Long-term services and supports (LTSS) manual

DDA Home and Community Based (HCB) waivers

Revised Date: 
January 2, 2014

Purpose: Determining Medicaid eligibility and client responsibility for cost of care for clients functionally eligible for a Developmental Disabilities Administration (DDA) Waiver program.

WAC 182-515-1510 Home and community based (HCB) waiver services authorized by the developmental disabilities administration (DDA).

Effective February 20, 2017

This chapter describes the general and financial eligibility requirements for categorically needy (CN) home and community based (HCB) waivers authorized by the developmental disabilities administration (DDA). The definitions in WAC 182-513-1100 and chapter 182-500 WAC apply throughout this chapter.

  1. The DDA waiver programs are:
    1. Basic Plus;
    2. Core;
    3. Community protection;
    4. Children's intensive in-home behavioral support (CIIBS); and
    5. Individual and family services (IFS).
  2. WAC 182-515-1511 describes the general eligibility requirements for HCB waiver services authorized by DDA.
  3. WAC 182-515-1512 describes the financial requirements for eligibility for HCB waiver services authorized by DDA if a person is eligible for a noninstitutional SSI-related CN program.
  4. WAC 182-515-1513 describes the financial eligibility requirements for HCB waiver services authorized by DDA when a person is not eligible for an SSI-related noninstitutional CN program under WAC 182-515-1512.
  5. WAC 182-515-1514 describes the rules used to determine a person's responsibility in the cost of care and room and board for HCB waiver services authorized by DDA if the person is eligible under WAC 182-515-1512.

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.

WAC 182-515-1511 Home and community based (HCB) waiver services authorized by the developmental disabilities administration (DDA) - General eligibility.

Effective February 20, 2017

  1.  To be eligible for home and community based (HCB) waiver services authorized by the developmental disabilities administration (DDA), a person must:
    1. Meet specific program requirements under chapter 388-845 WAC;
    2. Be an eligible client of the DDA;
    3. Meet the disability criteria for the supplemental security income (SSI) program under WAC 182-512-0050;
    4. Need the level of care provided in an intermediate care facility for the intellectually disabled (ICF/ID);
    5. Have attained institutional status under WAC 182-513-1320;
    6. Be able to reside in the community and choose to do so as an alternative to living in an ICF/ID;
    7. Be assessed for HCB waiver services, be approved for a plan of care, and receive HCB waiver services under (a) of this subsection, and:
      1. Be able to live at home with HCB waiver services; or
      2. Live in a department-contracted facility with HCB waiver services, such as:
        1. A group home;
        2. A group training home;
        3. A child foster home, group home, or staffed residential facility;
        4. An adult family home (AFH); or
        5.  An adult residential care (ARC) facility.
      3.  Live in the person's own home with supported living services from a certified residential provider; or
      4. Live in the home of a contracted companion home provider.
  2.  A person is not eligible for home and community based (HCB) waiver services if the person:
    1. Is subject to a penalty period of ineligibility for the transfer of an asset under WAC 182-513-1363; or
    2.  Has a home with equity in excess of the requirements under WAC 182-513-1350.
  3. See WAC 182-513-1315 for rules used to determine countable resources, income, and eligibility standards for long-term care (LTC) services.
  4. Current income and resource standard charts are found at http://www.hca.wa.gov/free-or-low-cost-health-care/program-administration/program-standard-income-and-resources.

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.

WAC 182-515-1512 Home and community based (HCB) waiver services authorized by the developmental disabilities administration (DDA)- Financial eligibility if a client is eligible for a noninstitutional SSI-related categorically needy (CN) program.

Effective January 1, 2018

  1. A client is financially eligible for home and community based (HCB) waiver services authorized by the developmental disabilities administration (DDA) if:
    1. The client is receiving coverage under one of the following categorically needy (CN) medicaid programs:
      1. Supplemental security income (SSI) program under WAC 182-510-0001. This includes SSI clients under 1619(b) status; or
      2. Health care for workers with disabilities (HWD) under chapter 182-511 WAC; or
      3.  SSI-related noninstitutional (CN) program under chapter 182-512 WAC; or
      4. The foster care program under WAC 182-505-0211 and the client meets disability requirements under WAC 182-512-0050.
    2.  The client does not have a penalty period of ineligibility for the transfer of an asset as under WAC 182-513-1363; and
    3.  The client does not own a home with equity in excess of the requirements under WAC 182-513-1350.
  2.  A client eligible under this section does not pay toward the cost of care, but must pay room and board if living in an alternate living facility (ALF) under WAC 182-513-1100.
  3.  A client eligible under this section who lives in a department-contracted ALF described under WAC 182-513-1100:
    1.  Keeps a personal needs allowance (PNA) under WAC 182-513-1105; and
    2.  Pays towards room and board up to the room and board standard under WAC 182-513-1105.
  4.  A client who is eligible under the HWD program must pay the HWD premium under WAC 182-511-1250, in addition to room and board if residing in an ALF.
  5.  Current resource, income, PNA and room and board standards are found at www.hca.wa.gov/free-or-low-cost-health-care/program-administration/program-standard-income-and-resources.

