Long-term services and supports (LTSS) manual

Medically Needy LTC programs

Revised Date: 
January 3, 2014

WAC 182-513-1395 Determining eligibility for institutional services for people living in a medical institution under the SSI-related medically needy program.

Effective February 20, 2017

  1. For the purposes of this section only, "remaining income" means all gross nonexcluded income remaining after the post-eligibility calculation under WAC 182-513-1380.
  2. General information. To be eligible for institutional services when living in a medical institution under the SSI-related medically needy (MN) program, a person must:
    1. Meet program requirements under WAC 182-513-1315;
    2. Have gross nonexcluded income in excess of the special income level (SIL) defined under WAC 182-513-1100; and
    3. Meet the financial requirements of subsection (3) or (4) of this section.
  3. Financial eligibility.
    1. The agency or its designee determines a person's resource eligibility, excess resources, and medical expense deductions using WAC 182-513-1350.
    2. The agency or its designee determines a person's countable income by:
      1. Excluding income under WAC 182-513-1340;
      2. Determining available income under WAC 182-513-1325 or 182-513-1330;
      3. Disregarding income under WAC 182-513-1345; and
      4. Deducting medical expenses that were not used to reduce excess resources under WAC 182-513-1350.
  4. Eligibility for agency payment to the facility for institutional services and the MN program.
    1. If a person's remaining income plus excess resources is less than, or equal to, the state-contracted daily rate times the number of days the person has resided in the facility, the person:
      1. Is eligible for agency payment to the facility for institutional services and the MN program; and
      2. Is approved for a twelve-month certification period.
    2. The person must pay income and excess resources towards the cost of care under WAC 182-513-1380.
  5. Eligibility for agency payment to the facility for institutional services and MN spenddown. If a person's remaining income is more than the state-contracted daily rate times the number of days the person has resided in the facility, but less than the private nursing facility rate for the same period, the person:
    1. Is eligible to receive institutional services at the state-contracted rate; and
      1. Is approved for a three-month or six-month base period;
      2. Pays income and excess resources towards the state-contracted cost of care under WAC 182-513-1380; and
    2. Is eligible for the MN program for the same three-month or six-month base period when the total of additional medical expenses incurred during the base period exceeds:
      1. The total remaining income for all months of the base period;
      2. Minus the total state-contracted rate for all months of the base period.
  6. If a person has excess resources and the person's remaining income is more than the state-contracted daily rate times the number of days the person has resided in the facility, the person is not eligible to receive institutional services and the MN program.

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

  1. Determination of eligibility for the categorically needy (CN) or medically needy (MN) programs – income only:
    1. Program policy requires the department to use only the amount of an individual's nonexcluded income when determining eligibility for institutional, waivered, or hospice services under the CN program and institutional or hospice services under the MN program.
    2. For services under the CN program, an individual's nonexcluded income cannot exceed the special income level (SIL). For services under the MN program, an individual's nonexcluded income exceeds the SIL, but cannot exceed the amount established in rule and described below. The SIL is 300% of the federal benefit rate (FBR). The current SIL is located on the Standards LTSS chart.
    3. When determining an individual's eligibility for LTC services in the initial or review month, the department allows an amount of excess resources if, when the excess resources are added together with nonexcluded income, the combined total amount does not exceed the program requirements described below.

      Note: Income standard: The income standard used to determine an individual's eligibility for CN or MN program services does not include any amount of the individual's resources. Institutional Medicaid Standards.

