Non Institutional Medicaid - Examples
DSHS Home Page
 
Search     for:


DSHS Home    Acronyms    Revisions    WAC Number Index    Site Map    WCCC

Non Institutional Medicaid - Examples


Revised December 10, 2013


Examples Document For Clarifying Information Non Institutional Medicaid In An Alternate Living Facility (ALF)G03/G95/G99


Clarifying information will refer to examples. A link will take the worker to the examples rather than put in the body of the clarifying information.

Some facilities are totally private and do not contract with the department to provide services. Determine eligibility for clients in non contracted facilities as if they are in their own home:


EXAMPLE

SSI related client lives in an adult family home that is licensed and contracted with DSHS. Client's countable income is $2000. The facility is charging the client $63 per day. The facility accepts clients with paid services from DDA, HCS or the RSN. Screen in G03 in ACES, indicate the $63 private daily rate on the INST screen. Client pays the entire cost direct to the facility. Case will trickle to the appropriate medical coverage group based on the income and daily rate of the facility. Do not indicate the amount the private facility is charging as a medical expense. Adult family homes and assisted living facilities are not medical institutions; therefore it is not a medical expense.


EXAMPLE

SSI related client lives in an adult family home that is licensed and contracted with DSHS. Client has countable income of $1500. The DDA case manager determines the client is functionally eligible for MPC with a state daily rate of $50 per day and notifies financial. Screen in G03 in ACES and indicate the state daily rate on the INST screen. Indicate MPC as a service in ACES and put the case manager address on the AREP screen. Client pays available income after SSI related disregards and PNA to the facility as their total responsibility. The ACES award letter will only show medical coverage. The DDA case manager will notify the client of their cost to the adult family home.


EXAMPLE

SSI related client lives in a private licensed assisted living facility and paying privately. Facility is not contracted with DSHS or Mental Health (RSN) to provide services such as COPES or MPC. Screen in S02. Eligibility for this client is determined as if the client were in their own home. A facility must be licensed AND contracted with DSHS in order for us to use rules for the G03 program. Do not use the amount the private facility is charging the client as a medical expense. Adult family homes and assisted living facilities are not medical institutions; therefore it is not a medical expense.


EXAMPLE



SSI related client with $1500 gross income living in a licensed/state contracted adult family home. DDA case manager determines the client is functionally eligible for the DDA waiver program and notifies financial. Screen in C01 program. G03 is not used for clients on either HCS or DDA Waiver services. These clients have eligibility determined using institutional rules under the C01 program. Refer to WAC 182-515-1505 for program eligibility for the HCS waiver programs. Refer to  WAC 182-515-1510  for program eligibility for the DDA waiver programs.


EXAMPLE

SSI related client with $1575 gross income living in a licensed/state adult family home. Client is paying the facility privately at $50 per day. Screen in G03 in ACES and indicate the private daily rate on the INST screen. 1 month later, the client elects Hospice services. This client is already eligible for a CN-P program and is paying all of their available income to the adult family home. The C01/Hospice program rules are not needed for this client. This client remains on the G03 program and the Hospice care are billed to DSHS as a service. For further instructions on Hospice, see Hospice clarifying information.


Examples on choosing the correct medical coverage group/program:


EXAMPLE

DDA Client receives $300 Social Security disability and $400 Disabled Adult Child (DAC) income on MPC in an Adult Family Home. This client is eligible for CN-P S02/SSI related Medicaid. 300% of the FBR rules are not needed to make this client eligible for CN-P Medicaid. The countable income ($300 SSA disability) is under the CNIL. This client is called a protected DAC. Keep client on the S02/SSI related CN-P Medicaid program. Indicate MPC service under the HCB/MPC service field on the INST screen in ACES. Indicate the agency authorizing the service (DDA) and the service start date. The daily rate is indicated on the INST screen. Client pays the ADSA room and board standard  to the facility as room and board. Indicate the DDA address on the AREP screen for the CN-P AU.


EXAMPLE

Client receives $300 DAC income and $680 social security disability. Client's countable income ($680 SSDI) is over the CNIL. Client is not otherwise eligible for a CN-P S01 or S02 program. Non institutional Medicaid in an alternate living facility rule is needed to determine CN-P Medicaid eligibility. Screen in a G03 program. The state daily rate is $55 per day. Client keeps the MPC PNA, $20 disregard and pays the remainder of their income to the ALF including DAC income. DDA is able to authorize services under the MPC program because client is receiving CN Medicaid. Indicate MPC on the INST screen with service start date and DD as the agency authorizing the service. Indicate the DDA address on the AREP screen for the CN-P AU.


EXAMPLE

DDA client receives $300 DAC income and $1600 earned income. Client does not qualify for 1619b status or DAC exclusion because they were never on SSI. This client has gross income over the SIL/300% FPL. Client is not eligible for CN-P using non institutional Medicaid in an alternate living facility rules. This client should be considered for the Healthcare for Workers with Disability program (HWD/S08). Refer this client to the HWD specialist in your area.


EXAMPLE

DDA client receives $300 DAC income, $600 social security disability and $1000 pension from a deceased parent. Client's gross income is over the SIL/300 % FPL. Client is unable to receive MPC services with DDA as their income is over the SIL/300 % of the FPL. Client will be paying privately to the licensed contracted facility at $59 per day. Indicate the private daily rate on the INST screen. Case will trickle to a G95. Medically Needy no spenddown. Notify DDA case manager client is not eligible for CN-P coverage and will be a private pay client. This client is not eligible for MPC services.


EXAMPLE

Client receives $1900 SSDI and not on services with the HCS/DDA or RSN. Client lives in a licensed contracted adult family home; the private daily rate is $55 per day ($1705 per month). The daily rate x 31 days plus $38.84 is over the private rate. This client's case will trickle to a G99/spenddown. The department will indicate incurred or unpaid medical expenses like any other spend down case. Do not use the client's payment to the adult family home as a medical expense to meet spenddown. Adult family homes, Assisted Living facilities, Adult Residential Centers, Enhanced Adult Residential Centers are not medical facilities.


EXAMPLE

DDA client is on HWD and receiving HWD with a premium of $107 per month based on $771 SSA disability and $665 earned income. Client is placed into an adult family home under MPC. Client pays the ADSA room and board rate  in addition to the HWD premium of $107. Client remains on HWD as it is a CN-P program and more beneficial to the client. A client on HWD pays no more than the ADSA room and board rate to the facility and the HWD premium. This client would be able to retain more of their earnings under the S08/ HWD than the G03 program.


EXAMPLE

DDA client receiving $900 DAC income from social security. Client was never on SSI, therefore does not meet the criteria for a DAC exclusion. Screen in G03 in ACES as client's countable income is over the CNIL. Client keeps the MPC PNA  and the $20 disregard. The remainder of the client's income goes to the facility as total responsibility. DDA is able to authorize MPC. Indicate service code for MPC on the INST screen and DDA on the AREP screen for the G03 AU.

Modification Date: December 10, 2013