WAC 388-515-1505

Effective July 1, 2008

WAC 388-515-1505 Financial eligibility requirements for long-term care services under COPES, New Freedom, PACE, MMIP and WMIP

Emergency July 1, 2008  

  1. This section describes the financial eligibility requirements and the rules used to determine a client’s participation in the total cost of care for home or community based long-term care (LTC) services provided under the following programs:   
    1. Community options program entry system (COPES).
    2. Program of all-inclusive care for the elderly (PACE);
    3. Medicare/Medicaid integration project (MMIP);
    4. Washington Medicaid Integration partnership (WMIP); and
    5. New Freedom consumer directed services (New Freedom).
    6. Hospice services for clients not in a medical institution with gross income at or below the SIL and not eligible for another CN or MN Medicaid program. 

  2. To be eligible for COPES a client must:

    1. Meet the program and age requirements for the specific program, as follows:

      1. Copes, per WAC 388-106-0310;

      2. PACE, per WAC 388-106-0705;

      3. MMIP waiver services, per WAC 388-106-0725;

      4. WMIP waiver services, per WAC 388-106-0750; or

      5. New Freedom, per WAC 388-106-1410.

      6. Hospice per WAC 388-551.

    2. Meet the aged, blind or disability criteria of the Supplemental Security Income (SSI) program as described in WAC 388-475-0050 (1);

    3. Require the level of care provided in a nursing facility as described in WAC 388-106-0355;

    4. Be residing in a medical facility as defined in WAC 388-500-0005, or likely to be placed in one within the next thirty days in the absence of home or community-based LTC services provided under one of the programs listed in subsection (1) of this section;

    5. Have attained institutional status as described in WAC 388-513-1320;

    6. Be determined in need of home or community-based LTC services and be approved for a plan of care as described in subsection (2) (a) (i), (ii), or (iii);

    7. Be able to live at home with community support services and chooses to remain at home, or live in a department-contracted:

      1. Enhanced adult residential care (EARC) facility;

      2. Licensed adult family home (AFH); or

      3. Assisted living (AL) facility.

    8. Not be subject to a penalty period of ineligibility for the transfer of an asset as described in WAC 388-513-1363,   WAC 388-513-1364, WAC 388-513-1365 and WAC 388-513-1366; and

    9. Meet the resource and income requirements described in subsections (3), (4) and (5) or be an SSI beneficiary not subject to a penalty period as described in subsection (2) (h).

  3. Refer to WAC 388-513-1315 for rules used to determine countable resources and eligibility standards. 

  4. Excess resources are reduced in an amount equal to medical expenses incurred by the institutional client as described in WAC 388-513-1350; and

    1. Must result in countable resources being at or below the resource standard in WAC 388-513-1350(1)

    2. If remaining resources are over the standard, the client is ineligible.  

  5. Nonexcluded income must be at or below the SIL (300% of the federal benefit rate  (FBR)) and is allocated in the following order:

    1. An earned income deduction of the first sixty-five dollars plus one-half of the remaining earned income;

    2. Maintenance and personal needs allowances  as described in subsection (7), (8),  (9), (10) and (11) of this section ;

    3. Guardianship fees and administrative costs including any attorney fees paid by the guardian only as allowed by chapter 388-79 WAC;

    4. Income garnished for child support or withheld according to a child support order in the month of the garnishment (for current and back support);

      1. For the time period covered by the PNA; and

      2. Is not counted as the child's income when determining the family allocation amount.

    5. Monthly maintenance needs  allowance for the community spouse not to exceed that in WAC 388-513-1380 (5)(b) unless greater amount is allocated as described in subsection (6) of this section. This amount: ;

      1. Is allowed only to the extent that the client's income is made available to the community spouse; and

      2. 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. For the purposes of this section, excess shelter expenses are the actual required maintenance expenses for the community spouse's principal residence. These expenses are:

          1. Rent;

          2. Mortgage;

          3. Taxes and insurance;

          4. Any maintenance care for a condominium or cooperative; and

          5. The food assistance standard utility allowance (for LTC Services this is set at the standard utility allowance  (SUA) for a four-person household), provided the utilities are not included in the maintenance charges for a condominium or cooperative;

