Long Term Care Medical Standards-Personal Needs Allowance (PNA) Charts

Revised December 30, 2011

Long Term Care Medical Standards

Resource standards   WAC 388-513-1350  Defining the resource standard and determining resource eligibility for long-term care (LTC) services

Income standards Used to determine income eligibility and financial participation in long-term care

PERSONAL NEEDS ALLOWANCE (PNA) and ADSA room and board standard

LTC personal needs allowance chart

Excess Home Equity Limits

Under section 6014 of the Deficit Reduction Act of 2005 (DRA), Medicaid will not pay for long-term care services for individuals whose equity interest in their home exceeds $500,000.  This provision applies to institutional and Waiver programs.  This rule also applies to Hospice when using institutional rules for eligibility. 

WAC 388-513-1350  implemented this change effective 5/1/2006.

Effective 1/1/2011 these limits are to be increased each year by the percentage increase in the consumer price index -Urban (CPIU).

Links to Federal Medicaid Standards

Standards used for long-term care Medicaid eligibility are based on federal income and resource standards. 

SSI Federal Payment Amounts

Poverty Guidelines United States Department of Health & Human Services.  Includes a link with current and past HHS poverty guidelines.

U.S. Department of Labor Consumer Price Index

SSI and Spousal Impoverishment Standards (Centers for Medicare & Medicaid Services) Link includes current substantial gainful activity (SGA) limit.  (Under download 1998-2011 SSI FBR, Resource limits).

Nursing facility private rate standard. Used to determine period of ineligibility due to asset transfer

This rate increases annually on October 1.  It is calculated using the reported date from Medicaid cost reports and determined by ADSA. 

 It is used to determine a period of ineligibility due to a resource transfer.

Rate effective 10/1/2011 through 9/30/2012

Rate effective 10/1/2010 through 9/30/2011

Rate effective 10/1/2009 through 9/30/2010

Rate effective 10/1/2008 through 9/30/2009

Rates Prior to 09/30/2008

Special Income Level (SIL) 300% of the FBR

1. The department compares a client’s non-excluded income to the SIL  to determine whether a client is eligible for LTC services under the CN program.
2. The SIL  is equal to 300% of the annually adjusted SSI Federal Benefit Rate (FBR).
3. The department does not allow income disregards when determining eligibility for CN institutional services. It reduces a client’s gross income only by the exclusions allowed by federal statute as described in WAC 388-513-1340. 

Federal Language regarding using gross income (before deductions) when comparing to the Medicaid SIL:

LIMITATIONS ON FFP.  Title 42: Public Health
PART 435—ELIGIBILITY IN THE STATES, DISTRICT OF COLUMBIA, THE NORTHERN MARIANA ISLANDS, AND AMERICAN SAMOA
Subpart K—Federal Financial Participation
Limitations on FFP

§ 435.1005   Recipients in institutions eligible under a special income standard.

For recipients in institutions whose Medicaid eligibility is based on a special income standard established under §435.236, FFP is available in expenditures for services provided to those individuals only if their income before deductions, as determined by SSI budget methodology, does not exceed 300 percent of the SSI benefit amount payable under section 1611(b)(1) of the Act to an individual in his own home who has no income or resources.

[58 FR 4933, Jan. 19, 1993]

CLARIFYING INFORMATION

1. Special income level (SIL): The department compares a client’s non-excluded income to the SIL to determine whether a client is eligible for LTC services under the institutional CN program.
   1. The SIL is equal to 300% of the annually adjusted SSI Federal Benefit Rate (FBR).
   2. The department does not allow income disregards when determining eligibility for CN services. It reduces a client’s gross income only by the exclusions allowed by federal statute as described in WAC 388-513-1340. 
   3. Income disregards not allowed before doing the SIL comparison are the $20 disregard and 65 ½ earned income deduction and Impairment Related Work Expenses (IRWE). 
   4. The SIL is the maximum amount allowed by law as the CN income standard for institutional Medicaid.
2. Disabled Adult Children (DAC), Pickle/COLA, Widowers, SSI clients and SSI clients because of 1619B status.  How does the SIL affect their eligibility for HCBS Waiver programs.   
   1. Clients who are on SSI and are considered eligible for SSI by Social Security Administration (1619B) or Deemed eligible for SSI (Protected DAC, Widowers, Pickle/COLA ) who have countable income under the SSI Standard.  These clients may have gross income above the SIL. 
   2. Clients who are eligible to receive non-institutional CN-P Medicaid based on countable income below the SSI standard do not need to meet the SIL criteria for institutional Waiver Medicaid.  These clients are already eligible for CN-P Medicaid because their countable income is under the SSI standard. 
   3. They are receiving SSI or considered a SSI client due to 1619B status with Social Security Administration.  It is possible that a 1619B status client can have gross income over the SIL because of their earnings.  A 1619B client is treated just like a SSI client.  Their eligibility is maintained by the Social Security Administration and they do not need to submit eligibility reviews to DSHS for Medicaid eligibility.  The SDX gives information on clients having 1619B status and to continue the CN-P Medicaid eligibility. 
   4. Client’s deemed “SSI eligible” such as the disabled adult child (DAC), Pickle/COLA and Widowers group because their countable income after the allowable exclusion    is under the SSI standard can have gross income over the SIL, but as long as this group is eligible for CN-P under the S02 program, they are financial eligible for the HCS or DDD Waiver and do not participate toward their personal care. 
   5. Not all clients receiving DAC are considered deemed SSI clients if their non DAC countable income is over the SSI standard.  Clients receiving DAC benefits who have other countable income (after the DAC and other SSI related exclusions) UNDER the SSI standard are called “protected DAC” clients. 
   6. These clients are eligible for non institutional CN-P medicaid (S02 in ACES).  Clients receiving DAC benefits who have countable income after SSI related exclusions OVER the SSI standard are not considered protected DAC, they are not automatically eligible for a CN-P program and their countable income is considered in determining Medicaid eligibility. 
   7. These clients do need to meet specific eligibility criteria for long-term care services.  Transfer of asset penalties and excess home equity (WAC 388-513-1350 (7)) apply to Waiver and institutional long-term care services.  Transfer of asset penalties and excess home equity criteria does not apply to MPC services. 
   8. For more information on SSI related exclusions including DAC, Pickle/COLA and Widowers: