN medicaid described in WAC 182-512-0100 (2)(a) and (b);
    3. SSI-related healthcare for workers with disabilities program (HWD) described in WAC 182-511-1000.  If you are receiving HWD you are responsible to pay your HWD premium as described in WAC 182-511-1250.
  2. You do not have a penalty period of ineligibility for the transfer of an asset as described in WAC 182-513-1363 through 182-513-1365. 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 182-513-1350.
  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 182-515-1506 (1)(g), you pay room and board up to the aging and disability services (ADS) room and board standard. The ADS  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  a. of this subsection applies and you are receiving HWD described in WAC 182-511-1000 you are responsible to pay your HWD premium as described in WAC 182-511-1250  in addition to the ADS room and board standard. 
  7. If you are eligible for aged, blind or disabled (ABD) cash assistance program described in WAC 388-400-0060 and receiving SSI related CN medicaid,  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 ADS room and board  standard;
    3. When you live in an assisted living facility or enhanced adult residential center, you are only eligible to receive an ABD cash grant of thirty-eight dollars and eighty-four cents as described in  WAC182-515-1500, which you keep for your PNA.
  8. Current resource and income standards are located at: http://www.hca.wa.gov/medicaid/Eligibility/Pages/Index.aspx
  9. Current PNA and ADS room and board standards are located at: http://www.hca.wa.gov/medicaid/Eligibility/Pages/index.aspx

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.

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

WAC 182-515-1508

WAC 182-515-1508

Effective October 1, 2013

WAC 182-515-1508 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 182-515-1507(1)?

Emergency WAC effective 1-1-2014

  1. If you are not eligible for medicaid under a categorically needy (CN) program listed in WAC 182-515-1507(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 WAC 182-513-1315 and 182-515-1506.
  3. You must meet the following resource requirements:
    1. Resource limits described in WAC 182-513-1350.
    2. If you have resources over the standard allowed in WAC 182-513-1350, the department reduces resources over the standard by your unpaid medical expenses described in WAC 182-513-1350  if you verify these expenses.
  4. You must meet the following income requirements:
    1. Your gross non-excluded 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 non-excluded 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 themedically needy income level (MNIL).  Net income is calculated by reducing gross non-excluded income by:
        1. Medically Needy (MN) disregards found in WAC 182-513-1345; and
        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.hca.wa.gov/medicaid/Eligibility/Pages/index.aspx
  5. The department follows the rules in WAC 182-513-1325182-513-1330 and 182-513-1340   to determine available income exclusions.
  6. Current resource and income standards (including the SILMNIL  and FBR) for long-term care are found at: http://www.hca.wa.gov/medicaid/Eligibility/Pages/index.aspx.

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.

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?

WAC 182-515-1509

WAC 182-515-1509

Effective January 10, 2013

WAC 182-515-1509 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 182-515-1508?

Emergency WAC effective 1-1-2014

If you are only eligible for Medicaid under WAC 182-515-1508, 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 effective one-person medically needy income level (MNIL ) for your PNA if your spouse lives at home with you. if you are married and living apart from your spouse, you're allowed to keep your income up to the FPL 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 non-excluded 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 ADS 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 liability if residing in an alternate living facility 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 182-513-1380 (5)(b) unless a greater amount is allocated as described in this (e) of this subsection.  This amount:
      1. Is allowed only to the extent that your income is made available to your community spouse; and
      2. Consists of a combined total of both:
        1. 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, plus;
          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 may change annually on July 1st and can be found at: http://www.hca.wa.gov/medicaid/Eligibility/Pages/index.aspx; and
          7. Is reduced by your community spouse's gross countable income.
      3. The amount allocated to the community spouse may be greater than the amount (d)(ii) of this subsection only when:

        1. There is a court order approving a 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.
    5. monthly maintenance needs amount  for each minor or dependent child, dependent parent, or dependent sibling of your community or institutionalized spouse. The amount the department allows is based on the living arrangement of the dependent. If the dependent:
      1. Resides with your community spouse, for each child, one hundred 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);
      2. Does not reside with the community spouse, the amount is equal to the effective one-person 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).
    6. Your unpaid medical expenses which have not been used to reduce excess resources. Allowable medical expenses are described in WAC 182-513-1350.
    7. 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) of this section;  and
      2. Earned income deduction of the first sixty-five dollars plus one-half of the remaining earned income in (4)(a) of this subsection; and
      3. Guardianship fees and administrative costs  in (b) of this subsection.
  5. You must pay your provider the combination of the room and board amount and the cost of personal care services after all allowable deductions.
  6. You may have to pay third party resources described in WAC 182-501-0200 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.
  7. Current income and resource standards for long-term care (including SIL, MNIL, FPL, FBR) are located at: http://www.hca.wa.gov/medicaid/Eligibility/Pages/indes.aspx.
  8. 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.
  9. Current PNA and ADS room and board standards are located at: http://www.hca.wa.gov/medicaid/Eligibility/Pages/index.aspx.

