Effective 4/1/2012 home and community based services authorized by home and community services (HCS) combines the categorically needy and medically needy programs described in WAC 388-515-1505 and 388-515-1508.
This section describes the financial eligibility requirements for waiver services under the medically needy in-home waiver (MNIW) and the rules used to determine a client's responsibility in the total cost of care.
To be eligible for MNIW, a client must:
Not meet financial eligibility for Medicaid personal care or the COPES program;
Require the level of care provided in a nursing facility as described in WAC 388-106-0355;
In the absence of waiver services described in WAC 388-106-0500, continue to reside in a medical facility as defined in WAC 388-513-1301, or will likely be placed in one within the next thirty days;
Have attained institutional status as described in WAC 388-513-1320;
Have been determined to be in need of waiver services as described in WAC 388-106-0510;
Be able to live at home with community support services and choose to remain at home;
Meet the resource and income requirements described in subsections (2) through (6) of this section.
The department determines a client's nonexcluded resources under MNIW as described in WAC 388-513-1350.
Nonexcluded resources, after disregarding excess resources described in subsection (4) of this section, must be at or below the resource standard described in WAC 388-513-1350 (1) and (2).
In determining a client's resource eligibility, the department disregards excess resources above the standard described in subsection (3) of this section:
In an amount equal to incurred medical expenses such as:
Premiums, deductibles, and co-insurance/co-payment charges for health insurance and Medicare premiums;
Necessary medical care recognized under state law, but not covered under the state's Medicaid plan; or
Necessary medical care covered under the state's Medicaid plan.
As long as the incurred medical expenses:
Are not subject to third-party payment or reimbursement;
Are not the result of medical and remedial care expenses that were incurred as the result of imposition of a transfer of asset penalty described in WAC 388-513-1363, 388-513-1364 and 388-513-1365;
Have not been used to satisfy a previous spenddown liability;
Have not previously been used to reduce excess resources;
Have not been used to reduce client responsibility toward cost of care; and
Are amounts for which the client remains liable.
The department determines a client's countable income under MNIW in the following way:
Deducts monthly health insurance premiums, except Medicare premiums, not used to reduce excess resources in subsection (4) of this section;
Allows an income deduction for a nonapplying spouse, equal to the one person medically needy income level (MNIL) less the nonapplying spouse's income, if the nonapplying spouse is living in the same home as the applying person.
A client whose countable income exceeds the MNIL may become eligible for MNIW:
When they have or expect to have medical expenses to offset their income which is over the MNIL; and
The portion of a client's countable income over the MNIL is called "excess income."
A client who has or will have "excess income" is not eligible for MNIW until the client has medical expenses which are equal in amount to that excess income. This is the process of meeting "spenddown." The excess income from each of the months in the base period is added together to determine the total "spenddown" amount.
The following medical expenses may be used to meet spenddown if not already used in subsection (4) of this section to disregard excess resources or to reduce countable income as described in subsection (5)(d) of this section:
An amount equal to incurred medical expenses such as:
Premiums, deductibles, and co-insurance/co-payment charges for health insurance and Medicare premiums;
Necessary medical care recognized under state law, but not covered under the state's Medicaid plan; and
Necessary medical care covered under the state's Medicaid plan.
The cost of waiver services authorized during the base period.
As long as the incurred medical expenses:
Are not subject to third-party payment or reimbursement;
Have not been used to satisfy a previous spenddown liability;
Have not been used to reduce client responsibility toward cost of care; and
Are amounts for which the client remains liable.
Eligibility for MNIW is effective the first full month the client has met spenddown. In cases where spenddown has been met, medical coverage and MNIW begin the day services are authorized.
A client who meets the requirements for MNIW chooses a three or six month base period. The months must be consecutive calendar months.
The client's income that remains after determining available income in WAC 388-513-1325 and WAC 388-513-1330 (1), (2), (3) and excluded income in WAC 388-513-1340 is paid towards the cost of care after deducting the following amounts in the order listed:
An earned income deduction of the first sixty-five dollars plus one-half of the remaining earned income;
The rules in this section are used for individuals that have gross income higher than the Medicaid SIL. These individuals live in a home setting.
The Medicaid SIL is 300% of the federal benefit rate (FBR).
For individuals with gross income under the Medicaid SIL, determine eligibility using the HCS CN Waiver (COPES) rules.
MNIW Database
Active participants and clients on the waiting list are tracked on the MNRW/MNIW database. (This data base is available only to DSHS staff at: http://adsaweb/mnwaiver/default2.htm).
Financial services staff will input the client data into the database after the client has been determined functionally and financially eligible for MNRW/MNIW services.
Financial services staff will enter a termination code MNRW/MNIW database when MNIW services are closed.
Use S02 Medical Coverage Group when screening into ACES.
The MNIW/MNRW calculator on the data base does the eligibility calculation for MNIW. In ACES the work around program is a S02 for this program. More information on ACES coding is at the end of this clarifying page.
Resource and income eligibility
Resources:
Single client $2000
Married client $3000
We can't use Community Spouse rules to there is no community spouse resource standard. Resource rules follow SSI related standard for MN.
Excess Resources:
Clients cannot participate excess resources toward their cost of care.
If a client has resources over the standard, use the following to disregard some or all of the excess: (WAC 388-513-1350)
Premiums, deductibles, co-pays.
Necessary medicare care recognized by state law and not covered by medicaid.
Necessary medical care covered by medicaid.
Not subject to third party payment or reimbursement
Not been used for previous spenddown.
Not been previously used to reduce excess resources
Not incurred during a transfer of asset period of ineligibility
Not been used to reduce client responsibility towards cost of care
ACES Medical Coverage group S99 is used as a work around for the MNIW program
Screen in for a S02-ACES will trickle to a S99
INST-Use HCB Waiver type C and date services begin.
In remarks indicate MNIW case
INST does not come up automatically in the screen flow. You must remember to "call up" that screen.
LTCX-Code the deductions we normally indicate on the LTCX screen for post eligibility as a reference.
Deductions on the LTCX screen is not part of the calculation for a S99 series. We put the deductions as a reference only.
Make sure health insurance deduction (not medicare) is indicated on the MEDX screen too. Health insurance premiums are indicated on the MEDX for S series.
LTCX does not come up automatically in the screen flow. You must remember to "call up" that screen.
When bills are provided that meet spenddown:
Complete AMEN, option T Spenddown Medical Expense Update (SDME)
Add expenses provided by the client as you would for any S99.
Meeting Excess Spenddown
Medicaid for MNIW with spenddown cannot be opened until services are opened.
The opening date for MN with spenddown is the date the MNIW services were authorized.
More about meeting excess spenddown
When clients provide bills advise the case manager when a client has met a spenddown and when base period will end.
When service authorization is received, open MNIW program through the end of the base period.
Manually generate ACES letter
Approval for LTC medical benefits-0002-17
Indicate you have been approved for Medically Needy in-home service (MNIW). Make sure the ending date of the base period is indicated on the letter.
Clearly document ACES narrative which bills were used to meet spenddown.
ACEScoding-Screening in Married Clients
Married client, spouse's income is under the MNIL:
Use Fin Resp code of SP
ACES will use a $3000 resource standard as a couple and deem client's income to the spouse up to the MNIL (taking into account the spouse's income).
Married client, spouse's income at or above the MNIL:
Use Fin Resp code of NM
ACES will use a $3000 resource standard as a couple.
