3 Eligibility for Social Security and Medicaid/Medicare SSI/MedicaidDisabled, blind, >65SGA - $1,000/month“Means tested”Income ($20 exemption)Earned - $2:$1 ($65 exemption)Unearned - $1:$1ISM – 1/3rd reductionResources (< $2000)Exempt Assets –Residence (<$500k)Vehicle (any value)Personal effectsSNTBurial, funeral, term insurance“SSA”/MedicareDisabled, blind, >65SGA - $1,000/month“Entitlement program”Individuals who have paid FICA taxes in the last 20 of 40 quarters prior to disabilitySurvivor, Retirement, and DisabilityMedicare 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 benefitsUnearned IncomeSources: 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 monthReceive $300 Gift from familyMaximum SSI Amount$674Earned Wages$275Less $65 exclusion$210½ of remaining earned income ($2 for $1)$105Unearned Income($1 for $1)$300Less $20 exclusion$280Total Countable Income$385Total SSI Benefit$289
8 SSI Asset Limitations Individual limit – $2,000 Family limit – $3,000 Calculated as 1st of the monthExempt Resources:Residence of $500,000 or lessVehicle with no limitationPersonal effectsSNTBurial, funeral, term insurance
9 SSI “Gate Keeper” to Medicaid SSI of $1 = categorical eligibility for MedicaidOther Medicaid medical programs existMedicaid 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 disqualifyAsset Limitation: $3,000 per family with some exemptions.
11 Parental Deeming-Eligibility General Guidelines Only (2006) Gross MonthlyIncome:All Earned Income:All Unearned# of ineligibleChildren in HouseOne ParentHouseholdTwo Parent$2,537$3,139$1,246$1,5471$2,838$3,440$1,8482$3,741$2,1493$4,042$2,4504$4,343$2,7515$4,644$3,0526$4,945$3,353
12 Social Security Disability Income (SSDI) “Earned” BenefitBased upon work history (20/40 rule)Variable cash benefitDual eligibility for SSI/SSDI possibleWho’s work history?OwnSpouseParent (DAC)GrandparentDAC benefit:½ during parent’s lifetime¾ after parent’s death
13 Social Security Appeals Notice of denial, termination, reduction or overpaymentRequest for ReconsiderationHearing before an Administrative Law JudgeFact finding role of hearing officerPresentation of evidenceSocial Security CouncilFederal District CourtFederal Court of Appeals (Circuit Court)Federal Supreme Court
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 NeedyMedical AssistanceLong Term CareSSI eligibilityMedically NeedyNot on SSI due to too much incomeSpend down implementedBased on income over maximum SSI benefit of $674/month.3 or 6 monthsEx. Income of $774/month results in spend down of $300 for 3 months or $600 for 6 monthsException 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 ProgramsMedicaid Personal Care (MPC)Community Options Program Entry System (COPES)Medically Needy In-Home or Residential WaiversRespite CareDDD ProgramsSettingsOwn homeAssisted livingAdult family homeCompanion homesHost homes
19 LTC Eligibility in Washington SSI = Categorically EligibleNon-SSI EligibilityIncomeIndividual: $2,022.00Couple: $4,044.00May be required to participate in cost of care (amount will vary)ResourceIndividual: $2,000.00Community Spouse Resource Allowance: $48,639.00
20 Comprehensive Assessment Reporting Evaluation (CARE) Tool Develops Individual Support Plan (“ISP”) and determines personal care hoursAlgorithm determines personal care hoursStructured for elderly, not developmentally disabledChanges to mood and behaviorDDD Assessment0-416 hoursAdditional Hours under an Exception to Rule possibleWAC 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
26 Activities of Daily Living Scores from 0 to 28ADLSPersonal HygieneBed MobilityTransfersEatingToilet UseDressingEither:Locomotion in RoomLocomotion Outside RoomWalk in RoomScoring Scale0 – Independent/client declined1 – Supervision2 – Limited Assistance3 – Extensive Assistance4 – Total Dependence/no provider/client not able
27 Reductions for Informal Support IADLs looked atSelf-administration of medicationBed mobilityWalk in roomEatingToilet useDressingPersonal hygieneBathingMeal PreparationOrdinary houseworkEssential shoppingTravel to medicalDetermine 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 dietCalorie reductionLow sodiumMechanically alteredPlanned weight change programRenal dietNutrition through tube or >25% of calories through tube/parenteral feedingHouseworkIncontinent all or most of the timeFrequently incontinentOccasionally incontinent
29 Automatic Reductions Client living with personal care provider Automatic reductions revokedJenkins 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 metMeal preparationHousekeepingShoppingWood supply
30 Children in the CARE Assessment ReductionsSome ADLs coded as met until a certain ageMost IADLs coded as met until 18Ex. Total toileting is met up to age 3Living with legally responsible natural/step/adoptive parent = met or partially met (75% - 100%)Certain conditions cannot exist prior to particular agesEx. No short or long term memory loss prior to age 12Ex. Decision making independent prior to age 12WACNext 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 RuleWACException to any DSHS regulation in individual casesCan’t contradict federal or state lawIndividual’s situation differs from the majorityInterest in overall economy and individual’s welfareEitherIncreases opportunities to function effectivelyImpairment or condition significantly interferes with procedures to determine eligibility or payment.Only DSHS staff can submit an ETRCan request non-covered medical or dental services or related equipmentIncreased 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 clientWAC governs hearingsInformal meeting with case worker or fair hearing coordinatorException to Rule (ETR)WAC provides hearing rightMust already be receiving hours on an ETRTotal hours reduced by a reduction or termination of ETR hoursNo 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 benefitsCoverage:HospitalDoctor visitsDurable medical equipmentPrescription DrugsLimited RehabCo-pays, premiums and deductibles exist
