Waiver Services - HCS MNP - Medically Needy Residential Waiver Program (MNRW) - C- Income
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Waiver Services - HCS MNP - Medically Needy Residential Waiver Program (MNRW) - C- Income

Revised October 28, 2007

Purpose:
WAC 388-515-1540Medically needy residential waiver (MNRW) program

Medically needy residential waiver (MNRW) program.

WAC 388-515-1540
WAC 388-515-1540

Effective June 15, 2008

WAC 388-515-1540 Medically needy residential waiver (MNRW) program

This section describes the financial eligibility requirements for waiver services under the medically needy residential waiver (MNRW) and the rules used to determine a client's responsibility in the total cost of care.

  1. To be eligible for MNRW, a client must meet the following conditions:

    1. Does not meet financial eligibility for Medicaid Personal Care or the COPES program;

    2. Is eighteen years of age or older;

    3. Meets the SSI related criteria described in WAC 388-475-0050;

    4. Requires the level of care provided in a nursing facility as described in WAC 388-106-0355;

    5. In the absence of waiver services described in WAC 388-106-0400, would 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;

    6. Has attained institutional status as described in WAC 388-513-1320;

    7. Has been determined to be in need of waiver services as described in WAC 388-106-0410;

    8. Lives in one of the following department-contracted residential facilities:

      1. Licensed adult family home (AFH);

      2. Assisted living (AL) facility; or

      3. Enhanced Adult Residential Care (EARC) facility.

    9. Is not subject to a penalty period of ineligibility for the transfer of an asset as described in WAC 388-513-1363, 388-513-1364,388-513-1365  and 388-513-1366; and

    10. Meets the resource and income requirements described in subsections (2) through (6).

  2. The department determines a client's nonexcluded resources under MNRW as described in WAC 388-513-1350.

  3. Nonexcluded resources, after disregarding excess resources described in (4), must be at or below the resource standard described in WAC 388-513-1350 (1) and (2).

  4. In determining a client's resource eligibility, the department disregards excess resources above the standard described in subsection (3) of this section:

    1. In an amount equal to incurred medical expenses such as:

      1. Premiums, deductibles, and co-insurance/co-payment charges for health insurance and Medicare premiums;

      2. Necessary medical care recognized under state law, but not covered under the state's Medicaid plan;

      3. Necessary medical care covered under the state's Medicaid plan.

    2. As long as the incurred medical expenses:

      1. Are not subject to third-party payment or reimbursement;

      2. Have not been used to satisfy a previous spend down liability;

      3. Have not previously been used to reduce excess resources;

      4. Have not been used to reduce client responsibility toward cost of care; and

      5. Are amounts for which the client remains liable.

  5. The department determines a client's countable income under MNRW in the following way:

    1. Considers income available described in WAC 388-513-1325 and WAC 388-513-1330(1), (2), and (3);

    2. Excludes income described in WAC 388-513-1340;

    3. Disregards income described in WAC 388-513-1345;

    4. Deducts monthly health insurance premiums, except Medicare premiums.

  6. If the client's countable income is:

    1. Less than the residential facility's department-contracted rate, based on an average of 30.42 days in a month the client may qualify for MNRW subject to availability per WAC 388-71-0465;

    2. More than the residential facility's department-contracted rate, based on an average of 30.42 days in a month the client may qualify for MNRW when they meet the requirements described in subsections (7) through (9), subject to availability per WAC 388-71-0465.

  7. That portion of a client's countable income, which is over the department-contracted rate, is called "excess income."

  8. A client who meets the requirements for MNRW chooses a three or six month base period. The months must be consecutive calendar months.

  9. A client who has or will have "excess income" is not eligible for MNRW 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.

  10. Medical expenses described in subsection (4) of this WAC may be used to meet spenddown if not already used in subsection (4) of this WAC to disregard excess resources or to reduce countable income in subsection (5)(d).

  11. In cases where spenddown has been met, medical coverage begins the day services are authorized.

  12. 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:

    1. An earned income deduction of the first sixty-five dollars plus one-half of the remaining earned income;

    2. Personal needs allowance (PNA) described in WAC 388-515-1505. (Long-term care standards can be found at http://www.dshs.wa.gov/manuals/eaz/sections/LongTermCare/LTCstandardspna.shtml );

    3. Medicare and health insurance premiums not used to meet spend down or reduce excess resources;

    4. Incurred medical expenses described in (4) not used to meet spend down or reduce excess resources described in WAC 388-513-1350.

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.

Income Eligibility

  1. To be eligible for MNRW without spenddown, a client’s countable income must be no more than their cost of care. The cost of care is the department contracted residential facility rate X 30.42 days per month.

  2. If the client’s countable income is more than the cost of their care, then the client will need to meet a spenddown before they can be authorized for services or placed on the wait list.

  3. Because we are not using the Spousal Impoverishment Rules for married clients, use the “Name on the Check” rule described in WAC 388-513-1330  (2).

Countable Income

Countable income for the MNRW program is the income available after:

  1. Excluding income described in  Long Term Care - Excluded Income - WAC 388-513-1340;

  2. Applying the Medically Needy disregards that are described in Long Term Care - Excluded Income -  WAC 388-513-1345; and

  3. Deducting monthly health insurance premiums except Medicare.

Excluded Income

Exclude the income sources identified in Long Term Care - Excluded Income -  WAC 388-513-1340.  Do not count excluded income when determining eligibility or the client’s responsibility towards cost of care.

