Participation

Revised April 25, 2008

Purpose:

Determining a client's financial participation in the cost of care for long-term care (LTC) services

WAC 388-513-1380

Effective July 17, 2008

WAC 388-513-1380 Determining a client's financial participation in the cost of care for long-term care (LTC) services

This rule describes how the department allocates income and excess resources when determining participation in the cost of care (in the post-eligibility process). The department applies rules described in WAC 388-513-1315 to define which income and resources must be used in this process.

For a client receiving institutional or hospice services in a medical institution, the department applies all subsections of this rule.
For a client receiving waiver services at home or in an alternate living facility, the department applies only those subsections of this rule that are cited in the rules for those programs.
For a client receiving hospice services at home, or in an alternate living facility, the department applies rules used for the community options program entry system (COPES) for hospice applicants with income under the Medicaid special income level (SIL). (300% of the Federal Benefit Rate (FBR)), if the client is not otherwise eligible for another noninstitutional categorically needy Medicaid program. (Note: For hospice applicants with income over the Medicaid SIL medically needy Medicaid rules apply.)
The department allocates nonexcluded income in the following order and the combined total of (4)(a), (b), (c), and (d) cannot exceed the medically needy income level (MNIL):
1. A personal needs allowance (PNA) of:
  1. One hundred sixty dollars for a client living in a state veterans' home;
  2. Ninety dollars for a veteran or a veteran's surviving spouse, who receives the ninety dollar VA improved pension and does not live in a state veterans' home; or
  3. Forty-one dollars and sixty-two cents for all clients in a medical institution receiving general assistance.
  4. Effective July 1, 2007 through June 30, 2008 fifty-five dollars and forty-five cents for all other clients in a medical institution. Effective July 1, 2008 this PNA increases to fifty-seven dollars and twenty-eight cents.
  5. Current PNA and long-term care standards can be found at http://www.dshs.wa.gov/manuals/eaz/sections/LongTermCare/LTCstandardspna.shtml
2. Mandatory federal, state, or local income taxes owed by the client.
3. Wages for a client who:
  1. Is related to the supplemental security income (SSI) program as described in WAC 388-475-0050(1) ; and
  2. Receives the wages as part of a department-approved training or rehabilitative program designed to prepare the client for a less restrictive placement. When determining this deduction employment expenses are not deducted.
4. Guardianship fees and administrative costs including any attorney fees paid by the guardian, after June 15, 1998, only as allowed by chapter 388-79 WAC.
The department allocates nonexcluded income after deducting amounts described in subsection (4) in the following order:
1. Income garnisheed for child support or withheld according to a child support order in the month of garnishment (for current and back support):
  1. For the time period covered by the PNA; and
  2. Is not counted as the dependent member's income when determining the family allocation amount.
2. A monthly maintenance needs allowance for the community spouse not to exceed, effective January 1, 2008, two thousand six hundred ten dollars, unless a greater amount is allocated as described in subsection (7) of this section. The community spouse maintenance allowance is increased each January based on the consumer price index increase (from September to September http://www.bls.gov/cpi/home.htm). Starting January 1, 2008 and each year thereafter the community spouse maintenance allocation can be found in the long-term care standards chart. The monthly maintenance needs allowance:
3. 1. Consists of a combined total of both:
    1. One hundred fifty percent of the two person federal poverty level. This standard increases annually on July 1st (http://aspe.os.dhhs.gov/poverty/); and
    2. Excess shelter expenses as described under subsection (6) of this section; and
  2. Is reduced by the community spouse's gross countable income; and
  3. Is allowed only to the extent the client's income is made available to the community spouse.
4. A monthly maintenance needs amount for each minor or dependent child, dependent parent or dependent sibling of the community spouse or institutionalized person who:
  1. Resides with the community spouse:
    1. In an amount equal to one third of one hundred fifty percent of the two person federal poverty level less the dependent family member's income. This standard increases annually on July 1st. (http://aspe.os.dhhs.gov/poverty/)
  2. Does not reside with the community spouse or institutionalized person, in an amount equal to the MNIL for the number of dependent family members in the home less the dependent family member's income.
  3. Child support received from noncustodial parent is the child's income.
5. Medical expenses incurred by the institutional client and not used to reduce excess resources. Allowable medical expenses and reducing excess resources are described in WAC 388-513-1350.
6. Maintenance of the home of a single institutional client or institutionalized couple:
  1. Up to one hundred percent of the one-person federal poverty level per month;
  2. Limited to a six-month period;
  3. When a physician has certified that the client is likely to return to the home within the six-month period; and
  4. When social services staff documents the need for the income exemption.
For the purposes of this section, "excess shelter expenses" means the actual expenses under subsection (6)(b) less the standard shelter allocation under subsection (6)(a). For the purposes of this rule:
1. The standard shelter allocation is five hundred fourteen dollars. This standard is based on thirty percent of one hundred fifty percent of the two person federal poverty level. This standard increases annually on July 1st. (http://aspe.os.dhhs.gov/poverty/) and
2. Shelter expenses are the actual required maintenance expenses for the community spouse's principal residence for:
  1. Rent;
  2. Mortgage;
  3. Taxes and insurance;
  4. Any maintenance care for a condominium or cooperative; and
  5. The food stamp standard utility allowance for four persons, provided the utilities are not included in the maintenance charges for a condominium or cooperative.
The amount allocated to the community spouse may be greater than the amount in subsection (6)(b) only when:
1. A court enters an order against the client for the support of the community spouse; or
2. A hearings officer determines a greater amount is needed because of exceptional circumstances resulting in extreme financial duress.
A client who is admitted to a medical facility for ninety days or less and continues to receive full SSI benefits is not required to use the SSI income in the cost of care for medical services. Income allocations are allowed as described in this section from non-SSI income.
Standards described in this section for long-term care can be found at: http://www.dshs.wa.gov/manuals/eaz/sections/LongTermCare/LTCstandardspna.shtml

