Long-term care Overview
DSHS Home Page
Search     for:
DSHS Home    Acronyms    Revisions    WAC Number Index    Site Map    WCCC

Long-term care Overview

Revised February 19, 2014

Purpose: To give an overview of long term care (LTC) services for those in medical institutions, receiving DDA Waiver, HCS Waiver or Hospice services This section also gives an overview of "non-institutional" Medicaid services such as Medicaid Personal Care (MPC)

Program Responsibility Chart

 Program  HBE  HCA  HCS  DDA/LTC Specialty  CSD  Notes
 Breast &Cervical Cancer -S30    X        May be on HCS or DDA MPC services Medical case maintained by HCA
 WAH Pregnant Teen    X        
 Take Charge Family Planning (P06)    X        
 Foster Care - D01, D02, D26    X       Maybe on HCS or DDA MPC services or in a NF.   Medical case maintained by HCA. Note: Will require coordination if approved for LTC waiver services. 
 MAGI N track Medical (individuals not on Medicare or 65 years or older).  X          May be on HCS or DDA MPC services or in a NF. Medical case maintained by HBE
 Post-enrollment quality assurance for MAGI cases    X        
 Healthcare for Workers with Disabilities (HWD) not on HCS services. No HH member on TANF cash        X    DDA LTC specialty unit maintains all HWD cases that are not on HCS services. 
 HWD with HCS services. No HH member on TANF cash      X      
 HWD not on HCS services. HH member on TANF cash        X  X

Shared case. HWD maintained by LTC HWD specialty worker, TANF cash and Basic Food maintained by CSD ACES work request on shared cases is pending. both agencies must coordinate