Medically Needy Income Disregards

Allow the Medically Needy income disregards found in Long Term Care - Excluded Income -  WAC 388-513-1345.

  1. $20 General Disregard: This disregard is used to reduce earned unearned income first, then earned income.

  2. $65 ½ Earned Income Disregard from the earned income:

    1. Clients with earned income can receive this disregard. This disregard is applied against the earned income, only. Do not use any unearned income when calculating this disregard.

    2. The Earned Income disregard is calculated as follows:

      Using the client’s gross income, first subtract $65. Next, divide the difference in ½. Add $65 to the result. The sum is the disregard.

Monthly Health Insurance Premiums

  1. Allow monthly health insurance premiums both in the financial eligibility determination process and the client responsibility calculation.

  2. For MNRW clients who pay health insurance premiums that are not monthly, such as bi-monthly, quarterly, semi-annually, or annually:

    1. In the Countable Income Calculation:

      Determine the portion of the premium that represents the amount for 1 month and use that in your calculation of countable income.


EXAMPLE

Client has a quarterly health insurance premium of $300. Since a quarterly premium represents a total of 3 months, then 1/3 of that would be for 1 month. Therefore, $100 represents the amount for 1 month.

To determine if the client is income eligible, we would deduct $100 from the total of the net unearned income and net earned income (amount after applying exclusions and disregards). The remainder is Countable Income.

  1. In the Client’s Responsibility Toward Cost of Care Calculation:

    1. The client can choose to prorate their health insurance premium and allow a “monthly” premium.

    2. However, before prorating premiums ensure that the client understands he or she is being allowed the deduction monthly rather than when the premium is due and the client is still responsible to pay the entire premium when billed.

    3. In addition, it is important to ensure clients understand that if their resources go over the standard because they are not spending the premiums as we are allowing them, then they will be ineligible and possibly terminated from services.

    4. If clients are not able to handle “saving” the prorated amount each month to pay when billed, then do not prorate the premiums and allow the premiums as deductions in the month they are paid.


Initial Income Eligibility Examples

EXAMPLE

A client has gross available, non-excluded unearned income of $2000.00. The client does not have a health insurance premium. The client’s residential facility daily rate is $68.52.

Step 1: Determine Countable Income

Allow the General Disregard

$2,000.00 Income

- $20.00 General Disregard

$1,980.00 Countable Income

Step 2: Determine Cost of Care

$68.52 Daily Rate

X 30.42

$ 2,084.37 Cost of Care at Residential Facility

Because the client’s countable income of $1980.00 is below the Cost of Care calculation of $2084.37, this client is income eligible for the MNRW program.

EXAMPLE

A client has gross available, non-excluded unearned income of $2,200.00. In addition, the client has private health insurance with a $150.00 per month premium. The daily rate at the anticipated residential facility is $68.52.

Step 1: Determine Countable Income

Allow the General Disregard

$2,200.00 Income

      - 20.00 General Disregard

$2,180.00

Allow the monthly Health Insurance Premium

$2,180.00

   - 150.00 Monthly Health Insurance Premium

$2,030.00 Countable Income

Step 2: Calculate the Cost of Care

    $68.52 Daily Rate

X   30.42

$2084.37 Cost of Care at Residential Facility

Because the client’s countable income of $2030 is below the Cost of Care calculation of $2084.37, this client is income eligible for the MNRW program.

EXAMPLE

A client receives the following income gross income:

$1250 Social Security

$  800 Pension

$  150 VA Aid & Attendance

The daily rate at the anticipated residential facility is $69.90.

Step 1: Determine Countable Income:

A. Exclude the VA Aid & Attendance

The VA Aid & Attendance is excluded income per WAC 388-513-1340  . Do not count the Aid & Attendance in the calculation.

B. Add together the Social Security and Pension income.

$1,250.00

+    800.00

$ 2,050.00  Income

C. Allow the General Disregard:

$2,050.00 Income

-     $20.00 General Disregard

$2,030.00 Countable Income

Step 2: Determine Cost of Care:

$     69.90 Daily Rate

X     30.42

$2,126.35 Cost of Care at Residential Facility

Because the countable income of $2030 is less than the cost of care of $2,126.35, the client is income eligible for the MNRW program. 

EXAMPLE

A client has gross available, non-excluded unearned income of $2,000.00. The daily rate and the anticipated residential facility is $51.52.

Step 1: Determine Countable Income

Allow the General Disregard

$2,000.00 Income

- $    20.00 General Disregard

$ 1,980.00 Countable Income

Step 2: Determine the Cost of Care

$    51.52 Daily Rate

X    30.42

$1567.23 Cost of Care

Because the client’s countable income exceeds the cost of care, the client must meet a spenddown before authorizing MNRW services or being placed on the waiting list.

Step 3: Calculating Spenddown

For MNRW, the spenddown for 1 month is the difference between the countable income and the monthly cost of care. Calculate the spenddown for each month of the base period. Add together the spenddown for all months in the base period. This total is the total spenddown for this base period.

Assuming there are no expected changes in the client’s income or cost of care during the base period:

$1980.00 Countable Income

- 1567.23 Cost of Care

$ 412.77 Spenddown for 1 month

X           3 Months

$1238.31 Spenddown for 3-month Base Period

or

$ 412.77 Spenddown for 1 month

X           6 Months

$2476.62 Spenddown for 6-month Base Period 

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Modification Date: October 28, 2007
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