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Participation in a medical facility
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.
- 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:
- WAC 182-513-1380 is used to determine participation for SSI related individuals in a medical institution including Hospice in a medical institution.
- WAC 182-514-0230 is used to determine participation for long term care for families and children.
- WAC 182-515-1509 is used to determine participation for HCS CN Waiver (COPES) and Hospice outside of a medical institution.
- WAC 182-515-1514 is used to determine participation for DDA CN 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:
- Advance notice is not required.
- 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 (14) 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. 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.
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 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) 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:
- Subtract nonexcluded income of the dependent from the Family and dependent allocation.
- 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:
- 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:
- Correct a previous award letter/notice.
- Make a retroactive change per a fair hearing decision.
- Make a change in participation per a court order.
- Make a change in the Health insurance premium that is paid quarterly.
- The beginning date of hospice care
- A change in hospice agencies
- Client chooses to stop receiving hospice services
- Client enters a medical facility for nonrespite care
- 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.
- 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:
- 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.
- Complete AREP screens as directed in AREP screens for long-term care cases.
- Follow Necessary supplemental accommodation (NSA) procedures.
Code the $90 veteran's payment (received by individuals residing in a nursing home) as VZ. Effective April 2009 individuals receiving the $90 VA payment are allowed to keep the $90 plus their PNA of $57.28 (or $62.79 if residing in a residential facility).