 HWD on HCS services. HH member on TANF cash      X    X Shared case. HWD maintained by HCS HWD worker. TANF cash and Basic Food maintained by CSD. ACES work request on shared cases is pending. both agencies must coordinate  
SSI related: S01, S02, S95, S99 not on HCS/DDA services          X  All Classic Medicaid cases with no HCS or DDA services attached are maintained by CSD
 Medicare Savings Program (MSP) only or attached to SSI related S01, S02, S95, S99 not on HCS Or DDA services          X  MSP is maintained by CSD unless attached to a classic medical case that is on HCS or DDA services
AEM/S07  IF a client is active on HCS program L04, L24 and is discharged for a hospitalization . . X . . HCS considers S07 when an HCS client active on the L04 or L24 45 slot non citizen program is admitted to the hospital.  HCS must refer to HCA for a pre approval of AEM.  AEM must be considered for any L24 or L04 discharge to a hospital due to the possibility of a federal matched program.  Once a S07 client is ready for discharge, coordinate with Karyn LaBonte regarding the pre approval for L04 or L24.  Hospital AEM not on HCS services is handled by CSD 
AEM/S07 for emergent hospitalization, kidney dialysis, cancer treatment . . . . X AEM must be pre-approved by HCA.  S07 does not cover HCS services NF or in home care. 
 Medical Care Services (MCS) not on HCS/DDA services          X  
 MCS on DDA services (with or without ABD/HEN cash)        X    Individuals on MCS or ABD cash on DDA services are maintained by the DDA LTC specialty unit unless attached to TANF cash case.  Duration determination for ABD cash must go through CSD incapacity worker (same process as former GA-X
 MCS on HCS services (with or without ABD/HEN cash)      X     Individuals on MCS or ABD cash on HCS services unless attached to TANF cash case.  Duration determination for ABD cash must go through CSD incapacity worker (same process as former GA-X)
 SSI related S01, S02 on DDA MPC residential services. No TANF cash attached        X    
 SSI related S01, S02 on DDA MPC in-home services.  With our without TANF cash attached          X  DDA LTC Specialty unit only maintains MPC cases in residential settings unless another family member is on HCB Waiver or residential. 
 SSI related S01, S02 on DDA residential services. Spouse or child on SSI related program not on services. No TANF cash attached        X    LTC specialty unit would manage the MPC residential case. Since the family is not living under the same roof, CSD would maintain the classic cases and the case would be separated
SSI related S01, S02 on HCS MPC services. No TANF cash attached      X      
SSI related S01, S02 on HCS MPC services, Spouse or child on SSI related program not on services No TANF cash      X      
SSI related S01, S02 on DDA or HCS in-home MPC services and HH member receiving TANF cash          X S01 or S02 cases on MPC with TANF cash attach are maintained by CSD. No shared case.
 Non Citizen LTC 45 slot program. L04 or L24      X      Must be pre-approved by Karyn LaBonte HCS HQ
 L track (L02, L02, L95, L21, L22) on HCS Waiver and HH member receiving TANF cash and food      X    X  Shared case. HCS maintains L21 or L22 and CSD maintains TANF cash and Food BenefitsACES work request on shared cases is pending. both agencies must coordinate  
 L Track (L01, L02, L95, L21, L22) on DDA Waiver and HH member receiving TANF cash and food.  HH member on N track medical  X      X  X  Shared case. LTC Specialty unit maintains L21 or L22, CSD maintains TANF cash and Food Benefits, HBE maintains N track medical.   ACES work request on shared cases is pending. both agencies must coordinate  
L21, L22 on Hospice only in a NF or home . . . X . DDA LTC specialty unit maintains hospice cases not attached to HCS services
 L21, L22 on Hospice and HCS HCB Waiver  .  .  X  .  .  Participation is always applied to the HCB Waiver (COPES) program first
L21, L22 couple one on Hospice one on HCB Waiver . .  X . .
 L21 or L22 married couple. One on DDA Waiver the other on HCS Waiver      X      Not a shared case. HCS maintains both cases.
Classic Medicaid on HCS services, no family member on TANF cash. Request for food benefits      X      HCS maintains Food Benefits for individuals on classic medicaid, on HCS services
 MAGI/N track or HCS or DDA MPC services. Request for food benefits/active food benefits          X  The HCS/DDA financial worker is not maintaining a medical case, therefore food benefits are determined and maintained by CSD.
 K track. Children/Family institutional        X    
 Childrens Health Insurance Program (CHIP)  X          
 MCS/HEN Active on HCS services or HCS state funded residential services.       X      MCS/HEN eligibility covers NF and State residential services. Not eligible for ABD cash because duration is not greater than 9 months. 
ABD cash - Active MCS/HEN Active on HCS service      X      MCS/HEN eligibility covers NF and State residential services. Receiving cash because duration determined over 9 months disability or over age 65.  Individuals under age 65 must go through CSD incapacity for duration for ABD cash.  HCS refers with the same process as former presumptive X. 
ABD cash - Active N track medical          X  ABD cash and food is a CSD program. The medical authorizing HCS/DDA  MPC or NF services is in the N track, which is maintained by the HBE. No medical program maintained by HCS
 Food benefits- Active N track medical          X  ABD cash and food is a CSD program. The medical authorizing HCS/DDA  MPC or NF services is in the N track, which is maintained by the HBE. No medical program maintained by HCS

What is an institutional Medicaid program and what are long term care services?

The term "institutional" Medicaid means institutional medicaid rules are used in eligibility. 

In ACES the institutional medical programs are under the L track for Aged, Blind and Disabled (ABD) or K track for children and families.

Long-term care (LTC) programs provide services for the elderly and disabled in need of institutional care. Some clients who receive LTC services are able to continue living in their home or in an alternate living facility   (ALF) on a Home and Community based (HCB) Waiver authorized by Home and Community Services (HCS) or the Development Disabilities Administration (DDA). 

Home & Community Based Services

Home and community-based services, provided under a Medicaid waiver granted by the federal government, enable a client to live in a residential setting outside of a nursing or other medical facility or in their own home. Such services are referred to as waiver services.  The HCB waiver services currently provided include:

  • COPES (Community Options Program Entry System)
  • New Freedom
  • PACE (Program for All-Inclusive Care to the Elderly)
  • Roads to Community Living
  • WMIP (Washington Medicaid Integrated Partnership)
  • Core
  • Community Protection
  • CIIBS (Children's Intensive In-home Behavioral Support)

HCB Waiver services cannot be authorized under a MAGI "N" track program. Eligibility for the L22 program must be done through the DDA/HCS financial worker. An HCA 18-001 and HCA 18-005 or Washington Connections application are needed to apply for HCB Waiver, Institutional Medicaid or any "Classic Medicaid" program.

Institutional Services

Some clients require institutional services that can be provided only in a medical facility.  Institutional medicaid rules must be used for clients who live in a medical facility for 30 days or more.

