Eligibility Requirements

Revised April 4, 2012

Long-term care

WAC 388-513-1315

CLARIFYING INFORMATION

Special income level (SIL):

1. The department compares a client’s non-excluded income to the SIL  to determine whether a client is eligible for LTC services under the CN program.  Effective 4/1/2012 individuals applying for HCB Waiver services authorized by Home and Community Services (HCS) can have income over the Medicaid SIL.  (see WAC 388-515-1508 ). 
2. The SIL  is equal to 300% of the annually adjusted SSI Federal Benefit Rate (FBR). 
3. The department does not allow income disregards when determining eligibility for CN services. It reduces a client’s gross income only by the exclusions allowed by federal statute as described in WAC 388-513-1340. 

Income transfers: 

1. The department considers any agreement between spouses to transfer or assign rights to future income to be invalid when determining a client’s income eligibility and participation in the cost of care.  
2. The department considers such income available when comparing a client’s income to program standards  and includes it when determining the participation amount whether or not the client continues to receive it.
3. The department considers all of a client’s income to be available as described in WAC 388-513-1325 and WAC 388-513-1330, unless exceptional circumstances exist that include but are not limited to the following:
   1. When income is established as unavailable in a fair hearing as described in chapter 388-02 WAC .
   2. When income that at one time belonged exclusively to a client becomes property of the spouse in a community property state. An example of this is when a court divides a pension between spouses by use of a "qualified domestic relations order" (QDRO). Under a QDRO a court transfers a portion of the pension, which it considers a resource, and thereby transfers a portion of the income produced by the resource.
4. The department does not consider income generated by a transferred resource to be available. The income is a part of the resource, which is why the department evaluates the transfer of such an asset as the transfer of a resource as described inWAC 388-513-1363, 388-513-1364  and  388-513-1365.

Private payments to facilities:

1. The department does not count private payments in the form of a deposit or as part of a contract when determining a client’s eligibility.
2. If eligibility is established for the period of time for which such payment was made, the facility must refund the amount that exceeds the client’s participation in the cost of care. The facility then bills the department and accepts payment as payment in full.
3. If the refund belongs to the client and adding the payment amount to non-excluded resources results in an excess of the resource standard, the department uses it to establish the client’s spenddown liability as described in WAC 388-513-1395.
4. The department does not count private payments made by relatives or others for amenities not provided by the facility when determining eligibility or participation in the cost of care. The definition of income as described in                            WAC 388-513-1325 and WAC 388-513-1330  does not include such payments.

LTC/Private Insurance: LTC Insurance and Third Party Resources   

Institutionalized SSI Clients: 

1. If an SSI client is admitted to a medical facility for a temporary period, SSI payments may continue for the first three months after admission.
2. As long as SSA determines a client eligible to receive SSI, the client does not participate in their cost of personal care. 

Involuntary Treatment Act (ITA):  

Under the ITA, clients of any age can be placed into certain institutions for mental diseases (IMD). No face to face interview is required when determining eligibility.

Inpatient mental health treatment in Eastern or Western State Hospital: 

1. Persons who are at least 21 and less than 65 years old who live in Eastern or Western State Hospital are not eligible for medical assistance. Their medical needs are the responsibility of the hospital.
2. As mandated by federal regulations, the department determines eligibility for medical assistance for all persons not disqualified by these age limits and requires participation in the cost of care as described in the program rules.

Parental responsibility: 

1. The financial responsibility of parents is limited to what they choose to contribute when their child is receiving inpatient chemical dependency and/or mental health treatment that is expected to last for 90 days or more
2. This rule remains in effect even if the expected length of treatment is shortened for any reason.
3. Children who are eligible for Medicaid under institutional rules while inpatient at Eastern or Western State Hospital remain continuously eligible for Medicaid through the end of their one year certification upon discharge from the facility.See Clarifying Information under Children’s Medical Programs for instructions.

Residency: 

1. The exempt status of the home for a client receiving LTC services in a medical facility or alternate living facility allows for a broad definition of state residency.
2. If the client or client’s representative expresses the client’s intent to return to the home, it is excluded when determining resources, even if the home is located in another state. 
3. The expressed intent to return to a home that is in another state does not affect the client’s status as a Washington resident.

Nursing facility (NF) - limitations on billing: 

1. For recipients active on Medicaid the NF cannot bill a client who applies for or receives institutional services for the days between admission and the date the facility first notified the department of the admission.  
2. For applicants, the department will back date the institutional date as long as the client is otherwise eligible.
3. Recipients of the Breast and Cervical Cancer or Healthcare for workers with disability (HWD) program must submit an application for a determination Medicaid eligibility using institutional rules if client is in a medical institution 30 days or over.  Recipients of the Breast and Cervical Cancer or HWD program can have nursing facility paid as a short stay for less than 30 day admissions only.
4. Nursing Home Services Prior Authorization is required under the State-funded nursing facility program. 

Medicare payment for NF cost of care:  Medicare and Long-term care

Home and Community Based (HCB) Waivers authorized by HCS

Home and Community Based (HCB) Waivers authorized by DDD

Hospice authorized by Health Care Authority

Roads to Community Living (RCL)

Active MN Medicaid client entering a nursing facility

Active MN Medicaid client entering a nursing facility. Active MN Medicaid clients who have met spenddown and are placed in a nursing home would be allowed the following deductions to determine the amount of the client's participation in the cost of care:

1. Allow the MNIL if the client is at home the first day of the month he or she is admitted to the facility, or the appropriate personal needs allowance  (PNA) based on the client's living arrangements if not at home on the first day of the month.  See institutional standards  for current PNA amounts.

