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?
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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?


Revised May 13, 2013



Purpose: This section describes how to determine the client's cost of care for the HCS CN (COPES) program, New Freedom, WMIP, PACE and Hospice. These clients are either residing at home or in a residential setting. This is commonly referred to as "participation". The client's cost of care is a combination of service participation, room and board if living in a residential setting and third party resource if receiving aid and attendance from the VA for attendant care. The combination of these is called "client responsibility".

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 388-515-1508?

NOTE:

The manual material for this section is under construction.  See Clarifying information on HCS HCB services. 




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 182-515-1509 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).


Effective 4/1/2012 combination of MN and CN HCS Waivers

This section is under construction

Nursing facility average state rate

 

 

Modification Date: May 13, 2013