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Waiver Services - HCS MNP - Medically Needy Residential Waiver Program (MNRW) - F - Scenarios

Revised October 28, 2007

Purpose:

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

Clarifying Information 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. 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; Is eighteen years of age or older; Meets the SSI related criteria described in WAC 388-475-0050; 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: Licensed adult family home (AFH); Assisted living (AL) facility; or Enhanced Adult Residential Care (EARC) facility. 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 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: Considers income available described in WAC 388-513-1325 and WAC 388-513-1330(1), (2), and (3); Excludes income described in WAC 388-513-1340; Disregards income described in WAC 388-513-1345; 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; 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 ); Medicare and health insurance premiums not used to meet spend down or reduce excess resources; 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.

Scenario #1 Relocating a Single, Active, Nursing Facility Client A single client, active on Medicaid in a nursing home (L95) and on S03, is identified as a potential MNRW candidate. The client’s countable resources total $1,500.00 and gross non-excluded income is $1,800.00 unearned (no earned income). In addition, the client has a $150.00 monthly health insurance premium. Active slots are available. The Social Services Worker (SSW) sends a 14-443 (updated Financial/Social Services Communication form) to the Financial Services Specialist (FSS) indicating that the client meets MNRW level of care (LOC), the anticipated facility’s daily rate is $69.90, and the client is expected to admit on 4/1/03. The FSS uses this information to determine if client is financially eligible for MNRW. The FSS can use the MNRW Trial Eligibility Calculator located on the MNRW Website. Eligibility is determined as follows: Resources:  Client’s resources are below the $2,000.00 standard for a single individual. The client is resource eligible. Income: Part 1 - Initial Income Calculation Unearned Income minus General Disregard: $1,800.00  - $20.00 $1,780.00   Countable Unearned Income +        0.00   No Earned Income $ 1,780.00  Net Available Income -      150.00    No Health Insurance Premiums $ 1,630.00  Total Countable Income Part 2 - Cost of Care Calculation: A. Multiply $69.90 X 30.42 = $2,126.35 anticipated residential facility’s Average Monthly Rate Part 3 - Income and Cost of Care Comparison: A. Compare Total Countable Income to facility’s Average Monthly Rate: $1,630.00 Total Countable Income is less than $2,126.35 Facility Rate Since the Total Countable Income is less than the residential facility’s Average Monthly Rate, the client does not have Excess Income; therefore, the client does not have a Spenddown and is income eligible for MNRW services at the anticipated residential facility. Part 4 - Determining Spenddown: There is no Excess Income so go to Part 5. Part 5: Calculating Client Responsibility: Month 1 and ongoing: $1,800.00  Gross Non-excluded Unearned Income -       58.84  PNA (admit on 4/1) -     150.00  Monthly Health Insurance Premium $ 1,591.16  Client’s Responsibility Towards Cost of Care Based on the Financial Eligibility determination, the client is eligible for MNRW at the anticipated residential facility. The client’s responsibility toward the cost of care will be $1,591.16 per month. Once the financial eligibility determination has been made and the client responsibility calculated, the FSS advises the SSW that the client is financially eligible what the client’s responsibility will be at the facility. The FSS gives this information to the SSW via the ACES 0065-10 LTC Communication. The SSW can now relocate the client from the nursing home and authorize MNRW services. SSW must advise the FSS on a 14-443 the actual date the services began. When the FSS receives the 14-443 stating the date services began, the FSS can open MNRW medical (G95) in the ACES system, manually issue award letters, and input the client into the MNRW Database via the MNRW website. Fast responses are essential from both the FSS and the SSW. Do not allow the Medicare premium as a deduction, as the state is already paying this premium. Even though the S03 will terminate when the MNRW medical is opened (G95), the state will continue to pay the premium through the state-pay buy-in process.  If there are any changes in the client’s level of care, facility rate, or relocation date, the SSW must immediately notify the FSS. Changes may affect a client’s eligibility for the program or responsibility towards cost of care for the initial month. If there are any changes in income, resources, or allowable deductions that affect a client’s financial eligibility for the program or responsibility towards cost of care, the FSS must notify the SSW immediately.  If there are no active slots, the FSS advises the SSW that although the client is financially eligible, there are no active slots so the client will be placed on the waiting list. The FSS will enter the client into the MNRW database and code the client to be on the waiting list. The client’s current SNF program will continue.

