9800.1 This chapter establishes standards governing financial eligibility determinations and post-eligibility treatment of income for long term care services and supports (LTCSS), which include health-related care and services provided in a nursing facility or Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID), or in a home or community setting through a Home and Community-Based Services Waiver (HCBS Waiver) program.

9800.2 Applicants and beneficiaries shall consist of the following three (3) eligibility groups:

(a) Individuals who have been determined eligible for Social Security Income (SSI) by the U.S. Social Security Administration (SSA);

(b) Individuals who meet the income and resource requirements under the Special Income Standard (SIS), which is equal to three hundred percent (300%) of the SSI federal benefit rate (FBR); and

(c) Individuals whose gross countable income exceeds the SIS and who elect to spend their excess income down to the Medically Needy Income Level (MNIL) to become financially eligible for LTCSS.

9800.3 The Department of Health Care Finance (the Department) shall establish an applicant or beneficiary's financial eligibility for LTCSS after evaluating the applicant's or beneficiary's non-financial eligibility for LTCSS.

9800.4 A determination of non-financial eligibility for LTCSS shall include consideration of the following five (5) components:

(a) District of Columbia residency, determined in accordance with Section 9502 of Title 29 DCMR;

(b) U.S. citizenship or satisfactory immigration status, determined in accordance with Section 9503 of Title 29 DCMR;

(c) Social Security number, determined in accordance with Section 9504 of Title 29 DCMR;

(d) Age (eighteen (18) years or older for all LTCSS applicants and beneficiaries, and sixty five (65) years or older for applicants and beneficiaries seeking LTCSS under the Elderly and Persons with Physical Disabilities (EPD) waiver program on the basis of advanced age); and

1. (e) Clinical determination that the applicant or beneficiary requires an institutional level of care.
2. 9800.5 Determinations of financial eligibility for LTCSS shall include those determinations made at the initial application, annual renewals, and periodic redeterminations.
3. 9800.6 A determination of financial eligibility for LTCSS shall include the following:
4. (a) An income test, as described at Subsection 9801.1; and
5. (b) A resource test, as described at Subsection 9802.1.
6. 9800.7 In calculating gross countable income and gross countable resources, the Department shall only count the income and resources available to the applicant or the applicant's spouse at the time of the initial eligibility determination.
7. 9800.8 The Department shall redetermine financial eligibility for LTCSS every twelve (12) months, except for individuals referenced in Subsection 9800.2(c). Financial eligibility for these individuals shall be redetermined every six (6) months.
8. 9800.9 A beneficiary shall immediately notify the Department of any change in circumstances that directly affects financial eligibility for LTCSS.
9. 9800.10 The Department shall redetermine eligibility for beneficiaries identified at Subsection 9800.9 at the time the change is reported.
10. 9800.11 After an applicant or beneficiary is determined financially eligible for LTCSS, the Department shall determine how much that individual shall contribute to the cost of care.

SOURCE: Final Rulemaking published at 63 DCR 1605 (February 12, 2016).