Understanding Guardianship Fees and Participation Under Medicaid
This session delves into how DSHS utilizes Medicaid State Plan and Home & Community-Based Waiver rules for deductions related to guardianship fees. Topics covered include personal needs allowance arrangements, cost of care rules, participation distinctions, and specific guidelines for deductions. A detailed exploration of Chapter 388-79 WAC regulations is provided to aid in understanding the complexities of guardianship fees for Department clients.
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Guardianship Fees and Participation Under the Medicaid State Plan and Home & Community-Based Waivers 1
This session will cover how DSHS uses the Medicaid State Plan and Home and Community-Based Waiver rules to allow deductions for persons with guardians. The discussion will include the rules around the personal needs allowance arrangements; a brief overview of cost of care rules, and how participation and room & board are different; and the specific rules regarding deductions to participation for approved guardianship fees and associated costs under Chapter 388-79 WAC. for certain living 2
Agenda Introduction to chapter 388-79 WAC Who Pays Participation? Post eligibility treatment of income ( PETI ) The personal needs allowance PETI and chapter 388-79 WAC Room & board Deeper look into chapter 388-79 WAC 3
introduction to CHAPTER 388-79 WAC 4
Chapter 388-79 WAC Guardianship fees for clients of the Department: 388-79-010 Purpose 388-79-020 Definitions 388-79-030 Maximum fees and costs 388-79-050 Procedure for allowing fees 5
WAC 388-79-050 (3) If the fees and costs requested and established by the order are equal to or less than the maximum . . .,then the department will adjust the client's current participation to reflect the amounts . . . . 6
WAC 388-79-050 (4)(c) Should the court determine after consideration of the facts and law that fees and costs in excess of the [maximum] are just and reasonable and should be allowed, then the department will adjust the client's current participation . . . . 7
WAC 388-79-030 The amount of fees shall not exceed $175 per month; The costs directly related to establishing a guardianship for a department client shall not exceed $700; and The costs shall not exceed a total of $600 during any three-year period. 8
WAC 388-79-020 "Participation" means the amount the client pays from current monthly income toward the cost of the client's long-term care. 9
Quick Summary Chapter 388-79 WAC only applies to people who are required to pay participation. It does not apply to any other Medicaid group who receive services from HCS or DDA. 10
medicaid state plan WHO PAYS PARTICIPATION? (PART 1)
Medicaid State Plan The state plan describes many groups of individuals that may be eligible for Medicaid, provided they meet the categorical and financial eligibility criteria. We will be focusing on the SSI and SSI-related groups today. 12
Medicaid State Plan A person who receives Supplemental Security Income (SSI) is eligible for categorically needy (CN) Medicaid in Washington, so long as they continue to receive an SSI payment. 13
Medicaid State Plan A person who does not receive SSI may also be eligible for SSI-related CN Medicaid if they meet (essentially) the same requirements to receive SSI. 14
Medicaid State Plan For SSI or SSI-related CN Medicaid in the community, there is no responsibility for the person to pay for any of the cost of their care. 15
Medicaid State Plan Services HCS and DDA services available to people eligible for CN Medicaid in the community are: Medicaid Personal Care (MPC), for those with lower needs; and Community First Choice (CFC), for those with higher needs. 16
Medicaid State Plan In addition to CN Medicaid in the community, the state plan also provides for CN and medically needy (MN) Medicaid in medical institutions, such as nursing facilities. This type of Medicaid is called institutional Medicaid or long-term care (LTC). 17
Medicaid State Plan Institutional Medicaid has similar categorical and financial eligibility rules to non- institutional, but there are significant differences. The biggest of which, where our topic today is leading us, is that a recipient of LTC in an institution is required to contribute to the cost of their care. 18
Medicaid State Plan The contribution towards the cost of care is calculated by a process known as post- eligibility treatment of income (PETI). Shorthand: participation 19
Summary Non-Institutional Institutional Medicaid (with or without services) in the community Can receive CN if income requirements are met No responsibility towards the cost of care Medicaid with services in a medical institution Can receive CN or MN (depending on income) Required to pay towards their cost of care. 20
home & community-based waivers WHO PAYS PARTICIPATION? (PART 2) 21
Home & Community-Based Waiver Premise: People eligible for CN Medicaid in the community have access to services in the community (e.g., personal care via CFC or MPC). People eligible for CN or MN in a medical institution have access to LTC services. Issue: What about people in the community who are not income eligible for CN, but need services? 22
HCB Waiver A home and community-based (HCB) waiver allows the state to provide services to people who would otherwise be eligible for CN or MN in a medical institution, but who want to remain in the community. 23
HCB Waiver Under 1915(c) of the Social Security Act (Act), we essentially waive the requirement for a person to be physically in a medical institution to received Medicaid-funded LTC services. 24
HCB Waiver What this means: An HCB waiver is not non-institutional Medicaid in the community. An HCB waiver is institutional Medicaid, just like services in a medical institution. Just like LTC recipients in a medical institution, (most) HCB waiver recipients pay participation. 25