 Hospice Services

Some clients receive hospice services in addition to or instead of services in their home or a medical facility. Hospice provides palliative care for clients dealing with a terminal illness or end-of-life issues. Hospice services are described in more detail in the Hospice section of the manual and in Chapter 182-551 WAC.

Institutional Status

All clients approved for DDA or HCS Waiver services, Hospice  services or in a medical institution 30 days or more have attained institutional status and are considered to be institutionalized as described in Medicaid law and the regulations used to implement these programs. A key difference for an institutionalized person is that eligibility is determined using only that person's income, and not the income of their spouse or children. 

Medicaid Personal Care (MPC)

Home & Community Services (HCS) and Developmental Disabilities Administration (DDA) can authorize Medicaid Personal Care (MPC) for clients eligible to receive a non-institutional CN Medicaid program and assessed to be eligible for MPC. This includes clients under the new adult Medicaid expansion group who receive coverage under the Alternative Benefit Plan (ABP) scope of care.

MPC clients are not considered institutionalized. The financial eligibility for MPC is eligibility for a "non-institutional" CN Medicaid program. A chart in the MPC section gives more information.

This category also describes the rules and procedures used to determine a client's eligibility for non-institutional medical assistance provided in an ALF. This is a SSI related non-institutional program and is known to department works as the G03 program.

See long-term care medical standards and personal needs allowance chart for current institutional standards.

Additional manual material on MPC.   

Eligibility Determinations  

The department must determine a client's eligibility for LTC services according to both functional and financial requirements. Both financial and functional eligibility must be established concurrently. Coordination between financial and social service/case management staff is required to process applications and provide services.

Additional manual material on Eligibility Requirements

Functional Eligibility

A department-designated social service specialist establishes functional eligibility for nursing home placement, home & community based waiver or Medicaid Personal Care (MPC) eligibility

  • The HCS SW must authorize all nursing facility admissions before a nursing home award letter can be issued. (See applications for nursing facility care on the bottom of this clarifying page). For active Medicaid clients with short stay admissions (under 30 days) see short stay instructions. The exception to this is an admission into a State Veteran's Nursing Facility where a Veteran's Affairs Registered Nurse (VARN) determines NFLOC for admissions into a State Veteran's Nursing Facility. A NFLOC determination is not needed when a client enters a NF and is active on a HCB Waiver under a L21 or L22.
  • The HCS social service specialist Area Agency on Aging (AAA) case manager, DDA case manager (CM) or the Veterans Affairs registered nurse (VARN) determines functional eligibility for HCB waivers and MPC based on the client's assessment which takes into account the client's place of residence and services that are appropriate for the plan of care.

Financial Eligibility

Financial Staff determines financial eligibility by comparing the client's income, resources, and circumstances to program requirements

The amount of income and excess resources a client must contribute to the cost of care for services received is established in what is called the post-eligibility determination (participation ).

Financial staff must also determine eligibility for non-institutional medical assistance at the same time they determine eligibility for institutional, waiver, or hospice services.  

When determining eligibility and the cost of care for LTC services, program policy requires an allocation of income and resources from the institutionalized spouse (the applicant for LTC services) to the community spouse.(the spouse of an LTC applicant who is not applying for or receiving LTC services). This is to allow the community spouse to keep some assets and income necessary to maintain their home without requiring that the couple spend down all their assts to the individual resource limit of $2000. The Medicare Catastrophic Care Act in 1988 began the spousal allocation process used to discourage the impoverishment of a spouse due to the need for LTC services by their husband or wife. That law and those that have extended and/or amended it are referred to as spousal impoverishment  legislation. (section 1924 of the Social Security Act).

The rules used to determine eligibility and participation costs for waiver services are similar to those for institutional services, but there are important differences. These differences, in addition to those related to hospice services, are described in 182-551 WAC

A client may be eligible for both healthcare coverage and institutional services, or be eligible for one but not the other.


