Long-Term Care Program Requirements

Medicaid Personal Care

Revised January 1, 2018

Purpose: To explain a Medicaid program called Medicaid Personal Care (MPC) for individuals eligible for a non institutional CN program and meeting the functional criteria for personal care services.

WAC 182-513-1225 Medicaid Personal Care (MPC)

Effective January 1, 2018

  1. Medicaid personal care (MPC) is a state-plan benefit available to a client who is determined:
    1. Functionally eligible for MPC services under WAC 388-106-0200 through 388-106-0235; and
    2. Financially eligible for a noninstitutional categorically needy (CN) or alternative benefits plan (ABP) Washington apple health (medicaid) program.
  2. MPC services may be provided to a client residing at home, in a department-contracted adult family home (AFH), or in a licensed assisted living facility that is contracted with the department to provide adult residential care services.
  3. A client who resides in an alternate living facility (ALF) listed in subsection (2) of this section:
    1. Keeps a personal needs allowance (PNA) under WAC 182-513-1105; and
    2. Pays room and board up to the room and board standard under WAC 182-513-1105, unless CN eligibility is determined using rules under WAC 182-513-1205.
  4. A client who receives MPC services under the health care for workers with disabilities (HWD) program under chapter 182-511 WAC must pay the HWD premium in addition to room and board under WAC 182-513-1105, if residing in an ALF.
  5. A client may have to pay third-party resources as defined under WAC 182-513-1100 in addition to room and board.
  6. Current PNA and room and board standards are found at www.hca.wa.gov/free-or-low-cost-health-care/program-administration/progr....

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.

What is Medicaid Personal Care (MPC)

A Medicaid program that is allowed under Washington State’s Medicaid State Plan, that provides assistance with activities of daily living to individuals who are eligible for non-institutional categorically needy (CN) or Alternative Benefit Plan (ABP) medical programs.

Functional eligibility for this program is based on Chapter 388-106 WAC.

MPC services are available in the individual’s own home, adult family homes (AFH), assisted living or DDA group home for clients that do not meet NFLOC, but meet functional eligibility for MPC.

MPC is authorized by Home and Community Services (HCS) and Developmental Disabilities (DDA) administrations.

A CARE assessment is done by a case manager, nurse or social service specialist from DDA, HCS or Area Agency on Aging (AAA).

Individuals must meet the functional criteria based on the social service assessment and financial eligibility based on eligibility for a non-institutional CN or ABP Medicaid program.

The only exception is the Alien Emergent Medical (AEM) Modified Adjusted Gross Income (MAGI) medical program under N21 and N25. AEM programs do not cover Medicaid Personal Care (MPC) services.

MPC individuals pay room and board if living in a adult family home, adult residential center (ARC) or DDA group home.

What is room and board?

Throughout the manual both terms, room and board and board and room are used to describe a living arrangement in which an individual purchases food, shelter, and household maintenance requirements from one vendor. In other words, room and board is considered "rent".

There is also a term used by ALTSA and DDA called the room and board rate. This rate is based on the FBR minus the HCS/COPES Waiver PNA in an ALF.

Most MPC individuals pay the ALTSA standard room and board rate for their rent.

The exception is individuals receiving medical under the G03 program. This is because the standard that is used to make them eligible for a CN program has been raised based on having to pay all of their countable income minus the PNA to the provider. This rate for the purpose of the G03 program is called the individual's total responsibility.

What is Classic Medicaid?

Classic medicaid are programs for individuals that are Aged, Blind or Disabled (ABD)

The ABD classic medical programs are also called SSI related programs. In order to receive one of these medical programs, you must be age 65 or over, or considered disabled or blind by Social Security criteria. All individuals age 65 or over or on Medicare must be considered for a Classic program unless they do not meet citizenship requirements for federal medicaid.

Classic medicaid included the institutional group (ABD individuals living in a medical institution 30 days or more) and Home and Community Based (HCB) Waiver programs. (L track).

What is the basic difference between "institutional" and "non-institutional"

Institutional medicaid has different income standards and rules for initial eligibility and higher resource standards for a couple when only one needs institutional services.

