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Participation in a medical facility

Revised Date:

December 27, 2021

Purpose: Describes the post-eligibility process for individuals residing in a medical institution and meet institutional status. The post eligibility process determines how much the individual must pay toward the cost of their institutional care. For rules on determining participation for Waiver programs, see chapter 388-515.

WAC 182-513-1380 Determining a client's financial participation in the cost of care for long-term care in a medical institution.

WAC 182-513-1380 Determining a client's financial participation in the cost of care for long-term care in a medical institution

Effective May 22, 2021

This rule describes how the agency or the agency's designee allocates income and excess resources when determining participation in the cost of care in a medical institution.

The agency or the agency's designee defines which income and resources must be used in this process under WAC 182-513-1315.
The agency or the agency's designee allocates nonexcluded income in the following order, and the combined total of (a), (b), (c), and (d) of this subsection cannot exceed the effective one-person medically needy income level (MNIL):
1. A personal needs allowance (PNA) under WAC 182-513-1105.
2. Mandatory federal, state, or local income taxes owed by the client.
3. Wages for a client who:
  1. Is related to the supplemental security income (SSI) program under WAC 182-512-0050(1); and
  2. Receives the wages as part of an agency-approved or department-approved training or rehabilitative program designed to prepare the client for a less restrictive placement. When determining this deduction, employment expenses are not deducted.
4. Guardianship fees and administrative costs, including any attorney fees paid by the guardian, as allowed under chapter 388-79A WAC.
The agency or the agency's designee allocates nonexcluded income after deducting amounts under subsection (2) of this section in the following order:
1. Current or back child support garnished or withheld from income according to a child support order in the month of the garnishment if it is:
  1. For the current month;
  2. For the time period covered by the PNA; and
  3. Not counted as the dependent member's income when determining the dependent allocation amount under WAC 182-513-1385.
2. A monthly maintenance needs allowance for the community spouse as determined using the calculation under WAC 182-513-1385. If the community spouse is also receiving long-term care services, the allocation is limited to an amount that brings the community spouse's income up to the PNA.
3. A dependent allowance for each dependent of the institutionalized client or the client's spouse, as determined using the calculation under WAC 182-513-1385.
4. Medical expenses incurred by the institutionalized individual and not used to reduce excess resources. Allowable medical expenses and reducing excess resources are described in WAC 182-513-1350.
5. Maintenance of the home of a single institutionalized client or institutionalized couple:
  1. Up to one hundred percent of the one-person federal poverty level per month;
  2. Limited to a six-month period;
  3. When a physician has certified that the client or couple is likely to return to the home within the six-month period; and
  4. When social services staff documents the need for the income deduction.
A client may have to pay third-party resources as defined under WAC 182-513-1100 in addition to the participation.
A client is responsible to pay only up to the state rate for the cost of care. If long-term care insurance pays a portion of the state rate cost of care, a client pays only the difference up to the state rate cost of care.
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 in a month.
Standards under this section for long-term care are found at https:www.hca.wa.gov/health-care-services-supports/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

Participation - the post-eligibility treatment of income (PETI) determination:

Participation is determined when a client is found eligible for long-term care (LTC) services (see Overview - Long-term Services and Supports Chart for a description).

This determination sets the amount the client must contribute toward the cost of care. For a client who is married or has dependent family members, this process determines how much of the client's income is allocated to the spouse and/or family members.

For a client who lives in a medical institution, the department allocates nonexcluded income according to WAC 182-513-1380.

Income that remains after deductions for the personal needs allowance (PNA) and other allocations are taken is the amount the client must participate in the cost of care in the medical institution.

For a client who lives at home or in an alternate living facility (ALF) and receives Home and Community Based waiver services, the department allocates non-excluded income and participation according to the rules of that specific program. For instructions on participation including room and board costs for Waivers see:

WAC 182-515-1505 (HCBS Waivers) This is commonly referred to as the COPES program.

WAC 182-515-1510 (DDA HCBS Waivers).

Washington Apple Health Income and Resource standards chart. See the Program standard for income and resources page for the latest chart.

Effective 4/10/2009 client's receiving the $90 from veteran's administration are allowed to keep the $90 plus their personal needs allowance indicated under all other PNA Med Inst of the Washington Apple Health Income and Resource standard chart.

The $90 is to be coded as VZ on the navigation tree under income in ACES 3G.