Aging and Long Term Supports Administration (ALTSA)


ALTSA is responsible for managing all the long-term care programs offered in the State of Washington. LTC programs are managed by both Home and Community Services (HCS) staff and by financial staff in the DDA/LTC specialty unit. The break up of duties is defined below;

  1. DDA/LTC Specialty Unit  financial service specialist (FSS) staff determine financial eligibility for the following long-term care (LTC) clients:
    • Developmental Disabilities administration   (DDA) clients receiving LTC services in a DDA medical institution, DDA Waiver or MPC  residential services paid for by DDA and authorized under a "Classic Medicaid" assistance unit.    (unless the DDA individual is married and spouse is on HCS services, see HCS responsibility below). 
    • DDA LTC medical institutions are:
    • Residential Habilitation Centers (RHC)
      • Fircrest School
      • Lakeland Village
      • Rainier School
      • Yakima Valley School
    • Intermediate Care Facilities for the Intellectually Disabled (ICF/ID)
      • Barclay Group Home
      • Chelsea
      • Brookhaven
      • Bedford
      • Camelot Group Home
      • Carlton
    • Mental health clients receiving residential services paid for by Mental Health / Regional Support Network (MH/RSN) in an ALF. (G03 program)
    • Institutional children or family medical (K track)
    • Hospice  services authorized if client is not on an HCS Waiver program or MPC authorized by HCS.
    • This includes Hospice elections in a nursing home or hospice care center.
    • Hospice services are paid by Health Care Authority (HCA).
    • Healthcare for Workers with Disabilities (HWD) unless on HCS services.
    • Basic food eligibility when associated with a DDA LTC case.
    • Medicare Savings Program eligibility when associated with a DDA LTC case.
    • TANF clients who receive COPES services (until April 2014)
  2.   Home and community services  (HCS) FSS staff determine financial eligibility for  LTC clients who receive the following services from HCS:
    • Nursing facility (NF) care;
      • New applications and maintenance for nursing facility (NF) care under the L track program.
      • Active Medicaid clients including WASHCAP cases when NF care is 30 days or longer.
      • Active WASHCAP  (CSO 130) when NF care is under 30 days and a NF short stay award letter is needed.
    • HCS services both in home or in an alternate living facility.  This includes:
    • Food stamp eligibility (associated with LTC services) when the non-LTC clients in the household do not receive TANF cash.
    • ABD cash  for clients receiving services authorized by HCS and eligible for HEN/MCS.  ABD cash requires a 9 month disability duration determination by CSD for individuals under age 65. 
    • Medical Care Services (MCS) for clients receiving services authorized by HCS if there is no TANF cash
    • Married couple, one individual is on HCS services ( Classic Medicaid MPC or HCS Waiver or nursing home) the other spouse is on active DDA services.(Classic Medicaid MPC or DDA Waiver).
    • Married couple, one individual is on HCS services (MPC, HCS Waiver or nursing home).  The other spouse is not on institutional medical, but is applying for a classic medical program HCS is responsible for the application and maintenance of the community spouse's application for classic medical.
    • The HCS SW is responsible to gather the information needed to submit a disability determination (NGMA) packet and referral if needed for the community spouse classic medicaid application even if the institutional spouse is receiving COPES and is being case managed by the Area Agency on Aging

Health Care Authority

3. The Health Care Authority staff are responsible for managing the following cases:

  • Foster Care/Adoption Support cases (D01/D02/D26)
  • Breast and Cervical Cancer cases (S30)
  • Take Charge Family Planning (P06)
  • MAGI-based Alien Emergency medical cases (N21-/N25) (updating the case with the medical consultant approval-initial eligibility is done through the Health Benefit Exchange)
  • Pregnant Teens program (not in ACES)

When a LTC client is active on a case managed by HCA, special handling of the case may be necessary. Here are some examples of when additional coordination activities are required:

  • A client that is approved for DDA waiver or COPES waiver services who is active on a foster care or adoption support program through the 076 Foster Care Unit. (Active D01/D02/D26) is not managed by ALTSA staff. The client will remain on the 'D' track program.
    • E-mail Lori Rolley HCS HQ to coordinate with HCA-Foster Care Unit.  Include client name and client ID.   
    • D02/D26 Foster Care cases remain with 076 until they age out, usually at age 26.
  • Client is active on S30 breasts and cervical cancer case. Clients on this program are eligible for MPC services if found functionally eligible. Active S30 cases will remain with the MEDS unit. S30 clients are not eligible for waiver services or nursing home coverage 30 days or longer. The client will need to submit an applications for LTC services to HCS. These cases will need to be coordinated between MEDS and HCS offices. Contact Kim Moore 360-725-1469
  • Client is active on N25 AEM medical in a hospital setting requiring discharge to a nursing home.A slot is approved for the state-funded nursing facility program by ALTSA HQ.    Staff will need to contact the HCA MEDS unit to update the AEM approval coding on the ALAS screen to reflect the institutional placement

