State-funded long-term care program for non citizens

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Revised May 8, 2013

Purpose:

WAC 182-507-0125

State-funded long-term care services program.

NOTE:

Effective 11/1/2009 there is no nursing home coverage under the AEM program. The legislature gave limited funding for a state funded long-term care program to cover services that were being authorized under AEM prior to 11/1/2009.

Effective 5/14/2011, the legislature directed ADS-HCS to move individuals to a residential setting if appropriate. The WAC has been changed to allow for either nursing facility or residential setting under this program.

WAC 182-507-0125 describes the state-funded long-term care program.

New admissions into nursing facilities, residential or home settings under the state-funded long-term care program must be pre-approved by Karyn LaBonte, Home & Community Services Headquarters. This program has limited 45 slots for coverage based on legislative funding

WAC 182-507-0125

Effective July 1, 2012

WAC 182-507-0125 State-funded long-term care services program.

The state-funded long-term care services program is subject to caseload limits determined by legislative funding. Services cannot be authorized for eligible persons prior to a determination by the aging and disability services administration (ADSA) that caseload limits will not be exceeded as a result of the authorization.
Long-term care services are defined in this section as services provided in one of the following settings:

a. In a person's own home, as described in WAC 388-106-0010;

b. Nursing facility, as defined in WAC 388-97-0001;

c. Adult family home, as defined in RCW 70.128.010;

d. Assisted living facility, as described in WAC 388-513-1301;

e. Enhanced adult residential care facility, as described in WAC 388-513-1301;

f. Adult residential care facility, as described in WAC 388-513-1301.

3. Long-term care services will be provided in one of the facilities listed in subsection (2) (b) through (2)(f) of this section unless nursing facility care is required to sustain life.

4. To be eligible for the state-funded long-term care services program described in this section, an adult nineteen years of age or older must meet all of the following conditions:

a. Meet the general eligibility requirements for medical programs described in WAC 388-503-0505 (2) and (3)(a), (3)(b), (3)(e), and (3)(f);

b. Reside in one of the settings described in subsection (2) of this section;

c. Attain institutional status as described in WAC 388-513-1320;

d. Meet the functional eligibility described in WAC 388-106-0355 for nursing facility level of care;

e. Not have a penalty period due to a transfer of assets as described in WAC 388-513-1363, 388-513-1364, 388-513-1365 and 388-513-1366;

f. Not have equity interest in a primary residence more than the amount described in WAC 388-513-1350 (7) (a) (ii); and

g. Any annuities owned by the adult or spouse must meet the requirements described in chapter 388-561 WAC.

5. An adult who is related to the supplemental security income (SSI) program as described in WAC 388-475-0050 (1), (2), and (3) must meet the financial requirements described in WAC 388-513-1325, 388-513-1330, and 388-513-1350.

6. An adult who does not meet the SSI-related criteria in subsection (2) of this section may be eligible under the family institutional medical program rules described in WAC 388-505-0250 or 388-505-0255.

7. An adult who is not eligible for the state-funded long-term care services program under categorically needy (CN) rules may qualify under medically needy (MN) rules described in:

a. WAC 388-513-1395 for adults related to SSI; or

b. WAC 388-505-0255 for adults related to family institutional medical.

8. All adults qualifying for the state-funded long-term care program will receive CN scope of medical coverage described in WAC 388-501-0060.

9. The department determines how much an individual is required to pay toward the cost of care using the following rules:

a. For an SSI-related individual residing in a nursing home, see rules described in WAC 388-513-1380.

b. For an SSI-related individual residing in one of the other settings described in subsection (2) of this section, see rules described in WAC 388-515-1505.

c. For an individual eligible under the family institutional program, see WAC 388-505-0265.

10. A person is not eligible for state-funded long-term care services if that person entered the state specifically to obtain medical care.

11. A person eligible for the state-funded long-term care services program is certified for a twelve month period.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

Medical Assistance EAZ manual material with WAC on AEM

Always consider the possibility of Aged Blind Disabled (ABD) cash or Medical Care Services (MCS)

Other programs should always be considered before considering the 45 slot state-funded long-term care program.

Many legally admitted non-citizens who are in a five year medicaid bar or other eligible non-federally qualified status can be considered for the ABD cash program. MCS should be considered for legally admitted non-citizens who do not qualify for ABD cash.

State funded medical care services (MCS) program is described in WAC 182-508-0005.

ABD cash is described in WAC 388-400-0060.

For nursing facility coverage under ABD cash or MCS the individual must meet income and resource criteria and be assessed as nursing facility level of care (NFLOC) by an HCS social worker.