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.

CLARIFYING INFORMATION

Participation - the post-eligibility determination:

Participation is determined after a client is found eligible for long-term care (LTC) services. This determination sets the amount the client must contribute toward the cost of care. For a client who is married or has dependent family members, this process also determines how much of the client's income is allocated to the spouse and/or family members.

For a client who lives in a medical facility, the department allocates nonexcluded income according to WAC 388-513-1380. For a client who lives at home or in an alternate living facility (ALF) and receives waiver services, the department allocates nonexcluded income according to WAC 388-515-1505 (HCS CN-P Waivers), WAC 388-515-1510 (DDD Waivers). For the HCS Medically Needy Waivers see MNIW for MN in home and MNRW for MN residential services.

Clients who live in an ALF must contribute to the cost of room and board, which they pay directly to the facility. Income that remains after deductions for the personal needs allowance and other allocations are taken is the amount the client must participate in the cost of personal care. Each of programs that provides waiver services has specific rules the department follows when determining how much a client pays toward the costs of board and room and personal care.

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

Institutional standards used in determining initial and post eligibility (participation) in long term care change annually. Depending on the standard, these changes occur in January, April, July and August. See the Institutional standard chart for current standards used in long term care. This chart indicates the formula for the standard and when the standard last changed.

SSI income:

Typically, when an individual enters a medical facility, the Social Security Administration (SSA) reduces the SSI cash payment to $30 per month. The full SSI benefit is continued, if SSA determines the individual's stay in the facility is not likely to exceed three months and the individual has expenses for maintaining a home. When SSA has made such a determination, the full SSI benefit/State supplementary payment (SSP) is continued and is excluded in the post-eligibility process. The SSI/SSP benefit is not excluded, however, when determining the amount a client must contribute toward the cost of room and board when living in an alternate living facility (ALF).

Personal needs allowance (PNA) for clothing, personal items and incidentals (CPI):Client's are allowed the highest personal needs allowance in a given month based on living arrangement, authorized service and marital status. If a client resided at home the first day of the month and went into a nursing home the same day, we would allow the in home PNA because they were residing in a home setting at least one moment during that given month. If a client went from a nursing home to an adult family home on COPES services the first day of the month, we would allow the COPES ALF PNA as it is the highest allowed. If that client were then discharged home on COPES from the ALF on the last day of the month, the benefit would be recalculated allowing the COPES in home PNA.

Hospice program:

Participation in the cost of care for hospice services received in a medical facility is determined according to WAC 388-513-1380. The client pays their participation amount to the hospice agency. Participation for hospice services received in a client's home is determined according to WAC 388-515-1505 that describes rules used for the Community Options Program Entry System (COPES) program. The client pays their participation amount to the COPES provider.Hospice eligibility cases are high priority cases. Clients who elect hospice services have a terminal illness with a prognosis of six months or less. Hospice information.

Veterans benefits: VA Benefits chart and clarifying information.

Guardianship fees Guardianship fees described in WAC 388-79 are allowed as a post eligibility deduction when determining participation for long-term care Medicaid programs.

Change of circumstances:The reporting requirements for LTC clients are described in WAC 388-418-0005. See CHANGE OF CIRCUMSTANCES for additional information. When taking action on a change in the client's circumstances, advance notice is not required with participation changes, but adequate notice is always required.

WORKER RESPONSIBILITIES

Deduct from the client's nonexcluded income the appropriate amount for the client's personal needs allowance or maintenance needs amount. Use rules that apply to the specific program for which the client is approved when determining the appropriate amount.
To reduce excess resources, deduct amounts for medical expenses for which the client is liable. WAC 388-513-1350.
To reduce participation, deduct medical expenses not already used to reduce excess resources as described in WAC 388-513-1350. Medical expenses referred to in numbers two and three include, but are not limited to the following:
1. Medicare premium for the first two months; limit this to the first two months, if the client will be approved for the QMB program.
2. Health insurance premiums for the month in which the premium is either billed, due or paid.
3. Medically necessary items not covered by Medicaid. Such expenses include current out-of-pocket expenses and payment for medical bills incurred prior to eligibility for medical assistance.
4. A medical deduction from participation that is a covered item under the state plan is not allowed as a deduction if the client was on Medicaid during the date of service.
  