4.  CSD financial staff are responsible for managing the following programs:

  • TANF/SFA cash assistance
  • ABD (Aged, blind disabled) cash assistance including those on a N track MAGI program through the Health Benefit Exchange and receiving MPC or NF services.
  • PWA (Pregnant Women's Assistance) case
  • HEN (Housing & Essential Needs)
  • RCA (Refugee Cash Assistance)
  • Medical Care Services (MCS (effective 1/1/14)
  • Basic Food for non-LTC recipients
  • Childcare Assistance
  • Classic non-LTC medical cases including, SSI-related (S02), medically needy/spenddown cases (S95/S99, Medicare Savings Program (S03, S04, S05, S06) and refugee medical (R03)

Health Benefit Exchange (HBE)

Effective 10/1/2013, children, parents and pregnant women must be converted over to health care coverage determined under the Modified Adjusted Gross Income (MAGI) methodology starting with the 11/2013 renewals.  In January 2014, under the Medicaid expansion, single adults and parents with income at or below 138% FPL will also be eligible for health care coverage using MAGI methodologies. Eligibility for these coverage groups is determined by the Health Benefit Exchange through the Washington Healthplanfinder portal.  The HBE is responsible for all 'N' Track programs as listed below, and determinations of eligibility for the Health Insurance Premium Tax Credit and Cost-Sharing reductions

  • WAH for parents and caretaker relatives (N01)
  • WAH transitional medical (N02)
  • WAH Pregnancy coverage (N03)
  • WAH MAGI-based adult coverage (N05)
  • WAH Newborn coverage (N10)
  • WAH Children's coverage (0 - 210%) - citizen and federally qualified non-citizens
  • WAH Premium based children's coverage (210% - 312% FPL) - citizen and federally qualified non-citizens (N13)
  • WAH Alien Emergency Medial for parents/caretaker relatives with income <= 53% FPL (N21)
  • WAH Pregnancy coverage (non-citizens) NN23
  • WAH Alien Emergency Medical for single adults and parents/caretaker relatives with income <= 138% FPL (N25)
  • WAH Children's coverage - non-citizen state-funded program (N31)
  • WAH Premium based children's coverage - non-citizen state-funded program (N33)

ALTSA staff have limited ability to determine eligibility for cases managed through Washington Healthplanfinder limited to cases which require redetermination when a classic case maintained by ALTSA closes. Contact your region designated staff if you have a case that needs redetermination through the healthplanfinder.  For all other changes and applications clients need to be referred to the HBE call center (1-855-923-4633).


Classic Medicaid or Modified Adjusted Gross Income (MAGI)?

Effective 10/1/2013, children, parents and pregnant women will be converted over to medical determined under the Modified Adjusted Gross Income (MAGI) methodology starting with the 11/2013 renewals.


A shared case is when cash, food and medical may be maintained by more than one agency or administration

  • TANF, SFA and Refugee cash is always maintained by Community Service Division (CSD)
  • HCB Waiver and institutional under the L track and K track is always maintained by HCS or DDA Specialty Unit financial workers. 
  • N track medical under MAGI is always maintained by the Health Benefit Exchange (HBE)
  • Breast and Cervical Cancer and Foster Care medical is always maintained by the Health Care Authority (HCA). 

Basic Program Division: 

  • HCS maintains Classic Medicaid cases when a HH member is receiving HCS MPC, HCB Waiver services or in a NF 30 days or more. 
  • DDA LTC specialty unit maintains Classic Medicaid cases when a HH member is receiving DDA HCB Waiver services, Classic CN Medicaid for MPC in DDA residential settings and DDA institutions.    In addition this unit does:
    • All HWD cases with the exception of HWD clients on HCS services. 
    • Hospice eligibility under the L track program and confirming medical eligibility with Hospice agencies.
    • RSN placements in Mental Health residential facilities, (G03 programs).
    • All K track cases (Institutional children and families).
  • L track hospitalization 30 days or more ONLY if the client is not eligible for another medical program including S99.  L track medical for hospitalization 30 days or more may need to be considered under L track because of higher resource allowances for a married couple. 
  • HCS maintains any Medicare Savings program associated with an LTC case under the 'L' track.

