1. e-mail: joshb@dussaultlaw.com
Public Benefits
Presented by:
Joshua L. Brothers
Dussault Law Group
(206)

2. Public Benefits Overview
Federal
Social Security
SSI - $674/mo max
SSDI - varies
Medicare
Hospital
Doctor Visits
Prescription Drugs
Limited Rehab
State
Medicaid
DSHS
Medical Assistance
Long Term Care
DDD
Extended dental
Family Support
Waivers
Residential
Work & Education
DVR
Food Stamps
Welfare

3. Eligibility for Social Security and Medicaid/Medicare
SSI/Medicaid
Disabled, blind, >65
SGA - $1,000/month
“Means tested”
Income ($20 exemption)
Earned - $2:$1 ($65 exemption)
Unearned - $1:$1
ISM – 1/3rd reduction
Resources (< $2000)
Exempt Assets –
Residence (<$500k)
Vehicle (any value)
Personal effects
SNT
Burial, funeral, term insurance
“SSA”/Medicare
Disabled, blind, >65
SGA - $1,000/month
“Entitlement program”
Individuals who have paid FICA taxes in the last 20 of 40 quarters prior to disability
Survivor, Retirement, and Disability
Medicare available when: over 65 or meets SSA disability definition, 29 months post injury

4. Supplemental Security Income (SSI)
Provides Cash benefit of up to $674 to be utilized for food and shelter expenses (as of 1/09).
Some States provide cash supplements to base SSI limit
“Gatekeeper” to Medicaid and other public benefit programs

5. SSI Income Earned Income: Unearned Income
Sources: wages, self employment, royalties and any other income received from employment activities
$20 general exclusion
$65 earned income exclusion
$2:$1 reduction in SSI benefits
Unearned Income
Sources: Payments from annuities or trusts, alimony/support payments, dividends, interest, gifts, other SSA benefits, etc.
$1:$1 reduction in SSI benefits

6. SSI Income (ISM) In-Kind Support & Maintenance
Any item an individual receives in cash or in-kind that can be used to meet his or her need for food or shelter.
Reduction to SSI benefits lesser of:
1/3rd reduction (presumed maximum value –PMV)
$1:$1 reduction

7. SSI Calculation Example
Individual earns $275 in wages in a month
Receive $300 Gift from family
Maximum SSI Amount
$674
Earned Wages
$275
Less $65 exclusion
$210
½ of remaining earned income ($2 for $1)
$105
Unearned Income($1 for $1)
$300
Less $20 exclusion
$280
Total Countable Income
$385
Total SSI Benefit
$289

8. SSI Asset Limitations Individual limit – $2,000 Family limit – $3,000
Calculated as 1st of the month
Exempt Resources:
Residence of $500,000 or less
Vehicle with no limitation
Personal effects
SNT
Burial, funeral, term insurance

9. SSI “Gate Keeper” to Medicaid
SSI of $1 = categorical eligibility for Medicaid
Other Medicaid medical programs exist
Medicaid Waiver programs typically have different eligibility criteria which may or may not be income/asset sensitive.

10. SSI/Medicaid Parental Deeming
Parental income and assets count against minor child’s eligibility.
Income eligibility based upon sliding scale based upon gross income less various exemptions.
Income amount vary from base level which will allow full SSI amount to maximum level which will completely disqualify
Asset Limitation: $3,000 per family with some exemptions.

