D04-014 Policy/Procedure

D04-014 – Policy/Procedure Revised June 18, 2004 TO: DDD Regional Administrators DDD Field Services Administrators DDD Regional Business Managers DDD Waiver Coordinators FROM: Linda Rolfe, Director, Division of Developmental Disabilities SUBJECT: PARTICIPATION FOR AFH, ARC AND GROUP HOME RESIDENTS PURPOSE: Note: This bulletin amends D04-014 issued on 6/4/04 by: . Clarifying that DDD does not need to provide clients with advance notice of a change in participation; and . Changing the room and board rate for group homes and the non- staff rate for some low-cost group homes.

This MB provides guidance to regional staff concerning the computation of client participation for non-SSI AFH/ARC residents and for DDD group home residents. Implementation of the four new DDD waivers moved the funding for adult family home (AFH) or adult residential care (ARC) facilities for waiver adults from the Medicaid Personal Care (MPC) program to the DDD Basic Plus Waiver. In addition, effective 7/1/2004, the non-staff rate for DDD group homes is being reduced from $504.50 to $492.50. Attachments to this MB associated with group home participation must reflect this change.

Because the rules governing client participation are different for MPC than waiver services, effective July 1, 2004, there may be an increase in the amount non-SSI AFH/ARC residents have to pay in participation. BACKGROUND: Medicaid rules governing categorically needy program (CNP) Medicaid State Plan services, including MPC, prohibit client participation in the cost of State Plan services. Non-SSI AFH/ARC waiver clients became CNP as a result of being placed on the CAP Waiver and did not have to participate at more than the AFH/ARC basic rate.

With the transfer of personal care services for AFH/ARC residents into the Basic Plus Waiver, the waiver rules control participation for non-SSI clients. As a result, non-SSI residents of AFHs and ARCs may (if their income exceeds what is needed for their personal allowance and room and board costs) have to use some of their income to pay for the cost of their services. Some individuals may elect to disenroll from the Basic Plus Waiver in order to retain this income.

Individuals impacted by this change in participation will need to be informed of the consequences of remaining on or disenrolling from the waiver. However, DDD clients need not be informed in advance of a change in the amount of their participation.

The ADSA Rates Section determines the portion of the amount paid to group homes for room and board. The room and board portion of the non- staff rate and the non-staff rate for low cost group homes are adjusted periodically. Staff will be notified of future changes via a management bulletin. WHAT’S NEW, The Participation Decision Tree attached to the December 2003 CHANGED, OR memorandum concerning client participation has been updated to reflect CLARIFIED the new participation requirements and computations (Attachment A).

Any changes in participation amount will be implemented effective July 1, 2004.

See Attachment B for instructions for implementation of the new participation procedures.

See Attachment C for talking points when discussing these changes with clients and their family members or legal representatives, and/or advocates.

See Attachment D for an analysis of the impact on clients of declining the waiver.

See Attachment E for a letter that may be sent to clients regarding notice of a change in participation. However, DDD can adjust client participation without advance notice. The Division is not required to provide clients with advance notice when their participation is changed.

See Attachment F for an updated version of the list of group homes with non-staff rates, which are lower than the new standard rate of $492.50.

An Excel file for each region containing updated lists of AFH/ARC residents has been sent to the regions. ACTION: CRMs must send a copy of the DSHS 14-154, Social Services Authorization or DSHS 14-159, Change of Service Authorization, to the facility by July 1, 2004. CRMs must send either a copy of the DSHS 14- 154 or DSHS 14-159 or a copy of the Letter to Clients Regarding Notice of a Change in Participation to the client and his/her legal representative or parent. It is not necessary to ensure a 10-day prior notice to the client, but the provider needs to know by July 1, 2004 how much to collect from the client. RELATED WAC 388-515-1510, Community Alternatives Program (CAP) and REFERENCES: Outward Bound Residential Alternatives (OBRA). WAC 388-845-3035, Will I have to pay toward the cost of waiver services?

