182-513-1240  <<  182-513-1245 >>   182-513-1315

WAC 182-513-1245

Medically needy hospice program in a medical institution.

(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 spenddown 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.
[Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 17-03-116, § 182-513-1245, filed 1/17/17, effective 2/17/17.]
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