Defining the resource standard and determining resource eligibility for long-term care (LTC) services
WAC 388-513-1350
WAC 388-513-1350
Effective July 1, 2009
WAC 388-513-1350 Defining the resource standard and determining resource eligibility for long-term care (LTC) services
This section describes how the department defines the resource standard and countable or excluded resources when determining a client's eligibility for LTC services. The department uses the term "resource standard" to describe the maximum amount of resources a client can have and still be resource eligible for program benefits.
The resource standard used to determine eligibility for LTC services equals:
Two thousand dollars for:
A single client; or
A legally married client with a community spouse, subject to the provisions described in subsections (5) through (11) of this section; or
Three thousand dollars for a legally married couple, unless subsection (3) of this section applies.
When both spouses apply for LTC services the department considers the resources of both spouses as available to each other through the month in which the spouses stopped living together.
When both spouses are institutionalized, the department will determine the eligibility of each spouse as a single client the month following the month of separation.
If the department has already established eligibility and authorized services for one spouse, and the community spouse needs LTC services in the same month, (but after eligibility has been established and services authorized for the institutional spouse), then the department applies the standard described in subsection (1)(a) of this section to each spouse. If doing this would make one of the spouses ineligible, then the department applies (1)(b) of this section for a couple.
When a single institutionalized individual marries, the department will redetermine eligibility applying the rules for a legally married couple.
The department applies the following rules when determining available resources for LTC services:
WAC388-475-0250, How to determine who owns a resource; and
WAC 388-470-0060 (6), Resources of an alien's sponsor.
For LTC services the department determines a client's nonexcluded resources as follows:
The department determines countable resources for SSI-related clients as described in WAC 388-475-0350 through 388-475-0550 and resources excluded by federal law with the exception of:
WAC 388-475-0350 (1)(b) clients who have submitted an application for LTC services on or after May 1, 2006 and have an equity interest greater than five hundred thousand dollars in their primary residence are ineligible for LTC services. This exception does not apply if a spouse or blind, disabled or dependent child under age twenty-one is lawfully residing in the primary residence. Clients denied or terminated LTC services due to excess home equity may apply for an undue hardship waiver described in WAC 388-513-1367.
For an SSI-related client one automobile per household is excluded regardless of value if it is used for transportation of the eligible individual/couple.
For an SSI-related client with a community spouse, the value of one automobile is excluded regardless of its use or value.
Vehicles not meeting the definition of automobile is a vehicle that has been junked or a vehicle that is used only as a recreational vehicle.
For a SSI-related client, the department adds together the countable resources of both spouses if subsections (2), (5) and (8)(a) or (b) apply, but not if subsection (3) or (4) apply.
For an SSI-related client, excess resources are reduced:
In an amount equal to incurred medical expenses such as:
Premiums, deductibles, and co-insurance/co-payment charges for health insurance and Medicare premiums;
Necessary medical care recognized under state law, but not covered under the state's Medicaid plan;
Necessary medical care covered under the state's Medicaid plan incurred prior to Medicaid eligibility.
As long as the incurred medical expenses:
Are not subject to third-party payment or reimbursement;
Have not been used to satisfy a previous spend down liability;
Have not previously been used to reduce excess resources;
Have not been used to reduce client responsibility toward cost of care;
Expenses not allowed to reduce excess resources or participation in personal care are:
Unpaid expense(s) prior to Waiver eligibility to an adult family home (AFH) or boarding home is not a medical expense.
Personal care cost in excess of approved hours determined by the CARE assessment described in 106 WAC is not a medical expense.
The amount of excess resources is limited to the following amounts:
For LTC services provided under the categorically needy (CN) program :
Gross income must be at or below the special income level (SIL) 300% of the federal benefit rate( FBR).
In a medical institution excess resources and income must be under the state Medicaid rate
For CN Waiver eligibility, incurred medical expenses must reduce resources within allowable resource limits for CN-waiver eligibility. The cost of care for the waiver services cannot be allowed as a projected expense.
