Waiver Services - CNP DDD Waivers
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Waiver Services - CNP DDD Waivers

Revised April 25, 2013

Purpose: Determining Medicaid eligibility and client responsibility for cost of care for clients functionally eligible for a DDD Waiver program.
WAC 182-515-1510Division of developmental disabilities (DDD) home and community based services waivers
WAC 182-515-1511What are the general eligibility requirements for waiver services under the four division of developmental disabilities (DDD) home and community based services (HCBS) waivers?
WAC 182-515-1512What are the financial requirements for the DDD waiver services if I am eligible for Medicaid under the noninstitutional categorically needy program (CN)
WAC 182-515-1513How does the department determine if I am financially eligible for DDD waiver service medical coverage if I am not eligible for Medicaid under a categorically needy program (CN) listed in WAC 388-515-1512 (1)?
WAC 182-515-1514How does the department determine how much of my income I must pay towards the cost of my DDD waiver services if I am not eligible for Medicaid under a categorically needy program (CN) listed in WAC 388-515-1512 (1)?

WAC 182-515-1510

WAC 182-515-1510

Effective January 1, 2013

WAC 182-515-1510 Division of developmental disabilities (DDD) home and community based services waivers

The four sections that follow describe the general and financial eligibility requirements for the division of developmental disabilities(DDD) home and community based services (HCBS) waivers.  

  1. WAC 388-515-1511 describes the general eligibility requirements under the DDD HCBS Waivers.
  2. WAC 388-515-1512 describes the financial requirements for the DDD waivers if you are eligible for Medicaid under the noninstitutional categorically needy program (CN).
  3. WAC 388-515-1513 describes the initial financial requirements for the DDD waivers if you are not eligible for Medicaid under a categorically needy program (CN) listed in WAC 388-515-1512(1).
  4. WAC 388-515-1514 describes the post eligibility financial requirements for the DDD waivers if you are not eligible for Medicaid under a categorically needy program (CN) listed in WAC 388-515-1512(1).

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.
WAC 182-515-1511
WAC 182-515-1511

Effective January 1, 2013

WAC 182-515-1511 What are the general eligibility requirements for waiver services under the four division of developmental disabilities (DDD) home and community based services (HCBS) waivers?

  1. This section describes the general eligibility requirements for waiver services under the DDD home and community based services (HCBS) waivers.
  2. The requirements for services for DDD HCBS waivers are described in chapter 388-845 WAC.  The department establishes eligibility for DDD HCBS waivers.  To be eligible, you must:
    1. Be an eligible client of the division of developmental disabilities (DDD);
    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 an intermediate care facility for the intellectually disabled (ICF/ID);
    4. Have attained institutional status as described in WAC 388-513-1320;
    5. Be able to reside in the community and choose to do so as an alternative to living in an ICF/ID;
    6. Need waiver services as determined by your plan of care or individual support plan; and:
      1. Be able to live at home with waiver services; or
      2. Live in a department contracted facility, which includes:
        1. A group home;
        2. Group training home;
        3. Child foster home, group home or staffed residential facility;
        4. Adult family home (AFH); or
        5. Adult residential care (ARC) facility.
      3. Live in your own home with supported living services from a certified residential provider; or
      4. Live in the home of a contracted companion home provider; and
    7. Be both Medicaid eligible under the categorically needy program (CN) and be approved for services by the division of developmental disabilities.

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.
WAC 182-515-1512
WAC 182-515-1512

Effective January 1, 2013

WAC 182-515-1512 What are the financial requirements for the DDD waiver services if I am eligible for Medicaid under the noninstitutional categorically needy program (CN)

