WAC 182-513-1205. Determining eligibility for noninstitutional coverage in an alternate living facility (ALF)

(1) This section describes the eligibility determination for noninstitutional coverage for a client who lives in an agency-contracted alternate living facility (ALF) defined under WAC 182-513-1100 . (2) The eligibility criteria for noninstitutional Washington apple health (medicaid) coverage in an ALF follows SSI-related rules under WAC 182-512-0050 through 182-512-0960 , with the exception of the higher income standard under subsection (3) of this section. (3) A client is eligible for noninstitutional coverage under the categorically needy (CN) program if the client's monthly income after allowable exclusions under chapter 182-512 WAC: (a) Does not exceed the special income level (SIL) defined under WAC 182-513-1100 ; and (b) Is less than or equal to the client's assessed state rate at an agency-contracted facility. To determine the CN standard: ((y × 31) + $38.84), where "y" is the state daily rate. $38.84 is based on the cash payment standard for a client living in an ALF setting under WAC 388-478-0006 . (4) A client is eligible for noninstitutional coverage under the medically needy (MN) program if the client's monthly income after allowable exclusions under chapter 182-512 WAC is less than or equal to the client's private rate at an agency-contracted facility. To determine the MN standard: ((z × 31) + $38.84), where "z" is the facility's private daily rate. To determine MN spenddown liability, see chapter 182-519 WAC. (5) For both CN and MN coverage, a client's countable resources cannot exceed the standard under WAC 182-512-0010 . (6) The agency or the agency's designee approves CN noninstitutional coverage for twelve months. (7) The agency or the agency's designee approves MN noninstitutional coverage for a period of months described in WAC 182-504-0020 for an SSI-related client, provided the client satisfies any spenddown liability under chapter 182-519 WAC. (8) Clients who receive medicaid personal care (MPC) or community first choice (CFC) pay all of their income to the ALF except a personal needs allowance under WAC 182-513-1105 . (9) A client may have to pay third-party resources as defined under WAC 182-513-1100 in addition to the payment under this subsection.