Application processes for Long-term care (LTC) eligibility
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Application processes for Long-term care (LTC) eligibility


Revised September 5, 2014



Purpose: This section describes the application processes used by Home and Community Services (HCS) when determining financial eligibility for long-term care

WAC 182-503-0005Washington apple health -- How to apply.
WAC 182-503-0010Washington apple health -- Who can apply.
WAC 182-503-0040Washington apple health-Interview requirements.
WAC 182-503-0060Washington apple health (WAH) -- Application processing times.
WAC 182-503-0070Washington apple health (WAH) -- When coverage begins.
WAC 182-503-0080Washington apple health -- Application denials and withdrawals.

How to apply:

WAC 182-503-0005

WAC 182-503-0005

Effective October 1, 2013

WAC 182-503-0005 Washington apple health -- How to apply.

(1) You may apply for Washington apple health (WAH) by giving us (the medicaid agency or its designee) an application:

(a) Online;

(b) By calling the Healthplanfinder customer support center number;

(c) By mail;

(d) By fax; or

(e) At a local department of social and health services (DSHS) office.

(2) You may start an application for WAH by:

(a) Giving us at least the following information:

(i) Name or names of those applying,

(ii) Birth dates, and

(iii) Contact information; and

(b) Signing the application.

(3) To complete an application for WAH, you must also give us all of the other information requested on the application form.

(4) You may need to complete a supplemental form for WAH if you are:

(a) Age sixty-five or older;

(b) On medicare;

(c) Applying for healthcare based on blindness or disability; or

(d) Applying for long-term care services.

(5) You may need to complete a separate application directly with the program providers for the following programs:

(a) Breast and cervical cancer treatment program described in WAC 182-505-0120, and

(b) Take-charge program described in Chapter 182-532 WAC.

(6) If you need help filing an application, you can:

(a) Contact the Healthplanfinder customer support center number listed on the application form;

(b) Contact an application assistor, certified application counselor or navigator; or

(c) Have an authorized representative apply on your behalf as described in WAC 182-500-0010.

(7) We will help you with the application or renewal process according to the equal access provisions described in WAC 182-503-0120 and the limited-English proficient provisions described in WAC 182-503-0110.

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.

How do I apply for Long term care services?

You can apply:

  • Online through Washington Connection; or
  • By calling the HealthPlanFinder customer service support center at 1-855-923-4633 Monday through Friday from 7:30 a.m. to 8 p.m. (If you are under age 65 and not on medicare); or
  • By mail (using the HCA 18-005 ); or 
  • By FAX (using the HCA 18-005 ); or
  • In person at a local HCS office

If made in person or by mail, applications should be completed at the nearest Home and Community Services - HCS office. 

Contact the local Home and Community Service - HCS office based on county

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

CLARIFYING INFORMATION

What is the best way to apply for Long-Term Care services?

Applications for Long-Term Care services may be submitted using any of the following methods:

  • Apply online at: www.WashingtonConnection.org    

    If the client applies using the Washington Connection website the application will be assigned to a Home & Community Services office to work. This is not a real-time eligibility process.

  • Apply online at www.wahealthplanfinder.org.  

    Applications that are submitted through this site will have a real-time determination of Washington Apple Health medical coverage eligibility; however eligibility for Long-Term care services will not be determined real-time.

    To apply for LTC services through this site, the client must indicate a need for LTC services in the Additional Questions screen in the Healthplanfinder application AND take the link at the end of the application to transfer the application data to the Washington Connection site to complete additional information that is needed specific to LTC services.

    Long-term care applications for parents and children must be submitted through the Washington Healthplanfinder site.    Hospitals and agencies applying on behalf of a child or parent for the (K01) program should also send a follow up email to K01Applications@dshs.wa.gov.

  • Apply by completing the HCA 18-005  Washington Apple Health Application for Long-Term Care/Aged, Blind, Disabled coverage and mail or FAX into HCS: or

NOTE: All the questions needed for Aged, Blind, Disabled Washington Apple Health including long-term care services have been incorporated in the Washington Connections online application. This is an electronic version of the DSHS 14-001 with added questions for Aged, Blind, Disabled medical and long-term care. (The paper version of the DSHS 14-001 is used only for cash and food).