11. Parental Deeming-Eligibility General Guidelines Only (2006)
Gross Monthly
Income:
All Earned Income:
All Unearned
# of ineligible
Children in House
One Parent
Household
Two Parent
$2,537
$3,139
$1,246
$1,547 1
$2,838
$3,440
$1,848 2
$3,741
$2,149 3
$4,042
$2,450 4
$4,343
$2,751 5
$4,644
$3,052 6
$4,945
$3,353

12. Social Security Disability Income (SSDI)
“Earned” Benefit
Based upon work history (20/40 rule)
Variable cash benefit
Dual eligibility for SSI/SSDI possible
Who’s work history?
Own
Spouse
Parent (DAC)
Grandparent
DAC benefit:
½ during parent’s lifetime
¾ after parent’s death

13. Social Security Appeals
Notice of denial, termination, reduction or overpayment
Request for Reconsideration
Hearing before an Administrative Law Judge
Fact finding role of hearing officer
Presentation of evidence
Social Security Council
Federal District Court
Federal Court of Appeals (Circuit Court)
Federal Supreme Court

14. Medicaid Administration in WA

15. Medicaid Coverage: “Medically necessary”
Medical Assistance (general medical care, hospitalization, physicians, medications, medical testing, surgical procedures, durable medical equipment, medical supplies, therapy, etc.)
Long Term Care (LTC)
“Medically necessary”
Limitations: Vision, dental, “experimental” or non-traditional treatments/therapies

16. Categorically vs. Medically Needy
Categorically Needy
Medical Assistance
Long Term Care
SSI eligibility
Medically Needy
Not on SSI due to too much income
Spend down implemented
Based on income over maximum SSI benefit of $674/month.
3 or 6 months
Ex. Income of $774/month results in spend down of $300 for 3 months or $600 for 6 months
Exception for recipient of SSDI based on parent’s work history (WAC )
Long Term Care has different income requirement & participation used, not spend downs.

17. Long Term Care Services
“The department provides long-term care services through programs that are designed to help you remain in the community. These programs offer an alternative to nursing home care.” WAC

18. Long Term Care Services
Programs
Medicaid Personal Care (MPC)
Community Options Program Entry System (COPES)
Medically Needy In-Home or Residential Waivers
Respite Care
DDD Programs
Settings
Own home
Assisted living
Adult family home
Companion homes
Host homes

19. LTC Eligibility in Washington
SSI = Categorically Eligible
Non-SSI Eligibility
Income
Individual: $2,022.00
Couple: $4,044.00
May be required to participate in cost of care (amount will vary)
Resource
Individual: $2,000.00
Community Spouse Resource Allowance: $48,639.00

20. Comprehensive Assessment Reporting Evaluation (CARE) Tool
Develops Individual Support Plan (“ISP”) and determines personal care hours
Algorithm determines personal care hours
Structured for elderly, not developmentally disabled
Changes to mood and behavior
DDD Assessment
0-416 hours
Additional Hours under an Exception to Rule possible
WAC to -0145

21. Basic Structure of CARE Tool
Placement in Classification Group (A to E) to determine “base hours”
Exceptional Care (ADL scores & additional requirements)
Clinically Complex (defined conditions & ADL scores)
Cognitive Performance (scores of 0-6)
Mood & Behaviors (defined conditions with frequency OR behavior point score of 0-12)
Activities of Daily Living or “ADL” (scores of 0-28)
Informal supports reduce the number of base hours

22. Determining In-Home Hours
Classification
ADL or
Behavior Point Score
Classification Group
Base Hours
Group E
EC = Yes
AND
M&B = Yes or No
CPS = 0-6
ADL (26-28)
E High
416
ADL (22-25)
E Med
346
Group D
CPS = 4-6
CC = Yes OR
CPS = 5-6
CC = No
ADL (25-28)
D High
277
ADL (18-24)
D Med-High
234
ADL (13-17)
D Med
185
ADL (2-12)
D Low
138

23. Determining In-Home Hours
Classification
ADL or
Behavior Point Score
Classification Group
Base Hours
Group C
CPS = 0-3
AND
CC = Yes
M&B = Yes or No
ADL (25-28)
C High
194
ADL (18-24)
C Med-High
174
ADL (9-17)
C Med
132
ADL (2-8)
C Low 87