Scenario #2 Single Client Admit Mid-month From Home Client is not currently on Medicaid and is living at home. Single client applies on 4/1/03 for LTC assistance. Client’s non-excluded resources on 4/1/03 are $2,200.00. Client has an old hospital bill for necessary medical care with a balance owing of $300.00. This is the amount still owing after all 3rd parties have paid and the client is responsible for the balance. Client’s non-excluded gross income is $1,700.00. In addition, the client pays a quarterly health insurance premium of $300.00. The FSS completes an ACES 0065-10 LTC Communication - Internal and sends to the SSW (through region’s normal intake/referral process) advising SSW client is requesting MNRW services and a functional assessment and daily rate are needed. Active slots are available. The SSW assesses client and sends a 14-443 to FSS informing that the client meets MNRW LOC, the anticipated residential facility for placement has a daily rate of $65.76, and the client is expecting to admit on 4/10/03. FSS uses this information to determine if the client is financially eligible for MNRW and will inform the SSW of the determination. FSS can use the MNRW Trail Eligibility Calculator on the MNRW Website. Eligibility is determined as follows: Resources: Client has $2,200.00 in countable resources and an incurred medical expense of $300.00. Use the medical bill to disregard the $200.00 of excess resources. This will bring the client’s resources down to the standard. Use the remaining $100.00 from this expense to reduce the client’s responsibility towards the cost of care for the first month. Income: Part 1: Initial Income Calculation Unearned Income minus General Disregard $1,700.00  - $20.00 $1,680.00   Countable Unearned Income +        0.00   No Earned Income $ 1,680.00  Net Available Income -     100.00    No Health Insurance Premiums $ 1,580.00  Total Countable Income   REMEMBER! The client pays a quarterly health insurance of $300.00. The amount that represents the premium for 1 month is $100.00. We can allow $100.00 in this initial income eligibility calculation. Part 2: Cost of care Calculation A. Multiply $69.90 per day X 30.42 = $2,126.35 anticipated facility’s Average Monthly Rate Part 3: Income and Cost of Care Comparison A. Compare the Total Countable Income to the facility’s Average Monthly Rate: $1,580.00 Income is less than $2,126.35 Cost of Care Because the client’s Total Countable Income of $1,580.00 is less than the facility’s Average Monthly Rate of $2,126.35, the client has no excess income and is MNRW eligible, without spenddown at the anticipated facility. Part 4 - Determining Spenddown There is no Excess Income so go to Part 5. Part 5: Calculating Client Responsibility Since client is not active and will be admitting from home, we can allow the Medicare premiums for months 1 and 2. In addition, the PNA amount for month 1 will be higher than the other months because the client is anticipating admitting to the facility mid-month. Month 1 (admit month) - April 2003   $1,700.00   Income -    571.00   Less PNA -   1 00.00   Less Health Ins*** -      58.70   Less MED A (Month 1 & 2 only) -    100.00   Outstanding Med $   870.30   Month 1 Client Responsibility Month 2 - May 2003:   $1,700.00   Income -       58.84   Less PNA -     100.00   ***Less Health Ins -        58.70  Less MED A $ 1,482.46   Month 2 Client Responsibility Month 3 - May 2003   $1,700.00    Income -       58.84   Less PNA -     100.00   ***Less Health Ins $ 1,541.16   Month 3 and ongoing Client Responsibility The FSS advises the SSW via the ACES 0065-10 LTC Communication that the client is financially eligible and what the client responsibility will be. The SSW can now authorize placement and MNRW services for the client in the facility. SSW must advise the FSS on the DSHS 14-443 the actual date the services began. When the FSS receives this DSHS 14-443 then MNRW medical (G95) can be opened in ACES. In addition, the FSS can manually issue award letters and input the client into the MNRW Database via the MNRW website. Fast responses are essential from both the FSS and the SSW. ***We can allow a prorated share of the medical insurance premium (the amount that represents 1 month’s premium) if the client understands that we are allowing it as a prorated expense; but the client must still pay it when it is due. The FSS or the SSW must make this very clear to the client that we will not allow it again when it is paid since we are prorating it monthly. If the client cannot budget their income so the money will be available, then we should allow the expense in the month paid, only, and not as a prorated share. In addition, the client must understand that if their resources exceed the resource standard because they are not paying their premium monthly, then they will be ineligible for MNRW and may be terminated from services. Do not open S03. Clients on MNRW are not eligible for S03. Beginning with the third month of eligibility, the state will pay the Medicare part B premium through the state-pay buy-in process. If there are any changes in the client’s level of care, facility rate, or relocation date, the SSW must immediately notify the FSS. Changes may affect a client’s eligibility for the program or responsibility towards cost of care. If there are any changes in income, resources, or allowable deductions that affect a client’s financial eligibility for the program or responsibility towards cost of care, the FSS must notify the SSW immediately.  If there are no active slots, the FSS will advise the SSW that the client is financially eligible but there are no active slots and the client must be placed on a waiting list. The SSW cannot place the client or authorize MNRW benefits. The FSS determines eligibility for other medical programs, at the client’s discretion. If the client does not want any other medical, the MNRW application is denied. The FSS enters the client into the MNRW database and codes the client to be put on the waiting list.

