Application processes for Long-term care (LTC) eligibility

Revised April 25, 2013

How individuals apply

The individual, Power of Attorney, legal guardian, or any authorized representative acting on behalf of the applicant can apply.

The individual can apply in person, by mail, or online using Washington Connection.   If made in person or by mail, applications should be completed at the nearest Home and Community Services (HCS) office.  If completed online, an LTC program should be selected in the LTC area of the page so it will be assigned to the correct office.  The choices are:

• In home long-term care services
• Assisted Living Facility/Adult Family Home
• Nursing Home

Please see the following links for additional information and rules about applying for LTC programs, including when to apply, Estate Recovery requirements, and applying online through Washington Connection. 

Home and Community Services Offices

How to apply for LTC Medicaid  through Home and Community Services

Filing an application for assistance Rules and Clarifying Information on filing an application

More information about Medicaid and Estate Recovery from the Aging and Disability Services Administration website

When should one file an application for long-term care coverage?

Washington Connection your link to services 

Social Service Intake Phone Numbers for Home and Community Services

Social Service central intake lines are divided by  Regions in the State of Washington.  This is used to request a social service assessment for home and community services (in-home care, care in a residential facility, nursing facility coverage). 

• Region 1 North HCS-Pend Oreille, Stevens, Ferry Okanagan, Chelan, Douglas, Grant, Lincoln, Spokane, Adams and Whitman:  1-866-323-9409
• Region 1 South HCS-Klickitat, Kittitas, Yakima, Benton, Franklin, Walla Walla, Columbia, Garfield and Asotin.  Contact the local Home and Community Service (HCS) office based on county
• Region 2 North HCS - Snohomish, Whatcom, Skagit, Island Counties 1-800-780-7094 or FAX 425-339-4859
• Region 2 South HCS - King County 206-341-7750 or FAX 206-373-6855
• Region 3 HCS- Pierce, Kitsap, Thurston, Mason, Lewis, Grays Harbor, Pacific, Cowlitz, Clark, Clallam, Jefferson Counties 1-800-786-3799 or 360-664-9138.   FAX 360-586-0499

Application forms

The application process begins and the application date is established when the request for benefits DSHS 14-001 or online application  is received.

Other forms used in the application process for long-term care services:

DSHS 14-113 Your Rights and Responsibilities Translations can be found at DSHS forms under 14-113

HCA 14-194 Medical Coverage Information    (PDF translations can be found on the Medicaid forms site under 14-194)

DSHS 14-251 Revocable Burial Fund Provision

DSHS 14-251A Irrevocable Burial Fund Provision

DSHS 14-454 Estate Recovery fact sheet.   Repaying the State for Medical and Long Term Care (LTC)

DSHS 14-501 Community Resource Declaration Used to evaluate resources (assets) for an applicant and their spouse based on date of institutionalization.

DSHS 14-532 Authorized Representative  Release of information.

DSHS 10-438 Long-Term Care Partnership (LTCP) Asset Designation form  Used to designate assets (resources) for those with a Long-term care partnership insurance policy.

DSHS 14-012 Consent (release of information form) Used for all DSHS programs

* note HCA 80-020 Authorization for Release of Information is for Medical benefits under Health Care Authority and will be accepted as a release of information for all Medical programs including LTC programs.  The DSHS consent form is preferred as it is used for all programs including medical, food and cash. 

Note:  The term asset and resources mean the same thing. 

Application Process (staff who make eligibility determinations)

Financial staff determine financial eligibility by comparing the client's income, resources and circumstances to program criteria.  Financial staff also determine participation amount in the cost of care.

Social service staff and case managers determine functional eligibility and what services to authorize.

Both functional and financial eligibility are done concurrently.  Both must be determined before an application for LTC services can be completed. 

Financial and social service staff must coordinate their activities in order to process applications and provide services to clients timely and efficiently.

An interview is required for LTC services applications

It is the policy of Home and Community Services to have an interview with the applicant or their representative.  

Use NSA policies for long-term care applicants and recipients. 

The interview can be conducted in person or by phone.  If the client or representative cannot be reached by phone, send a letter of request for what is needed based only on what was declared and ask the person to call you and arrange the interview. 

The financial worker must:

1. Go over the application, particularly what was declared in the income and resource sections.  Ask about other resources not declared on the application.  General open-ended questions about resources and income should also be asked.  Family members and other representatives are often just learning about the client's income and resources when they apply.  Open-ended questions often reveal that additional sources of income and assets may exist.
2. Ask about any transfers, gifts, or property sales during the 5 year look back period and the circumstances of why they were made.
3.  Ask about other medical coverage.  If there is other medical coverage and you can obtain the information during the interview, complete a 14-194 medical coverage form and send to the HIU.  Otherwise, send the form to the client for them to complete and return.   
4. Ask if there are unpaid medical expenses and request verification if medical expenses  exist. Ask if any of these bills were within the last 3 months.
5. Explain the financial and social service functional eligibility process.  Explain to the applicant that there is a financial worker and a social worker making determinations concurrently for long term care eligibility. 
6. For in home service applicants, discuss the food assistance program and inquire if the individual would like to be considered for food benefits. 
7. Explain the medical service card, automatic Medicare D enrollment if not on a credible coverage or Medicare D PDP plan.
8. Explain the medicare savings program (MSP).  If the applicant is eligible for a MSP program based on MSP income and resource guidelines and all information is received to determine eligibility for MSP, do not hold up processing this program while the LTC medical is still pending. 
9. Explain what participation and room and board is, how the amount is determined and that it must be paid to the provider. 
10. Explain what Estate Recovery is and mail the Estate Recovery fact sheet if the applicant has not received one. 
11. Explain what changes of circumstances  need to be reported
12. In the case of the community spouse, explain how all resources in excess of the $2,000 resource limit must be transferred to the spouse within 1 year and to provide verification of this by the first annual review. 
13.  Explain what proof is needed to complete the application and that a follow-up letter will be sent listing what they are.  Encourage the applicant to begin gathering required documents as soon as possible in order to expedite the application.  Explain  how to request an extension if more time is needed.  

