WAC 182-515-1505 Home and community based (HCB) waiver services authorized by home and community services (HCS).

Effective February 20, 2017

This chapter describes the general and financial eligibility requirements for categorically needy (CN) home and community based (HCB) waiver services authorized by home and community services (HCS). The definitions in WAC 182-513-1100 and chapter 182-500 WAC apply throughout this chapter.

1. The HCS waivers are:
   1. Community options program entry system (COPES);
   2. New Freedom consumer-directed services (New Freedom); and
   3. Residential support waiver (RSW).
2. WAC 182-515-1506 describes the general eligibility requirements for HCB waiver services authorized by HCS.
3. WAC 182-515-1507 describes financial requirements for eligibility for HCB waiver services authorized by HCS when a person is eligible for a noninstitutional SSI-related categorically needy (CN) medicaid program.
4. WAC 182-515-1508 describes the financial eligibility requirements for HCB waiver services authorized by HCS when a person is not eligible for SSI-related noninstitutional CN medicaid under WAC 182-515-1507.
5. WAC 182-515-1509 describes the rules used to determine a person's responsibility for the cost of care and room and board for HCB waiver services if the person is eligible under WAC 182-515-1508.

WAC 182-515-1506 Home and community based (HCB) waiver services authorized by home and community services (HCS) general eligibility.

Effective February 25, 2023

1. To be eligible for home and community based (HCB) waiver services a person must:
   1. Meet the program and age requirements for the specific program:
      1. Community options program entry system (COPES), under WAC 388-106-0310;
      2. Residential support waiver (RSW), under WAC 388-106-0310; or
      3. New Freedom, under WAC 388-106-0338.
   2. Meet the disability criteria for the supplemental security income (SSI) program under WAC 182-512-0050;
   3. Require the level of care provided in a nursing facility under WAC 388-106-0355;
   4. Reside in a medical institution as defined in WAC 182-500-0050, or be likely to be placed in one within the next 30 days without HCB waiver services provided under one of the programs listed in (a) of this subsection;
   5. Attain institutional status under WAC 182-513-1320;
   6. Assessed for HCB waiver services, be approved for a plan of care, and receiving an HCB waiver service under (a) of this subsection;
   7. Be able to live at home with community support services and choose to remain at home, or live in a department-contracted alternate living facility under WAC 182-513-1100.
2. A person is not eligible for home and community based (HCB) waiver services if the person:
   1. Is subject to a penalty period of ineligibility for the transfer of an asset under WAC 182-513-1363; or
   2. Has a home with equity in excess of the requirements under WAC 182-513-1350.
3. See WAC 182-513-1315 for rules used to determine countable resources, income, and eligibility standards for long-term care (LTC) services.
4. Current income and resource standards are found at www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/program-standard-income-and-resources.

WAC 182-515-1507 Home and community based (HCB) waiver services authorized by home and community services (HCS) — Financial eligibility if a client is eligible for an SSI-related noninstitutional categorically needy (CN) medicaid program.

Effective February 25, 2023

1. A client is financially eligible for home and community based (HCB) waiver services if the client:
   1. Is receiving coverage under one of the following categorically needy (CN) medicaid programs:
      1. SSI program under WAC 182-510-0001. This includes SSI clients under Section 1619(b) of the Social Security Act;
      2. SSI-related noninstitutional CN program under chapter 182-512 WAC; or
      3. Health care for workers with disabilities program (HWD) under chapter 182-511 WAC.
   2. Does not have a penalty period of ineligibility for the transfer of an asset under WAC 182-513-1363; and
   3. Does not own a home with equity in excess of the requirements under WAC 182-513-1350.
2. A client eligible under this section does not pay toward the cost of care, but must pay room and board if living in an alternate living facility (ALF) under WAC 182-513-1100.
3. A client eligible under this section who lives in a department-contracted ALF described under WAC 182-513-1100 :
   1. Keeps a personal needs allowance (PNA) under WAC 182-513-1105; and
   2. Pays towards room and board under WAC 182-513-1105.
4. A client who is eligible under the HWD program must pay the HWD premium under WAC 182-511-1250, in addition to room and board, if residing in an ALF.
5. Current resource, income, PNA, and room and board standards are found at www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/program-standard-income-and-resources.

WAC 182-515-1508 Home and community based (HCB) waiver services authorized by home and community services (HCS) — Financial eligibility using SSI-related institutional rules.

