Wash. Admin. Code § 182-561-0300

Current through Register Vol. 24-23, December 1, 2024

Section 182-561-0300 - Eligibility

To be eligible for the community behavioral health support services (CBHS) benefit, a person must meet all requirements and criteria in this section.

(1)General requirements. A person must:

(a) Be eligible for apple health under categorically needy or alternate benefit plan scope of care;

(b) Receive at least one of the following home and community services at home or in a community residential setting:

(i) Medicaid personal care (MPC), as described in WAC 388-106-0015(1);

(ii) Community options program entry system (COPES), as described in WAC 388-106-0015(2);

(iii) Community first choice (CFC), as described in WAC 388-106-0015(3);

(iv) New freedom consumer directed services (NFCDS), as described in WAC 388-106-0015(16); or

(v) Residential support, as described in WAC 388-106-0015(17).

(c) Have countable income at or below 150 percent of the federal poverty level (FPL);

(d) Be age 18 or older; and

(e) Have an eligible diagnosis, as identified in WAC 182-561-0700.

(2)Needs-based criteria. A person must be assessed by home and community services (HCS) or an HCS designee and found to have a demonstrated need for:

(a) Assistance with three or more activities of daily living (ADL), or assistance with body care, or both, as defined in WAC 388-106-0010; or

(b) Hands-on assistance with one or more ADLs.

(3)Risk-based criteria. A person must have:

(a) A behavioral or clinical complexity that requires the level of supplementary or specialized services and staffing available only under the CBHS benefit. This determination is based on the person exhibiting one or more of the following behaviors within the last 12 months and can be prevented only with a high level of staffing, or skilled staff intervention, or both:

(i) Multiple assaults related to a behavioral health condition during inpatient or long-term care;

(ii) Self-endangering behaviors related to a behavioral health condition that would result in bodily harm;

(iii) Intrusiveness related to a behavioral health condition (e.g., rummaging, unawareness of personal boundaries) that places the person at risk of assault by others;

(iv) Chronic psychiatric symptoms that cause distress to and escalate the person or other residents to crisis if not monitored or redirected by staff;

(v) Sexual inappropriateness related to a behavioral health condition that may compromise the safety of the person and other vulnerable adults; or

(b) A history of any of the above behaviors, which are currently only prevented by additional skilled staff intervention.

(4)Other criteria. A person must have:

(a) A history of being unsuccessful in community living settings, as evidenced by at least one or more of the following:

(i) A history of multiple failed stays in residential settings within the past two years;

(ii) Be in imminent danger of losing a current community living setting due to behaviors related to a behavioral health condition or conditions;

(iii) Frequent caregiver turnover due to behaviors related to a behavioral health condition or conditions within the past two years; or

(iv) Be at imminent risk of losing a long-term care living setting without currently receiving the CBHS benefit.

(b) A past psychiatric history, where significant functional improvement has not been effectively maintained due to the lack of the CBHS benefit, as evidenced by one or more of the following:

(i) Two or more inpatient psychiatric hospitalizations in the last 12 months;

(ii) An inpatient stay in a community hospital (acute or psychiatric) or a free-standing evaluation and treatment facility for 30 days or more in the last 12 months, with barriers to discharge related to a behavioral health condition or conditions;

(iii) Discharge from a state psychiatric hospital or a long-term 90/180-day inpatient psychiatric setting in the last 12 months; or

(iv) Be at imminent risk of requiring inpatient level of care without currently receiving the CBHS benefit.

(5)Service eligibility. Covered services may begin on the date the client meets all CBHS benefit criteria described in subsections (1) through (4) of this section. The agency approves one year of continuous eligibility for the CBHS benefit, unless the client:

(a) Moves out-of-state;

(b) Is admitted to an institution, as defined in WAC 182-500-0050, and is likely to reside there for 30 days or longer;

(c) No longer receives any of the home and community services as described in WAC 388-106-0015 (1), (2), (3), (16), or (17), at home or in a community residential setting;

(d) Dies;

(e) Has countable income over 150 percent federal poverty level (FPL); or

(f) Otherwise loses eligibility for medicaid.

(6)Service eligibility denial or termination. The agency provides a written explanation for denials as described in chapter 182-518 WAC.

(a) A change that results in termination takes effect the first of the month following the change as described in WAC 182-504-0120.

(b) A change that results in a decreased scope of care takes effect the first of the month following the advance notice period, as described in WAC 182-504-0120.

(c) A person who does not agree with an agency decision regarding CBHS services, including a denial of eligibility, may request an administrative hearing as described in chapter 182-526 WAC.

(7)Redetermination. The agency reviews client eligibility for CBHS services at least once every 12 months.

Wash. Admin. Code § 182-561-0300

Adopted by WSR 24-10-081, Filed 4/30/2024, effective 7/1/2024