WAC 182-514-0240 General eligibility requirements for family institutional medical coverage.

1.  This section applies to all individuals applying for long term care services under the family institutional medical program.  Additional rules may apply based upon an individual's age at the time he or she applies for long term care services and whether the facility the individual is admitted to is a medical institution, inpatient psychiatric facility, or an institution for mental diseases (IMD).  Additional rules are described in WAC 388-505-0245 through 388-505-0265.

2.  Individuals must meet the following requirements to qualify for family institutional coverage:

a.  Institutional status described in WAC 388-513-1320.  An individual meets institutional status if he or she is admitted to:

i.  A medical institution and resides, or is likely to reside, there for thirty days or longer, regardless of age;

ii.  An inpatient psychiatric facility or IMD and resides, or likely to reside, there for thirty days or longer and is eighteen through twenty years of age; or

iii.  An inpatient psychiatric facility or IMD and resides, or is likely to reside, there for ninety days or longer and is seventeen years of age or younger.

b.  General eligibility requirements described in WAC 388-503-0505  (with the exception that subsections (3)(c) and (3)(d) of that section do not apply to individuals who are eligible under the alien emergency medical (AEM) program) and meet one of the following:

i.  Be a parent of, or a relative caring for, an eligible dependent child and meet the program requirements under:

A.  A family medical program described in WAC 388-505-0220;

B.  A transitional family medical program described in WAC 388-523-0100; or

C.  The temporary assistance for needy families (TANF) cash assistance program.

ii.  Be a child and meet the program requirements under apple health for kids as described in WAC 388-505-0210;

iii.  Be a pregnant woman and meet the program requirements for a pregnancy medical program as described in WAC 388-462-0015;

iv.  Meet the alien emergency medical (AEM) program requirements as described in WAC 388-438-0110  (with the exception that for family long term care services, AEM coverage may be authorized for children through twenty-one years of age) and:

A.  Have a qualifying emergency condition; and

B.  For payment for long term care services and room and board costs the institution, request authorization from the department's medical consultant if the individual is admitted to a nursing facility.

v.  Be an individual nineteen through twenty years of age but not eligible under subsections (i) through (iv) of this section.

c.  Resource requirements described in WAC 388-505-0245;

d.  Have countable income below the applicable standard described in WAC 388-505-0250(4), 388-505-0255 (3) or 388-505-0260  (4);

e.  Contribute income remaining after the post eligibility process described in WAC 388-505-0265  towards the cost of care in the facility; and

f.  Be assessed as needing nursing facility level of care as described in WAC 388-106-0355  if the admission is to a nursing facility.  (This does not apply to nursing facility admissions under the hospice program.)

3.  Once the department determines an individual meets institutional status, it does not count the income of parent(s), a spouse, or dependent child(ren) when determining countable income.  The department counts the following as the individual's income:

a.  Income received by the individual in his or her own name;

b.  Funds given to him or her by another individual towards meeting his or her needs; and

c.  Current child support received on behalf of the individual by his or her parents.

4.  Individuals eligible for a cash grant under the temporary assistance for needy families (TANF) program can remain eligible for a cash payment and the categorically needy (CN) medicaid program while in the institution.  The expected length of stay in the institution may impact the amount of the TANF payment. 

a.  When the institutionalized individual is expected to return to the home within one hundred and eighty days, the department considers this to be a temporary absence from the home and the individual remains eligible for their full TANF grant.  Rules defining a temporary absence are described in WAC 388-454-0015.

b.  When the department determines that the institutionalized individual's stay in the facility is likely to exceed one hundred and eighty days, the department reduces his or her share of the TANF grant to the personal needs allowance (PNA) described in WAC 388-478-0040.  This is also referred to as the clothing, personal maintenance and necessary incidentals (CPI) amount.

5.  Individuals who are not United States citizens or qualified aliens do not need to provide or apply for a social security number or meet the citizenship requirements under WAC 388-424-0010 (1) or 388-424-0010  (2) as long as the requirements in subsection (2) of this section are met.

6.  Individuals who are aged, blind or disabled under federal criteria may qualify for institutional benefits with income of up to three hundred percent of the federal benefit rate (FBR).  Rules relating to institutional eligibility for aged, blind or disabled individuals are described in WAC 388-513-1315.

7.  If an individual does not meet institutional status, the department determines his or her eligibility for a noninstitutional medical program.  An individual who is determined eligible for CN or medically needy (MN) coverage under a noninstitutional program who is admitted to a nursing facility for less than thirty days is approved for coverage for the nursing facility room and board costs, as long as the individual is assessed by the department as meeting nursing facility level of care as described in WAC 388-106-0355.