Scenario #3 Married Client Relocating From NF A married client is in the nursing home and active on L95. The client receives $1,700.00 in countable unearned income. Spouse lives at home and receives $3,000.00 per month of unearned income. The client has separate countable resources totaling $2,000.00. The spouse has separate countable resources totaling $23,000.00. Active slots are available. The SSW sends a DSHS 14-443 to the FSS advising that the client is MNRW LOC and is anticipating placement 4/1/03 into a facility with a daily rate of $69.90. FSS uses this information to determine if the client is financially eligible for MNRW and will inform the SSW of the determination. Eligibility is determined as follows: Resources: Because this married couple live apart, we treat their resources as if they are separate individuals. Even though the spouse has $23,000.00 in resources, they are separate and do not count in the client’s resource eligibility. The client’s separate resources are $2,000.00; therefore, the client is resource eligible for MNRW. Income: Part 1: Initial Income Calculation A. Unearned Income minus General Disregard: Use the client’s income only, do not use the spouse’s income $1,700.00  - $20.00 $1,680.00   Countable Unearned Income +        0.00   No Earned Income $ 1,680.00  Net Available Income -        0.00    No Health Insurance Premiums $ 1,680.00  Total Countable Income Part 2: Cost of care Calculation A. Multiply $69.90 per day X 30.42 = $2,126.35 anticipated facility’s Average Monthly Rate Part 3 - Income and Cost of Care Comparison: A. Compare Total Countable Income to facility’s Average Monthly Rate: $1,680.00 Total Countable Income is less than $2,126.35 Facility Rate Since the Total Countable Income is less than the residential facility’s Average Monthly Rate, the client does not have Excess Income; therefore, the client does not have a Spenddown and is income eligible for MNRW services at the anticipated residential facility. Part 4 - Determining Spenddown. There is no Excess Income so go to Part 5. Part 5: Calculating Client Responsibility: Month 1 and ongoing:   $1,700.00   Gross Non-excluded Unearned Income -      58.84   PNA (admit on 4/1) $1,641.16  Client’s Responsibility Towards Cost of Care Do not allow a spousal or dependant allocation! MNRW does not use the spousal impoverishment rules! Based on the Financial Eligibility determination, the client is eligible for MNRW at the anticipated residential facility. The client’s responsibility toward the cost of care will be $1,641.16 per month. Once the financial eligibility determination has been made and the client responsibility calculated, the FSS advises the SSW that the client is financially eligible what the client’s responsibility will be at the facility. The FSS gives this information to the SSW via the ACES 0065-10 LTC Communication. The SSW can now relocate the client from the nursing home and authorize MNRW services. The SSW must advise the FSS on a 14-443 the actual date the services began. When the FSS receives the 14-443 stating the date services began, the FSS can open MNRW medical (G95) in the ACES system, manually issue award letters, and input the client into the MNRW Database via the MNRW website.

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Modification Date: October 28, 2007

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