  2. Excess resources: Individuals who have resources in excess of the resource standard in the month of application, or in the month in which they are completing an eligibility review, can be approved for or continue to receive LTC services, if the following conditions are met:
    1. For institutional or hospice services provided under the medically needy (MN) program, the combined total of the individual's nonexcluded income and excess resources cannot exceed the private rate of the facility in which the individual receives the services plus the amount of recurring medical expenses. The department adds the excess resources when determining the individual's participation in the cost of care for that month. Medically needy (MN) with no spenddown for institutional or hospice services: When the individual's nonexcluded income exceeds the facility's department-contracted rate with the department and is less than the facility's private rate plus the amount of recurring medical expenses, the individual is locked into the department-contracted rate for facility care only. The department counts the individual's nonexcluded income in excess of the department-contracted rate plus excess resources when determining the individual's spenddown liability for noninstitutional medical. See Spenddown. The contracted rate is equal to that of the medical facility in which the individual lives, or the monthly rate based on a thirty-one day month for hospice services provided in a medical facility.
    2. The department cannot approve noninstitutional medical for the individual, until the individual incurs medical expenses that are at least equal to the amount of nonexcluded income in excess of the department-contracted rate in the base period plus any excess resources. The individual remains liable for all such medical expenses, the amount of which is referred to as the individual's spenddown amount. WAC 182-513-1350 describes what medical expenses we can allow to reduce spenddown for long term care. The medical expenses are incurred by the institutional individual.
  3. Medically needy (MN) with no spenddown for institutional or hospice services: When the individual's nonexcluded income exceeds the facility's department-contracted rate with the department and is less than the facility's private rate plus the amount of recurring medical expenses, the individual is locked into the department-contracted rate for facility care only.
    1. The department counts the individual's nonexcluded income in excess of the department-contracted rate plus excess resources when determining the individual's spenddown liability for noninstitutional medical. See Spenddown. The contracted rate is equal to that of the medical facility in which the individual lives, or the monthly rate based on a thirty-one day month for hospice services provided in a medical facility.
    2. The department cannot approve noninstitutional medical for the individual, until the individual incurs medical expenses that are at least equal to the amount of nonexcluded income in excess of the department-contracted rate in the base period plus any excess resources. The individual remains liable for all such medical expenses, the amount of which is referred to as the individual's spenddown amount.
    3. WAC 182-513-1350 (8)(d) describes what medical expenses we can allow to reduce spenddown for long term care. The medical expenses are incurred by the institutional individual.

Worker Responsibilities

  1. When determining whether an individual is CN or MN eligible, do not add any resource amount to the individual's nonexcluded income.
  2. Include any excess resource amount in the initial or review month when determining an individual's participation in the cost of care or spenddown liability for noninstitutional medical.
  3. Establish the amount of excess resources and nonexcluded income used to determine an individual's participation in the cost of care by subtracting medical expenses from excess resources in an amount equal to incurred medical expenses such as:
    1. Premiums, deductibles, and coinsurance/copayment charges for health insurance and Medicare premiums;
    2. Necessary medical care recognized under state law, but not covered under the state's Medicaid plan;
    3. Necessary medical care covered under the state's Medicaid plan incurred prior to Medicaid eligibility.
      1. As long as the incurred medical expenses:
        1. Are not subject to third-party payment or reimbursement;
        2. Have not been used to satisfy a previous spend down liability;
        3. Have not previously been used to reduce excess resources;
        4. Have not been used to reduce the individual's responsibility toward cost of care;
        5. Were not incurred during a transfer of asset penalty described in WAC 182-513-1363, and
        6. Are amounts for which the individual remains liable.
      2. Expenses not allowed to reduce excess resources or participation in personal care are:
        1. Unpaid expense(s) prior to Waiver eligibility to an adult family home (AFH) or boarding home is not a medical expense.
        2. Personal care cost in excess of approved hours determined by the CARE assessment described in 106 WAC is not a medical expense.
  4. For LTC services provided under the medically needy (MN) program when excess resources are added to nonexcluded income, the combined total is less than the:
    1. Private medical institution rate plus the amount of recurring medical expenses for institutional services; or
    2. Private hospice rate plus the amount of recurring medical expenses, for hospice services in a medical institution.
    3. For MN Waiver eligibility, incurred medical expenses must reduce resources within allowable resource limits for MN-Waiver eligibility. The cost of care for the waiver services cannot be allowed as a projected expense.
  5. Contact the medical facility or hospice provider to obtain necessary documentation or verification as appropriate, since the individual will generally be physically and/or mentally unable to provide the information. It is not necessary to interview the individual.
  6. Use the rules described in WAC 182-513-1395 (5) when approving institutional or hospice services under the MN program. See SPENDDOWN when approving noninstitutional medical.