  There are some exceptions, the care has to be reasonably available.
  
  Example: Many dentists do not accept Medicaid. There are areas in the state where there isn't a Medicaid provider located within a reasonable distance. We will allow a dental medical expense if the client is unable to find a provider to accept medicaid or cannot reasonably travel to a dentist that accepts medicaid.
  
  If we do an exception, the reasoning has to be documented and it should not happen often.
  
  We do not allow a medical expense deduction at a private rate if the care/expense is available at the Medicaid rate.

NOTE:

A client must receive continued assistance, if all of the following conditions apply:

Advance notice is not required.

Adequate notice is mailed less than ten days before the effective date.

A fair hearing is requested within ten days of the date the letter is mailed.

Advance notice is not required to change a client's participation in the cost of care, since no reduction, suspension, or termination of services will result. A change in the participation amount is not considered an adverse action.

NOTE:

Do not deduct an amount for medical expenses for which the client was given a reduction of income and/or resources to meet participation or spenddown obligations in the past. It does not matter whether or not the client paid the previous amount.

Allocate the income of a client who is married to a community spouse as described in WAC 388-513-1380 . Always request an exception to rule (ETR) for allocating the client's income to a former spouse when the Court has ordered a spousal maintenance amount to be paid.
When both spouses are receiving LTC services, allocate the income according to the maintenance needs amount provided under the program from which services are received..

EXAMPLE

The amount of nonexcluded income that is allocated from a client in a medical facility who is married to a spouse receiving COPES in the home is limited to the maintenance needs amount provided under the COPES program

NOTE:

The maximum community spouse maintance allowance includes any excess shelter costs.

Allocate the income of a client with a community spouse and a dependent family member by determining the monthly maintenance needs amount in the following way:
1. Subtract nonexcluded income of the dependent from the family allocation standard.
2. Divide that amount by three.
Allocate the income of a client with dependent family members, but no community spouse, by determining the monthly maintenance needs amount in the following way:

Subtract the dependents' total nonexcluded income from the MNIL standard for the number of legal dependents living in the home.

For all LTC services, send service providers and facilities an award letter in order to bill correctly and to receive the correct amount of participation from the client. Each change in status and/or living arrangements requires an award letter.
For a client who chooses to stop receiving hospice services, tell the client to obtain and keep a copy of the "revocation" form from the hospice agency. Most medical providers, including pharmacists, will deny services to a client whose medical card indicates hospice services, since the hospice agency is otherwise responsible for all the client's medical needs.
Complete and update as necessary the AREP screen to identify individuals or agencies who need to receive a copy of client notices, e.g., hospice agencies, social workers, case managers, guardians, authorized representatives, and protective payees.
When a client changes providers or facilities during the month, the participation amount may need to be split between the two. Assign any participation amount the client does not owe the first provider or facility to the second one.
Treat hospice revocation or discharge like any other change from one nursing facility to another.See hospice. Since excluded income amounts can sometimes be quite high, consider the amount excluded in terms of how soon the client's resources may exceed the resource standard. Establish a "tickler" to review resources periodically.
When changes in the participation amount are made and confirmed within ACES, the system automatically generates a notice to the client/ representative. Since some notices do not contain enough information, add sufficient freeform text to explain what changes are being made and the reason for them. If appropriate, suppress the notice and generate a letter to replace the notice. Situations for which a new notice and letter are appropriate include, but are not limited to the following:
1. Correct a previous award letter/notice.
2. Make a retroactive change per a fair hearing decision.
3. Make a change in participation per a court order.
4. Make a change in the Health insurance premium that is paid quarterly.
5. The beginning date of hospice care
6. A change in hospice agencies
7. Client chooses to stop receiving hospice services
8. Client enters a medical facility for non-respite care
9. Client leaves a facility or dies
When a client dies, review the participation amount assigned in the current award letter. Determine the actual cost of care for services provided using the daily department-contracted rate. If the client's cost of care is less than the participation amount, send an amended award letter that equates the participation amount with the actual cost of care. If the client's cost of care is more than the participation amount, do not change the amount before closing the case.
When a client loses institutional status e.g., is no longer eligible for COPES, redetermine the client's eligibility for non-institutional medical in the following way:
1. Use information in the case record (ACES) unless you need further verification. If a client was CN eligible before losing COPES eligibility, continue CN until you have redetermined the client's eligibility.
2. If the client remains eligible for medical care, change the appropriate ACES screens, complete and send the client a new award letter through the ACES system.
Follow necessary supplemental accommodation (NSA) procedures.

ACES PROCEDURES

See Long Term Care, Alternate Care and Waivered Services

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