  • Call the HCS intake line in the area in which you reside to schedule an assessment. See ‘How to request an LTC assessment”.

Mailing or FAXING Documents to Home and Community Services (HCS)

Mail to:

Home and Community Services - LTC Services

PO Box 45826

Olympia WA  98504-5826; or

FAX to:   1-855-635-8305

Always include the full case name and the DSHS client ID (if known) on any document mailed or FAXED to DSHS. 


What if the applicant for LTC services is already on Washington Apple Health?

  1. A new application is not required for clients active on classic medicaid who need LTC services as long as the financial worker is able to determine institutional eligibility using information in the current case record.  Examples of classic medicaid programs are the SSI or SSI-related programs or Healthcare for Workers with Disabilities. Use the original eligibility review date to open institutional coverage. 
  2. Review excess home equity, annuity and transfer of resource provisions that are specific to institutional and home and community waivers. 
  3. SSI recipients who need institutional services must complete and sign the DSHS 14-416  Eligibility Review for Long-Term Care Benefits (http://www.dshs.wa.gov/forms/eforms.shtml ) 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 an application, review or LTC review is in the electronic case record within that past year, a new review form is not needed. 

LTC Applications for clients on MAGI-based Washington Apple Health

A client   that is active on Modified Adjusted Gross Income (MAGI) medical (N track in ACES) (with the exception of AEM N21 and N25), needing nursing facility long-term care services or Medicaid Personal Care (MPC) does not need to submit an additional application.   

MAGI medical coverage is determined through the Health Benefit Exchange (HBE), not DSHS and includes nursing facility care and MPC within the benefit package.  

If the client needs services that can only be provided through one of the home and community based waiver programs, the client must submit the HCA18-005  application form so a resource determination can be made.  In addition the client will need to be approved for a disability determination through the Division of Disability Determination services (DDDS) if disability has not already been established. 

A nursing facility award letter is not issued by the HBE.  Nursing facilities must coordinate payment for MAGI clients with the client’s managed care plan (if enrolled at the time of admission) and bill HCA directly for any custodial services provided once payment under the Managed Care Organization (MCO)  has ended. 

 


Other useful information:

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.

 


How to request a LTC assessment:

Call and schedule an assessment through our Central intake lines.

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

Who can apply?

WAC 182-503-0010

WAC 182-503-0010

Effective October 1, 2013

WAC 182-503-0010 Washington apple health -- Who can apply.

(1) You may apply for Washington apple health (WAH) for yourself.

(2) You can apply for WAH for another person if you are:

(a) A legal guardian;

(b) An authorized representative;

(c) A parent or caretaker relative of a child less than nineteen years of age;

(d) A tax filer applying for a tax dependent less than nineteen years of age; or

(e) A spouse.

(3) If you reside in one of the following public institutions, you may turn in an application up to forty-five days before you are released:

(a) Washington state department of corrections;

(b) City or county jails; or

(c) An institution for mental disease (IMD).

(4) You are automatically enrolled in WAH and do not need to turn in an application if you are a:

(a) Supplemental security income (SSI) recipient;

(b) Person deemed to be an SSI recipient under 1619(b) of the SSA;

(c) Newborn as described in WAC 182-505-0210; or

(d) Child in foster care placement as described in WAC 182-505-0211.

(5) You are the primary applicant on an application if you complete and sign the application on behalf of your household.

(6) If you are an SSI recipient, then you or your authorized representative as defined in WAC 182-500-0010 must submit a signed application to apply for long-term care services per WAC 182-513-1315.

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.

Interview requirements

WAC 182-503-0040

WAC 182-503-0040

Effective October 1, 2013

WAC 182-503-0040 Washington apple health-Interview requirements.

(1) An individual applying for Washington apple health (WAH) (as defined in WAC 182-500-0120) is not required to have an in-person interview to determine eligibility.