CSD Cases: 

  • Classic Medicaid cases when no HH member is receiving DDA or HCS services including Hospital applications under S track medical programs. The exception to this is HWD (S08), RSN placements in residential (G03), institutional children (K track) and Hospice where L track is needed for eligibility. 
  • Food benefits if a medical program under N track (MAGI) maintained by HBE even if there is MPC services authorized by HCS or DDA
  • Medicare Savings Program
  • TANF, SFA and Refugee cash assistance
  • CSD has out-stationed workers at Eastern and Western State hospital that determine eligibility for individuals:
    • age 21 or under
    • 65 or older
    • Individuals needing classic medicaid upon discharge



Parent is on L21 receiving HCS HCB Waiver services. The parent is also receiving TANF cash for 3 children.  The children are receiving N track medical through the HBE. The entire household is on basic food.

The L21/HCB Waiver case will be maintained by the HCS financial worker;

The TANF cash and basic food will be maintained by the CSD financial worker; and

The children's medical will be maintained by the Health Benefit Exchange (HBE)

An ACES work request (AWR) is pending to automate the ability to have a shared case.  Until this is promoted in ACES, CSD, HCS and DDA Specialty Unit financial workers must coordinate and work together when there is a Institutional or HWD case attached to a TANF cash program.


Children and families may still be on F track medical programs until converted to the MAGI N track program based on review date.  This conversion will be complete 8/31/2014.  There may be COPES cases (L22) still attached to a TANF cash and F track medical.  Until conversion of F track cases is complete, the DDA LTC specialty unit will maintain and coordinate with CSD and HCS.  These are COPES cases authorized by HCS and TANF, F track medical attached.    Once the F track case is converted to MAGI medical and the only medical case is L01 or L22 COPES, the COPES case will be maintained by HCS financial workers.

Desk Tools-Medicaid Programs-LTC chart

Insert here:  Medicaid programs and Long term care

Insert here:  ACES codes for MPC

Forms, WACs, Rule Making and useful LTC links

DSHS & HCA forms, WACs, Rule Making and Useful Links

  • HCA and DSHS forms
  • HCA and DSHS WACS and rulemaking
  • Aging and Long term Supports Administration (ALTSA) intake phone number
  • Developmental Disabilities Administration (DDA) and DDA LTC specialty financial unit
  • Community Service Division (CSD) contact numbers
  • EAZ and CSD Social Service manual links
  • Administrative hearings for cash and food
  • ACES manual LTC links
  • Health Care Authority (HCA) links frequently used in LTC
    • HCA WAC eligibility rules index
    • HCA internet
    • Washington Health Benefit Exchange (HBE) 1-855-923-4633 or e-mail customersupport@wahbexchange.org
    • HCA Medical Assistance Customer Service Center (MACSC) 1-800-562-3022
    • HCA coverage - scope of care, medical coverage booklet, medication coverage lists, DME.
    • Administrative rules for Medical services
    • Managed Care
    • HCA Washington Apple Health Managed care (formally called Healthy Options)
    • HCS Nursing facility provider guide
    • Provider One billing and Resource guide
    • Using your medical service card
    • Washington State Provider One find a provider
    •  HCA Medicare buy in issues
  • Northwest Law Center, LTC ombudsman, SHIBA links

Washington Apple Health Managed Care (Healthy Options)

Individuals enrolled in managed care that have questions regarding their scope of care and coverage need to be directed to their managed care plan, not the HCA Medical Assistance Customer Service Center. 

If a medically necessary item has been denied by the managed care plan, the client has a right to an appeal through the plan.

Washington Apple Health-Managed Care Plans: 

Amerigroup (AMG)
Basic Health
Community Health Plan of WA (CHPW)
Coordinated Care Corporation (CCC)/Centene
Molina (MHC)
UnitedHealthcare Community Plan (UHC)

Washington State Health Care Authority income and resource standards for Medicaid

HCA Income and Resource current and historical standard charts

Medicaid eligibility standards and changes in medicaid eligibility in 2014 under the Affordable Care Act starting January 1, 2014

Modification Date: February 19, 2014