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.

WAC 182-515-1513 Home and community based (HCB) waiver services authorized by the developmental disabilities administration (DDA)—Financial eligibility using SSI-related institutional rules.

Effective February 20, 2017

  1. If a person is not eligible for a categorically needy (CN) program under WAC 182-515-1512, the agency determines eligibility for home and community based (HCB) waiver services authorized by the developmental disabilities administration (DDA) using institutional medicaid rules. This section explains how a person may qualify using institutional rules.
  2. A person must meet:
    1. General eligibility requirements under WAC 182-513-1315 and 182-515-1511;
    2. Resource requirements under WAC 182-513-1350; and
    3. Have available income at or below the special income level (SIL) defined under WAC 182-513-1100.
  3. The agency determines available income and income exclusions according to WAC 182-513-1325, 182-513-1330, and 182-513-1340.
  4. A person eligible under this section is responsible to pay income toward the cost of care and room and board, as described under WAC 182-515-1514.
  5. Current resource, income standards are found at http://www.hca.wa.gov/free-or-low-cost-health-care/program-administration/program-standard-income-and-resources.

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.

WAC 182-515-1514 Home and community based (HCB) services authorized by the developmental disabilities administration (DDA)- Client financial responsibility

Effective January 1, 2018

  1. A client eligible for home and community based (HCB) waiver services authorized by the developmental disabilities administration (DDA) under WAC 182-515-1513 must pay toward the cost of care and room and board under this section.
    1. Post-eligibility treatment of income, participation, and participate are all terms that refer to a client's responsibility towards cost of care.
    2. Room and board is a term that refers to a client's responsibility toward food and shelter in an alternate living facility (ALF).
  2. The agency determines how much a client must pay toward the cost of care for home and community based (HCB) waiver services authorized by the DDA when the client is living at home, as follows:
    1. A single client who lives at home (as defined in WAC 388-106-0010) keeps a personal needs allowance (PNA) of up to the special income level (SIL) defined under WAC 182-513-1100.
    2. A single client who lives at home on the roads to community living program authorized by DDA keeps a PNA up to the SIL but must pay any remaining available income toward cost of care after allowable deductions described in subsection (4) of this section.
    3. A married client who lives with the client's spouse at home (as defined in WAC 388-106-0010) keeps a PNA of up to the SIL but must pay any remaining available income toward cost of care after allowable deductions under subsection (4) of this section.
    4. A married couple living at home where each client receives HCB waiver services, one authorized by DDA and the other authorized by home and community services (HCS) is allowed the following:
      1. The client authorized by DDA keeps a PNA of up to the SIL but must pay any remaining available income toward the client's cost of care after allowable deductions in subsection (4) of this section; and
      2. The client authorized by HCS pays toward the cost of care under WAC 182-515-1507 or 182-515-1509.
  3. The agency determines how much a client must pay toward the cost of care for HCB wavier services authorized by DDA and room and board when the client is living in a department-contracted ALF defined under WAC 182-513-1100. A client:
    1. Keeps a PNA under WAC 182-513-1105;
    2. Pays room and board up to the room and board standard under WAC 182-513-1105; and
    3. Pays the remainder of available income toward the cost of care after allowable deductions under subsection (4) of this section.
  4. If income remains after the PNA and room and board liability under subsection (2) or (3) of this section, the remaining available income must be paid toward the cost of care after it is reduced by allowable deductions in the following order:
    1. An earned income deduction of the first $65, plus one-half of the remaining earned income;
    2. Guardianship fees and administrative costs including any attorney fees paid by the guardian only as allowed under WAC 182-513-1505 through 182-513-1525;
    3. Current or back child support garnished or withheld from the client's income according to a child support order in the month of the garnishment if it is for the current month. If the agency allows this as a deduction from income, the agency does not count it as the child's income when determining the family allocation amount in WAC 182-513-1385;
    4. A monthly maintenance-needs allowance for the community spouse under WAC 182-513-1385. If the community spouse is on long-term care services, the allocation is limited to an amount that brings the community spouse's income to the community spouse's PNA;
    5. A monthly maintenance-needs allowance for each dependent of the institutionalized client, or the client's spouse, as calculated under WAC 182-513-1385; and
    6. Incurred medical expenses which have not been used to reduce excess resources. Allowable medical expenses are under WAC 182-513-1350.
  5. The total of the following deductions cannot exceed the SIL defined under WAC 182-513-1100:
    1. The PNA described in subsection (2) or (3) of this section, including room and board;
    2. The earned income deduction in subsection (4)(a) of this section; and
    3. The guardianship fees and administrative costs in subsection (4)(b) of this section.
  6. A client may have to pay third-party resources defined under WAC 182-513-1100 in addition to the room and board and participation.
  7. A client must pay the client's provider the sum of the room and board amount, the cost of care after all allowable deductions, and any third-party resources defined under WAC 182-513-1100.
  8. A client on HCB waiver services does not pay more than the state rate for cost of care.
  9. When a client lives in multiple living arrangements in a month, the agency allows the highest PNA available based on all the living arrangements and services the client has received in a month.
  10. Standards described in this section are found at www.hca.wa.gov/free-or-low-cost-health-care/program-administration/program-standard-income-and-resources.