SSI income:

Typically, when an individual enters a medical facility, the Social Security Administration (SSA) reduces the SSI cash payment to $30 per month. The full SSI benefit is continued, if SSA determines the individual's stay in the facility is not likely to exceed three months and the individual has expenses for maintaining a home. When SSA has made such a determination, the full SSI benefit/State supplementary payment (SSP) is continued and is excluded in the post-eligibility process. The SSI/SSP benefit is not excluded, however, when determining the amount a client must contribute toward the cost of room and board when living in an alternate living facility (ALF). Room and board is discussed under the HCBS Waiver and MPC chapters.

Personal needs allowance (PNA) for clothing, personal items and incidentals (CPI):

Client's are allowed the highest personal needs allowance in a given month based on living arrangement, authorized service and marital status. If a client resided at home the first day of the month and went into a nursing home the same day, we would allow the in home PNA because they were residing in a home setting at least one moment during that given month. If a client went from a nursing home to an adult family home on COPES services the first day of the month, we would allow the COPES ALF PNA as it is the highest allowed. If that client were then discharged home on COPES from the ALF on the last day of the month, the benefit would be recalculated allowing the COPES in home PNA.

Mandatory taxes, department approved wages and guardianship fees

Mandatory taxes, department approved wages and Guardianship fees are allowed as a post eligibility deduction when determining participation for long-term care Medicaid programs. The combination of PNA, mandatory taxes, department approved wages, guardianship fees and administrative costs cannot exceed the MNIL for clients in a medical institution. There are times when the guardianship and/or administrative fees are over the amount allowed in a month (MNIL). It may take 2 or more months to allow for the administrative cost and guardianship fee. The correct order of deductions that cannot exceed the MNIL are:

PNA
Mandatory Taxes
Wages from approved employment
Guardianship/Attorney fees

Note: 65 and 1/2 deduction is not allowed for earnings in a Medical institution, however a wage deduction is allowed dollar for dollar up to the MNIL after allowing the PNA and mandatory tax deduction.

Approved wages need to be coded as RH ACES on the EARN screen.

Dependent and Family Allocation used in HCBS Waiver or Institutional Participation Calculation.

Family and dependent allocation

Home Maintenance Allowance (HMA)

The HMA is income that the client can keep in order to maintain their residence during their nursing facility stay. The HMA is approved by the social worker/case manager.

HMA can be approved for up to 6 months when it is determined the client is likely to return home within 6 months.

The monthly HMA amount is the current federal poverty level (FPL).

The Social Worker/Case manager notifies the Public Benefit Specialist (PBS) of the start date of the HMA when it has been approved. The PBS indicates the FPL as the HMA amount.

HMA eligibility is determined with each nursing home admission by the HCS SW. There is no limit to HMA for multiple admissions and discharges to a facility other than it is not allowed for more than 6 consecutive months.

Hospice

Hospice index

Participation in the cost of care for hospice services received in a medical facility is determined according to WAC 182-513-1380. The client pays their participation amount to the hospice agency.

Changes in income and deductions. Using Method 1 and 2 for institutional cases

Federal rule allows 2 methods for changes in income and deductions in institutional cases

Method 1: Allow the expense in the month it was incurred; or
Method 2: Estimate medical expense incurred in the preceding period, not to exceed 6 months if the expenses are expected to continue (Method 2)
1. At the end of the prospective period, or if there is a significant change of 25%, the expense is reconciled for the next time period.
2. A reconciliation is required, at least every 6 months when using method 2. Use barcode ticklers to track the expenses and reconciliation period.
3. Use the Method 2 training instructions and calculator and document that method 2 is being used to estimate medical expenses.

For additional information on Method 1, Method 2 and Method 3, go to the financial SharePoint site, financial training under the policy and program changes. HCB Waiver-Method 3

Change of circumstances The reporting requirements for LTC clients are described in WAC 182-504-0105. See LTC change of circumstances for additional information. When taking action on a change in the client's circumstances, advance notice is not required with participation changes, but adequate notice is always required.

Worker Responsibilities

Deduct from the client's nonexcluded income the appropriate amount for the client's personal needs allowance or maintenance needs amount. Use rules that apply to the specific program for which the client is approved when determining the appropriate amount:
1. WAC 182-513-1380 is used to determine participation for SSI related individuals in a medical institution including Hospice in a medical institution.
2. WAC 182-515-1509 is used to determine participation for HCS HCBS Waiver and Hospice as a program outside of a medical institution.
3. WAC 182-515-1514 is used to determine participation for DDA HCBS Waivers
To reduce excess resources, deduct amounts for medical expenses for which the client is liable. WAC 182-513-1350. See Allowable medical expenses.
To reduce participation, deduct medical expenses not already used to reduce excess resources as described in WAC 182-513-1350. See Allowable medical expenses.
Note: A client must receive continued assistance, if all of the following conditions apply:
1. Advance notice is not required.
2. Adequate notice is mailed less than ten days before the effective date.
  A fair hearing is requested within ten days of the date the letter is mailed.
  
