Current through Register Vol. 24-18, September 15, 2024
(1) General
information.
(a) This section describes how
the agency or the agency's designee defines the resource standard and countable
or excluded resources when determining a person's eligibility for SSI-related
long-term care (LTC) services.
(b)
"Resource standard" means the maximum amount of resources a person can have and
still be resource eligible for program benefits.
(c) For a person not SSI-related, the agency
applies program specific resource rules to determine eligibility.
(2) Resource standards.
(a) The resource standard for the following
people is $2000:
(i) A single person;
or
(ii) An institutionalized
spouse.
(b) The resource
standard for a legally married couple is $3000, unless subsection (3)(b)(ii) of
this section applies.
(c) The
resource standard for a person with a qualified long-term care partnership
policy under WAC
182-513-1400 may be higher based
on the dollar amount paid out by a partnership policy.
(d) Determining the amount of resources that
can be allocated to the community spouse when determining resource eligibility
is under WAC
182-513-1355.
(3) Availability of resources.
(a) General. The agency or the agency's
designee applies the following rules when determining available resources for
LTC services:
(i) WAC
182-512-0300 SSI-related
medical-Resources eligibility;
(ii)
WAC 182-512-0250 SSI-related
medical-Ownership and availability of resources; and
(iii) WAC
182-512-0260 SSI-related
medical-How to count a sponsor's resources.
(b) Married couples.
(i) When both spouses apply for LTC services,
the resources of both spouses are available to each other through the month in
which the spouses stopped living together.
(ii) When both spouses are institutionalized,
the agency or the agency's designee determines the eligibility of each spouse
as a single person the month following the month of separation.
(iii) If the agency or the agency's designee
has already established eligibility and authorized services for one spouse, and
the community spouse needs LTC services in the same month, but after
eligibility has been established and services authorized for the
institutionalized spouse, then the agency applies the standard under subsection
(2)(a) of this section to each spouse. If doing this would make one of the
spouses ineligible, then the agency applies subsection (2)(b) of this section
for the couple.
(iv) The resources
of the community spouse are unavailable to the institutionalized spouse the
month after eligibility for LTC services is established, unless (v) or (vi) of
this subsection applies.
(v) When a
single institutionalized individual marries, the agency or the agency's
designee redetermines eligibility applying the resource and income rules for a
legally married couple.
(vi) A
redetermination of the couple's resources under this section is required if:
(A) The institutionalized spouse has a break
of at least 30 consecutive days in a period of institutional status;
(B) The institutionalized spouse's countable
resources exceed the standard under subsection (2)(a) of this section, and WAC
182-513-1355(2)(b)
applies; or
(C) The
institutionalized spouse does not transfer the amount, under WAC
182-513-1355(3) or
(5), to the community spouse by either:
(I) The end of the month of the first
regularly scheduled eligibility review; or
(II) A reasonable amount of time necessary to
obtain a court order for the support of the community spouse.
(4) Countable resources.
(a) The agency or the agency's designee
determines countable resources using the following sections:
(i) WAC
182-512-0200 SSI-related
medical-Definition of resources.
(ii) WAC
182-512-0250 SSI-related
medical-Ownership and availability of resources.
(iii) WAC
182-512-0260 SSI-related
medical-How to count a sponsor's resources.
(iv) WAC
182-512-0300 SSI-related
medical-Resources eligibility.
(v)
WAC 182-512-0350 SSI-related
medical-Property and contracts excluded as resources;
(vi) WAC
182-512-0400 SSI-related
medical-Vehicles excluded as resources;
(vii) WAC
182-512-0450 SSI-related
medical-Life insurance excluded as a resource; and
(viii) WAC
182-512-0500 SSI-related
medical-Burial funds, contracts and spaces excluded as resources.
(ix) Chapter 182-516 WAC, Trusts, annuities,
life estates, and promissory notes-Effect on medical programs.
