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Chapter 388-105 WAC

Last Update: 10/23/19

MEDICAID RATES FOR CONTRACTED HOME AND COMMUNITY RESIDENTIAL CARE SERVICES

WAC Sections

HTMLPDF388-105-0035Requirements for a capital add-on rate for licensed boarding homes contracted to provide assisted living (AL) services.
HTMLPDF388-105-0045Bed or unit hold—Medicaid residents at an ESF, AFH, ARC, EARC, or AL who need short-term care at a nursing home or hospital.
HTMLPDF388-105-0050Supplementation—General requirements.
HTMLPDF388-105-0055Supplementation—Unit or bedroom.
DISPOSITION OF SECTIONS FORMERLY CODIFIED IN THIS TITLE
388-105-0005The daily medicaid payment rates for clients who have been assessed using the CARE tool and reside at an AFH or assisted living facility contracted to provide assisted living, adult residential care, or enhanced adult residential care services. [Statutory Authority: RCW 74.39A.030 (3)(a). WSR 18-21-001, § 388-105-0005, filed 10/3/18, effective 11/3/18; WSR 18-03-097, § 388-105-0005, filed 1/17/18, effective 2/17/18; WSR 17-02-029, § 388-105-0005, filed 12/28/16, effective 1/28/17. Statutory Authority: RCW 74.39A.050 (3)(a). WSR 16-05-028, § 388-105-0005, filed 2/9/16, effective 3/11/16; WSR 14-03-113, § 388-105-0005, filed 1/21/14, effective 2/21/14. Statutory Authority: RCW 74.39A.030 (3)(a). WSR 13-03-093, § 388-105-0005, filed 1/15/13, effective 2/15/13. Statutory Authority: RCW 74.34 RCW based on 2011 1st sp.s. c 7. WSR 12-02-050, § 388-105-0005, filed 12/30/11, effective 1/30/12. Statutory Authority: RCW 74.39A.030(3) and 2010 c 37 § 206 (19)(a). WSR 10-21-035, § 388-105-0005, filed 10/12/10, effective 10/29/10. Statutory Authority: RCW 74.39A.030(3), 18.20.290, and 2009 c 564 § 206(4). WSR 09-20-011, § 388-105-0005, filed 9/25/09, effective 10/26/09. Statutory Authority: RCW 74.39A.030 (3)(a). WSR 09-11-053, § 388-105-0005, filed 5/13/09, effective 6/13/09. Statutory Authority: Chapter 74.39A RCW, RCW 18.20.290, 2006 c 372, 260, and 64. WSR 06-19-017, § 388-105-0005, filed 9/8/06, effective 10/9/06. Statutory Authority: Chapter 74.39A RCW. WSR 06-07-013, § 388-105-0005, filed 3/3/06, effective 4/3/06. Statutory Authority: RCW 74.39A.030, 2003 c 231. WSR 04-09-092, § 388-105-0005, filed 4/20/04, effective 5/21/04. Statutory Authority: 2002 c 371. WSR 02-22-058, § 388-105-0005, filed 10/31/02, effective 12/1/02. Statutory Authority: 2001 c 7 § 206. WSR 01-21-077, § 388-105-0005, filed 10/18/01, effective 11/18/01. Statutory Authority: Chapter 74.39A RCW. WSR 01-14-056, § 388-105-0005, filed 6/29/01, effective 7/30/01.] Repealed by WSR 19-21-175, filed 10/23/19, effective 11/23/19. Statutory Authority: RCW 74.39A.030 (3)(a).
388-105-0010What are care levels? [Statutory Authority: Chapter 74.39A RCW. WSR 01-14-056, § 388-105-0010, filed 6/29/01, effective 7/30/01.] Repealed by WSR 06-07-013, filed 3/3/06, effective 4/3/06. Statutory Authority: Chapter 74.39A RCW.
388-105-0015How does the department determine whether the medicaid resident needs assistance in completing ADLs and/or has unmet care needs? [Statutory Authority: Chapter 74.39A RCW. WSR 01-14-056, § 388-105-0015, filed 6/29/01, effective 7/30/01.] Repealed by WSR 06-07-013, filed 3/3/06, effective 4/3/06. Statutory Authority: Chapter 74.39A RCW.
388-105-0020How does the department determine at which care level the medicaid resident will be placed? [Statutory Authority: Chapter 74.39A RCW. WSR 01-14-056, § 388-105-0020, filed 6/29/01, effective 7/30/01.] Repealed by WSR 06-07-013, filed 3/3/06, effective 4/3/06. Statutory Authority: Chapter 74.39A RCW.
388-105-0025How many ADL values and unmet care need points correspond to the four care levels? [Statutory Authority: Chapter 74.39A RCW. WSR 01-14-056, § 388-105-0025, filed 6/29/01, effective 7/30/01.] Repealed by WSR 06-07-013, filed 3/3/06, effective 4/3/06. Statutory Authority: Chapter 74.39A RCW.
388-105-0030What are the daily medicaid payment rates for contracted assisted living facilities (AL) not receiving a capital rate add-on? [Statutory Authority: RCW 74.39A.030, 2003 c 231. WSR 04-09-092, § 388-105-0030, filed 4/20/04, effective 5/21/04. Statutory Authority: 2002 c 371. WSR 02-22-058, § 388-105-0030, filed 10/31/02, effective 12/1/02.] Repealed by WSR 06-07-013, filed 3/3/06, effective 4/3/06. Statutory Authority: Chapter 74.39A RCW.
388-105-0040What are the daily capital add-on rates for assisted living facilities (AL) and the AL daily payment rates with a capital add-on rate? [Statutory Authority: RCW 74.39A.030, 2003 c 231. WSR 04-09-092, § 388-105-0040, filed 4/20/04, effective 5/21/04. Statutory Authority: 2002 c 371. WSR 02-22-058, § 388-105-0040, filed 10/31/02, effective 12/1/02.] Repealed by WSR 06-07-013, filed 3/3/06, effective 4/3/06. Statutory Authority: Chapter 74.39A RCW.