Document the interview in the ACES case. 

Documentation reflects:

• Statements made by the client or their representative
• Eligibility decisions made and actions taken on the case; and
• Why the actions were taken

Documentation provides:

• An ongoing permanent history of actions and decisions taken;
• A support of eligibility, ineligibility and benefit determination;
• Credibility for decisions when used as evidence in legal matters;
• A trail for reviewers to determine the accuracy of the benefits issued

Follow these principles when documenting:

• Clear.  Use readily understood language
• Concise.  Documentation is subject to public review.  Stick to the facts relevant to determining eligibility or benefit level. 
• Complete.  The documentation must support the eligibility decision and allow a reviewer to determine what was done and why.
• Consistent.  Explain how conflicts or inconsistencies of information were resolved.  Demonstrate the reasonableness of decisions.  Ensure what you document accurately describes what happened with the case. 

Information needed to determine eligibility

Applications for Assistance-Information needed to Determine Eligibility

Verification Chart - Medical

Verifications needed to determine eligibility for long-term care eligibility are:

1. ID and citizenship status
2. Gross monthly income.
3. Out of pocket medical expenses including insurance premiums.  If proof is not provided, the expense will not be allowed as a deduction. 
4. Resource amounts including the primary residence for both husband and wife, even if only one is applying for long-term care services. 
5. Explanation and proof of any resources that have been sold, traded, given away or transferred in the last 5 years including trusts, vehicles or life estates.   
6. If there is a community spouse, proof of the spouse's gross income and shelter expenses in order to determine the amount of the client's income that can be allocated to the spouse. 

What if the applicant for LTC services is already on Medicaid?

1. A new application is not required for individuals active on Medicaid and needing LTC services as long as the financial worker is able to determine institutional eligibility using information in the current case record.  Use the original eligibility review date to open institutional medicaid. 

2. Review excess home equity, annuity and transfer of resource provisions that are specific to institutional and home and community Waivers. 

3. SSI recipients needing institutional services must complete and sign LTC eligibility review in order to review home equity, annuity and transfer of resource provisions.  Do not hold up eligibility for long-term care awaiting a signed review.  If a 14-001, 14-078, or a 14-416  is in the electronic case record within that past year, a new review form is not needed. 

What if the applicant withdraws their application and decides within 30 days they want to pursue the application?

If an applicant has withdrawn their request for medical benefits and decides they want to pursue the application, we will redetermine eligibility benefits without a new application as long as the client has notified the department within 30 days of the withdrawal.  The financial worker would need to go over the original application to make sure there are no changes and proceed to determine eligibility.

HCA clarification has confirmed that when using WAC 388-406-0065 for the reconsideration of a denied benefit, a withdrawal of a medical request is allowed reconsideration rights if it is within 30 days of the withdrawal. 

Time Limits for Processing

Time Limits for Processing

Completing the Application Process

Completing the application process

Application for Nursing Facility Care

1. Department-designated social service staff:
   1. Assess the client's functional eligibility for institutional care
   2. Screen all clients to determine potential for home and community services
   3. Determine if the client is likely to attain institutional status as described in WAC 182-513-1320.Notify the facility when the client doesn't appear to meet the need for NF care.
   4. Determine if a Housing Maintenance Allowance (HMA) formerly Medical Institution Income Exemption (MIIE) is appropriate.  Instructions are found in the LTC manual - Nursing Facility Case Management & relocation discharge resources. 
   5.  Determine if there is potential for relocation and what level of intervention would be required following the procedures outlined in nursing facility case management.
   6. Provide financial services staff with the following information:
      1. Date of NF admission
      2. Does the client meet nursing facility level of care (NFLOC)
      3. For Medicaid recipients, the first date DSHS was notified of the admission by the nursing facility
      4. If the client is likely to attain institutional status (projected in a medical facility for 30 days or more)
      5. The amount of housing maintenance exemption and the start date if appropriate. 
2. Financial services staff:
   1. Refer the client to the SW for a CA if the client contacts the FSS first and document the date the client first requested NF care.
   2. Determine the client's financial eligibility for LTC services and non-institutional medical assistance.
   3. Authorize payment for NF care if the client is both functionally and financially eligible. 
      1. For Medicaid applicants, institutional services are approved based on the date the client is eligible up to 3 months prior to the date of application. 
      2. For Medicaid recipients, institutional services are approved based on the first date the admission is known to DSHS as long as the client meets all other eligibility factors. 
   4. Issue the NF award letter to the applicant/recipient and the nursing facility. 

Application for in home or residential services

1. Department-designated social service staff:
   1. Assess the client's functional eligibility for in home or residential  care.
   2. Provide financial services staff with the following information:
      1. Service start date
      2. Type of service (COPES, RCL, New Freedom, MPC, PACE)
      3. Residential facility name and address
2. Financial services staff:
   1. Refer the client to the SW for a CA if the client contacts the FSS first and document the date the client first requested in home or residential  care.
   2. Give a projected participation and room and board amount to the SW using the LTC referral 65-10.  Clearly indicate this is a projection and the financial application is in process. 
   3. Determine the client's financial eligibility for LTC medicaid and/or non-institutional medical assistance including a request for retro medical if needed.
   4. Authorize in ACES for in home or residential Waiver if the client is both functionally and financially eligible. 
   5.  Issue the award letter to the applicant/recipient.