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HCB waivers, room and board, ETRs and bed holds
Purpose: Individuals that reside in residential settings have certain issues that apply to residential settings only. This section describes special circumstances that apply to HCB services in residential settings.
HCS services in residential settings, room and board and ETRs
HCS and DDA authorizes Waiver services for individuals residing in contracted alternate living facilities (ALF) such as Assisted Living (AL), DDA Group Home or Adult Family Homes (AFH).
The total responsibility paid by the individual to the assisted living or adult family home provider is a combination of the Waiver service participation, room and board and VA third party responsibility. VA third party responsibility is an amount paid to the individual by VA for aid and attendance and/or unusual medical expenses or UME.
What does room and board mean?
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. There is a term used by ALTSA called the room and board standard This standard is based on the Federal Benefit Rate (FBR) minus the HCBS Waiver PNA in an ALF.
- Individuals who reside in alternate living facilities pay room and board (R & B) in addition to their personal care participation.
- R & B is all state-funded; therefore you cannot automatically reduce R &B with the deductions listed under the HCS Waiver/COPES program.
- All deductions from room and board require an approved Exception to Rule (ETR)
- For HCS services, approvals are made by the regional designee.
- For DDA services, the DDA case-manager notifies the LTC specialty unit of an approved ETR via the DSHS 15-345
- R & B should only be reduced when all other income has been allocated toward participation and the individual does not have enough income available to pay toward the expenses.
- Limit requests for reducing R & B to those deductions that are allowed from participation. Don't reduce R & B for expenses that we would not allow from participation.
- Before requesting an ETR to reduce R & B, ensure you have factored in other income the individual may have available that is not being used to pay toward participation. Ensure the individual is allowed to keep the appropriate PNA.
Is room and board different from participation?
Yes, participation is a term that an individual must pay toward the cost of personal care. We use WAC 182-515-1509 (HCS Waiver) and WAC 182-515-1514 (DDA Waivers) to determine how much an individual must pay toward the cost of personal care. The reality is most people, including social workers call the entire amount the individual has to pay toward the care as "participation". For the financial worker determining eligibility, it is important to know the difference between the cost of personal care (participation) and room and board. The reason for this is there are deductions that are allowable to reduce the cost of personal care (participation) and not allowed to reduce the room and board rate without an ETR.
Note: What does residential setting mean? It means an individual is placed in either a boarding home (assisted living, enhanced adult residential center (EARC), adult residential center (ARC), DDA group home or an adult family home (AFH). See definition of an alternate living facility.
What residential settings are used for the HCB CN (COPES) program? Assisted living, EARC and adult family homes. ARC settings are contracted for MPC only. DDA group homes are contracted for DDA services only.
These residential facilities, or "alternate living facilities" are not medical institutions. A bill incurred prior to medicaid eligibility cannot reduce participation or be applied toward a spenddown.
Why are they sometimes called boarding homes? Because assisted living facilities, EARC, ARC and DDA group home are licensed as "boarding homes". Adult family homes are licensed as adult family homes.
Search for an adult family home or boarding home.
Bed holds for residential settings (boarding homes and adult family homes)
Financial services determines the amount of the individual's payment towards room and board and their participation toward the cost of personal care. When determining this payment amount, the goals are to avoid making individuals pay room and board/participation to multiple facilities whenever possible, and to preserve funding by keeping room and board/participation at the residential (ALF) facility rather than sending it to the nursing home. Social Service LTC manual Chapter 8 Residential Services/Bed hold for Medical Leave describes this process.
Financial workers will:
- Take no action until the bed hold has expired. The maximum length of the bed hold payment is 20 days.
- Determine how much the individual should pay to the residential facility during the discharge month. Assign any remainder to the new facility. If the individual:
- Did not return to the residential facility, change the individual's medical program to nursing facility coverage or other appropriate program and assign room and board/participation to the new facility after determining how much room and board/participation was used at the residential facility during the month the individual left.
- Does return to the residential facility either in the same month or the next month, assign room and board/participation to that facility.
- Returns to the residential facility, do not reassign any room and board/participation to the nursing home for any bed hold month(s) unless there are not enough days at the residential facility to account for it.
Community Spouse paying private in a residential setting
Scenario: Community Spouse (CS) paying privately in a residential setting, usually an assisted living facility. Institutionalized spouse is in the nursing home or receiving COPES.
For this scenario the department is counting the private pay in the residential setting minus the 4 person SUA/LTC utility standard as the shelter cost for the purposes of determining excess shelter for the CS.
Whenever we are looking at spousal deeming for institutional programs (Waiver or residing in a medical institution) and the CS is paying privately at a residential facility (adult family home, assisted living facility) use this method to determine the community spouse's shelter cost.
Indicate the private pay cost minus the LTC utility standard as the shelter cost on the institutionalized spouse SHEL screen. Since ACES adds the 4 person SUA/LTC utility standard to the shelter cost in the calculation, we need to make sure we have subtracted that amount out from the cost of the private pay to the residential setting.
Mrs. Smith is on COPES in an AFH. Her monthly income is $1500 per month. Mr. Smith is paying privately at the same AFH. His income is $2650 per month. The AFH is charging him a private rate of $2600 per month.
Mr. Smith is a community spouse. Although both Mr. and Mrs are residing in the same facility, only Mrs. Smith is considered institutionalized because she is receiving Waiver services.
The department will deem some of Mrs. income to Mr. Smith since he has excess shelter costs and is considered the community spouse.
As of 1/2009 the 4 person SUA-LTC utility standard is $384. $2,600 private rate - $384 = $2,216.00 shelter cost for the community spouse. This is indicated on Mrs. (the one on COPES) shelter expense in ACES 3G.