PDF388-105-0035

Requirements for a capital add-on rate for licensed boarding homes contracted to provide assisted living (AL) services.

(1) To the extent funds are appropriated to pay a capital add-on rate to AL contractors, beginning July 1, 2006 and every July 1 thereafter, the department will pay a capital add-on rate to AL contractors that have a medicaid occupancy percentage that equals or exceeds sixty percent as determined in accordance with subsection (2) and (3) of this section. The department will pay the capital add-on rate to those AL contractors meeting the sixty percent medicaid occupancy percentage for a full fiscal year i.e., July 1 through June 30.
(2) The department will determine an AL contractor's medicaid occupancy percentage by dividing its medicaid resident days from the last six months of the calendar year preceding the applicable July 1 rate effective date by the product of the weighted average for all its licensed boarding home beds irrespective of use times the calendar days (one hundred eighty-four) for the same six-month period.
(3) For the purposes of this section, medicaid resident days include those clients enrolled in medicaid managed long-term care programs, including but not limited to the program for all inclusive care (PACE) and medicaid/medicare integration project (MMIP).
[Statutory Authority: Chapter 74.39A RCW, RCW 18.20.290, 2006 c 372, 260, and 64. WSR 06-19-017, § 388-105-0035, filed 9/8/06, effective 10/9/06. Statutory Authority: Chapter 74.39A RCW. WSR 06-07-012, § 388-105-0035, filed 3/3/06, effective 4/3/06. Statutory Authority: 2002 c 371. WSR 02-22-058, § 388-105-0035, filed 10/31/02, effective 12/1/02.]


PDF388-105-0045

Bed or unit hold—Medicaid residents at an ESF, AFH, ARC, EARC, or AL who need short-term care at a nursing home or hospital.