D04-014 Revised Page 2 of 14 7/19/04 December 18, 2003 memorandum: SSI INCREASES, CLIENT PARTICIPATION, AND THE INCOME STANDARD FOR THE CAP WAIVER ATTACHMENT(S): Attachment A - Participation Decision Tree for Residents of Group Homes, IMR & Children’s Foster Care and Waiver AFH/ARC Attachment B - Instructions for Implementing Waiver Participation Rules for Non-SSI Residents of AFHs and ARCs Attachment C - Talking Points-Waiver Participation Rules for Adult Family Homes (AFH) and Adult Residential Care (ARC) Attachment D – Medicaid and Participation for AFH Residents Who Decline the Waiver Attachment E – Letter to Clients Regarding Notice of a Change in Participation Attachment F – Group Homes with Non-Staff Rates Less Than the DDD Standard Group Home Room and Board Rate

CONTACT(S): Dave Langenes, Waiver Requirements Manager, 360-902-8476 Sue Poltl, Compliance and Monitoring Unit Manager, 360-902-8474

D04-014 Revised Page 3 of 14 7/19/04 July 2004 revision New Waiver AFH/ARC participation rules effective July 1, 2004

ATTACHMENT A PARTICIPATION DECISION TREE FOR RESIDENTS OF Group Home, IMR & Children’s Foster Care* and Waiver AFH/ARC

DDD Group Home Room and Board = $492.50 month AFH/ARC Room and Board = $492.50 SSI = $564 SSI including 1619b status $564 With or without additional - $38.84 earned or unearned income,  Payee/Guardian Fees Participation cannot exceed the Room including SSP  Medical Expenses and Board rate. 1619b = SSI status + SSP

[SSA + other non-SSI unearned income] – CPI Non-SSI social security CPI = whichever amount is greater of income and/or these two: Other Unearned Income  $38.84 + $20 or  $564 – room and board rate With or without earned  income  Payee/Guardian Fees  Medical Expenses Participation may exceed the Room and Board rate + [(Gross wages – $65) x ½]

Earned Income Only [Gross wages – ($65 + $20)] x ½] - $38.84 Note: this scenario is unlikely  Payee/Guardian Fees for a waiver client  Medical Expenses

INSTRUCTIONS

Personal Needs Allowance (PNA): federal rules require that clients keep the equivalent of the SSI standard for their maintenance needs allowance [room and board and personal needs allowance] PNA is also referred to as “CPI.”

1. SSI (including 1619b) client participation is limited to the basic room and board rate and a personal needs allowance (PNA) of at least $38.84,  When the difference between the SSI standard and the basic rate is more than $38.84, the client keeps the greater amount.  Example #1: SSI standard = $564; AFH basic rate = $492.50. PNA = $564 – 492.50 = $71.50  Example #2: SSI standard = $564; AFH basic rate = $492.50. Payee/Guardian fees=$30. PNA=$564-$30-$492.50=$41.50

2. Non-SSI unearned income: clients are not limited to the basic room and board rate and keep an additional $20 for a minimum PNA of $58.84  A waiver client receiving SSA and residing in a DDD group home with a room and board rate of $492.50 retains $71.50 PNA. [$564-$492.50]  A waiver client living in an AFH/ARC also retains $71.50 PNA. [$564- $492.50]

Earned Wages 3. If the individual is 1619b or receives any amount of SSI, earned income (employment wages) does not have to be computed by the case resource manager.  Wages earned by SSI clients (including 1619b) are reported to Social Security and the amount of future SSI checks is adjusted accordingly.  Clients/Payees should be aware that earned income in month one will increase or decrease the SSI amount received in month three.

4. If an individual receives only SSA as unearned income, the DDD case resource must recalculate participation at least annually or more often if the earned income changes.  Wages earned in month one is reported in month two.  Participation is recalculated by DDD effective in month three.  Example: Wages earned in January are reported in February and affect the March participation.