(b) The agency or the agency's
designee determines excluded resources based on federal law and WAC
182-512-0550, except:
(i) For institutional and HCB waiver
programs, pension funds owned by a nonapplying spouse are counted toward the
resource standard.
(ii) For
long-term services and supports (LTSS), based on the need for either nursing
facility level of care or intermediate care facility for the intellectually
disabled level of care, one home is excluded only if it meets the home equity
limits of subsection (8) of this section. See WAC
182-512-0350(1)(b).
(c) The agency or the agency's
designee adds together the countable resources of both spouses if subsections
(3)(b)(i) and (iv) apply, but not if subsection (3)(b)(ii) or (iii) apply. For
a person with a community spouse, see WAC
182-513-1355.
(5) Excess resources.
(a) For LTC programs, a person may reduce
excess resources by deducting incurred medical expenses under subsection (6) of
this section;
(b) The amount of
excess resources is limited to the following amounts:
(i) For LTC services provided under the
categorically needy (CN) program:
(A) In a
medical institution, excess resources and available income must be under the
state medicaid rate based on the number of days the person spent in the medical
institution in the month.
(B) For
HCB waiver eligibility, incurred medical expenses must reduce resources within
allowable resource standards. The cost of care for the HCB waiver services
cannot be allowed as a projected expense.
(ii) For LTC services provided under the
medically needy (MN) program, see:
(A) WAC
182-513-1395 for LTC programs;
and
(B) WAC
182-513-1245 for
hospice.
(c)
Excess resources not otherwise applied to medical expenses will be applied to
the projected cost of care for services in a medical institution under WAC
182-513-1380.
(6) Allowable medical expenses.
(a) The following incurred medical expenses
may be used to reduce excess resources:
(i)
Premiums, deductibles, coinsurance, or copayment charges for health insurance
and medicare;
(ii) Medically
necessary care defined under WAC
182-500-0070, but not covered
under the state's medicaid plan. Information regarding covered services is
under chapter 182-501 WAC;
(iii)
Medically necessary care defined under WAC
182-500-0070 incurred prior to
medicaid eligibility. Expenses for nursing facility care are reduced at the
state rate for the specific facility that provided the services.
(b) To be allowed, the medical
expense must:
(i) Have been incurred no more
than three months before the month of the medicaid application;
(ii) Not be subject to third-party payment or
reimbursement;
(iii) Not have been
used to satisfy a previous spenddown liability;
(iv) Not have been previously used to reduce
excess resources;
(v) Not have been
used to reduce participation;
(vi)
Not have been incurred during a transfer of asset penalty under WAC
182-513-1363; and
(vii) Be an amount for which the person
remains liable.
(7) Nonallowable expenses. The following
expenses are not allowed to reduce excess resources:
(a) Unpaid adult family home (AFH) or
assisted living facility expenses incurred prior to medicaid
eligibility;
(b) Personal care cost
in excess of approved hours determined by the CARE assessment under chapter
388-106 WAC; and
(c) Expenses
excluded by federal law.
(8) Excess home equity.
(a) A person with an equity interest in a
primary residence in excess of the home equity limit is ineligible for
long-term services and supports (LTSS) that are based on the need for either
nursing facility level of care or intermediate care facility for the
intellectually disabled level of care, unless one of the following persons
lawfully resides in the home:
(i) That
person's spouse; or
(ii) That
person's dependent child under age 21, blind child, or disabled
child.
(b) The home
equity provision applies to all applications for LTSS received on or after May
1, 2006.
(c) The excess home equity
limit is the federal maximum allowed. On January 1st of each year, this
standard may change by the percentage in the consumer price index for all
consumers (CPI-U). The current maximum home equity limit is posted by the
Centers for Medicare and Medicaid Services. (See subsection (9) of this section
for institutional resource standards.)
(d) A person who is denied or terminated LTC
services due to excess home equity may apply for an undue hardship waiver under
WAC 182-513-1367.