(1) An enhanced services facility (ESF) that contracts to provide services under chapter 70.97 RCW and an adult family home (AFH) or assisted living facilities contracted to provide adult residential care (ARC), enhanced adult residential care (EARC), or assisted living services (AL) under chapter 74.39A RCW, must hold a medicaid eligible resident's bed or unit if:
(a) The medicaid resident needs short-term care in a nursing home or hospital;
(b) The medicaid resident is likely to return to the ESF, AFH, ARC, EARC, or AL; and
(c) The department pays the ESF, AFH, ARC, EARC, or AL as set forth under subsection (3), (4), or (5) of this section.
(2) The ESF, AFH, ARC, EARC, or AL must hold a medicaid resident's bed or unit for up to twenty days when the department pays the ESF, AFH, ARC, EARC, or AL under subsections (3), (4), or (5) of this section.
(3) The department will pay an ESF seventy percent of the resident's medicaid daily rate set at the time he or she left the ESF for the first through twentieth day of the resident's hospital or nursing home stay.
(4) The department will pay an ARC, EARC, or AL seventy percent of the resident's medicaid daily rate set at the time he or she left the ARC, EARC, or AL for the first through seventh day of the resident's hospital or nursing home stay and eleven dollars a day for the eighth through twentieth day.
(5) The department will pay an AFH seventy percent of the resident's medicaid daily rate set at the time he or she left the AFH for the first through seventh day of the resident's hospital or nursing home stay and fifteen dollars per day for the eighth through twentieth day.
(6) A medicaid resident's short-term stay in a nursing home or hospital must be longer than twenty-four hours for subsection (3) or (4) of this section to apply.
(7) If a medicaid resident stays at a hospital or nursing home for more than twenty-four hours, the ESF, AFH, ARC, EARC, or AL must notify the department by email, fax, or telephone within twenty-four hours after the initial twenty-four hour period. If the end of the initial twenty-four hour period falls on a weekend or state holiday, the ESF, AFH, ARC, EARC, or AL must notify the department within twenty-four hours after the weekend or holiday.
(8) If a medicaid resident returns to the ESF, AFH, ARC, EARC, or AL from the hospital or nursing home and stays there for less than twenty-four hours before returning to the hospital or nursing home, the existing bed hold period continues to run. If the medicaid resident stays at the ESF, AFH, ARC, EARC, or AL for more than twenty-four hours before returning to the hospital or nursing home, a new bed hold period begins.
(9) The department's social service worker or case manager may determine that the medicaid resident's hospital or nursing home stay is not short term and he or she is unlikely to return to the ESF, AFH, ARC, EARC, or AL. If the social service worker or case manager makes such a determination, the department may cease payment the day it notifies the contractor of its decision.
(10) An ESF, AFH, ARC, EARC, or AL may seek third-party payment for a bed or unit hold that lasts for twenty-one days or longer or if the department determines that the medicaid resident's hospital or nursing home stay is not short-term and he or she is unlikely to return. The third-party payment must not exceed the resident's medicaid daily rate paid to the ESF, AFH, ARC, EARC, or AL.
(11) If third-party payment is not available for a bed or unit hold that lasts for twenty-one days or longer, the medicaid resident may return to the first available and appropriate bed or unit at the ESF, AFH, ARC, EARC, or AL if he or she continues to meet the admission criteria under chapter 388-106 WAC.
(12) When the medicaid resident's stay in the hospital or nursing home exceeds twenty days or the department's social service worker or case manager determines that the medicaid resident's stay in the nursing home or hospital is not short-term and he or she is unlikely to return to the ESF, AFH, ARC, EARC, or AL, only subsection (10) and (11) of this section apply to a private contract between the contractor and a third party regarding the medicaid resident's unit or bed.
[Statutory Authority: RCW 74.08.090, 74.09.520. WSR 16-19-055, § 388-105-0045, filed 9/16/16, effective 10/17/16. Statutory Authority: RCW 74.39A.030(3), 18.20.290, and 2009 c 564 § 206(4). WSR 09-20-011, § 388-105-0045, filed 9/25/09, effective 10/26/09. Statutory Authority: RCW 74.39A.030 (3)(a). WSR 09-11-053, § 388-105-0045, filed 5/13/09, effective 6/13/09. Statutory Authority: Chapter 74.39A RCW, RCW 18.20.290, 2006 c 372, 260, and 64. WSR 06-19-017, § 388-105-0045, filed 9/8/06, effective 10/9/06. Statutory Authority: Chapter 74.39A RCW. WSR 06-07-013, § 388-105-0045, filed 3/3/06, effective 4/3/06. Statutory Authority: RCW 74.39A.030, 2003 c 231. WSR 04-09-092, § 388-105-0045, filed 4/20/04, effective 5/21/04.]