  1. You automatically meet income and resource eligibility for DDD Waiver services if you are eligible for Medicaid under a categorically needy program (CN)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. These clients have Medicaid eligibility determined and maintained by the Social Security Administration;
    2. Healthcare for workers with disabilities (HWD) described in WAC 182-5511-1000 through 182-511-1250;  
    3. SSI-related (CN) Medicaid described in WAC 182-512-0100 (2) (a) and (b) or meets the requirements in WAC 182-512-0880  and is CN-P eligible after the income disregards have been applied;
    4. CN Medicaid for a child as described in WAC 182-505-0210  (1), (2), (7) or (8); or
    5. Aged, blind or disabled (ABD) cash assistance described in WAC 388-400-0060.
  2. If you are eligible for a CN-P Medicaid program listed in subsection (1) above, you do not have to pay (participate) toward the cost of your personal care and/or habilitation services.
  3. If you are eligible for a CN Medicaid program listed in subsection (1) above, you do not need to meet the initial eligibility income test of gross income at or below the special income level(SIL), which is three hundred percent of the federal benefit rate (FBR).
  4. If you are eligible for a CN Medicaid program listed in subsection (1), you pay up to the ADSA room and board standard described in WAC 388-515-1507. Room and board and long-term care standards are located at http://www.dshs.wa.gov/manuals/eaz/sections/LongTermCare/LTCstandardspna.shtml.
    1. If you live in an ARC, AFH or DDD group home, you keep a personal needs allowance (PNA) and use your income to pay up to the ADSA room and board standard.  Effective January 1, 2009 the PNA is sixty-two dollars and seventy-nine cents. 
  5. If you are eligible for a premium based Medicaid program such as healthcare for workers with disabilities (HWD), you must continue to pay the Medicaid premium to remain eligible for that CN-P program.

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.
WAC 182-515-1513
WAC 182-515-1513

Effective January 1, 2013

WAC 182-515-1513 How does the department determine if I am financially eligible for DDD waiver service medical coverage if I am not eligible for Medicaid under a categorically needy program (CN) listed in WAC 388-515-1512 (1)?

If you are not eligible for Medicaid under a categorically needy program (CN) listed in WAC 388-515-1512 (1) we must determine your eligibility using institutional Medicaid rules. This section explains how you may qualify under this program. You may be required to pay towards the cost of your care if you are eligible under this program. The rules explaining how much you have to pay are listed in WAC 388-515-1514.  To qualify, you must meet both the resource and income requirements. 

  1. Resource limits are described in WAC 388-513-1350 If you have resources which are higher than the standard allowed we may be able to reduce resources by your unpaid medical expenses described in WAC 388-513-1350.
  2. You are not subject to a transfer of asset penalty described in WAC 388-513-1363 through 388-513-1365.
    1. Not have a home with equity in excess of the requirements described in WAC 388-513-1350.
  3. 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). The department follows the rules in WAC 388-513-1325, 388-513-1330 and 388-513-1340  to determine available income and income exclusions.
  4. Refer to WAC 388-513-1315 for rules used to determine countable resources, income and eligibility standards for long-term care services.
  5. Current income and resources standards are located at: http://www.dshs.wa.gov/manuals/eaz/sections/LongTermCare/LTCstandardspna.shtml

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.
WAC 182-515-1514
WAC 182-515-1514

Effective January 1, 2013

WAC 182-515-1514 How does the department determine how much of my income I must pay towards the cost of my DDD waiver services if I am not eligible for Medicaid under a categorically needy program (CN) listed in WAC 388-515-1512 (1)?

If you are not eligible for Medicaid under a categorically need program (CN) listed in WAC 388-515-1512(1), the department determines how much you must pay based upon the following:

