Participation in a medical institution

Revised date
Purpose statement

Describes the post-eligibility treatment of income (PETI) process for individuals residing in a medical institution, who meet institutional status. The PETI process determines how much the individual must pay toward the cost of their institutional care. This amount is called participation or client responsibility toward the cost of care.

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 February 25, 2023

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.

  1. The agency or the agency's designee defines which income and resources must be used in this process under WAC 182-513-1315.
  2. 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.
  3. 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 100 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.
  4. A client may have to pay third-party resources as defined under WAC 182-513-1100 in addition to the participation.
  5. 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.
  6. 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.
  7. Standards under this section for long-term care are found at 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

Income that remains after allowable deductions is the amount the client must pay toward the cost of care in the medical institution. The order and description of deductions follows WAC 182-513-1380. The combination of 1 - 4 can't exceed the medically needy income level (MNIL).

  1. Personal Needs Allowance (PNA)
  2. Mandatory taxes
  3. Wage deduction from department approved employment
  4. Guardianship fees and related attorney costs
  5. Court ordered child support
  6. Spousal maintenance allowance
  7. Dependent maintenance allowance
  8. Allowable medical expenses
  9. Home Maintenance Allowance (HMA)

Note: The 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 are coded as RH ACES on the income screen. 

SSI Income:

When an individual enters a medical institution, 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 institution is not likely to exceed three months and the individual has expenses for maintaining a home. When SSA makes this determination, the full SSI benefit/State supplementary payment (SSP) is continued and is excluded in the post-eligibility process. 

Personal Needs Allowance (PNA):

Client's are allowed the highest PNA in a given month based on living arrangement, authorized service and marital status. If a client resides at home at least one moment in the month and admits into a nursing facility (NF) we would allow the in home PNA. 

Dependent and Family Allocation Calculation:

Family and dependent allocation

Home Maintenance Allowance (HMA):

The HMA is income that the client can keep to maintain their residence during their NF 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).

There is no limit to HMA for multiple admissions and discharges to a NF. 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.

For further information see LTC change of circumstance.

Worker Responsibilities

  1. To reduce excess resources, deduct amounts for medical expenses for which the client is liable. WAC 182-513-1350. See Allowable medical expenses.
  2. To reduce participation, deduct medical expenses not already used to reduce excess resources as described in WAC 182-513-1350. See Allowable medical expenses.
  3. Allocate the income of a client to a former spouse when the Court has ordered a spousal maintenance amount to be paid. These orders can be called Qualified Domestics Relations Order (QDRO) or alimony.
  4. Allocate the income of the client with a spouse or dependent. See Family and dependent allocation.
  5. Treat hospice revocation or discharge like any other change from one nursing facility to another. See Hospice.
  6. Clients receiving the $90 from Veteran's Administration are allowed to keep the $90 plus their PNA indicated under all other PNA Med Inst of the Washington Apple Health Income and Resource standard chart.  The $90 is to be coded as VA Non-Countable as unearned income.
  7. Approved wages are coded as Rehabilitation Income in ACES as earned income.
  8. 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 and codes the starting month in ACES.
  9. When a client changes providers or facilities during the month, code the discharge and admit dates. ACES will recalculate the participation between the 2 medical institutions.
  10. 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.
  11. 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.

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