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Public Benefits

Public Benefits. Presented by: Joshua L. Brothers Dussault Law Group (206) 324-4300 e-mail: joshb@dussaultlaw.com. www.dussaultlaw.com. Public Benefits Overview. Federal Social Security SSI - $674/mo max SSDI - varies Medicare Hospital Doctor Visits Prescription Drugs

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Public Benefits

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  1. Public Benefits Presented by: Joshua L. Brothers Dussault Law Group (206) 324-4300 e-mail: joshb@dussaultlaw.com www.dussaultlaw.com

  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 www.dussaultlaw.com

  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 www.dussaultlaw.com

  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 www.dussaultlaw.com

  5. 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

  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 www.dussaultlaw.com

  7. SSI Calculation Example • Individual earns $275 in wages in a month • Receive $300 Gift from family

  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 www.dussaultlaw.com

  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. www.dussaultlaw.com

  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. www.dussaultlaw.com

  11. Parental Deeming-EligibilityGeneral Guidelines Only (2006)

  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 www.dussaultlaw.com

  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 www.dussaultlaw.com

  14. Medicaid Administration in WA

  15. 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 non-traditional treatments/therapies www.dussaultlaw.com

  16. 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 388-475-0880) • Long Term Care has different income requirement & participation used, not spend downs. www.dussaultlaw.com

  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 388-106-0015 www.dussaultlaw.com

  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 www.dussaultlaw.com

  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 www.dussaultlaw.com

  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 388-106-0050 to -0145 www.dussaultlaw.com

  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 www.dussaultlaw.com

  22. Determining In-Home Hours www.dussaultlaw.com

  23. Determining In-Home Hours www.dussaultlaw.com

  24. Determining In-Home Hours

  25. Determining In-Home Hours www.dussaultlaw.com

  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 www.dussaultlaw.com

  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 www.dussaultlaw.com

  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 www.dussaultlaw.com

  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 www.dussaultlaw.com

  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 388-106-213 • Next lawsuit? www.dussaultlaw.com

  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) www.dussaultlaw.com

  32. 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

  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 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

  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 www.dussaultlaw.com

  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 www.dussaultlaw.com

  36. 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 Medicaid vs. Medicare www.dussaultlaw.com

  37. 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

  38. DDD Regional Map www.dussaultlaw.com

  39. DDD Eligibility & Assessment Process www.dussaultlaw.com

  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) www.dussaultlaw.com

  41. 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

  42. DDD Eligibility by Age www.dussaultlaw.com

  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 www.dussaultlaw.com

  44. 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

  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 www.dussaultlaw.com

  46. Individual and Family Service Program (IFS) • Formerly Family Support • WAC 388-832 • 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 www.dussaultlaw.com

  47. 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

  48. 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

  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 www.dussaultlaw.com

  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 www.dussaultlaw.com

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