Guardianship Fees and Participation Under Medicaid

undefined
 
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 for certain living
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.
 
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
 
CHAPTER 388-79 WAC
 
introduction to
 
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
 
WHO PAYS PARTICIPATION?
(PART 1)
 
medicaid state plan
 
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
 
Medicaid (with or without
services) in the community
Can receive CN if income
requirements are met
No responsibility towards
the cost of care
Institutional
 
Medicaid with services in a
medical institution
Can receive CN or MN
(depending on income)
Required to pay towards
their cost of care.
20
 
WHO PAYS PARTICIPATION?
(PART 2)
 
home & community-based waivers
 
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 use
 
the higher-income
HCB waiver rules, because they are already
eligible for CN Medicaid, don’t participate.
 
28
Comparing HCB Waiver Groups
Lower Income
 
Institutional Medicaid
Otherwise eligible for CN
under the state plan in the
community, but needs HCB
waiver services
Does not pay participation
Higher Income
 
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
 
Physically in an institution
receiving services
Pays participation
(regardless of income)
HCB Waiver
 
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
 
POST-ELIGIBILITY TREATMENT OF
INCOME (PETI)
 
what is “participation”?
 
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
 
THE PERSONAL NEEDS ALLOWANCE
 
federal limits and state options
 
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
 
APPLYING CHAPTER 388-79 WAC TO PETI
 
for persons in medical institutions
 
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
 
APPLYING CHAPTER 388-79 WAC TO PETI
 
for persons in the community
 
46
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
 
SSI recipients
People deemed to be
receiving SSI
Pickle people
Protected DACs
SSI-related CN recipients
Participation
 
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
 
WAC 182-515-1514
 
Special note about DDA clients on HCB waiver
services at home:
The income limit for DDA HCB waivers is the SIL;
The in-home PNA for these folks is the SIL;.
In almost all circumstances, a DDA HCB waiver
recipient has $0 participation while in-home.
 
51
 
WHAT IS ROOM & BOARD?
 
applicable to both hcb waiver and state plan services
 
52
Room & Board
Is the client’s liability for the costs of their
food, shelter, and heat in a residential setting.
It is not part of their “cost of care” nor is it
considered a share of their “medical
assistance.”
Room & board is not participation.
53
 
Who Pays Room & Board?
 
Any Medicaid service recipient who is living in
a residential setting, including those who are
not required to pay participation:
State plan services (CFC, MPC, PACE)
HCB waiver (both groups)
 
54
 
Deductions from Room & Board?
 
There are no allowed deductions from Room
& board.
Chapter 388-79 WAC does not give authority
to reduce Room & board.
 
55
 
WAC 388-79-050
 
a deeper look
 
56
 
RCW 11.92.180
 
The amount of guardianship fees and
additional compensation for administrative
costs shall not exceed the amount allowed by
the department of social and health services
by rule.
 
57
 
Exceeding Maximum Fees
 
“Usual and customary”
The maximum allowed by WAC 388-79-030 
must
be deemed adequate
 for clients who receive usual
and customary guardianship services.
 
58
 
Exceeding Maximum Fees
 
If “extraordinary services” are provided, DSHS
must weight several factors in determining
whether the fees are appropriate.
Should the court determine, after the
consideration of the facts and this rule, that
the fees are “just and reasonable,” DSHS will
adjust participation.
 
59
 
Exceeding Maximum Fees
 
Once in receipt of a court order, DSHS will
adjust participation, constrained by the
requirements of our participation WACs.
In no circumstance can the court order DSHS
to violate WAC (and in turn, federal rule and
law regarding Medicaid).
 
60
 
Other Issues
 
Chapter 388-79 WAC gives the court no other
jurisdiction over DSHS other than to allow
deductions to participation.
Meaning, court orders direct how much to
deduct in the participation calculation, not
how much income to “exclude” or “disregard”
for Medicaid (before the calculation).
 
61
 
Other Issues
 
When a person does not pay participation,
Chapter 388-79 WAC does not even apply to
that person.
In other words, it’s not that applying Chapter
388-79 WAC to a person who does not pay
participation results in a $0 deduction, it’s
that the rule does not even apply to them.
 
62
 
SUMMARY
 
 
63
 
Summary
 
Deductions in participation for guardianship
fees and costs are only applicable to those
who pay participation.
Federal rule does not allow this deduction, so
an agreement was made to roll such
deductions into the PNA.
 
64
 
Summary
 
Chapter 388-79 WAC determines 
how much to
allow 
as a deduction from participation.
Title 182 WAC determines 
how to allow 
the
deduction from participation.
 
65
 
Summary
 
Chapter 388-79 cannot be construed to
conflict with Title 182 WAC, the Medicaid
state plan, approved HCB waivers, federal rule,
and federal law.
 
66
undefined
 
Thank You
 
Will Reeves
william.p.reeves@dshs.wa.gov
 
67
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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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  1. Guardianship Fees and Participation Under the Medicaid State Plan and Home & Community-Based Waivers 1

  2. 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

  3. 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

  4. introduction to CHAPTER 388-79 WAC 4

  5. 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

  6. 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

  7. 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

  8. 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

  9. 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

  10. 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

  11. medicaid state plan WHO PAYS PARTICIPATION? (PART 1)

  12. 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

  13. 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

  14. 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

  15. 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

  16. 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

  17. 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

  18. 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

  19. 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

  20. 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

  21. home & community-based waivers WHO PAYS PARTICIPATION? (PART 2) 21

  22. 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

  23. 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

  24. 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

  25. 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

  26. 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

  27. 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

  28. 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

  29. 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

  30. 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

  31. 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

  32. what is participation? POST-ELIGIBILITY TREATMENT OF INCOME (PETI) 32

  33. 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

  34. 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

  35. 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

  36. 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

  37. federal limits and state options THE PERSONAL NEEDS ALLOWANCE 37

  38. 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

  39. 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

  40. 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

  41. 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

  42. 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

  43. for persons in medical institutions APPLYING CHAPTER 388-79 WAC TO PETI 43

  44. 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

  45. 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

  46. for persons in the community APPLYING CHAPTER 388-79 WAC TO PETI 46

  47. 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

  48. 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

  49. 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

  50. 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

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