For LTC services provided under the medically needy (MN) program when excess resources are added to nonexcluded income, the combined total is less than the:
Private medical institution rate plus the amount of recurring medical expenses for institutional services; or
Private hospice rate plus the amount of recurring medical expenses, for hospice services in a medical institution.
For MN Waiver eligibility, incurred medical expenses must reduce resources within allowable resource limits for MN-Waiver eligibility. The cost of care for the waiver services cannot be allowed as a projected expense.
For a client not related to SSI, the department applies the resource rules of the program used to relate the client to medical eligibility.
For legally married clients when only one spouse meets institutional status, the following rules apply. If the client's current period of institutional status began:
Before October 1, 1989, the department adds together one-half the total amount of countable resources held in the name of:
The institutionalized spouse; or
Both spouses.
On or after October 1, 1989, the department adds together the total amount of nonexcluded resources held in the name of:
Either spouse; or
Both spouses.
If subsection (8)(b) of this section applies, the department determines the amount of resources that are allocated to the community spouse before determining countable resources used to establish eligibility for the institutionalized spouse, as follows:
If the client's current period of institutional status began on or after October 1, 1989 and before August 1, 2003, the department allocates the maximum amount of resources ordinarily allowed by law. Effective January 1, 2009, the maximum allocation amount is one hundred and nine thousand five hundred and sixty dollars This standard increases annually on January 1st based on the consumer price index. (For the current standard starting January 2009 and each year thereafter see long-term care standards at http://www.dshs.wa.gov/manuals/eaz/sections/LongTermCare/LTCstandardspna.shtml; or
If the client's current period of institutional status began on or after August 1, 2003, the department allocates the greater of:
A spousal share equal to one-half of the couple's combined countable resources as of the beginning of the current period of institutional status, up to the amount described in subsection (9)(a) of this section; or
The state spousal resource standard of forty-five thousand one hundred four dollars effective July 1, 2007 through June 30, 2009. Effective July 1, 2009 this standard increases to forty-eight thousand six hundred thirty-nine dollars (this standard increases every odd year on July 1st). This increase is based on the consumer price index published by the federal bureau of labor statistics. For the current standard starting July 2009 and each year thereafter see long-term care standards.
The amount of the spousal share described in (9)(b)(i) can be determined anytime between the date that the current period of institutional status began and the date that eligibility for LTC services is determined. The following rules apply to the determination of the spousal share:
Prior to an application for LTC services, the couple's combined countable resources are evaluated from the date of the current period of institutional status at the request of either member of the couple. The determination of the spousal share is completed when necessary documentation and/or verification is provided; or
The determination of the spousal share is completed as part of the application for LTC services if the client was institutionalized prior to the month of application, and declares the spousal share exceeds the state spousal resource standard. The client is required to provide verification of the couple's combined countable resources held at the beginning of the current period of institutional status.
The amount of allocated resources described in subsection (9) of this section can be increased, only if:
A court transfers additional resources to the community spouse; or
An administrative law judge establishes in a fair hearing described in chapter 388-02 WAC, that the amount is inadequate to provide a minimum monthly maintenance needs amount for the community spouse.
The department considers resources of the community spouse unavailable to the institutionalized spouse the month after eligibility for LTC services is established, unless subsection (5) or (13)(a), (b), or (c) of this section applies.
A redetermination of the couple's resources as described in subsections (7) is required, if:
The institutionalized spouse has a break of at least thirty consecutive days in a period of institutional status;
The institutionalized spouse's countable resources exceed the standard described in subsection (1)(a), if subsection (8)(b) applies; or
The institutionalized spouse does not transfer the amount described in subsections (9) or (11) to the community spouse or to another person for the sole benefit of the community spouse as described in WAC 388-513-1365(4) by either:
The first regularly scheduled eligibility review; or
The reasonable amount of additional time necessary to obtain a court order for the support of the community spouse.