Allowable Deductions 5. Some expenditures can be deducted from the gross earned and unearned income available for participation:  Court ordered guardianship fees.  Payee fees when a payee is required for the receipt of SSI or SSA benefits.  Medical expenditures not covered by Medical Assistance.

VPP 6. For Individuals in the Voluntary Placement Program, the protective Payee/Guardian is responsible to pay the foster care or group care provider the room and board basic maintenance from the child’s SSI/SSA income. In some cases an SSPS payment may need to be made also to fully cover the cost of basic maintenance.

7. For Individuals who are not CN via waiver or other status. If a client is not CN due to SSI or income, he may become CN eligible if the cost of care in the AFH or ARC exceeds his income.  The client must participate in cost of care with all his or her income except minus the $58.84 (and appropriate exclusions for guardian fees, earned income, medical expenses, etc.) and the $58.84 personal needs allowance.  By paying for MPC from available income, the client is “spending down” and can qualify for G03 CN status for Medicaid. This is a form of CN that allows the DDD to pay the remaining cost of the care with federally matched funds (MPC).  It is important to coordinate with the CSO since this is a CSO determination and not everyone meets the criteria.

D04-014 Revised Page 6 of 14 7/19/04 DDD Management Bulletin D04-014 Attachment B

INSTRUCTIONS FOR IMPLEMENTING WAIVER PARTICIPATION RULES FOR NON-SSI RESIDENTS OF AFHs AND ARCs

The transfer of MPC into the new DDD HCBS waivers effective April 01, 2004, changes the participation rules governing non-SSI residents of an AFH or ARC who are enrolled in the Basic Plus Waiver.

Non-SSI = persons not receiving SSI income or not in 1619b status.

Medicaid rules governing CNP state plan services, including MPC, prohibits client participation to state plan services. Non-SSI CAP Waiver clients became CNP per the waiver and did not have to participate more than basic rate in AFH or ARC under these CNP state plan rules.

With the transfer of personal care, AFH, and ARC into the Basic Plus waiver, the waiver rules control participation for non-SSI clients. These rules are the same as for DDD group home residents who are non- SSI but will result in significant decreases in discretionary income for some people.

The full explanation of these changes is in the attached “Talking Points” and the participation decision tree and instructions.

ADSA agreed to delay implementation of these participation rules until July 1, 2004, to give DDD Case Resource Managers time to talk with residents and their families or legal representatives. While people can opt to disenroll from the Waiver, there may be very real consequences to doing so and DDD will want to encourage people to remain on the waiver.

1. All of their waiver services, including day program, would be terminated; and

2. Medicaid eligibility would have to be reviewed and continued Medicaid eligibility would be based on their earned and unearned income and cost of care issues. DDD cannot guarantee continued eligibility for Medicaid.

The data sent to the regions are current AFH and ARC authorizations for Waiver clients.

1. The QCC team has identified the non-SSI recipients and 1619b recipients by color-coding the entry. Note: If a resident receives any amount of SSI or is a 1619b recipient, he/she is not affected by this change in participation.

2. CRMs may need training in how to use the attached participation decision tree to correctly calculate participation.

3. The 7000 SSPS codes need to be terminated and reauthorized with the appropriate 8200 SSPS code.

DDD is not required to provide advance notice prior to implementing this participation change, but SSPS changes need to be processed by July 1, 2004 so the provider is informed of the new participation amount by July 1.

1. The CRM will send a copy of DSHS 14-154 (Social Services-SSPS-Authorization)/14-159 (Change of Service Authorization) to the facility by July 1, 2004 to ensure that the provider knows how much to collect from the resident on July 1, 2004.

D04-014 Revised Page 7 of 14 7/19/04 2. The provider will also receive a notice generated by SSPS.

