Waiver Services - HCS MNP - Medically Needy Residential Waiver Program (MNRW) - D - Determining Cost of Care and Client Responsibility
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Waiver Services - HCS MNP - Medically Needy Residential Waiver Program (MNRW) - D - Determining Cost of Care and Client Responsibility

Revised December 31, 2007

Purpose:
WAC 388-515-1540Medically 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.

Calculating Cost of Care

DSHS uses the daily rate for the community residential facility. In order to project what the cost would be monthly, multiply the specific facility’s daily rate X 30.42. The result is the projected monthly cost of care.


EXAMPLE

  1. A client is in, or considering to go into, a facility with a daily rate of $62.92.

  2. Multiply this rate by 30.42. The result is $1914.02.

  3. To be eligible for MNRW without spenddown, the client’s countable income must be at or below this rate.

MNRW and Spenddown

  1. Spenddown is the amount of countable income over the facility’s contracted rate for a 30.42-day month.

  2. Clients must incur medical expenses of at least the total spenddown amount for the base period and provide proof to the department before we can:

    1. Authorize MNRW services; or

    2. Place the client on the wait list.

  3. If you are considering approving MNRW for a client with spenddown, you must ensure the client will meet their spenddown at the beginning of every base period. Otherwise, it would be a disservice to relocate a client from the nursing home if he or she cannot maintain MNRW eligibility.

  4. If a client’s spenddown is so low that he or she will meet spenddown within one or two days of the base period, work with the client or the representative to get the bill into the HCS office at the beginning of the base period.

  5. For spenddown clients at each eligibility review, do not remove them from an active slot at the end of the certification period unless they cannot meet spenddown in the first 30 days of the new base period.

Client Responsibility Toward Cost of Care

Active MNRW clients must contribute towards their cost of care. The client’s responsibility is calculated using their gross non-excluded income (not-countable income) and reducing it by allowed deductions. The amount of non-excluded income remaining after the deductions is called available income. This available income is the amount of the client’s contribution. (See Scenarios 1-3.)

Do not allow the private charges for a residential facility as a medical expense. These charges are not considered a medical expense.

Exception To Rule (ETR)

  1. An approved ETR is required to allow a client’s expenses for the following as they are not automatically allowed as a deduction in the MNRW

    1. Guardianship fees and associated costs (per chapter 388-79 WAC);

    2. Child support; and

    3. Income taxes.

  2. HCS staff are to request ETRs per their regional procedures.

  3. The total of the following deductions cannot be more than the Medically Needy Income Level - MNIL   See Long Term Care - Participation - WAC 388-513-1380  (2) (a)  for a description of how to allow these deductions from the client’s responsibility toward the cost of care.

    1. PNA

    2. Deductions approved via an ETR:

      1. Guardianship fees and associated costs

      2. Income Taxes

      3. Child Support

Using the Correct PNA

Determining the correct Personal Needs Allowance (PNA) that should be used in the client responsibility calculation depends on the living arrangment from the first to the end of the month.   The highest PNA based on living arrangement and service is allowed.   Unlike the COPES or nursing facility program, marital status does not have an affect on the client’s PNA.

See LTC standards and PNA chart  for current PNA amount

From

To

Day

PNA

Home

MNRW

Any day

MNIL

NF

MNRW

Any day

$60.78

Private Pay ALF

MNRW

Any day

$60.78

MNRW

Home

Any day

MNIL

MNRW

Nursing Home

Any day

$60.78

MNRW

Private Pay ALF

Any day

MNIL

Splitting Client Responsibility Between Facilities

When an active Medicaid client transitions to the MNRW program, the client’s contribution towards the cost of care may need to be split between the facilities for the month the client made the move.

To determine how much the client’s contribution is towards the new facility:

  1. Determine how much the client must pay towards the cost of care in the discharge facility. Do this by determining how many days the client was in the discharge facility in the month of the change (do not count the day the client discharges).

  2. Multiply the number of days by the facility’s department contracted daily rate. The result is the amount of the client’s cost of care for the discharge facility. Allow this as a deduction towards the client’s responsibility in the new facility.

  3. When re-computing client participation or responsibility because of a change, be sure to use the correct PNA based on the chart in the previous section.

  4. Manually generate ACES LTC change letters, as needed.

  5. Do not allow the private charges for a residential facility as a medical expense. These charges are not considered a medical expense.

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Modification Date: December 31, 2007
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