24. Determining In-Home Hours
Classification
ADL or
Behavior Point Score
Classification Group
Base Hours
Group B
M&B = Yes
AND
CC = No
CPS = 0-4 OR
CPS = 2-6
BPS > 1
ADL > 1
CPS >2
ADL >1
ADL (15-28)
B High
147
ADL (5-14)
B Med 82
ADL (0-4)
B Low 47
BPS (>12)
BPS (7-11)
B Med-High
101
BPS (5-6)
BPS (1-4)

25. Determining In-Home Hours
Classification
ADL or
Behavior Point Score
Classification Group
Base Hours
Group A
M&B = No
AND
CC =No
CPS = 0-4
ADL (10-28)
A High 71
ADL (5-9)
A Med 56
ADL (0-4)
A Low 26

26. Activities of Daily Living
Scores from 0 to 28
ADLS
Personal Hygiene
Bed Mobility
Transfers
Eating
Toilet Use
Dressing
Either:
Locomotion in Room
Locomotion Outside Room
Walk in Room
Scoring Scale
0 – Independent/client declined
1 – Supervision
2 – Limited Assistance
3 – Extensive Assistance
4 – Total Dependence/no provider/client not able

27. Reductions for Informal Support
IADLs looked at
Self-administration of medication
Bed mobility
Walk in room
Eating
Toilet use
Dressing
Personal hygiene
Bathing
Meal Preparation
Ordinary housework
Essential shopping
Travel to medical
Determine if IADL is unmet (1), met (0), service declined (0), or partially met (25%, 25%-50%, 50%-75%, or 75%-100%)
Each IADL is weighted from 0 to 1 and placed in a formula to reduce hours

28. Automatically Unmet Needs
Meal Preparation (special diets)
ADA (diabetes)
Autism diet
Calorie reduction
Low sodium
Mechanically altered
Planned weight change program
Renal diet
Nutrition through tube or >25% of calories through tube/parenteral feeding
Housework
Incontinent all or most of the time
Frequently incontinent
Occasionally incontinent

29. Automatic Reductions Client living with personal care provider
Automatic reductions revoked
Jenkins v. DSHS, 160 Wn.2d 287 (2007); 157 P.3d 388 (Wash. 2007)
Multiple clients receiving personal care who live in same household – met or partially met
Meal preparation
Housekeeping
Shopping
Wood supply

30. Children in the CARE Assessment
Reductions
Some ADLs coded as met until a certain age
Most IADLs coded as met until 18
Ex. Total toileting is met up to age 3
Living with legally responsible natural/step/adoptive parent = met or partially met (75% - 100%)
Certain conditions cannot exist prior to particular ages
Ex. No short or long term memory loss prior to age 12
Ex. Decision making independent prior to age 12
WAC
Next lawsuit?

31. Add on hours Offsite laundry +8 hours
>45 minutes from essential services (full-service market)
+5 hours (unmet or <25% met)
+4 hours (25% - 50% met)
+2 hours (50% - 100% met)
0 hours (met)
Wood supply as sole source of heat
+8 hours (unmet or <25% met)
+6 hours (25% - 50% met)
+4 hours (50% - 75% met)
+2 hours (>75% met)
0 hours (met or declined)

32. Exception to Rule
WAC
Exception to any DSHS regulation in individual cases
Can’t contradict federal or state law
Individual’s situation differs from the majority
Interest in overall economy and individual’s welfare
Either
Increases opportunities to function effectively
Impairment or condition significantly interferes with procedures to determine eligibility or payment.
Only DSHS staff can submit an ETR
Can request non-covered medical or dental services or related equipment
Increased DSHS scrutiny on ETR requests previously granted

33. Right to Administrative Hearing
Clients have a right to administrative hearing if they disagree with the assessment.
Difficult to challenge the CARE Tool itself – focus on application of CARE Tool to the client
WAC governs hearings
Informal meeting with case worker or fair hearing coordinator
Exception to Rule (ETR)
WAC provides hearing right
Must already be receiving hours on an ETR
Total hours reduced by a reduction or termination of ETR hours
No hearing right for newly requested ETR which is denied