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.

NOTE: 

A section was inadvertently left out of the re-write of WAC 182-515-1509.  WAC 388-515-1509 will be updated under (2) allowing the Waiver spouse living at home but apart from the community spouse to be able to keep the FPL. 

For a Waiver spouse living at home but apart from the community spouse code ACES on DEM1 "A" (married living apart) under marital status.  Code the LTCD CS living arrangement as "LP" (living apart).  This will allow the Waiver spouse to be able to keep the FPL as the maintenance/PNA.   (The Waiver spouse living at home with the community spouse is allowed to keep the MNIL).


This section contains the following HCB CN services:
  1. Community options program (COPES)
  2. New Freedom consumer directed services  (New Freedom)

  3. Program of all-inclusive care for the elderly  (PACE)

  4. Washington Medicaid integration partnership (WMIP)


Clarifying Information on the consolidation of Medically Needy Waivers into the COPES Waiver effective 4/1/2012

Consolidation of MN Waivers into COPES


Clarifying Information on HCS HCB Services (COPES, New Freedom, WMIP, PACE)

Overview including eligibility process and staff who make eligibility determinations. (This section includes instructions on New Freedom).

Working clients on COPES (or any HCB service with HCS)

1619B and "Deemed SSI eligible" clients (after DAC, Pickle/COLA, Widower exclusion)

HCS services in residential settings, room and board, ETRs, Bed-hold processes

Dependent/family allocation used in CN Waiver or Institutional Participation Calculation

WAC 388-106-0315 When do COPES Services start?

WAC 388-106-0325 How do I pay for COPES Services

 


Clarifying Information on Hospice and Roads to Community Living

Hospice Clarifying Information

Roads to Community Living (RCL) Clarifying Information

 




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.  Depending on the standard, these changes occur in January, April, July and August.  See the Institutional standard chart for current standards used in long term care.  This chart indicates the formula for the standard and when the standard last changed. 

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

Medical 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.


Income and Deduction changes in HCB Waivers. Method 3 effective 8/29/2014

WAC 182-504-0120 (12) Effective date of changes was permanent effective 8/29/2014.  For HCB Waivers, a change in income or deductions is effective the first of the month followng the date the change was reported rather than the month the income or deduction changed (Method 1).   

When a change in income, or allowable expenses, changes the amount you pay towards the cost of your care for a home and community-based waiver or service, we calculate your new participation amount effective the first of the month following the date the change was reported, except that the new participation amount will be effective the month the change occurs if the change is the loss of an income source that you report within thirty days of the change.

  • This process is called "Method 3"
  • Any change to an HCB Waiver client's income or deductions that affect cost of care take effect in the onoing month in ACES. 
  • With the exception of loss of an income source or the lowering of income
    • The change takes effect the actual month of change.
    • We will make these historical changes in ACES.
    • To be considered a loss or reduction of income:
      • We must have a timely report of the change to income
      • We must have verification that this change is to last two months or longer;
      • Otherwise, it is a "change" in income that takes effect the following month.

What if a loss or lower of income is not reported timely?

  • Financial will not make historical adjustments in ACES.
  • Treat as an underpayment, or "client reimbursement".
  • Send a 65-10 to let the case manager know what the client's income actually was, and what we had in ACES.  Indicate what the correct participation should have been and that change was not reported timely.
  • The case manager/social worker will determine if the provider is to be paid more, or if the client is owed any money.

 

 


Worker Responsibilities- HCB CN Services (COPES, New Freedom, WMIP PACE)

Worker responsibilities

Additional clarification and worker responsibilities can be found in in the institutional participation section.   


ACES PROCEDURES

See Long Term Care, Alternate Care and Waiver Services


NSA (Equal Access) and Long Term Care

NSA and Clients receiving HCS services
Modification Date: September 8, 2014