Determining eligibility for noninstitutional coverage in an Alternative Living Facility (G03 or L52 group C and D)
Purpose: This program is used for SSI-related people receiving a long-term service and support (LTSS) such as Medicaid Personal Care (MPC)(G03) or Community First Choice (CFC) when countable income is over the CNIL, but under the Special Income Level (SIL) and state-contracted rate.
Starting 10/2015, CFC clients using these rules will be under medical coverage group L52.
This program is used for Regional Support Network (RSN) placements in alternate living facilities (ALF). (G03).
This program is used for SSI-related people paying privately in a state-contracted ALF under medically needy (CN) G95, G99.
WAC 182-513-1205 Determining eligibility for noninstitutional coverage in an alternate living facility
WAC 182-513-1205 Determining eligibility for noninstitutional coverage in an alternate living facility (ALF).
Effective February 8, 2020
- This section describes the eligibility determination for noninstitutional coverage for a client who lives in a agency-contracted alternate living facility (ALF) defined under WAC 182-513-1100.
- The eligibility criteria for noninstitutional Washington apple health (medicaid) coverage in an ALF follows SSI-related rules under WAC 182-512-0050 through 182-512-0960, with the exception of the higher income standard under subsection (3) of this section.
- A client is eligible for noninstitutional coverage under the categorically needy (CN) program if the client's monthly income after allowable exclusions under chapter 182-512 WAC:
- Does not exceed the special income level (SIL) defined under WAC 182-513-1100; and
- Is less than or equal to the client's assessed state rate at a agency-contracted facility. To determine the CN standard: ((y × 31) + $38.84), where "y" is the state daily rate. $38.84 is based on the cash payment standard for a client living in an ALF setting under WAC 388-478-0006.
- A client is eligible for noninstitutional coverage under the medically needy (MN) program if the client's monthly income after allowable exclusions under chapter 182-512 WAC is less than or equal to the client's private rate at a agency-contracted facility. To determine the MN standard: ((z × 31) + $38.84), where "z" is the facility's private daily rate. To determine MN spenddown liability, see chapter 182-519 WAC.
- For both CN and MN coverage, a client's countable resources cannot exceed the standard under WAC 182-512-0010.
- The agency or the agency's designee approves CN noninstitutional coverage for twelve months.
- The agency or the agency's designee approves MN noninstitutional coverage for a period of months described in WAC 182-504-0020 for an SSI-related client, provided the client satisfies any spenddown liability under chapter 182-519 WAC.
- Clients who receive medicaid personal care (MPC) or community first choice (CFC) pay all of their income to the ALF except a personal needs allowance under WAC 182-513-1105.
- A client may have to pay third-party resources as defined under WAC 182-513-1100 in addition to the payment under this subsection.
- See WAC 182-513-1200 Long-term services and supports authorized under Washington Apple Health.
- See SSI related Medical Income and SSI related Resources to determine income and resource eligibility.
- When an individual is placed in a facility on a HCS or DDA Waiver service, use Chapter 182-515 WAC to determine eligibility. Screen in a L22 for these programs.
- When an individual is otherwise eligible for a SSI related CN program (S01 or S02) the S01/S02 program is a priority program. If an MPC S02 individual residing in a contracted ALF has an increase in income that causes the S02 to trickle to a S95, do a redetermination under the G03 program. Starting 10/2015 all CFC SSI-related clients using rules of this program will be under MCG L52.
- HWD is a priority program for individuals on MPC or CFC when it is beneficial to the individual. Individuals on HWD pay the HWD premium plus the ALTSA room and board standard.
- If the individual's nonexcluded gross income is above the SIL and/or the department-contracted rate plus the PNA/CPI standard use the private facility rate plus the PNA/CPI standard. Cases that trickle to MN are not eligible for MPC or CFC. Consider eligibility for a HCB Waiver.
- To determine the individual's spenddown liability for noninstitutional medical assistance under the MN program, use the individual's nonexcluded income in excess of the private rate plus the PNA to determine the individual's spenddown liability. Do not use the amount charged by the ALF to reduce the spenddown amount, however the individual may use other incurred medical expenses to meet spenddown. (ALFs are not medical institutions).
- The agency will consider income and resources separately as of the first day of the month following the month of separation when spouses stop living together because of placement into a boarding home or adult family home when:
- Only one spouse enters the facility;
- Both spouses enter the same facility but have separate rooms; or
- Both spouses enter separate facilities.
- The agency will consider income and resources jointly when spouses are placed in a boarding home or adult family home and share a room. See WAC 182-512-0960.
- Indicate the type of services in ACES under HCBS/MPC services under the institutional care tab in ACES 3G with the service start date indicated by the social worker and the agency authorizing the service (DDA or HCS).
- Services authorized by DDA, HCS are tied to eligibility for CN Medicaid. If medicaid closes, the service authorized by the social service specialist/case manager must close too. Individuals must be eligible for a non institutional CN medicaid program in order to receive MPC or CFC.
- HCS social service specialists use the DSHS 14-443 Financial/Social Service communication form. This form is automated in barcode.
- DDA case managers use the DSHS 15-345 CSO/DDA Communication form. This form is automated in barcode.
- BHO case managers use the DSHS 13-348 BHO/CS0 communication form.
- The assigned case manager/social service specialist indicates what services are authorized with the start date, the state daily rate, the current address and any other pertinent information needed to process the case such as if a payee or power of attorney is involved in the case. The assigned case manager/social service specialist determines the functional eligibility for the service; the financial worker is responsible to determine the financial eligibility for Medicaid. Changes need to be communicated back and forth between the financial worker and assigned case manager/social service specialist.
- If G03 eligibility trickles to a G95 or G99 because the income is excess of the SIL or the state daily rate and the individual is receiving MPC services, notify the agency approving the MPC service that the individual is no longer eligible to receive MPC because of excess income.
- For people paying privately in a state-contracted ALF, contact the facility for the private rate.
- For more information search the DSHS Adult Family Home Locator or Assisted Living Facility Locator for Professionals and Providers.