34. Medicare Individual eligible post age 65 or 29 months post disability.
Disabled child eligible if eligible under parents SSDI benefits
Coverage:
Hospital
Doctor visits
Durable medical equipment
Prescription Drugs
Limited Rehab
Co-pays, premiums and deductibles exist

35. Dually Eligible Eligible for both Medicaid & Medicare
Primary Program is Medicare
Hospital Visits
Doctor’s Appointments
Prescription Drug Coverage
Medicaid supplements
Premiums & Deductibles for Hospital and Medical Insurance may apply
Out of pocket costs
LTC
Non-Medicare Services

36. Medicaid vs. Medicare Medicare Eligibility similar to SSDI/SSA
Eligibility similar to SSI
Disability
“Means” tested
Large variety of medical-related services
Residential placements
Personal care attendants
Respite care
Mental health services
Extended health care
Department of Social & Health Services (DSHS)
Division of Developmental Disabilities (DDD)
Aging and Adult Services (AAS)
Medicare
Eligibility similar to SSDI/SSA
29 months after disability or 65 & older
Work History
Health Insurance
Hospitals & physicians
Limited custodial care
Prescription drugs
U.S. Department of Health & Human Services

37. DDD Overview Legal Authority Eligibility ≠ Services
RCW Title 71A
WAC to -850
Eligibility ≠ Services
DDD is a Division of DSHS

38. DDD Regional Map

39. DDD Eligibility & Assessment Process

40. DDD Services Case Management Dental Services
Employment and Day Programs
Individual and Family Service Program (formerly Family Support)
Medicaid Personal Care Hours
Vocational, Employment & Educational Assistance
Early Intervention (recently moved to Department of Education)
Medically Intensive Children’s Program
Mental Health Programs
Disability-specific program, especially for autism
Living facilities
Adult family homes
Supported Living
Host homes/companion homes
Residential Habilitation Centers (Institutions)
Home & Community Based Waivers (HCBS)
Children’s Intensive In-Home Behavior Support Program (CIIBS)
Voluntary Placement Program (VPP)

41. Defining “Developmental Disability”
RCW 71A (3) and WAC
Disability Attributable to:
Intellectual Disability
Cerebral Palsy
Epilepsy
Autism
Another Neurological Condition
Other Condition Related to Intellectual Disability
Other diagnosis under age 18
Originated prior to age 18
Expected to continue indefinitely
Substantial limitations to adaptive functioning

42. DDD Eligibility by Age Eligible Condition Age 0-5 Age 6-9 Age 10-17
Age 18 and older
Developmental Delays X
Downs Syndrome
Too severe to be assessed
Medically Intensive
Mental Retardation
Cerebral Palsy
Epilepsy
Autism
Another Neurological Condition
Other condition similar to MR

43. DDD Assessment
Broader than CARE Assessment for Medicaid Personal Care Hours
Currently does not create different hours than the CARE Assessment
May change in the future
Assess eligibility and need for other DDD programs
Better assessment of the needs of individuals with developmental disabilities
Consolidates the assessment of need for services being provided through DDD
Value of Individual Support Plan
Can take between 2 and 6 hours to complete

44. DDD Assessment
WAC
Determines each client’s individual support needs
3 sections of DDD Assessment
Support Assessment Module
HCBS Waiver eligibility
Determine need for other modules (those receiving or approved for paid services)
Support Intensity Scale (SIS) for 16+ (developed for DD community)
Children’s Support Needs Assessment for under 16
Exceptional Medical and Behavior Supports and Family Caregiver Needs
Service Level Assessment Module
Assists in developing the ISP
CARE Assessment
Additional questions to determine services needed (seizure and allergy information, employment support levels for individuals receiving county services)
Individual Support Plan Module
Description of services client is to receive

