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.

     (1) 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

     (a) Be an SSI-related client with countable income as described in subsection (4)(a) that is more than the special income level (SIL); or

     (b) 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.

     (2) For an SSI-related client, excess resources can be reduced by medical expenses as described in WAC 388-513-1350.

     (3) The department determines a client's countable resources for institutional and hospice services under the MN programs as follows:

     (a) For an SSI-related client, the department determines countable resources per WAC 388-513-1350.

     (b) For a child not described in subsection (3)(a), no determination of resource eligibility is required.

     (4) The department determines a client's countable income for institutional and hospice services under the MN program as follows:

     (a) For an SSI-related client, the department reduces available income as described in WAC 388-513-1325 and 388-513-1330 by:

     (i) Excluding income described in WAC 388-513-1340;

     (ii) Disregarding income described in WAC 388-513-1345; and

     (iii) 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.

     (b) For a child not described in subsection (4)(a), the department:

     (i) Follows the income rules described in WAC 388-505-0210 for the children's medical program; and

     (ii) Subtracts the medical expenses described in subsection (4).

     (5) 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:

     (a) Is eligible for institutional or hospice services in a medical institution, and noninstitutional medical assistance;

     (b) Is approved for twelve months; and

     (c) Participates in the cost of care as described in WAC 388-513-1380.

     (6) If the combined total of a client's countable income, which when added to countable resources in excess of the standard described in WAC 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:

     (a) Is eligible for nursing facility care only and is approved for a three or six month base period as described in chapter 388-519 WAC; and

     (i) Pays the nursing home at the current state rate;

     (ii) Participates in the cost of care as described in WAC 388-513-1380; and

     (iii) Is not eligible for medical assistance or hospice services unless the requirements in (6)(b) or (c) are met.

     (b) Is approved for medical assistance for a three or six month base period as described in chapter 388-519 WAC, if:

     (i) No income and resources remain after the post eligibility treatment of income process described in WAC 388-513-1380.

     (ii) Medicaid certification is approved beginning with the first day of the base period.

     (c) 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.

     (i) This process is known as spenddown and is described in WAC 388-519-0100.

     (ii) Medicaid certification is approved on the day the spenddown is met.

     (7) If the combined total of a client's nonexcluded income, which when added to nonexcluded resources is above the facility monthly private rate:

     (a) The client is ineligible using institutional rules.

     (b) Eligibility is considered under a noninstitutional medical assistance program described in chapter 388-416 and 388-519 WAC.



[Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, 74.39.010. 07-19-129, § 388-513-1395, filed 9/19/07, effective 10/20/07. Statutory Authority: RCW 11.92.180, 43.20B.460, 48.85.020, 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, 74.[09.]575, 74.09.585; 20 C.F.R. 416.1110-1112, 1123 and 1160; 42 C.F.R. 435.403 (j)(2) and 1005; and Sections 17, 1915(c), and 1924 (42 U.S.C. 1396) of the Social Security Act. 00-01-051, § 388-513-1395, filed 12/8/99, effective 1/8/00. Statutory Authority: RCW 74.08.090 and 74.09.500. 99-06-045, § 388-513-1395, filed 2/26/99, effective 3/29/99. Statutory Authority: RCW 74.08.090 and Budget Note 17. 96-16-092, § 388-513-1395, filed 8/7/96, effective 8/29/96. Statutory Authority: RCW 74.08.090 and 1995 2nd sp.s. c 18 §§ 2095a and 5b. 95-24-017 (Order 3921, #100267), § 388-513-1395, filed 11/22/95, effective 1/1/96. Statutory Authority: RCW 74.08.090. 94-10-065 (Order 3732), § 388-513-1395, filed 5/3/94, effective 6/3/94. Formerly WAC 388-95-400.]