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.
To be eligible for MNRW, a client must meet the following conditions:
Does not meet financial eligibility for Medicaid Personal Care or the COPES program;
Requires 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 388-106-0400, 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;
Has attained institutional status as described in WAC 388-513-1320;
Has been determined to be in need of waiver services as described in WAC 388-106-0410;
Lives in one of the following department-contracted residential facilities:
Meets the resource and income requirements described in subsections (2) through (6).
The department determines a client's nonexcluded resources under MNRW as described in WAC 388-513-1350.
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).
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;
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;
Have not been used to satisfy a previous spend down 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 MNRW in the following way:
Deducts monthly health insurance premiums, except Medicare premiums.
If the client's countable income is:
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;
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.
That portion of a client's countable income, which is over the department-contracted rate, is called "excess income."
A client who meets the requirements for MNRW chooses a three or six month base period. The months must be consecutive calendar months.
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.
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).
In cases where spenddown has been met, medical coverage begins the day services are authorized.
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;
There are a maximum number of active participants in any waiver year. A waiver year runs from May - April.
Active slots are filled on a first come, first served basis. All slots are available statewide and are not distributed regionally.
When headquarters advises the field that all active slots have been taken, no new MNRW clients may be authorized for services without authorization from headquarters.
Once the program reaches it’s maximum participation, all clients who are determined functionally and financially eligible will be put on a wait list.
Spenddown clients must meet spenddown before being authorized for services or being placed on the wait list.
HCS Headquarters staff will monitor the active list and notify regions when all active slots are filled.
Wait List
When all active slots are filled, functionally and financially eligible clients will be placed on a wait list.
When an active slot becomes available, headquarters staff will select the next eligible client from the wait list and contact the regional HCS office. The wait list selection criteria is based on 3 factors, listed below in their order of importance:
Clients residing in nursing home
Acuity level (Level of care)
Date of request
The Social service worker must determine if the client continues to be functionally eligible and what the cost of care will be at the anticipated residential facility. Once this is done, the social services worker notifies the financial services worker via the DSHS 14-443, Financial/Social Services Communication (ADSA).
A new application or eligibility review may be required for wait list clients that are transitioning into an active slot.
For clients who are active on another Medicaid program, or are within a spenddown base period, or are not active but less than 45 days from last application:
FSS completes a desk review
Ensure the income and resources are accurate
Neither an application nor an eligibility review will be required.
For clients who are not active on another Medicaid program, are not within a spenddown base period, or are more than 45 days from last application:
Financial worker must have client complete a new application.
Financial worker will need to make a new financial eligibility determination.
An eligibility review form can be used if the client had been active on assistance but has been closed less than 30 days.
The active slot will be “held” for this client until both financial and functional eligibility decisions are made.
MNRW Database
Active participants and clients on the waiting list are tracked on the MNRW 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 services.
If there are active slots available, and services have been authorized, the FSS inputs the client into the database as active.
If there are no active slots available, but a client has been determined both functionally and financially eligible, then the FSS inputs the client data into the database as on the wait list.
Updating the Data Base
FSS field staff must keep the client database updated with current information, when known, for active clients who terminate MNRW services due to a change in eligibility or death. This frees up an active slot that can be filled by a new or wait list client.
To remove a client from an active MNRW slot, the HCS Financial worker must update the disposition code on the client data section of the website using the following codes:
TN - Terminate - Enter a nursing facility
Use this code when an active client terminates MNRW services because they have entered a nursing facility and have been out of the residential facility more than 30 days.
TD - Terminate - Death
Use this code when an active client terminates MNRW services because of death.
Wait list clients who are authorized to take an active MNRW slot
To move a wait list client into an active MNRW slot, the HCS Financial worker must change the disposition code to “A - Active” on the client data section of the website.
Wait list clients who have a change in selection criteria, such as entering or leaving a nursing home or a change in their level of care
This ensures they are given the correct priority on the wait list.
To update the client’s selection criteria data, the HCS Financial worker must update the correct client data fields in the database:
A client enters or leaves a nursing home
Yes - Client is in a nursing home
No - Client is not in a nursing home
A client has a change in level of care
Levels are based on the Social Services assessment. If the Social Services worker reports the client’s level of care has changed, update the client’s information.
Wait list clients who are no longer eligible for MNRW services
This ensures the wait list contains only those individuals who are eligible, reducing the time needed to monitor the list.
To remove a client from the MNRW wait list, the HCS Financial worker must update the disposition code on the client data section of the website using the following codes:
WD - Remove - Death
Use this code to remove a wait list client who has died.
WO - Remove - Other
Use this code to remove a client from the wait list for any other reason.
Modification Date: October 28, 2007
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