WAC 388-513-1395 Determining eligibility for institutional or hospice services for individuals living in a medical institution under the medically needy (MN) program



This section describes how the department determines a client's eligibility for institutional or hospice services in a medical institution and for facility care only under the MN program. In addition, this section describes rules used by the department to determine whether a client approved for these benefits is also eligible for noninstitutional medical assistance in a medical institution under the MN program.

1. To be eligible for institutional or hospice services under the MN program for individuals living in a medical institution, a client must meet the financial requirements described in subsection (5)- In addition, a client must meet program requirements described in WAC 388-513-1315; and
   1. Be an SSI-related client with countable income as described in subsection (4)(a) that is more than the special income level (SIL); or
   2. Be a child not described in subsection (1)(a) with countable income as described in subsection (4)(b) that exceeds the categorically needy (CN) standard for the children's medical program
2. For an SSI-related client, excess resources are reduced by medical expenses as described in WAC 388-513-1350 to the resource standard from a single or married individual.
3. The department determines a client's countable resources for institutional and hospice services under the MN programs as follows:
   1. For an SSI-related client, the department determines countable resources per WAC 388-513-1350;
   2. For a child not described in subsection (3) (a), no determination of resource eligibility is required.
4. The department determines a client's countable income for institutional and hospice services under the MN program as follows:
   1. For an SSI-related client, the department reduces available income as described in WAC 388-513-1325 and WAC 388-513-1330 by:
      1. Excluding income described in WAC 388-513-1340;
      2. Disregarding income described in WAC 388-513-1345; and
      3. Subtracting previously incurred medical expenses incurred by the client and not used to reduce excess resources. Allowable medical expenses and reducing excess resources are described in WAC 388-513-1350. For a child not described in subsection (4) (a), the department:
   2.                                                         
      1. Follows the income rules described in WAC 182-505-0210 for the children’s medical program; and
      2. Subtracts the medical expenses described in subsection (4).
5. If the combined total of a client's countable income, when added to countable resources in excess of the standard described in WAC 388-513-1350 (1), is less than the department-contracted rate plus the amount of recurring medical expenses, the client:
   1. Is eligible for institutional or hospice services in a medical institution, and medical assistance;
   2. Is approved for twelve months; and
   3. Participates income and excess resources toward the cost of care as described in WAC 388-513-1380;
6. If the income remaining after the allowed deductions described in WAC 388-513-1380, plus countable resources in excess of the standard described inWAC 388-513-1350 (1) is more than the department- contracted rate times the number of days residing in the facility the client:
   1. Is not eligible for payment of institutional services; and
   2. Eligibility is determined for medical assistance only as described in chapter 182-519 WAC.
7. If the income remaining after the allowed deductions described in WAC 388-513-1380 is more than the department contracted nursing facility rate based on the number of days the client is in the facility, but less than the private nursing rate plus the amount of medical expenses not used to reduce excess resources the client:
   1. Is eligible for nursing facility care only and is approved for a three or six month based period as described in chapter 182-519 WAC. This does not include hospice in a nursing facility; and
      1. Pays the nursing home at the current state rate;
      2. Participates in the cost of care as described in WAC 388-513-1380 and;
      3. Is not eligible for medical assistance or hospice services unless the requirements in (6)(b) is met.
   2. Is approved for medical assistance for a three or six month base period as described in chapter 182-519 WAC, if:
      1. No income and resources remain after the post eligibility treatment of income process described in WAC 388-513-1380.
      2. Medicaid certification is approved beginning with the first day of the base period.
   3. Is approved for medical assistance for up to three or six months when they incur additional medical expenses that are equal to or more than excess income remaining after the post eligibility treatment of income process described in WAC 388-513-1380. 
      1. This process is known as spenddown and is described in WAC 182-519-0100.
      2. Medicaid certification is approved on the day the spenddown is met.
8. If the income remaining after the allowed deduction described in WAC 388-513-1380, plus countable resources in excess of the standard described in WAC 388-513-1350 is more than the private nursing facility rate times the number of days in a month residing in the facility, the client:
   1. Is not eligible for payment of institutional services.
   2. Eligibility is determined for medical assistance only as described in chapter 182-519 WAC.