PDF388-105-0050

Supplementation—General requirements.

(1) Supplementation of the medicaid daily payment rate is an additional payment requested from a medicaid recipient or a third-party payer by an adult family home (AFH) contractor or a licensed boarding home contractor with a contract to provide adult residential care (ARC), enhanced adult residential care (EARC), or assisted living (AL) services.
(2) The AFH, ARC, EARC, or AL contractor may not request supplemental payment of a medicaid recipient's daily rate for services or items that are covered in the daily rate, and the contractor is required to provide:
(a) Under licensing chapters 388-76 or [388-] 78A WAC and chapter 388-110 WAC; and/or
(b) In accordance with his or her contract with the department.
(3) Before a contractor may request supplemental payments, the contractor must have a supplemental payment policy that has been given to all applicants for admittance and current residents. In the policy, the contractor must inform the applicant for admittance or current resident that:
(a) The department medicaid payment plus any client participation assigned by the department is payment in full for the services, items, activities, room and board required by the resident's negotiated service plan per chapter 388-78A WAC or the negotiated care plan per chapter 388-76 WAC and its contract with the department; and
(b) Additional payments requested by the contractor are for services, items, activities, room and board not covered by the medicaid per diem rate.
(4) For services, items and activities, the supplementation policy must comply with RCW 70.129.030(4).
(5) For units or bedrooms for which the contractor may request supplemental payments, the contractor must include in the supplemental payment policy the:
(a) Units and/or bedrooms for which the contractor may request supplementation;
(b) Action the contractor will take when a private pay resident converts to medicaid and the resident or a third party is unwilling or unable to pay a supplemental payment in order for the resident to remain in his or her unit or bedroom. When the only units or bedrooms available are those for which the contractor charges a supplemental payment, the contractor's policy may require the medicaid resident to move from the facility. However, the contractor must give the medicaid resident thirty days notice before requiring the medicaid resident to move.
(6) For the medicaid resident for whom the contractor receives supplemental payments, the contractor must indicate in the resident's record the:
(a) Unit or bedroom for which the contractor is receiving a supplemental payment;
(b) Services, items, or activities for which the contractor is receiving supplemental payments;
(c) Who is making the supplemental payments;
(d) Amount of the supplemental payments; and
(e) Private pay charge for the unit or bedroom for which the contractor is receiving a supplemental payment.
(7) When the contractor receives supplemental payment for a unit or bedroom, the contractor must notify the medicaid resident's case manager of the supplemental payment.
[Statutory Authority: RCW 74.39A.901. WSR 07-04-042, § 388-105-0050, filed 1/30/07, effective 3/2/07.]


PDF388-105-0055

Supplementation—Unit or bedroom.

When the AFH, ARC, EARC, or AL contractor only has one type of unit or all private bedrooms, the contractor may not request supplementation from the medicaid applicant/resident or a third party, unless the unit or private bedroom has an amenity that some or all of the other units or private bedrooms lack e.g., a bathroom in private bedroom, a view unit, etc.
[Statutory Authority: RCW 74.39A.901. WSR 07-04-042, § 388-105-0055, filed 1/30/07, effective 3/2/07.]