45. Support Intensity Scale
The SIS evaluates supports needed for a person in:
49 life activities,
8 protection & advocacy activities,
16 medical conditions, and
16 problem behaviors
Measures type, frequency, and amount of time of supports a person needs to be successful

46. Individual and Family Service Program (IFS)
Formerly Family Support
WAC
Purpose:
Form a partnership between the state and families to help support families who have a DDD eligible family member living in the family home
Provide families with a choice of services and allow families more control over the resources allocated to them.
Eligibility based on need
No financial criteria
Other DDD services reduce & eliminate IFS
$2,000 to $6,000 for therapies, respite, equipment, etc.
Access
Waiting lists exist
Emergency funding available for up to 2 months.
One-time awards

47. DDD Home & Community Based Service (HCBS) Waivers
WAC
Alternative to institutions
Focus: remaining in homes & communities
Broad, flexible, individualized services determined through assessment
Community placements
Home (own or family)
Adult Family Homes
Supported Living Facility
Nursing Facility
Companion, host, and foster homes

48. DDD HCBS Waivers Types of Waivers Eligibility
Basic
Basic Plus
CORE
Community Protection
Children’s Intensive In-Home Behavior Support Program (CIIBS)
Eligibility
Eligible for DDD services
ICF/MR level of care
SSA disability
Financial eligibility
Types of services and money available depend on the type of Waiver
“In the database” vs. “receiving the waiver”
Priority may be given to “Persons DDD has determined to be in immediate risk of ICF/MR admission due to unmet health and welfare needs.” WAC (2)(b)

49. HCBS Waiver Services Case management Respite care
Behavior management & intervention
Community access and involvement (guides, work, transportation)
Mental health services
Skilled nursing
Family & staff training
Speech & language services
Occupational & physical therapy
Personal care services
Dental Care
Habilitation services
Medical & Adaptive supplies
Emergency Services

50. CIIBS Waivers RCW 71A.24; WAC 388-828-8500 to -8520 (emergency rule)
Focus on:
Behavior Support
Staff and Family Training and Consultation
Respite Care
Contract with behavior support specialist
Positive Behavior Support Plan
100 Children initially + 6 each month
Priority/eligibility based on out-of-home risk score through CIIBS Algorithm (data collected in DDD Assessment)
Other services may include:
Personal Care
Specialized Nutrition and clothing
Therapeutic Equipment and Supplies
Environmental Accessibility Adaptations
Vehicle Adaptations
Specialized Medical Equipment and Supplies
Assistive Technology

51. Administrative Hearing Process
RCW and WAC
Process
Planned Action Notice
Request for hearing
Pre-hearing conference call
Administrative Hearing before an independent ALJ with OAH
DSHS Appeals Council
Petition for Review before Superior Court
WA Court of Appeals
WA Supreme Court
US Supreme Court (if federal issue exists)
Exception to Rule (ETR)
Hearing rights for reduction or termination of DDD services only.
“No hearing right” for newly requested ETR which is denied.

52. Other Public Benefits Income/Asset Sensitive
Vocational Rehabilitation
Housing and Urban Development (HUD) Programs
Temporary Assistance for Needy Families (TANF)
General Assistance (GA)
Food Stamps
State/County specific programs
Early Childhood Development (EPSDT)
Insurance Alternatives (CHIPs)
Non-Income/Asset Sensitive
Special Education
Some Medicaid Waiver Programs
Community/Church programs
Generic Recreational Programs (i.e. Park Department, Special/Para/Quad Olympics)

53. Disclaimer/Notice
This training and written materials are designed to provide accurate and authoritative information in regard to the subject matter covered. It is provided with the understanding that the presenter is not engaged in rendering legal, financial or other professional services. If legal advice or other expert assistance is required, the services of a competent professional should be sought.
Please keep in mind all written materials and power point slides are the intellectual property of the Dussault Law Group. These materials may not be distributed without the express written consent of the authors.

54. Thank You!
Joshua L. Brothers Dussault Law Group (206)