Medicaid & Beyond

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Public Benefits
Presented by:
Joshua L. Brothers
Dussault Law Group
(206) 324-4300
e-mail: [email protected]
www.dussaultlaw.com
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
www.dussaultlaw.com
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
www.dussaultlaw.com
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
www.dussaultlaw.com
SSI Income
• Earned 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.
– $20 general exclusion
– $1:$1 reduction in SSI benefits
www.dussaultlaw.com
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
www.dussaultlaw.com
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
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
www.dussaultlaw.com
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.
www.dussaultlaw.com
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.
www.dussaultlaw.com
Parental Deeming-Eligibility
General Guidelines Only (2006)
Gross Monthly
Income:
All Earned Income:
All Unearned
Income:
# of ineligible
Children in House
One Parent
Household
Two Parent
Household
One Parent
Household
Two Parent
Household
0
$2,537
$3,139
$1,246
$1,547
1
$2,838
$3,440
$1,547
$1,848
2
$3,139
$3,741
$1,848
$2,149
3
$3,440
$4,042
$2,149
$2,450
4
$3,741
$4,343
$2,450
$2,751
5
$4,042
$4,644
$2,751
$3,052
6
$4,343
$4,945
$3,052
$3,353
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?
–
–
–
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Own
Spouse
Parent (DAC)
Grandparent
• DAC benefit:
– ½ during parent’s lifetime
– ¾ after parent’s death
www.dussaultlaw.com
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
www.dussaultlaw.com
Medicaid Administration in WA
Dep’t of Social &
Health Services
(DSHS)
Division of
Developmental
Disabilities (DDD)
Aging and Adult
Services (AAS)
Division of
Vocational
Rehabilitation (DVR)
Medicaid
• Coverage:
– 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 nontraditional treatments/therapies
www.dussaultlaw.com
Categorically vs. Medically Needy
• Categorically Needy
– Medical Assistance
– Long Term Care
– SSI eligibility
• Medically Needy
– Medical Assistance
• 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 388-4750880)
– Long Term Care has different income requirement & participation
used, not spend downs.
www.dussaultlaw.com
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 388-106-0015
www.dussaultlaw.com
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
www.dussaultlaw.com
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
www.dussaultlaw.com
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 388-106-0050 to -0145
www.dussaultlaw.com
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
www.dussaultlaw.com
Determining In-Home Hours
Classification
Group E
EC = Yes
AND
M&B = Yes or No
AND
CPS = 0-6
Group D
CPS = 4-6
AND
CC = Yes
AND
M&B = Yes or No
OR
CPS = 5-6
AND
CC = No
AND
M&B = Yes or No
ADL or
Behavior Point Score
ADL (26-28)
Classification Group
E High
Base Hours
416
ADL (22-25)
E Med
346
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
www.dussaultlaw.com
Determining In-Home Hours
Classification
Group C
CPS = 0-3
AND
CC = Yes
AND
M&B = Yes or No
ADL or
Behavior Point Score
ADL (25-28)
Classification Group
C High
Base Hours
194
ADL (18-24)
C Med-High
174
ADL (9-17)
C Med
132
ADL (2-8)
C Low
87
www.dussaultlaw.com
Determining In-Home Hours
Classification
Group B
M&B = Yes
AND
CC = No
AND
CPS = 0-4
OR
CPS = 2-6
AND
BPS > 1
AND
ADL > 1
OR
CPS >2
AND
ADL >1
ADL or
Behavior Point Score
Classification Group
Base Hours
ADL (15-28)
B High
147
ADL (5-14)
B Med
82
ADL (0-4)
B Low
47
BPS (>12)
B High
147
BPS (7-11)
B Med-High
101
BPS (5-6)
B Med
82
BPS (1-4)
B Low
47
Determining In-Home Hours
Classification
Group A
M&B = No
AND
CC =No
AND
CPS = 0-4
ADL or
Behavior Point Score
ADL (10-28)
Classification Group
A High
Base Hours
71
ADL (5-9)
A Med
56
ADL (0-4)
A Low
26
www.dussaultlaw.com
•
•
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
www.dussaultlaw.com
Reductions for Informal Support
•
IADLs looked at
–
–
–
–
–
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–
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•
•
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
www.dussaultlaw.com
Automatically Unmet Needs
• Meal Preparation (special diets)
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–
–
–
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–
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–
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
www.dussaultlaw.com
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
www.dussaultlaw.com
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 388-106-213
• Next lawsuit?
www.dussaultlaw.com
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)
www.dussaultlaw.com
Exception to Rule
• WAC 388-440
• 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
www.dussaultlaw.com
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 388-02 governs hearings
• Informal meeting with case worker or fair hearing coordinator
• Exception to Rule (ETR)
–
–
–
–
WAC 388-106-1315 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
www.dussaultlaw.com
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
www.dussaultlaw.com
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
www.dussaultlaw.com
Medicaid vs. Medicare
•
Medicaid
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
www.dussaultlaw.com
DDD Overview
• Legal Authority
– RCW Title 71A
– WAC 388-823 to -850
• Eligibility ≠ Services
• DDD is a Division of DSHS
• http://www.dshs.wa.gov/ddd
www.dussaultlaw.com
DDD Regional Map
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DDD Eligibility & Assessment
Process
Intake &
Eligibility
Start
Support
Assessment
Paid or No Paid
Services?
Paid
Svcs
Service Level
Assessment
Individual
Support Plan
Case Mgmt
and
Services
No Paid
Svcs
Assessment
Details Report
Case Mgmt
www.dussaultlaw.com
•
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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)
www.dussaultlaw.com
Defining “Developmental Disability”
• RCW 71A.10.020(3) and WAC 388-823-0040
• 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
www.dussaultlaw.com
DDD Eligibility by Age
Eligible Condition
Age 0-5
Age 6-9
Age 10-17
Age 18 and older
Developmental Delays
X
X
Downs Syndrome
X
X
Too severe to be assessed
X
X
Medically Intensive
X
X
X
Mental Retardation
X
X
X
Cerebral Palsy
X
X
X
Epilepsy
X
X
X
Autism
X
X
X
Another Neurological Condition
X
X
X
Other condition similar to MR
X
X
X
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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
www.dussaultlaw.com
DDD Assessment
• WAC 388-828
• 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
www.dussaultlaw.com
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
www.dussaultlaw.com
•
•
•
Individual and Family Service
Program (IFS)
Formerly Family Support
WAC 388-832
Purpose:
–
–
•
Eligibility based on need
–
–
•
•
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.
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
www.dussaultlaw.com
DDD Home & Community
Based Service (HCBS) Waivers
•
•
•
•
•
WAC 388-845
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
www.dussaultlaw.com
DDD HCBS Waivers
• Types of Waivers
–
–
–
–
–
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 388-845-0045(2)(b)
www.dussaultlaw.com
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
www.dussaultlaw.com
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
www.dussaultlaw.com
Administrative Hearing Process
•
•
RCW 34.05.410 - .598 and WAC 388-02
Process
•
Exception to Rule (ETR)
–
–
–
–
–
–
–
–
–
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)
– Hearing rights for reduction or termination of DDD services only.
– “No hearing right” for newly requested ETR which is denied.
www.dussaultlaw.com
Other Public Benefits
• Income/Asset Sensitive
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



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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)
www.dussaultlaw.com
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.
www.dussaultlaw.com
Thank You!
Joshua L. Brothers
Dussault Law Group
(206) 324-4300
E-mail: [email protected]
www.dussaultlaw.com
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