An active G01 (MCS) does not require a pre-approval by HCS HQ prior to nursing facility admission.

G01 in residential setting. (MCS).

Long-term care services under State Funds for non citizens

Aging and Disability Services Administration has a limited amount of state funding available for non citizens who have been denied or terminated from AEM coverage and are in need of long-term care services outside of a hospital. These non citizens are not eligible for the ABD cash or MCS program

IMPORTANT

An L04 is used in ACES for nursing facility cases. ACES program L24 is used for LTC services pre-approved by HCS HQ in a residential or home setting.

ADSA/HCS headquarters must track each case using the state funds to pay for long-term care services under this program.

For state funded nursing home denials and terminations contact Karyn LaBonte, Financial at ADS-HCS headquarters via e mail.

The following must be reported to Karyn LaBonte LaBonKJ@dshs.wa.gov:

New admits. Include the date and facility.
Discharges. Include the date and circumstances.
Any closures. Include the date and circumstances.
If a state funded client's medical condition causes re-hospitalization, re-refer to the AEM hospital specialty team at CSD for consideration of federal coverage under the AEM program. Notify Karyn LaBonte of this referral and if AEM approval is received for the hospitalization.

Specialty Hospital Unit for AEM coverage

Most admissions into the state-funded long-term care program start out in a hospital. These applications are completed by a specialty hospital unit at the CSO. This unit refers to HCA medical consultant for possible AEM coverage in the hospital.

Prior to admission into a NF, a prior approval by ADS-HCS is needed. Even if there is an approval of AEM in the hospital, AEM does not cover NF admissions.

Once an AEM Hospital case has been approved a NF slot by ADS-HCS HQ, HCS financial staff will transfer the case into HCS for maintenance and tracking.

A client receiving services under the state funded long-term care program may have a health event that would require hospitalization. The federal AEM program must be considered for any hospitalization. HCS financial staff must coordinate with the CSD AEM Hospital specialty unit so a referral to the HCS medical consultant can be made. Contact Nhan Thai, Supervisor of the AEM Hospital Unit.

Notify Karen LaBonte, ADS-HCS Headquarters of any hospitalization so a slot can be held for a discharge to a nursing facility or residential setting.

EXAMPLE

Joe Smith is approved through 10/31/2009 under the federal AEM program. The federal AEM program for nursing home ended on 10/31/2009. Effective 11/1/2009, this client was grandfathered into the state-funded nursing facility program as Mr. Smith is still in need of nursing home care. The medical coverage group in ACES is an L04.

EXAMPLE

Jane Smith has been in a hospital for six months. All options for alternative settings have been explored by the hospital. She must either remain in the hospital indefinitely or be placed in a nursing home.

She is assessed by the HCS social worker and meets NFLOC. The HCS office handling the assessment contacts HCS headquarters for an available slot under the state-funded long-term care program. Once headquarters approves a slot and the client is financially and resource eligible, an L04 is opened in ACES. The nursing home will be able to admit Jane and bill under the state-funded nursing facility program.

EXAMPLE

Jayna Smith is a legally admitted alien in the 5 year bar. Jayna is exempt from sponsored deeming because she has no income. (income less than 130% of the FPL).

Jayna is over 65 and has been hospitalized and is in need of nursing home care due to a stroke. She has been assessed by the HCS SW and meets NFLOC.

Jayna can be opened on ABD cash and state funded MCS medical. There is no need to refer for the state-funded funded nursing home program. MCS covers nursing facility coverage.

MCS placements do not need a pre-approval by HCS HQ. See managed care section for instructions on the MCS program and nursing facility admissions.

If this individual is a candidate for SSI, submit a packet to the SSI facilitator.

EXAMPLE

John Doe has been hospitalized and is in need of LTC. Mr. Doe's needs can be met in an adult family home setting. Mr. Doe is financially eligible for the L24 program and there has been a pre-approval from HCS HQ. Any new admissions into the state-funded long-term care program must be served in a residential setting unless the person's needs cannot be met except in a nursing facility.

ACES instructions

L04 is used for state funded long-term care nursing facility admissions.

L24 is used for state funded residential admissions and in-home services. Eligibility for residential settings and in home care is the same as the COPES program. The determination of room and board and participation would follow the calculation described in WAC 182-515-1509.

ACES Instructions-Alien Medical

Notify Karyn LaBonte LaBonKJ@dshs.wa.gov 360-725-2450, HCS HQ of any admission, discharge, closure, or hospitalization under this program.