Do not use G03/G95/G99 in the following situations

CN SSI related Medicaid under S01 or S02 For SSI-related individuals who are eligible to receive CN coverage because they are on SSI (S01) or are SSI related with income at or below the CNIL (S02), the higher standard used for non institutional Medicaid in an ALF is not needed because they already meet CN-P eligibility. Special income disregards for SSI-related programs such as disabled adult child (DAC) and COLA/Pickle are found in the clarifying section under WAC 182-512-0880 . Individual's receiving services authorized by DDA or HCS pay the ALTSA room and board amount.

Health Care for workers with disability (HWD)(S08) In most cases, individuals who are on Health Care for Workers with disabilities (HWD/S08) would be better off remaining on HWD if receiving services from HCS or DDA. HWD individuals on MPC would pay their HWD premium to financial service administration (FSA) and the ALTSA Room and Board amount to the ALF provider.

Individuals receiving HCB Waiver services with DDA or HCS Individuals authorized for an HCB Waiver program through DDA (described in WAC 182-515-1510 ) or HCS (described in WAC 182-515-1505 ) may be living in an ALF. If the individual is authorized services through a HCB Waiver program, the L22 medical coverage group is used. There are exceptions to this if the client is eligible for HWD or D01 and receiving HCB Waiver services. The L22 Waiver medical coverage group is an institutional program using post eligibility rules to determine how much the client pays toward their cost of care. The amount the client pays along with the standard room and board amount is called participation. There are allowable deductions that can be used in post eligibility under an HCB Waiver program, but not allowed as a deduction in the SSI related rules used for the noninstitutional SSI related in an ALF program. Some examples of these deductions allowed in the post eligibility process for the Waiver programs are guardianship fees, court ordered child support, health insurance premiums, incurred medical expenses and spousal allocation under the spousal impoverishment act.

The Hospice program uses institutional rules under the L22 program for individual's who would benefit in using institutional rules.

For an individual electing hospice and paying private to an ALF Do use the G95 program as a priority if eligible. If not eligible under G95 rules, consider the L32 program for hospice elections. View the hospice description .

Individuals residing in a noncontracted alternate living facility. (private facilities) Some facilities are totally private and do not contract with the department to provide services. Determine eligibility for individuals in non contracted facilities as if they are in their own home. Do not use the amount the individual pays to the private non contracted facility as a medical expense. Alternate living facilities such as private assisted living, private adult family homes are not medical institutions, therefore the amount the individual pays to the facility is not considered a medical expense. The standard used for residents of private non contracted facilities is the MNIL standard.

Individuals receiving Medicaid under a MAGI program

Examples of noncontracted and private facilities or home settings

Residents of veteran's homes who received domiciliary or assisted living care are not eligible for Medicaid. The Department of Veterans Affairs is responsible for meeting the needs of the domiciliary or assisted living residents.

Private boarding home, continuing care retirement center (CCRC), private assisted living facilities, supported living, and state operated living alternative (SOLA). Determine eligibility as if they are in their own home. (S02/S95/S99).