Washington Administrative Code
Title 182 - Health Care Authority
WASHINGTON APPLE HEALTH
Chapter 182-513 - Client not in own home-Institutional medical
Section 182-513-1245 - Medically needy hospice program in a medical institution
Universal Citation: WA Admin Code 182-513-1245
Current through Register Vol. 24-18, September 15, 2024
(1) General information.
(a) When living in a medical
institution, a person may be eligible for medically needy coverage under the
hospice program. A person must:
(i) Meet
program requirements under WAC
182-513-1315;
(ii) Have available income that exceeds the
special income level (SIL), defined under WAC 182-513-1100, but is below the
institution's monthly state-contracted rate;
(iii) Meet the financial requirements of
subsection (4) or (5) of this section; and
(b) Elect hospice services under chapter
182-551 WAC.
(2) Financial eligibility.
(a) The agency or its
designee determines a person's resource eligibility, excess resources, and
medical expense deductions using WAC
182-513-1350.
(b) The agency or its designee determines a
person's countable income by:
(i) Excluding
income under WAC
182-513-1340;
(ii) Determining available income under WAC
182-513-1325 or
182-513-1330;
(iii) Disregarding income under WAC
182-513-1345; and
(iv) Deducting medical expenses that were not
used to reduce excess resources under WAC
182-513-1350.
(3) Determining the state-contracted daily rate in an institution, and the institutional medically needy income level (MNIL).
(a) The agency or
its designee determines the state-contracted daily rate in an institution and
the institutional MNIL based on the living arrangement, and whether the person
is entitled to receive hospice services under medicare.
(b) When the person resides in a hospice care
center:
(i) If entitled to medicare, the
state-contracted daily rate is the state-contracted daily hospice care center
rate. The institutional MNIL is calculated by multiplying the state-contracted
daily rate by 30.42.
(ii) If not
entitled to medicare, the state-contracted daily rate is the state-contracted
daily hospice care center rate, plus the state-contracted daily hospice rate.
To calculate the institutional MNIL, multiply the state-contracted daily rate
by 30.42.
(c) When the
person resides in a nursing facility:
(i) If
entitled to medicare, the state-contracted daily rate is ninety-five percent of
the nursing facility's state-contracted daily rate. The institutional MNIL is
calculated by multiplying the state-contracted daily rate by 30.42.
(ii) If not entitled to medicare, the
state-contracted daily rate is ninety-five percent of the nursing facility's
state-contracted daily rate, plus the state-contracted daily hospice rate. The
institutional MNIL is calculated by multiplying the state-contracted daily rate
by 30.42.
(4) Eligibility for agency payment to the facility for institutional hospice services and the MN program.
(a) If a person's
countable income plus excess resources is less than or equal to the
state-contracted daily rate under subsection (3) of this section times the
number of days the person has resided in the medical institution, the person:
(i) Is eligible for agency payment to the
facility for institutional hospice services;
(ii) Is approved for MN coverage for a
twelve-month certification period;
(b) Pays excess resources under WAC
182-513-1350; and
(c) Pays income towards the cost of care
under WAC
182-513-1380.
(5) Eligibility for institutional MN spenddown.
(a) If a person's countable
income is more than the state-contracted daily rate times the number of days
the person has resided in the medical institution, but less than the
institution's private rate for the same period, the person:
(i) Is not eligible for agency payment to the
facility for institutional hospice services; and
(ii) Is eligible for the MN spenddown program
for a three-month or six-month base period when qualifying medical expenses
meet a person's spenddown liability.
(b) Spenddown liability is calculated by
subtracting the institutional MNIL from the person's countable income for each
month in the base period. The values from each month are added together to
determine the spenddown liability.
(c) Qualifying medical expenses used to meet
the spend-down liability are described in WAC
182-519-0110, except that only
costs for hospice services not included within the state-contracted daily rate
are qualifying medical expenses.
(6) Eligibility for MN spenddown.
(a) If a person's countable income is more
than the institution's private rate times the number of days the person has
resided in the medical institution, the person is not eligible for agency
payment to the facility for institutional hospice services and institutional MN
spenddown; and
(b) The agency or
its designee determines eligibility for MN spenddown under chapter 182-519
WAC.
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