3. The CRM will send either a copy of the 14-154/14-159 or a copy of the Letter to Clients Regarding a Change in Participation to the client and his/her legal representative or parent.

D04-014 Revised Page 8 of 14 7/19/04 DDD Management Bulletin D04-014 Attachment C

TALKING POINTS - WAIVER PARTICIPATION RULES FOR ADULT FAMILY HOMES (AFH) AND ADULT RESIDENTIAL CARE (ARC)

Issue Implementation of the four new DDD Waivers April 01, 2004 moved the funding for AFH or ARC facilities for waiver adults from the Medicaid Personal Care (MPC) program to the DDD Basic Plus Waiver.

Because the rules governing participation are different for MPC, a state plan Medicaid service, than for Waiver services, there may be an increase in the amount non-SSI residents have to pay in participation effective July 01, 2004. For some individuals, this will result in a significant reduction in their discretionary income. These changes DO NOT affect SSI recipients, including those in 1619b status.

Example: Monthly Income of $600 SSA + $300 in earned wages [no SSI income and not 1619b]

Participation PNA (CPI) & other Discretionary Income MPC participation $492.50 $407.50 Waiver participation $658.66 $241.34 Difference + $166.16 - $166.16

MPC AFH/ARC vs. Waiver AFH/ARC MPC is a state plan service. It is one of the services available under the Categorically Needy Program (CNP) through Medicaid. No CNP person is allowed to pay towards their state plan services. Waiver eligibility makes non-SSI people CNP Medicaid eligible. The CAP Waiver did not include personal care services, so CAP clients accessed MPC.

Personal care is now a service under three of the four DDD waivers, making DDD waiver clients ineligible for MPC because their personal care needs can be met with Waiver services. Waiver services are not “state plan” Medicaid services (i.e., not available to every Medicaid eligible client who meets the financial and program eligibility requirements). Participation towards Waiver services is subject to different laws and rules.

Legal Authority Federal Medicaid and Social Security rules determine what income is available for client participation towards services. Our state rules and our waiver determine which services require client participation (WAC 388-515- 1510 and 388-845-3035). Currently client participation is only required of DDD residents of facilities (e.g., child foster homes, group homes, AFH, ARC).

SSI Eligible Persons

SSI eligible clients, including those in 1619b status, do not participate towards their waiver services.

This limits their participation to the room and board rate. Room and board costs are excluded from Medicaid reimbursement and are not waiver services.

Waiver services eligible for Medicaid match is staff/personal care/administrative components of the rate. The Waiver requires that the SSI standard of $564 be available to the client for room and board and personal allowance.

D04-014 Revised Page 9 of 14 7/19/04 Personal Needs Allowance (PNA or CPI) = at least $38.84. They keep an additional $20 if they also receive SSA. They keep more than $38.84 if the difference between $564 and the room and board rate is more than $38.84. Earned income is reported to Social Security.

The SSI standard (currently $564) is always used when determining participation regardless of the actual amount of SSI and other earned or unearned income is received. Social Security makes the income calculations and adjusts future SSI amounts accordingly.

SSP is received and used for participation towards room and board. The person is not eligible for SSP unless there is insufficient income to pay the full cost of room and board and guarantee the $38.84 PNA.

SSA and/or other unearned or earned income with no SSI income and not in 1619b status

Non-SSI persons participate towards the cost of their waiver services in addition to their room and board if their income exceeds what is needed for their personal allowance and room and board costs.

The person keeps the SSI standard of $564 for their room and board and personal allowance. Personal Needs Allowance (PNA or CPI) = $58.84. They keep more than $58.84 if the difference between $564 and the room and board rate is more than $58.84. In addition, the person keeps some of their earned income (see decision tree). Earned income is reported to DDD whenever there is change and participation for the following month is adjusted accordingly. The remainder of the SSA and earned wages is paid as participation towards the cost of the waiver residential services.