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.

Clarifying Information

DDA Waivers

  1. DDA Waivers are categorically needy (CN) waiver programs that provide clients described in WAC 182-515-1510 through 182-515-1514 with alternatives to placement in an Intermediate Care Facility for the Mentally Retarded (ICF/MR). These alternatives include remaining in their home or placement in an alternate living facility (ALF) approved by the Developmental Disabilities Administration (DDA). The goal of these programs is to provide a safe level of care with maximum independence.
  2. In addition to the income allocations described in WAC 182-515-1514 the case manager (CM) can request an exception to rule to reduce the client's participation in the cost of care when the client requires the services of a guardian.
  3. If the client lives in an alternate living facility (ALF), the DDA case manager determines the amount the client keeps for personal needs and the amount the client pays for room and board.
  4. The department determines financial eligibility for these services according to WAC 182-513-1315. A client must have non excluded income at or below the special income level (SIL), but can reduce excess resources in the initial or review months as described in WAC 182-513-1350.
  5. Guardianship fees can be deducted in the post eligibility (participation determination) process if approved by court order for DDA Waivers in an ALF. See guardianship fee for clarifying information and a training module regarding guardianships. Since in home DDA Waiver clients keep the Medicaid SIL as a PNA, there is no guardianship deduction available.
  6. DDA Waiver clients at home do not pay toward personal care costs as they keep up to the Medicaid SIL. (300% of the FBR). DDA Waiver clients can pay up to the ALTSA room and board standard if living in an alternative living facility (ALF) such as a DDA group home or adult family home.
  7. Clients who are eligible to receive Apple Health for Workers with Disabilities (HWD) can receive DDA Waiver services if approved by DDA. HWD/S08 is the priority program in ACES if the client is better off with HWD/S08 over the L22 program. See HWD for more instructions on HWD for DDA Waiver clients. HWD clients on a DDA Waiver pay a premium and have no participation toward personal care. These clients do pay the ALTSA room and board rate if living in a DDA group home or Adult Family Home (these are also called Alternate living facilities (ALF)) See Working clients and long-term care programs (Waiver, Residing in a medical institution, or MPC).

1619B and "Deemed SSI eligible" clients

SSI deemed eligible clients (countable income is under the SSI standard after DAC, Pickle/COLA exclusion and SSI closed due to the receipt of DAC, COLA) do not pay toward the cost of personal care. They DO pay room and board if residing in an adult family home, boarding home or DDA group home. These facilities are also referred to as alternate living facilities or ALFs. ALFs are not medical institutions.

1619(b) clients are considered the same as an "SSI client". SSI payments have stopped due to earnings. SDX indicates continue Medicaid on SDX 1 in the Med Elig field. 1619(b) clients do not pay toward the cost of personal care. (also called participation). They DO pay room and board in an ALF.

"Deemed SSI clients" and 1619(b) status clients can have gross income over the Medicaid SIL (300% of the FBR) and still be eligible for the Waiver. 1619(b) is described in WAC 182-508-0001 (2).

Deemed SSI eligible clients. What does that mean?

Clients who have countable income under the SSI standard after allowing the exclusion for Disabled Adult Child (DAC), Pickle/COLA, Widow/Widowers and their SSI was closed because of the receipt of the DAC/COLA/Widow(er) income. These exclusions are described in the Overview chapter. Clients continue to receive CN Medicaid as long as they meet resource criteria. Not every client receiving DAC income is eligible for this exclusion. These are the requirements:

  • Lost cash payment of SSI after 7/1/88 due to receipt of DAC benefits from SSA or a COLA to those benefits.
  • Disability onset date prior to age 22

Deemed SSI eligible clients do not pay Waiver service participation, they do pay room and board if living in an adult family home, DDA group home or boarding home (ALFs).