(2) The agency or its designee may contact an individual by phone or in writing to gather any additional information that is needed to make an eligibility determination.

(3) A phone or in-person interview is required to determine initial financial eligibility for WAH long-term care services.

(4) The interview requirement described in subsection (3) of this section may be waived if the applicant is unable to comply:

(a) Due to his or her medical condition; or

(b) Because the applicant does not have a family member or another individual that is able to conduct the interview on his or her behalf.

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.

CLARIFYING INFORMATION

There is no interview requirement for Washington Apple Health coverage unless information is missing from the application or the department needs more information.   However, an interview is required to determine eligibility for LTC services.    The interview may be held with the applicant or their authorized representative.  If the client is unable to complete the interview due to a medical condition or because no-one is available to assist the client complete the application, then the FSS may waive the interview requirement and document why the interview was waived.

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

 


WORKER RESPONSIBILITIES

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. 

Application processing times

WAC 182-503-0060

WAC 182-503-0060

Effective October 1, 2013

WAC 182-503-0060 Washington apple health (WAH) -- Application processing times.

(1) We (the agency or its designee) process applications for Washington apple health (WAH) within forty-five calendar days, with the following exceptions:

(a) If you are pregnant, we process your application within fifteen calendar days.

(b) If you are applying for a program that requires a disability decision, we process your application within sixty calendar days.

(c) The modified adjusted gross income (MAGI)-based WAH application process using Washington Healthplanfinder may provide faster or real-time determination of eligibility for Medicaid.

(2) For calculating time limits, "day one" is the day we get an application from you that includes at least the information described in WAC 182-503-0005(2). If you give us your application during business hours, "day one" is the day you give us your application. If you give us your application outside of business hours, "day one" is the next business day.

(3) We determine eligibility as quickly as possible and respond promptly to applications and information received. We do not delay a decision by using the time limits in this section as a waiting period.

(4) If we need more information to decide if you can get WAH coverage, we will send you a letter within twenty calendar days of your initial application that:

(a) Follows the rules in Chapter 182-518 WAC;

(b) States the additional information we need; and

(c) Allows at least ten calendar days to provide it. We will allow you more time if you ask for more time or need an accommodation due to disability or limited English proficiency.

(5) Good cause for a delay in processing the application exists when we acted as promptly as possible but:

(a) The delay was the result of an emergency beyond our control;

(b) The delay was the result of needing more information or documents that could not be readily obtained;

(c) You did not give us the information within the time frame specified in subsection (1) of this section.

(6) Good cause for a delay in processing the application does NOT exist when:

(a) We caused the delay in processing by:

(i) Failing to ask you for information timely; or

(ii) Failing to act promptly on requested information when you provided it timely; or

(b) We did not document the good cause reason before missing a timeframe specified in subsection (1) of this section.

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.

When coverage begins

WAC 182-503-0070

WAC 182-503-0070

Effective October 1, 2013

WAC 182-503-0070 Washington apple health (WAH) -- When coverage begins.

(1) Your Washington apple health (WAH) coverage starts on the first day of the month you applied for and we (the agency) decided you are eligible to receive coverage, unless one of the exceptions in subsection (4) of this section applies to you.

(2) Sometimes we can start your coverage up to three months before the month you applied (see WAC 182-504-0005).

(3) If you are confined or incarcerated as described in WAC 182-503-0010, your coverage cannot start before the day you are discharged, except when:

(a) You are hospitalized during your confinement; and

(b) The hospital requires you to stay overnight.

(4) Your WAH coverage may not begin on the first day of the month if:

(a) Subsection (3) of this section applies to you. In that case, your coverage would start on the first day of your hospital stay;

(b) You must meet a medically needy spenddown liability (see WAC 182-519-0110). In that case, your coverage would start on the day your spenddown is met; or

(c) You are eligible under the WAH alien emergency medical program (see WAC 182-507-0115). In that case, your coverage would start on the day your emergent hospital stay begins.

(5) For long-term care, the date your services start is described in WAC 388-106-0045.

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.