WSR 13-01-017, recodified as §182-513-1350, filed
12/7/12, effective 1/1/13. Statutory Authority:
RCW
74.04.050,
74.04.057,
74.08.090,
74.09.530, section 6014 of the
Deficit Reduction Act of 2005 (DRA), and 2010 1st sp.s. c 37§ 209(1). WSR
12-21-091, § 388-513-1350, filed 10/22/12, effective 11/22/12. Statutory
Authority:
RCW
74.04.050,
74.04.057,
74.08.090,
74.09.500,
74.09.530, and
74.09.575. WSR 09-12-058, §
388-513-1350, filed 5/28/09, effective 7/1/09. Statutory Authority:
RCW
74.04.050,
74.04.057,
74.08.090,
74.09.500, and
74.09.530. WSR 08-13-072, §
388-513-1350, filed 6/16/08, effective 7/17/08. Statutory Authority:
RCW
74.04.050,
74.04.057,
74.08.090,
74.09.575,
74.09.500, and
74.09.530. WSR 07-19-128, §
388-513-1350, filed 9/19/07, effective 10/20/07. Statutory Authority:
RCW
74.04.050,
74.04.057,
74.08.090,
74.09.500,
74.09.530,
74.09.575, 2005 Federal Deficit
Reduction Act (DRA) Public
Law 109-171, and Section 1924 of the Social
Security Act (42 U.S.C.
1396r-5) . WSR 07-01-073, §
388-513-1350, filed 12/18/06, effective 1/18/07. Statutory Authority:
RCW
74.04.050,
74.04.057,
74.08.090,
74.09.500,
42 U.S.C.
9902(2). WSR 05-07-033,
§ 388-513-1350, filed 3/9/05, effective 4/9/05. Statutory Authority:
RCW
74.04.050,
74.04.057,
74.08.090,
74.09.500,
74.09.575; 2003 1st sp.s. c 28,
and section 1924 of the Social Security Act (
42 U.S.C.
1396R-5) . WSR 04-04-072, §
388-513-1350, filed 2/2/04, effective 3/4/04. Statutory Authority:
RCW
74.04.050,
74.04.057,
74.08.090,
74.09.500 and Section 1924 (
42 U.S.C.
1396R-5) . WSR 01-18-055, §
388-513-1350, filed 8/30/01, effective 9/30/01. 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. WSR
00-01-051, § 388-513-1350, filed 12/8/99, effective 1/8/00. Statutory
Authority:
RCW
74.08.090 and
74.09.500. WSR 99-06-045, §
388-513-1350, filed 2/26/99, effective 3/29/99. Statutory Authority:
RCW
74.04.050,
74.04.057,
74.08.090,
74.09.530,
74.09.575 and Section 1924 (
42 U.S.C.
1396r-5) . WSR 98-11-033, §
388-513-1350, filed 5/14/98, effective 6/14/98. Statutory Authority:
RCW
74.04.050,
74.04.057,
74.08.090 and
74.09.575. WSR 97-09-112, §
388-513-1350, filed 4/23/97, effective 5/24/97. Statutory Authority:
RCW
74.08.090 and Title XIX State Agency Letter
95-44. WSR 96-09-033 (Order 3963), § 388-513-1350, filed 4/10/96,
effective 5/11/96. Statutory Authority:
RCW
74.08.090 and Title XIX State Agency Letter
94-49, notice of increase in SSI level. WSR 95-05-022 (Order 3832), §
388-513-1350, filed 2/8/95, effective 3/11/95. Statutory Authority:
RCW
74.08.090. WSR 94-23-129 (Order 3808), §
388-513-1350, filed 11/23/94, effective 12/24/94; WSR 94-10-065 (Order 3732),
§ 388-513-1350, filed 5/3/94, effective 6/3/94. Formerly parts of WAC
388-95-337 and 388-95-340.