  1. If you are an SSI-related client living at home as defined in WAC 388-106-0010, you keep all your income up to the SIL (three hundred percent of the FBR) for your personal needs allowance (PNA ).
  2. If you are an SSI-related client and you live in an ARC, AFH or DDD group home, you:
    1. Keep a personal needs allowance (PNA ) from your gross non excluded income. Effective January 1, 2009 the PNA is sixty-two dollars and seventy-nine cents; and  
    2. Pay for your room and board up to the ADSA room and board  rate described in http://www.dshs.wa.gov/manuals/eaz/sections/LongTermCare/LTCstandardspna.shtml.
  3. 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 described in (2) above, is reduced by allowable deductions in the following order:
    1. If you are working, we allow 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 we allow this as a deduction from your income, we 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 your income is made 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 (FPL ). This standard may change annually on July 1st and can be found at http://www.dshs.wa.gov/manuals/eaz/sections/LongTermCare/LTCstandardspna.shtml
        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) 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.dshs.wa.gov/manuals/eaz/sections/LongTermCare/LTCstandardspna.shtml
          7. Is reduced by your community spouse's gross countable income.
          8. May be greater than the amount in subsection (d)(ii) only when:
        3. There is a court order approving a higher amount for the support of your community spouse; or
        4. A hearings officer determines a greater amount is needed because of exceptional circumstances resulting in extreme financial duress.
    5. A monthly maintenance needs amount for each minor or dependent child, dependent parent or dependent sibling of your community or institutionalized spouse. The amount we allow 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 388-513-1350.
    7. The total of the following deductions cannot exceed the SIL  (three hundred percent of the FBR):
      1. Personal needs allowances (PNA )  in subsection (1) for in home or subsection (2) (a) in a residential setting; and
      2. Earned income deduction of the first sixty-five dollars plus one-half of the remaining earned income in subsection (3) (a); and
      3. Guardianship fees  and administrative costs in subsection (3) (b).
  4. If you are eligible for aged, blind, or disabled (ABD) cash assistance 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 the ABD cash program;
    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 described in http://www.dshs.wa.gov/manuals/eaz/sections/LongTermCare/LTCstandardspna.shtml;or
    3. When you live in an ARC or DDD group home, you are only eligible to receive a cash grant of thirty-eight dollars and eighty-four cents which you keep for your PNA.
  5. You may have to pay third party resources (TPR) described in WAC 182-501-0200 in addition to room and board and the cost of personal care and/or habilitation services (participation) after all allowable deductions have been considered is called your total responsibility.  You pay this amount to the ARC, AFH or DDD group home provider.

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.

Clarifying Information

DDD Waivers

  1. DDD Waivers are categorically needy (CN) waiver programs that provide clients described in WAC 182-515-1510 through 182-515-1514 with alternatives to placement in an Intermediate Care Facility for the Mentally Retarded (ICF/MR).  These alternatives include remaining in their home or placement in an alternate living facility (ALF) approved by the Division of Developmental Disabilities (DDD).  The goal of these programs is to provide a safe level of care with maximum independence.
  2. In addition to the income allocations described in WAC 182-515-1514  the case manager (CM) can request an exception to rule to reduce the client's participation in the cost of care when the client requires the services of a guardian.
  3. If the client lives in an alternate living facility (ALF), the DDD case manager determines the amount the client keeps for personal needs and the amount the client pays for room and board.
  4. The department determines financial eligibility for these services according to WAC 182-513-1315.  A client must have non excluded income at or below the special income level (SIL),  but can reduce excess resources in the initial or review months as described in WAC 182-513-1350.
  5. Guardianship fees  can be deducted in the post eligibility (participation determination) process if approved by court order for DDD Waivers in an ALF.  Click on the guardianship fee link for clarifying information and a training module regarding guardianships. Since in home DDD Waiver clients keep the Medicaid SIL as a PNA, there is no guardianship deduction available. 
  6. DDD Waiver clients at home do not pay toward personal care costs as they keep up to the Medicaid SIL.  (300% of the FBR).  DDD Waiver clients can pay up to the ADSA room and board  standard if living in an alternative living facility (ALF) such as a DDD group home or adult family home. 
  7. Clients who are eligible to receive Healthcare for Workers with Disabilities (HWD) can receive DDD Waiver services if approved by DDD.  HWD/S08 is the priority program in ACES if the client is better off with HWD/S08 over the C01 program.  See HWD  for more instructions on HWD for DDD Waiver clients. HWD clients on a DDD Waiver pay a premium and have no participation toward personal care.  These clients do pay the ADSA room and board rate if living in a DDD group home or Adult Family Home (these are also called Alternate living facilities  (ALF)) See working clients and LTC.  

1619B and "Deemed SSI eligible" clients

SSI deemed eligible clients (countable income is under the SSI standard after DAC, Pickle/COLA exclusion and SSI closed due to the receipt of DAC, COLA) do not pay toward the cost of personal care.  They DO pay room and board if residing in an adult family home, boarding home or DDD group home.  These facilities are also referred to as alternate living facilities or ALFs.  ALFs are not medical institutions. 