  Advance notice is not required to change a client's participation in the cost of care, since no reduction, suspension, or termination of services will result. A change in the participation amount is not considered an adverse action.
Allocate the income of a client who is married to a community spouse as described in WAC 182-513-1380. Always request an exception to rule (ETR) for allocating the client's income to a former spouse when the Court has ordered a spousal maintenance amount to be paid. For Waiver programs (COPES) see WAC 182-515-1509 for instructions.
When both spouses are receiving LTC services, allocate the income according to the maintenance needs amount provided under the program from which services are received. Note: WAC 182-513-1315 states: The department determines a client's eligibility as it does for a single person when the client's spouse has already been determined eligible for LTC services.
Example: Mr. Jones is on COPES at home. Mrs. Jones fell and broke her hip and now needs services too. Mrs. Jones has been determined financially and functionally eligible for COPES. Since they are both institutionalized they are treated as a single individual. Each is allowed the 1 person FPL as a PNA.
Example: The amount of nonexcluded income that is allocated from a client in a medical facility who is married to a spouse receiving COPES in the home is limited to the maintenance needs amount provided under the COPES program.

Note: The maximum community spouse maintenance allowance includes any excess shelter costs.

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 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. ACES adds the 4 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.

Example: 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 HCBS Waiver services.

The agency will deem some of Mrs. income to Mr. Smith since he has excess shelter costs and is considered the community spouse.

As of 10/2021, SUA-LTC utility standard is $459. $2,600 private rate - $459 = $2,141 shelter cost for the community spouse. This is indicated on Mrs. (the one on COPES) SHEL screen.
Allocate the income of a client with a community spouse and a Family and dependent allocationby determining the monthly maintenance needs amount in the following way:
1. Subtract nonexcluded income of the dependent from the Family and dependent allocation.
2. Divide that amount by three.
Allocate the income of a client with Family and dependent allocation, but no community spouse, by determining the monthly maintenance needs amount in the following way:
1. Subtract the dependents' total nonexcluded income from the MNIL standard for the number of legal dependents living in the home
When a client changes providers or facilities during the month, the participation amount may need to be split between the two. Assign any participation amount the client does not owe the first provider or facility to the second one.
In determining split participation, the department figures the cost based on the day of admit and not the day of discharge. Example. Client discharges from facility A on 8/2 and admits to facility B on 8/2. Participation for 8/2 is assigned to facility B.
Treat hospice revocation or discharge like any other change from one nursing facility to another. See Hospice.
When changes in the participation amount are made and confirmed within ACES, the system automatically generates a notice to the client/ representative. Since some notices do not contain enough information, add sufficient freeform text to explain what changes are being made and the reason for them. If appropriate, suppress the notice and generate a letter to replace the notice. Situations for which a new notice and letter are appropriate include, but are not limited to the following:
1. Correct a previous award letter/notice.
2. Make a retroactive change per a fair hearing decision.
3. Make a change in participation per a court order.
4. Make a change in the health insurance premium that is paid quarterly.
5. The beginning date of hospice care
6. A change in hospice agencies
7. Client chooses to stop receiving hospice services
8. Client enters a medical facility for nonrespite care
9. Client leaves a facility or dies
When a client dies, review the participation amount assigned in the current award letter. Determine the actual cost of care for services provided using the daily department-contracted rate. If the client's cost of care is less than the participation amount, send an amended award letter that equates the participation amount with the actual cost of care. If the client's cost of care is more than the participation amount, do not change the amount before closing the case. The date of death is considered a discharge with the exception of Hospice and Waiver in an ALF.
1. When a client loses Institutional status e.g., is no longer eligible for COPES, redetermine the client's eligibility for noninstitutional medical in the following way:
2. Use information in the case record (ACES) unless you need further verification. If a client was CN eligible before losing COPES eligibility, Continue CN until you have redetermined the client's eligibility.
If the client remains eligible for medical care, change the appropriate ACES screens, complete and send the client a new award letter through the ACES system.