Clarifying Information

There are two start dates for long term care services, the medicaid eligibility date and the LTC services start date:

1. The date medicaid eligibility begins, which is always backdated to the first day of the month the individual is eligible for long term care services.

2. The long term care services start date (also called the authorization date) is described in WAC 388-106-0045 and RCW 74.42.056. If there is a transfer penalty as described in WAC 182-513-1363, the LTC services start date begins the day after the transfer penalty ends.

  1. The LTC services start date can't be backdated for HCB Waiver services. Social services indicates the start date for HCB Waiver on the DSHS 14-443 (communication from social services to HCS financial), or the DSHS 15-345 (communication from DDA case manager to financial).
  2. The LTC services start date can be backdated for nursing facility services up to 3 months prior to the date of application on an applicant of medicaid as long as the client is nursing facility level of care (NFLOC) and financially eligible.  
  3. The LTC services start date for nursing facility services on an active medicaid recipient is based on the first date the admission is reported to DSHS as long as the client meets all other eligibility factors. 

Application denials and withdrawals:

WAC 182-503-0080

WAC 182-503-0080

Effective October 1, 2013

WAC 182-503-0080 Washington apple health -- Application denials and withdrawals.

(1) We (the agency or its designee) follow the rules about notices and letters in chapter 182-518 WAC. We follow the rules about timelines in WAC 182-503-0060.

(2) We deny your application for Washington apple health (WAH) coverage when:

(a) You tell us either orally or in writing to withdraw your request for coverage; or

(b) We cannot determine eligibility based on the information we have from you and other sources within the timeframes stated in WAC 182-503-0060, including any extra time given at your request or to accommodate a disability or limited English proficiency..

(3) We send you a written notice explaining why we denied your application (per chapter 182-518 WAC).

(4) We reconsider our decision to deny your WAH coverage without a new application from you when:

(a) We receive the information that we need to decide if you are eligible within thirty days of the date on the denial notice; or

(b) You request a hearing within ninety days of the date on the denial letter and an administrative law judge (ALJ) or HCA review judge decides our denial was wrong (per chapter 182-526 WAC).

(5) If you disagree with our decision, you can ask for a hearing. If we denied your application because we don't have enough information, the ALJ will consider the information we already have and anymore information you give us. The ALJ does not consider the previous absence of information or failure to respond in determining if you are eligible.

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.

CLARIFYING INFORMATION

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 re-determine 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.

 


Forms used in the Application process

The application process begins and the application date is established when the request for benefits is received. These are the forms used in the application process for long-term care services. 

HCA forms, including translations are found on the HCA forms website. 

DSHS forms, including translations are found on the DSHS forms website . 

 

Note:

The 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. 


The Long-Term Care Application Process - Who makes the eligibility determinations

Financial staff determines 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 based on a complete and comprehensive care assessment.   The HCS social worker may contact the applicant to schedule a time to come to the client’s home to do an assessment if the client is requesting personal care services. 

Both functional and financial eligibility are done concurrently.  Financial and social service staff must coordinate their activities in order to process applications and provide services to clients timely and efficiently.  When a client is found both financially eligible and functionally eligible for LTC services and an approved provider is in place, then LTC services can begin.

 


What is the process for Nursing Facility Care?

For Classic Washington Apple Health programs:

  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. (Will the client be likely to reside at the nursing facility for 30 days or longer?) 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 including 3 months retroactive medical coverage if financially eligible. 
    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.

What is the process of in home or residential waiver services?

 

This process applies to classic WAH programs only – MAGI-based clients are not eligible for HCBS waiver.

  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. 

NOTE:

Applications for residential services take priority.  It is essential to start the process by referring to the Social Worker for an assessment as soon as an application for residential is received.   Services cannot be backdated prior to the date of the assessment.

Clients who are switching from private pay to medicaid are advised to apply for benefits at least 45 days before being resource eligible for the program.  There is good information on the Washington LawHelp site which explains the timing of an LTC application.   http://www.washingtonlawhelp.org/resource/when-should-one-file-an-application-for-long

Modification Date: September 5, 2014