1619(b) 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. 1619(b) clients do not pay toward the cost of personal care. (also called participation).  They DO pay room and board in an ALF. 

 "Deemed SSI clients" and 1619(b) status clients can have gross income over the Medicaid SIL (300% of the FBR) and still be eligible for the Waiver.  1619(b) is described in WAC 182-508-0001 (2)

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 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 do not pay Waiver service participation, they do pay room and board if living in an adult family home, DDD group home or boarding home (ALFs). 

If countable income is over the SSI standard after the exclusion then all income is counted in post eligibility in determining service participation for DDD Waiver clients living in an ALF.  This includes DAC income.

Individuals who qualify for the DAC exclusion and countable income after the exclusion is under the SSI standard are referred to as "Protected DAC" cases. 

Instructions are found in WAC 182-512-0880  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 182-513-1350  

The room and board amount ADSA uses is based on the FBR minus the current HCS CN Waiver personal needs allowance (PNA) for individuals residing in an ALF.

See Long-term care standards and PNA amounts. 

1619(b) 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 an SSI recipient and continue to send in reviews to Social Security.  The SDX indicates continued Medicaid when a client is 1619(b).  1619(b) clients don’t pay toward the cost of personal care because they are considered to be an SSI client.  Follow the same instructions as SSI clients on a waiver for 1619(b) 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 a DDD Waiver as long as Social Security maintains their 1619(b) status

How is this different if the client enters a Medical Institution?

Individuals entering a Medical institution and are "institutionalized" 30 days or more do participate toward the cost of care.  This includes "deemed SSI eligible" clients.  Institutional rules do apply once a client has entered a Medical institution.  (WAC 388-513-1380) This means most of these individuals would participate in a medical institution.  This is called the post eligibility process. 

 

Worker Responsibilities

  1. Follow procedures in ELIGIBILITY REQUIREMENTS to establish financial eligibility. 
  2. This section from the main long-term care index links to the following eligibility requirements for DDD Waivers:
    5. Gross income cannot exceed the Special Income Level  (SIL) which is 300% of the FPL. 
    9. AREP screens for long-term care cases  (Required for some DDD programs).
  3. Consider a client who is approved for DDD Waivers by DDD as having attained institutional status. 
  4. The DDD case manager sends a DSHS 15-345 CSO/DDD Communication to inform the financial worker of DDD Waiver eligibility and the start date of services, type of service, change of service, if in an alternate living facility  (ALF) such as an adult family home or DDD group home, the state daily rate of the facility, address of facility placement and other changes described in the instructions of the DSHS 15-345  form. 
  5. Eligibility for the L21 or L22 DDD Waiver is a 2 prong eligibility program.  The individual must meet both the financial and functional eligibility for the program.  If DDD waiver services are closed by DDD, DDD must inform the financial worker via the DSHS 15-345.  Financial would then to consider eligibility for other medical programs.
  6. The L21/L22 program code is used for the DDD Waivers.  There are exceptions:
    1. Eligibility for Healthcare for Workers with Disabilities (HWD), use the S08/HWD program.  Refer to the HWD specialist.
    2. DDD Foster Care Program
    3. Because of systems issues such as a SSI deemed eligible client with gross income over the SIL.  Use a S02 program.
  7. For a DDD client with earnings, see Working clients on long-term care  . This link includes information on the Healthcare for Workers with Disability program. 
  8. Out of pocket medical expenses can be allowed as a deduction in post eligibility (another term for this is determining the client total responsibility toward the cost of care, or participation).  See Medical Deductions-Long term care.    
  9. Court ordered guardianship fees used as a deduction in long term care are described in the guardianship section.    
  10. Information on DDD community based waivers are in WAC 388-845
  11. Follow necessary supplemental accommodation services (NSA).  The DDD case manager will inform the CSO of any additional NSA services indicated in the CARE plan with a accommodation to access or maintaining services.

ACES Instructions

ACES and LTC

DDD Information

Division of Developmental Disabilities (DDD) (Internet site)

Information on DDD Waiver programs.

Modification Date: April 25, 2013