Effective February 25, 2023

1. If a person is not eligible for a categorically needy (CN) program under WAC 182-515-1507, the agency determines eligibility for home and community based (HCB) waiver services authorized by home and community services (HCS) using institutional medicaid rules. This section explains how a person may qualify using institutional rules.
2. A person must meet:
   1. General eligibility requirements under WAC 182-513-1315 and 182-515-1506;
   2. The resource requirements under WAC 182-513-1350;
   3. The following income requirements:
      1. Available income must be at or below the special income level (SIL), defined under WAC 182-513-1100;
      2. If available income is above the SIL, net available income is no greater than the effective one-person medically needy income level (MNIL). Net income is calculated by reducing available income by:
         1. Medically needy (MN) disregards found under WAC 182-513-1345;
         2. The average monthly nursing facility state rate;
         3. Health insurance premiums, other than medicare; and
         4. Outstanding medical bills, prorated monthly over a 12-month certification period, that meet the requirements of WAC 182-513-1350.
3. The agency determines available income and income exclusions under WAC 182-513-1325, 182-513-1330, and 182-513-1340.
4. A person eligible under this section is responsible to pay toward the cost of care and room and board, as described under WAC 182-515-1509.
5. Current resource, income standards, and the average state nursing facility rate for long-term care are found at www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and access-apple-health/program-standard-income-and-resources.

WAC 182-515-1509 Home and community based (HCB) waiver services authorized by home and community services (HCS) – Client financial responsibility.

Effective February 25, 2023

1. A client eligible for home and community based (HCB) waiver services authorized by home and community services (HCS) under WAC 182-515-1508 must pay toward the cost of care and room and board under this section.
   1. Post-eligibility treatment of income, participation, and participate are all terms that refer to a client's responsibility towards cost of care.
   2. Room and board is a term that refers to a client's responsibility toward food and shelter in an alternate living facility (ALF).
2. The agency determines how much a client must pay toward the cost of care for HCB waiver services authorized by HCS when living in their own home:
   1. A single client who lives in their own home (as defined in WAC 388-106-0010) keeps a personal needs allowance (PNA) of up to 300% of the federal benefit rate (FBR) for the supplemental security income (SSI) cash grant program and must pay the remaining available income toward cost of care after allowable deductions described in subsection (4) of this section. The Washington apple health income and resource standards chart identifies 300% of the FBR as the medical special income level (SIL).
   2. A married client who lives with the client's spouse in their own home (as defined in WAC 388-106-0010) keeps a PNA of up to the effective one-person medically needy income level (MNIL) and pays the remainder of the client's available income toward cost of care after allowable deductions under subsection (4) of this section.
   3. A married client who lives in their own home and apart from the client's spouse keeps a PNA of up to the SIL but must pay the remaining available income toward cost of care after allowable deductions under subsection (4) of this section.
   4. A married couple living in their own home where each client receives HCB waiver services is each allowed to keep a PNA of up to the SIL but must pay remaining available income toward cost of care after allowable deductions under subsection (4) of this section.
   5. A married couple living in their own home where each client receives HCB waiver services, one spouse authorized by the developmental disabilities administration (DDA) and the other authorized by HCS, is allowed the following:
      1. The client authorized by DDA pays toward the cost of care under WAC 182-515-1512 or 182-515-1514; and
      2. The client authorized by HCS retains the SIL and pays the remainder of the available income toward cost of care after allowable deductions under subsection (4) of this section.
3. The agency determines how much a client must pay toward the cost of care for HCB waiver services authorized by HCS and room and board when living in a department contracted alternate living facility (ALF) defined under WAC 182-513-1100. A Client:
   1. Keeps a PNA of under WAC 182-513-1105;
   2. Pays room and board up to the room and board standard under WAC 182-513-1105; and
   3. Pays the remainder of available income toward the cost of care after allowable deductions under subsection (4) of this section.
4. If income remains after the PNA and room and board liability under subsection (2) or (3) of this section, the remaining available income must be paid toward the cost of care after it is reduced by deductions in the following order:
   1. An earned income deduction of the first $65 plus one-half of the remaining earned income;
   2. Guardianship fees and administrative costs including any attorney fees paid by the guardian only as allowed under chapter 388-79A WAC;
   3. Current or back child support garnished or withheld from the client's income according to a child support order in the month of the garnishment if it is for the current month. If the agency allows this as a deduction from income, the agency does not count it as the child's income when determining the family allocation amount in WAC 182-513-1385;
   4. A monthly maintenance-needs allowance for the community spouse as determined 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 to the community spouse's PNA, as calculated under WAC 182-513-1385;
   5. A monthly maintenance-needs allowance for each dependent of the institutionalized client, or the client's spouse, as calculated under WAC 182-513-1385;
   6. Incurred medical expenses which have not been used to reduce excess resources. Allowable medical expenses are under WAC 182-513-1350.
5. The total of the following deductions cannot exceed the special income level (SIL) defined under WAC 182-513-1100:
   1. The PNA allowed in subsection (2) or (3) of this section, including room and board;
   2. The earned income deduction in subsection (4)(a) of this section; and
   3. The guardianship fees and administrative costs in subsection (4)(b) of this section.
6. A client may have to pay third-party resources defined under WAC 182-513-1100 in addition to the room and board and participation.
7. A client must pay the client's provider the sum of the room and board amount, and the cost of care after all allowable deductions, and any third-party resources defined under WAC 182-513-1100.
8. A client on HCB waiver services does not pay more than the state rate for cost of care.
9. 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 received in a month.
10. Standards described in this section are found at www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/program-standard-income-and-resources.