          6. Less the standard shelter allocation. 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

      3. Is reduced by the community spouse's gross countable income.

    6. A Monthly maintenance needs amount for each minor or dependent child, dependent parent or dependent sibling of the community or institutionalized spouse based on the living arrangement of the dependent. If the dependent:

      1. Resides with the community spouse, the amount is equal to one-third of the community spouse income allocation  as described in WAC 388-513-1380 (6) (b) (i) (A) that exceeds the dependent family member’s income;

      2. Does not reside with the community spouse, the amount is equal to the MNIL  for the number of dependent family members in the home less the income of the dependent family members.

      3. Child support received from a non-custodial is the child’s income;

    7. 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.

  6. The amount allocated to the community spouse may be greater than the amount in subsection (5) (e) 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.

  7. A client who receives SSI and lives at home as defined in WAC 388-106-0010  does not use income to participate in the cost of personal care.

  8. A client who receives SSI and lives in an enhanced adult residential center (EARC), adult family home (AFH) or assisted living  (AL) does not use income to participate in the cost of personal care; and

    1. Retains a personal needs allowance (PNA)  of sixty two dollars and seventy-nine cents; and

    2. Uses income to pay the facility for the cost of room and board.

    3. Room and board is the SSI FBR  minus sixty two dollars and seventy-nine cents.

  9. A client who is eligible to receive CN-P Medicaid described in WAC 388-475-0100 (2)(a) and (b) and lives at home , defined in WAC 388-106-0010, does not use income to participate in the cost of personal care.

  10. A client who is eligible to receive CN-P Medicaid described in WAC 388-475-0100(2)(a) and (b) and lives in an EARC, AFH or AL does not use income to participate in the cost of personal care; and

    1. Retains a personal needs allowance (PNA)  of sixty two dollars and seventy-nine cents; and

    2. Uses income to pay the facility for the cost of  room and board.

    3. Room and board is the SSI FBR  minus sixty two dollars and seventy-nine cents

  11. An institutionalized SSI-related client living:

    1. At home, retains a maintenance needs amount equal to the following:

      1. Up to one hundred percent of the one-person FPL, if the client is:

        1. Single; or

        2. Married, and is:

          1. Not living with the community spouse; or

          2. Whose spouse is receiving long-term care (LTC) services outside of the home.

          3. Up to one hundred percent of the one-person FPL for each client, if both spouses are receiving COPES, New Freedom, PACE, MMIP, or WMIP services;

          4. Up to the one-person medically needy income level (MNIL) for a married client who is living with a community spouse who is not receiving COPES, New Freedom, PACE, MMIP, or WMIP.

    2. In an EARC, AFH, or AL, retains a maintenance needs amount equal to the SSI FBR  and:

      1. Retains a personal needs allowance (PNA) of sixty two dollars and seventy-nine cents from the maintenance needs; and

      2. Pays the remainder of the maintenance needs to the facility for the cost of room and board. (Refer to subsection (14) in this section for allocation of the balance of income remaining over maintenance needs.)

  12. A client who is eligible for the general assistance expedited Medicaid disability (GAX) program does not participate in the cost of personal care. When such a client lives:

    1. At home, the client retains the cash grant amount authorized under the general assistance  program;

    2. In an AFH, the client retains a PNA  of thirty-eight dollars and eighty-four cents, and pays remaining income and GAX grant to the facility for the cost of board and room; or

    3. In an EARC or AL, the client only receives a PNA  of thirty-eight dollars and eighty-four cents and retains it.

    1. The total of the following amounts cannot exceed the SIL:

      1. Maintenance and personal needs allowances as described in subsections (7), (8), (9) (10), (11) and (12);

      2. Earned income deduction of the first sixty-five dollars plus one-half of the remaining earned income in subsection (5)(a); and

      3. Guardianship fees  and administrative costs in subsection (5)(c).
    2. The client's remaining income after the allocations described in subsections (5) through (12) is the client's responsibility in the cost of care.

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.