If countable income is over the SSI standard after the exclusion then all income is counted in post eligibility in determining service participation for DDA Waiver clients living in an ALF. This includes DAC income.

Individuals who qualify for the DAC exclusion and countable income after the exclusion is under the SSI standard are referred to as "Protected DAC" cases.

Instructions are found in WAC 182-512-0880 Special income disregards for SSI-related medical programs.

In other words, an individual who would be eligible for CN-P/S02 in ACES

A client who would otherwise qualify for S02/CN SSI related medicaid because their countable income is at or below the SSI standard does not participate towards personal care under the Waiver program. (but they are responsible to pay room and board when living in an ALF).

These clients do need to meet the same criteria for long-term care services as other Waiver clients and may be subject to Asset transfers or excess home equity described in WAC 182-513-1350

The room and board amount ALTSA uses is based on the FBR minus the current HCS CN Waiver personal needs allowance (PNA) for individuals residing in an ALF.

See Standards - Long-term care (LTC) Long Term Services and Supports (LTSS) and PNA amounts.

1619(b) status, what does it mean?

SSI clients whose earnings put them over the SSI cash benefit standard but Social Security continues their SSI eligibility. They are considered an SSI recipient and continue to send in reviews to Social Security. The SDX indicates continued Medicaid when a client is 1619(b). 1619(b) clients don’t pay toward the cost of personal care because they are considered to be an SSI client. Follow the same instructions as SSI clients on a waiver for 1619(b) clients. Code SI on UNER to prevent an eligibility review from being generated for the L22. Clients would pay the ALTSA room and board amount if residing in an ALF. Clients can have GROSS income over the SIL and continue to receive a DDA Waiver as long as Social Security maintains their 1619(b) status.

How is this different if the client enters a Medical Institution?

Individuals entering a Medical institution and are "institutionalized" 30 days or more do participate toward the cost of care. This includes "deemed SSI eligible" clients. Institutional rules do apply once a client has entered a Medical institution. (WAC 182-513-1380) This means most of these individuals would participate in a medical institution. This is called the post eligibility process.

Worker Responsibilities

  1. Follow procedures in General eligibility for Long-Term Care to establish financial eligibility.
  2. This section from the main long-term care index links to the following eligibility requirements for DDA Waivers:
    1. Transfer of assets
    2. Available resources
    3. How annuities affect eligibility 
    4. Aged-Blind-Disabled requirements
    5. Gross income cannot exceed the Special Income Level (SIL) which is 300% of the FPL.
    6. Available Income
    7. Excluded Income
    8. Overview - Long Term Services and Supports chart for responsibilities and program administration (Who does what program).
    9. AREP Screens for long-term care cases Required for some DDA programs).
  3. Consider a client who is approved for DDA Waivers by DDA as having attained Institutional status.
  4. The DDA case manager sends a DSHS 15-345 CSO/DDA Communication from barcode to inform the financial worker of DDA Waiver eligibility and the start date of services, type of service, change of service, if in an alternate living facility (ALF) such as an adult family home or DDA group home, the state daily rate of the facility, address of facility placement and other changes described in the instructions of the DSHS 15-345 form in barcode.
  5. Eligibility for the L21 or L22 DDA Waiver is a 2 prong eligibility program. The individual must meet both the financial and functional eligibility for the program. If DDA waiver services are closed by DDA, DDA must inform the financial worker via the DSHS 15-345 in barcode. Financial would then need to consider eligibility for other medical programs.
  6. The L21/L22 program code is used for the DDA Waivers. There are exceptions:
    1. Eligibility for Health Care for Workers with Disabilities (HWD), use the S08/HWD program. Refer to the HWD specialist.
    2. DDA Foster Care Program
    3. Because of systems issues such as a SSI deemed eligible client with gross income over the SIL. Use a S02 program.
  7. For a DDA client with earnings, see Working clients on long-term services and supports This link includes information on the Health Care for Workers with Disability program.
  8. Out-of-pocket medical expenses can be allowed as a deduction in post eligibility (another term for this is determining the client total responsibility toward the cost of care, or participation). See Allowable Medical Expenses.
  9. Court ordered guardianship fees used as a deduction in long term care are described in the Guardianship section.
  10. Information on DDA community based waivers are in WAC 388-845
  11. Follow necessary supplemental accommodation services (NSA). The DDA case manager will inform the DDA financial worker of any additional NSA services indicated in the CARE plan with a accommodation to access or maintaining services.