Determining eligibility for institutional or hospice services for individuals living in a medical institution under the medically needy (MN) program
WAC 388-513-1395
WAC 388-513-1395
Effective October 20, 2007
WAC 388-513-1395 Determining eligibility for institutional or hospice services for individuals living in a medical institution under the medically needy (MN) program
This section describes how the department determines a client's eligibility for institutional or hospice services in a medical institution and for facility care only under the MN program. In addition, this section describes rules used by the department to determine whether a client approved for these benefits is also eligible for noninstitutional medical assistance in a medical institution under the MN program.
To be eligible for institutional or hospice services under the MN program for individuals living in a medical institution, a client must meet the financial requirements described in subsection (5)- In addition, a client must meet program requirements described in WAC 388-513-1315; and
Be an SSI-related client with countable income as described in subsection (4)(a) that is more than the special income level (SIL); or
Be a child not described in subsection (1)(a) with countable income as described in subsection (4)(b) that exceeds the categorically needy (CN) standard for the children's medical program
For an SSI-related client, excess resources can be reduced by medical expenses as described in WAC 388-513-1350.
The department determines a client's countable resources for institutional and hospice services under the MN programs as follows:
For an SSI-related client, the department determines countable resources per WAC 388-513-1350;
For a child not described in subsection (3) (a), no determination of resource eligibility is required.
The department determines a client's countable income for institutional and hospice services under the MN program as follows:
Subtracting previously incurred medical expenses incurred by the client and not used to reduce excess resources . Allowable medical expenses and reducing excess resources are described in WAC 388-513-1350. For a child not described in subsection (4) (a), the department:
Follows the income rules described in WAC 388-505-0210 for the children’s medical program; and
Subtracts the medical expenses described in subsection (4).
If the combined total of a client's countable income, when added to countable resources in excess of the standard described in WAC 388-513-1350 (1), is less than the department-contracted rate plus the amount of recurring medical expenses, the client:
Is eligible for institutional or hospice services in a medical institution, and non institutional medical assistance;
If the combined total of a client's countable income, which when added to countable resources in excess of the standard described inWAC 388-513-1350 (1) is less than the private nursing facility rate plus the amount of recurring medical expenses, but more than the department contracted rate, the client:
Is eligible for nursing facility care only and is approved for a three or six month base period as described in chapter WAC 388-519 and
Pays the nursing home at the current state rate;
Participates in the cost of care as described in WAC 388-513-1380 and;
Is not eligible for medical assistance or hospice services unless the requirements in (6)(b) or (c) are met.
Is approved for medical assistance for a three or six month base period as described in WAC 388-519 if:
No income and resources remain after the post eligibility treatment of income process described in WAC 388-513-1380 Medicaid certification is approved beginning with the first day of the base period.
Is approved for medical assistance for up to three or six months when they incur additional medical expenses that are equal to or more than excess income and resources remaining after the post eligibility treatment of income process described in WAC 388-513-1380.
Determination of eligibility for the categorically needy (CN) or medically needy (MN) programs – income only:
Program policy requires the department to use only the amount of a client’s non-excluded income when determining eligibility for institutional, waivered, or hospice services under the CN program and institutional or hospice services under the MN program.
For services under the CN program, a client’s non-excluded income cannot exceed the special income level (SIL). For services under the MN program, a client’s non-excluded 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 theinstitutional standards chart.
When determining a client’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 non-excluded income, the combined total amount does not exceed the program requirements described below.
NOTE:
Income standard: The income standard used to determine a client’s eligibility for CN or MN program services does not include any amount of the client’s resources.Institutional Medicaid Standards.
Excess resources: Clients 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: .
For institutional or hospice services provided under the medically needy (MN) program, the combined total of the client’s non-excluded income and excess resources cannot exceed the private rate of the facility in which the client receives the services plus the amount of recurring medical expenses.
The department adds the excess resources when determining the client’s participation in the cost of care for that month.
Medically needy (MN) with no spenddown for institutional or hospice services: When the client’s non-excluded 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 client is locked into the department-contracted rate for facility care only.
The department counts the client’s non-excluded income in excess of the department-contracted rate plus excess resources when determining the client’s spenddown liability for non-institutional medical. See SPENDDOWN. The contracted rate is equal to that of the medical facility in which the client lives, or the monthly rate based on a thirty-one day month for hospice services provided in a medical facility.
The department cannot approve non-institutional medical for the client, until the client incurs medical expenses that are at least equal to the amount of non-excluded income in excess of the department-contracted rate in the base period plus any excess resources. The client remains liable for all such medical expenses, the amount of which is referred to as the client’s spenddown amount.
WAC 388-513-1350 (7) (d) describes what medical expenses we can allow to reduce spenddown for long term care. The medical expenses are incurred by the institutional client.
WORKER RESPONSIBILITIES
When determining whether a client is CN or MN eligible, do not add any resource amount to the client’s non-excluded income.
Include any excess resource amount in the initial or review month when determining a client’s participation in the cost of care or spenddown liability for non-institutional medical.
Establish the amount of excess resources and non-excluded income used to determine a client’s participation in the cost of care by subtracting medical expenses from excess resources in an amount equal to incurred medical expenses such as:
Premiums, deductibles, and co-insurance/co-payment charges for health insurance and Medicare premiums;
Necessary medical care recognized under state law, but not covered under the state's Medicaid plan;
Necessary medical care covered under the state's Medicaid plan incurred prior to Medicaid eligibility.
As long as the incurred medical expenses:
Are not subject to third-party payment or reimbursement;
Have not been used to satisfy a previous spend down liability;
Have not previously been used to reduce excess resources;
Have not been used to reduce client responsibility toward cost of care;
Expenses not allowed to reduce excess resources or participation in personal care are:
Unpaid expense(s) prior to Waiver eligibility to an adult family home (AFH) or boarding home is not a medical expense.
Personal care cost in excess of approved hours determined by the CARE assessment described in 106 WAC is not a medical expense.
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:
Private medical institution rate plus the amount of recurring medical expenses for institutional services; or
Private hospice rate plus the amount of recurring medical expenses, for hospice services in a medical institution.
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.
Contact the medical facility or hospice provider to obtain necessary documentation or verification as appropriate, since the client will generally be physically and/or mentally unable to provide the information. It is not necessary to interview the client.
Use the rules described in WAC 388-513-1395 (5) when approving institutional or hospice services under the MN program. See SPENDDOWN and CERTIFICATION PERIODS when approving non-institutional medical.