Available Options

1. Remain on the Waiver  Your health and welfare needs will be met as identified in your Waiver Plan of Care, such as day program/employment.  You continue to be Medicaid eligible.  Your waiver eligibility may result in an increased amount of participation.

2. Disenroll from the Waiver and apply for AFH/ARC services through MPC  You will be terminated from any waiver services you are receiving, including employment support or community access.  Your continued Medicaid Eligibility will have to be re-determined based on you income and cost of care. Your required participation will depend on your Medicaid eligibility.

D04-014 Revised Page 10 of 14 7/19/04 DDD Management Bulletin D04-014 Attachment D

MEDICAID/PARTICIPATION FOR AFH CLIENTS WHO DECLINE WAIVER

The effect of waiver is to extend Medicaid eligibility to persons who meet certain standards. Some of these persons may not be Medicaid eligible if they should elect not to remain in the waiver. This can have an impact on their participation in the AFH.

There are two categories of persons who will remain eligible for CN Medicaid if they elect to no longer participate in the waiver:

 persons who remain eligible for SSI (or SSI-related 1619b); and  client’s who receive SS DAC benefits and who are CN eligible because of the income exemption in WAC 388-505-0110(e).

Clients in the above group would therefore have their participation fixed at $492.50.

CLIENTS WHO WILL NOT BE CN

There are 4 categories of clients who are risk of losing CN status if they elect to no longer participate in the waiver program.

 clients who never received SSI before becoming entitled to SS DAC benefits;  clients who received SSI and lost SSI status due to DAC benefits before 07/01/1988;  clients who receive SS Disability Insurance Benefits (DIB) based on their own work record in an amount so high ($584/month) that there is no potential for SSI.  clients with other unearned income (VA, RRB, Civil Service, etc) so high that they do not qualify for SSI.

Since these clients can not be CN, they must participate in cost of care at the AFH in amount equal to their total countable income minus $58.84. These clients will be in G03 status for Medicaid eligibility purposes.

EXAMPLE: John has worked thru an employment vendor for several years. He has earned sufficient SS credits that he now receives a SS DIB payment on his own record in the amount of $650/month. He works and receives waived employment services thru a vendor. If John opts out of waiver, he will no longer receive employment services. Assuming his income is then $650/month, he must participate in the amount of $591.16 per month leaving a CPI of $58.84. He will be G03 for Medicaid purposes. G03 is a special class of Medicaid eligibility. It is a form of CN that results when a person is using their income to pay for MPC services.

EXAMPLE: Mary is age 50. She has been receiving SS DAC since 1984 when her father died in an accident. She lost her SSI eligibility at that time. Her current DAC benefit is $800/month. If Mary opts out of waiver, she will not be CN. She will have to participate in cost of care with all her income except $58.84. She is G03 for Medicaid purposes. The Case Manager coordinates the G03 status with the CSO when CN is lost.

D04-014 Revised Page 11 of 14 7/19/04 DDD Management Bulletin D04-014 Attachment E

NOTICE OF CHANGE IN PARTICIPATION

(Date)

Client Name Legal Representative Name Address Legal Representative Address

Dear ______,

This Notice is to inform you about an increase in your participation towards the cost of your care. Client participation means the amount of money you are required to pay toward the cost of your adult family home (AFH) or adult residential care (ARC) services. This increase is caused by a change in the Division of Developmental Disabilities’ (DDD’s) Waivers.

You were previously enrolled in DDD’s CAP Waiver and also received Medicaid Personal Care AFH or ARC services. While you were enrolled in the CAP waiver you also received Medicaid Personal Care (MPC), which paid for your AFH or ARC services. MPC is a Medicaid State Plan service, not a waiver service. Medicaid rules governing MPC limited your participation in the AFH or ARC to the $492.50 per month room and board or “Basic rate.”