Institutional also has a 2nd eligibility component called "post-eligibility treatment of income". This 2nd eligibility computation determines the amount the individual must pay toward their cost of care to the medical institution or to the HCB Waiver provider. This is called "participation".

Non-institutional medicaid does not have a "post eligibility" component, therefore individuals living in the community on non-institutional medicaid do not "participate" toward the cost of their personal care.

MPC individuals do not pay "participation" but they are responsible to pay room and board (their rent) when living in an alternate living facility.

Classic Programs that do not fall into the Aged/Blind/Disabled group:

  • Foster care medical authorized and maintained by the Health Care Authority. Some foster care children may be disabled, but disability is not a requirement for this program that can be authorized up to age 26. (D01, D02, D26)
  • Institutional children (K01, K95, K99) This program uses Modified Adjusted Gross Income (MAGI) income methodology to determine initial eligibility but the eligibility is not done by the Health Benefit Exchange. The eligibility is determined by the Health Care Authority and is primarily used for children's mental health facilities (CLIP) and children needing hospitalization that are not eligible for medical under a N track MAGI program.

Consult the medical program chart desk tool under the MPC column to determine what classic medical programs can authorize MPC.

What is Modified Adjusted Gross Income (MAGI) Medicaid

MAGI medicaid eligibility is determined by the Health Benefit Exchange.

These programs show up as "N" track in ACES and are for children, pregnant woman, and adults under age 65. In order to be considered for medical under MAGI methodology, you can't be on Medicare.

It is possible for a disabled individual not on Medicare to qualify under MAGI by the Health Benefit Exchange.

Once an individual is eligible to receive Medicare, the case is re-determined from the MAGI program to a ABD Classic Medicaid program.

Individuals receiving MAGI programs under "N" track in ACES with the exception of AEM N21 and N25 are eligible to receive MPC if functionally eligible.

What is Medical Care Services (MCS)

MCS is a state funded medical program used for legally admitted non citizens that do not qualify for a Classic or MAGI medicaid program because they are in their 5 year bar for federal medicaid.

MCS covers nursing home and HCS has a state funded residential program for individuals eligible to receive MCS.

MCS does not cover MPC or HCB Waiver.

Agency Responsibilities

CSD, HCS and DDA LTC specialty unit Financial staff determines eligibility for Classic medical assistance programs.

The Health Benefit Exchange (HBE) determines eligibility for MAGI based medical.

The LTC overview includes a chart to indicate which specific agency is responsible to determine financial eligibility for each medical program.

DDA, HCS or AAA case manager responsible for placement and case management services, determines functional eligibility, initiates the payment to the provider via ProviderOne and determines the amount the individual must pay to the facility for their cost of care and notifies the individual.

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 financial worker is responsible to determine the financial eligibility for Classic medicaid. Changes need to be reported back and forth between the financial worker and assigned case manager/social service specialist.

HCS social service specialists use the DSHS 14-443 Financial/Social Service communication form in barcode.

DDA case managers use the DSHS 15-345 DDA Communication in barcode.

Worker Responsibilities

HCS financial staff:

All Classic Medicaid receiving MPC services through HCS:

Indicate M for MPC service in ACES under the HCB type field. Indicate the start date of the service and the approving agency under the approval source. Indicate the payment authorization date. For MPC the start date of the service and the payment authorization date is the same date.

If the individual is living in an alternate living facility, the facility section must be completed. A provider number is not needed for an alternate living facility, but the entry date, level of care, payment authorization date and state rate are needed.

DDA and HCS Financial Staff Responsibilities:

If MPC services end, indicate the service end date on the HCBS field in the month services ended.

If in an ALF/residential setting indicate the end date under the facility line.

If the individual is not eligible for a non-institutional Classic CN program, notify the agency authorizing MPC services that the individual is not financially eligible for MPC. The individual may be considered for a CN institutional Waiver program such as COPES.

See HCS CN Waivers or DDA CN Waivers for rules describing Waiver services authorized by each agency.

An individual going from MPC to Waiver must qualify under the rules for the Waiver program including transfer of asset and excess home equity rules, income and resource rules that apply to Waiver/institutional programs.

Social service specialists and case managers must consult financial service staff prior to switching a MPC case to a Waiver case to make sure the individual is eligible under Waiver rules.

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