2. Client's monthly spenddown liability that has been met for each month through the certification period.

3. All allowable deductions are found in WAC 388-515-1509 for HCS CN Waivers, WAC 388-515-1514  for DDD CN Waivers and WAC 388-513-1380  for residing in a medical institution.

4. The $20.00 disregard used as a deduction for MN non-institutional spenddown is counted towards the client's monthly nursing home participation in the post eligibility process.

MN client entering nursing facility, spenddown has not been met.

• Nursing facility charges can be used as an incurred medical expense for client's who have not met a spenddown within the base period. See instructions above for guidance once a spenddown has been met.

Short Stay-Less than 30 days in a Nursing Facility.

• For clients who do not meet institutional status described in WAC 388-513-1320 but meet the functional eligibility requirement and are eligible for Medicaid.

1. If it appears that a client admitted to such a facility is eligible for medical benefits, facility staff determine if the client is already approved for a particular program. Facility staff notify the CSO in writing of the client’s admission.

2. If a client is not already approved for medical benefits, facility staff assist the client as needed to complete the application and sends it to the CSO.

3. Facility staff make referrals as appropriate to the disability specialist for a determination. 

4. When written notification of admission from the facility is received in the CSO, document whether the client intends to return home upon discharge, if the client is a member of a TANF/SFA household (H/H). If so, obtain an estimated length of stay. If not, remove the client from the H/H assistance unit (AU), and determine eligibility for all program benefits as appropriate upon the client’s discharge from the facility.

5. If the client intends to return to the TANF H/H, family members are responsible for the client’s personal needs as grant is continued up to 180 days.  See WAC 388-454-0015 If a client who was expected to be inpatient for more that ninety days does not remain that long, increase the TANF/SFA grant to the full amount. This does not create an underpayment.

6. If an SSI-related client is admitted to such a facility and remains there for at least one full calendar month, make program changes in ACES to reflect the change in the coverage group and living arrangement. Determine eligibility for all program benefits as appropriate upon the client’s discharge from the facility.

1. If the client is not discharged and remains eligible for Medicaid, complete an eligibility review (ER) every twelve months. Contact facility staff for information to complete the ER.

2. Follow necessary supplemental accommodation (NSA) procedures.   

WORKER RESPONSIBILITIES

1. See Application processes for LTC services

2. See CITIZENSHIP/ALIEN STATUS, RESIDENCY, and SSN to determine whether a client meets the general eligibility requirements.

3. Determine the program to which the client can be related to medical eligibility. See ADULT MEDICAL, FAMILY MEDICAL PROGRAMS, and INCAPACITY.

4. See INCOME and RESOURCES  to determine the program to which the client can be related to medical eligibility.

5. For a nursing facility or state funded residential client whose eligibility is established under the G01 program, waive the sequential evaluation process (SEP) for a client who is eligible to receive ADSA services in a nursing facility or state funded residential, refer any MCS opening to the CSO disability specialist for a determination of ABD cash if potentially eligible for ABD cash;

6. To be eligible for waiver services, a G02 client must be receiving CN Medical due to Aged, Blind, Disabled criteria.

7. Determine whether the client should be referred to the CSO Disability Specialist/SSI facilitator for a determination of eligibility for the disability program.

8. For a client with a potential long-term disability who is not eligible for ABD cash, submit a request to the division of disability determination services  (DDDS) as described in the ADULT MEDICAL – SSI-Related Medical section and include a copy of the client assessment (CA) (non grant medical assistance-NGMA ).

9. If a person is ineligible because of excess income or resources, or does not meet functional eligibility requirements, notify the client of the reasons why the application is denied. Determine eligibility for non-institutional medical assistance as if the client were living in their own home.

10. If notice is received that a client no longer needs care provided in a medical facility, redetermine eligibility for other medical programs. CN Medicaid is continued during the redetermination process. 

11. If a client who is denied services for not meeting functional requirements requests a fair hearing, notify the SW. The staff person who completed the CA represents the department at the hearing, unless someone else is designated for that responsibility.

12. A 14-194 Medical Coverage Information form  must be completed if a client has insurance including LTC insurance. For offices in the DMS system, the Coordination of Benefits (COB) unit at H.R.S.A/MPA will receive an automatic assignment of the 14-194 Medical Coverage Information.  The COB unit enters information from the Medical Coverage Form into their system. The information is interfaced with ACES and the TPL screens are auto populated. For offices not in the DMS system, submit the 14-194 Medical Coverage form to the Coordination of Benefits (COB) Section of MPA at MS 45561. Link to DSHS 14-194 and instructions:

13. Nursing facilities will be responsible for collecting payments from TPL carriers or obtaining a denial of benefits before DSHS can pay the facilities.  The department will continue to assign participation, which the nursing facility may collect until the TPL party begins making payments.  See Long-term care insurance and third party resources.   

ACES PROCEDURES

See Long Term Care and Waiver Services - Interview

See Long Term Care, Alternate Care and Waiver Services