HCB Waiver Special eligibility note: HCB waivers fill a gap where a person would otherwise need to be in a medical institution to get the care they need, because their income is too high to be eligible for CN Medicaid in the community. 26
HCB Waiver Special eligibility note: Further, people who are otherwise eligible for CN Medicaid in the community (because they meet the income requirements) are eligible for HCB waivers, too. This group of HCB waiver recipients, however, does not participate. 27
HCB Waiver Special eligibility note: One way to think about this is that people who need to use the higher-income HCB waiver rules participate. Those who don t need to usethe higher-income HCB waiver rules, because they are already eligible for CN Medicaid, don t participate. 28
Comparing HCB Waiver Groups Lower Income Higher Income Institutional Medicaid Otherwise eligible for CN under the state plan in the community, but needs HCB waiver services Does not pay participation Institutional Medicaid Not eligible for CN under the state plan, but would be CN/MN in a medical institution Pays participation 29
Comparing HCB Waiver & Institutional Institutional HCB Waiver Physically in an institution receiving services Pays participation (regardless of income) Would be in an institution if no HCB waiver services May pay participation (based on income) 30
Summary Allowance of deductions for guardianship fees and costs apply only to those HCS or DDA clients who pay participation: Persons physically in medical institutions; and Persons who received HCB waiver services, and their income is too high to be otherwise eligible for CN Medicaid in the community. 31
what is participation? POST-ELIGIBILITY TREATMENT OF INCOME (PETI) 32
PETI The PETI process is a series of deductions from a LTC recipients gross income to determine a final amount that they are to contribute towards their cost of care. 33
PETI Federal rule (C.F.R.) requires that only certain, and specific, deductions are allowed as a deduction. The amounts are deducted in sequence, meaning if no income is left after the first deduction, there is no income to allow further deductions. 34
42 C.F.R. 435.725 Institutional 42 C.F.R. 435.726 HCB Waiver Deductions: Personal needs allowance Maintenance needs of spouse Maintenance needs of family Medical expenses Home maintenance (institutional only) 35
Important Point Notice under C.F.R. there is no mandatory or optional deduction for guardian fees or costs. Federal rule does not allow this deduction. However, Washington came up with a way to allow the deduction, but that deduction still remains limited by federal rule. 36
federal limits and state options THE PERSONAL NEEDS ALLOWANCE 37
PNA Institutional The first PETI deduction under federal rule is the personal needs allowance (PNA). The federal floor of this deduction is $30. The federal ceiling of this deduction is the medically needy income level (MNIL). For 2016, this is $733 in Washington. 38
PNA Institutional Under the Medicaid state plan, an institutional LTC recipient s PNA is $57.28. The remainder of the difference between the PNA ceiling and the $57.28 is utilized to allow deductions from participation not allowed by federal rule. 39
PNA Institutional In essence, we have the MNIL as the PNA, with four, in sequence, specific, and defined types of deductions within the PNA. The last of these deductions is the allowance for guardianship related fees and costs. The total of these four can t exceed the MNIL. 40
PNA HCB Waiver Very similar to how we approach the PNA under the state plan, we also choose the ceiling for HCB waiver. The ceiling in this case is the special income level (SIL), which is 3x the SSI standard. For 2016, this is $733 x 3 = $2,199. 41
PNA HCB Waiver Although there are different deductions under the HCB waiver PNA, guardianship related fees and costs are also included last. Again, the total of these deductions cannot exceed the federal maximum of the SIL. 42
for persons in medical institutions APPLYING CHAPTER 388-79 WAC TO PETI 43
WAC 182-513-1380 This WAC describes the PETI process and applies federal law, federal rule, and chapter 388-79 WAC to LTC Medicaid clients in medical institutions. This WAC does not apply to Medicaid recipients in the community (state plan or HCB waiver). 44
WAC 182-513-1380 The agency allocates income in the following order, the total cannot exceed the MNIL: PNA; Income taxes actually owed; Wages for certain people; and Guardianship fees/costs only as allowed under chapter 388-79 WAC. 45
for persons in the community APPLYING CHAPTER 388-79 WAC TO PETI 46
HCS DDA WAC 182-515-1509/1514 Before we discuss participation deductions for HCB waiver clients, a reminder. There is only one group of people who pay participation when receiving HCB waiver services: Those who are not otherwise eligible for CN Medicaid in the community, and need to use HCB waiver rules to be eligible (i.e., high income). 47
Who Pays Again? No Participation Participation SSI recipients People deemed to be receiving SSI Pickle people Protected DACs SSI-related CN recipients Generally, people without SSI income, whose income is over $733 after all Medicaid deductions and exclusions 48
WAC 182-515-1509/1514 This WAC describes the PETI process and applies federal law, federal rule, and chapter 388-79 WAC to LTC Medicaid clients in the community who are required to pay participation. This WAC does not apply to Medicaid recipients in medical institutions. 49
WAC 182-515-1509/1514 The agency allocates income in the following order, the total cannot exceed the SIL: PNA; Room & board liability (if residential); Earned income deduction; and Guardianship fees/costs only as allowed under chapter 388-79 WAC. 50