DDD’s CAP Waiver was terminated March 31, 2004 and on April 1, 2004, you were transferred to the new Basic Plus waiver, which now includes AFH and ARC services. Under your new waiver, AFH and ARC services are funded as waiver services not as MPC; the Medicaid rules for client participation in the waiver are different than the Medicaid rules for MPC.

DDD waiver rules now require client participation towards the total cost of AFH and ARC services for persons who do not receive SSI income or are not in 1619b status.

 You do not receive SSI income and are not in 1619b status so the new rules apply to you.  Your total earned and unearned monthly income will be considered when calculating participation. This may result in your paying more in participation.

If you want to keep your participation amount at its current level by continuing to receive your services through the Medicaid Personal Care program, you will have to voluntarily terminate your enrollment in the DDD Basic Plus Waiver. It is important that you understand the consequences of Waiver termination before making this decision. Your DDD Case Resource Manager can help explain this to you.

D04-014 Revised Page 12 of 14 7/19/04  Voluntary disenrollment from the Waiver will result in termination of all of your DDD waiver services.  In addition, there is no guarantee that you will remain Medicaid eligible for Medicaid Personal Care.

Effective July 1, 2004 your participation will increase from $(amount) to $(amount), based on the following information:

Unearned Income = Earned Income = Personal Needs Allowance = Guardianship Fees = Other Allowable Exemptions =

If you would like to talk about this change, please contact your case manager, ______at ______. If you do not call your case manager, DDD will leave you enrolled in the new Basic Plus Waiver and your increase in client participation will begin on July 1, 2004.

Please call me if you have questions or concerns.

______Case/Resource Manager Name Phone Email Address

D04-014 Revised Page 13 of 14 7/19/04 DDD Management Bulletin D04-014 Attachment F GROUP HOMES WITH NON-STAFF RATES LESS THAN THE DDD STANDARD GROUP HOME ROOM AND BOARD RATE JULY 2004

NON-STAFF RATE Group Provider # or Daily 30.4-Day Region Home Number Individuals Rate Month County

1 MERRY GLEN GROUP HOME 158076 20 $13.84 $ 420.74 Spokane

3 CASCADE GROUP HOME 588510 1 11.81 359.02 Whatcom

4 RESIDENCE EAST-BELLEVUE 610042 1 15.40 468.16 King 4 RESIDENCE EAST-ISSAQUAH 702656 1 15.40 468.16 King

5 L'ARCHE TAHOMA HOPE 236004 1 14.66 445.66 Pierce

ALL OTHER DDD-CERTIFIED GROUP HOMES $492.50

DIVISION OF DEVELOPMENTAL DISABILITIES CLIENTS WITH INCOMES AT THE SSI PAYMENT STANDARD WHO RESIDE IN THESE GROUP HOMES SHOULD ONLY PARTICIPATE IN THE COST OF ROOM AND BOARD. DIVISION OF DEVELOPMENTAL DISABILITIES CLIENTS THAT DO NOT RECEIVE SSI AND HAVE INCOMES ABOVE THE SSI PAYMENT STANDARD AND RESIDE IN THESE GROUP HOMES SHOULD PARTICIPATE IN THE COST OF ROOM AND BOARD AND TOWARD THEIR COST OF CARE ACCORDING TO THE GUIDELINES PROVIDED IN ATTACHMENT B. AS A RESULT, INDIVIDUALS THAT RECEIVE NON-SSI INCOME MAY PARTICIPATE MORE THAN SSI CLIENTS WHO LIVE IN THE SAME FACILITY.

SSI PAYMENT STANDARD(S), THE CPI FOR THE CAP WAIVER AND THE SSI PAYMENT STANDARD LESS THE CAP WAIVER CPI Couple/Both Are CAP SSI PAYMENT STANDARD (Individual) Individual Eligible for SSI Waiver CPI LESS THE CAP WAIVER CPI $ 564.00 $ 846.00 $38.84 $ 525.16

D04-014 Revised Page 14 of 14 7/19/04