35 Dually Eligible Eligible for both Medicaid & Medicare Primary Program is MedicareHospital VisitsDoctor’s AppointmentsPrescription Drug CoverageMedicaid supplementsPremiums & Deductibles for Hospital and Medical Insurance may applyOut of pocket costsLTCNon-Medicare Services
36 Medicaid vs. Medicare Medicare Eligibility similar to SSDI/SSA Eligibility similar to SSIDisability“Means” testedLarge variety of medical-related servicesResidential placementsPersonal care attendantsRespite careMental health servicesExtended health careDepartment of Social & Health Services (DSHS)Division of Developmental Disabilities (DDD)Aging and Adult Services (AAS)MedicareEligibility similar to SSDI/SSA29 months after disability or 65 & olderWork HistoryHealth InsuranceHospitals & physiciansLimited custodial carePrescription drugsU.S. Department of Health & Human Services
37 DDD Overview Legal Authority Eligibility ≠ Services RCW Title 71AWAC to -850Eligibility ≠ ServicesDDD is a Division of DSHS
40 DDD Services Case Management Dental Services Employment and Day ProgramsIndividual and Family Service Program (formerly Family Support)Medicaid Personal Care HoursVocational, Employment & Educational AssistanceEarly Intervention (recently moved to Department of Education)Medically Intensive Children’s ProgramMental Health ProgramsDisability-specific program, especially for autismLiving facilitiesAdult family homesSupported LivingHost homes/companion homesResidential 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 WACDisability Attributable to:Intellectual DisabilityCerebral PalsyEpilepsyAutismAnother Neurological ConditionOther Condition Related to Intellectual DisabilityOther diagnosis under age 18Originated prior to age 18Expected to continue indefinitelySubstantial limitations to adaptive functioning
42 DDD Eligibility by Age Eligible Condition Age 0-5 Age 6-9 Age 10-17 Age 18 and olderDevelopmental DelaysXDowns SyndromeToo severe to be assessedMedically IntensiveMental RetardationCerebral PalsyEpilepsyAutismAnother Neurological ConditionOther condition similar to MR
43 DDD AssessmentBroader than CARE Assessment for Medicaid Personal Care HoursCurrently does not create different hours than the CARE AssessmentMay change in the futureAssess eligibility and need for other DDD programsBetter assessment of the needs of individuals with developmental disabilitiesConsolidates the assessment of need for services being provided through DDDValue of Individual Support PlanCan take between 2 and 6 hours to complete
44 DDD AssessmentWACDetermines each client’s individual support needs3 sections of DDD AssessmentSupport Assessment ModuleHCBS Waiver eligibilityDetermine 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 16Exceptional Medical and Behavior Supports and Family Caregiver NeedsService Level Assessment ModuleAssists in developing the ISPCARE AssessmentAdditional questions to determine services needed (seizure and allergy information, employment support levels for individuals receiving county services)Individual Support Plan ModuleDescription 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, and16 problem behaviorsMeasures type, frequency, and amount of time of supports a person needs to be successful
46 Individual and Family Service Program (IFS) Formerly Family SupportWACPurpose:Form a partnership between the state and families to help support families who have a DDD eligible family member living in the family homeProvide families with a choice of services and allow families more control over the resources allocated to them.Eligibility based on needNo financial criteriaOther DDD services reduce & eliminate IFS$2,000 to $6,000 for therapies, respite, equipment, etc.AccessWaiting lists existEmergency funding available for up to 2 months.One-time awards
47 DDD Home & Community Based Service (HCBS) Waivers WACAlternative to institutionsFocus: remaining in homes & communitiesBroad, flexible, individualized services determined through assessmentCommunity placementsHome (own or family)Adult Family HomesSupported Living FacilityNursing FacilityCompanion, host, and foster homes
48 DDD HCBS Waivers Types of Waivers Eligibility BasicBasic PlusCORECommunity ProtectionChildren’s Intensive In-Home Behavior Support Program (CIIBS)EligibilityEligible for DDD servicesICF/MR level of careSSA disabilityFinancial eligibilityTypes 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 & interventionCommunity access and involvement (guides, work, transportation)Mental health servicesSkilled nursingFamily & staff trainingSpeech & language servicesOccupational & physical therapyPersonal care servicesDental CareHabilitation servicesMedical & Adaptive suppliesEmergency Services
50 CIIBS Waivers RCW 71A.24; WAC 388-828-8500 to -8520 (emergency rule) Focus on:Behavior SupportStaff and Family Training and ConsultationRespite CareContract with behavior support specialistPositive Behavior Support Plan100 Children initially + 6 each monthPriority/eligibility based on out-of-home risk score through CIIBS Algorithm (data collected in DDD Assessment)Other services may include:Personal CareSpecialized Nutrition and clothingTherapeutic Equipment and SuppliesEnvironmental Accessibility AdaptationsVehicle AdaptationsSpecialized Medical Equipment and SuppliesAssistive Technology
51 Administrative Hearing Process RCW and WACProcessPlanned Action NoticeRequest for hearingPre-hearing conference callAdministrative Hearing before an independent ALJ with OAHDSHS Appeals CouncilPetition for Review before Superior CourtWA Court of AppealsWA Supreme CourtUS 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 RehabilitationHousing and Urban Development (HUD) ProgramsTemporary Assistance for Needy Families (TANF)General Assistance (GA)Food StampsState/County specific programsEarly Childhood Development (EPSDT)Insurance Alternatives (CHIPs)Non-Income/Asset SensitiveSpecial EducationSome Medicaid Waiver ProgramsCommunity/Church programsGeneric Recreational Programs (i.e. Park Department, Special/Para/Quad Olympics)
53 Disclaimer/NoticeThis 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)