For resource rules and related information that define ownership and availability, refer to SSI related Medical RESOURCES See Institutional and Medical standards for resource standards.
The client shall be resource eligible on the first day of the month to be eligible for any day or days of that month. The department shall make a resource determination of the first moment of the first day of the month. The department shall determine changes in the amount of a client's countable resources during a month do not affect eligibility or ineligibility for that month.
Resources of a married couple - one spouse institutionalized:The rules regarding resources for married couples are different depending on when the institutionalized spouse began the current period of institutional status.
If the current period of institutional status began before October 1, 1989, the determination of eligibility does not include any resources of the community spouse that are owned and maintained separately from community resources. Once eligibility has been established, this rule remains in effect unless a break of at least thirty consecutive days occurs.
If the current period of institutional status began on or after October 1, 1989, the spousal impoverishment rules apply. When these rules apply, count all non-excluded resources owned by either or both spouses, separately or jointly. The department then allocates the amount set aside for the community spouse
The amount that is allocated is based upon the onset date of the current period of institutional status. One set of rules covers married clients who become institutionalized before 8/1/03. A separate set of rules covers married clients who become institutionalized on or after 8/1/03.
The amount of allocation allowed, based on the appropriate set of rules, can be increased only as described in WAC 388-513-1350 :
Pursuant to a court order for spousal support; or
When an administrative law judge (ALJ) approves a determination by Home and Community Services (HCS) that the excess resources are needed to produce income to provide the community spouse the minimum maintenance allocation.
Once eligibility has been established, this resource determination remains in effect unless a break of at least thirty consecutive days occurs, or if the institutionalized spouse acquires resources above the program standard.
If the onset date of the current period of institutional status is after October 1, 1989 and before August 1, 2003, the federal Community Spouse Resource maximum that was in place at the time of the application is used as the Community Spouse Resource Allocation. See Example #1.
If the onset date of the current period of institutional status is on or after August 1, 2003, the State Spousal Resource Standard that was in place at the time of the application is used as the Community Spouse Resource Allocation, unless:
The client or community spouse requests an evaluation of their community resources; and
The results of the evaluation show the spousal share of the community resources at the onset of institutional status, or ½ of the couple’s total non-excluded resources, was greater than theState Spousal Resource Standard. See Example #2
Resource Evaluations: Married clients who become institutionalized on or after 8/1/03 and have a community spouse can request HCS to evaluate their resources. This evaluation is used to determine if they are eligible for a higher spousal resource allocation than the State Spousal Resource Allocation standard. When evaluating community resources, consider the value of all non-excluded resources owned by either spouse separately or jointly as of the first day of the month that institutionalization began. Resource Evaluations can be requested and completed prior to the LTC Medicaid application or at the time of the LTC Medicaid application. Verification of all resources is required to complete the evaluation.
HCS Community Resource Declaration: The HCS Community Resource Declaration form has been developed for clients to use when requesting an evaluation. The form is available to DSHS staff on the ADSA forms page at http://adsaweb/hcs/resourceForms.htm.
Evaluation letter templates: In addition to the HCS Community Resource Declaration form, four letter templates are available for staff use when communicating with clients when resource evaluations are requested prior to receiving the Medicaid application. These forms are available to DSHS staff on the ADSA forms page at http://adsaweb/hcs/resourceForms.htm.
Request for Verification - This letter is sent to request resource verification. Allow 10 days for the client or spouse to provide the information.
Community Resource Evaluation Completed - This letter is sent to advise the client and spouse that the community resource evaluation is completed. A copy of the completed HCS Community Declaration form that includes the amount of the spousal share is sent with this letter.
Unable to Complete the Community Resource Evaluation - This letter is sent when the client or spouse does not provide resource verification. This letter advises them that the evaluation cannot be completed without the verification. It will also tell the client that the evaluation will be completed when the verification is received.
Evaluation is not Required -This letter is sent when a couple requests an evaluation of community resources but it is not required. An evaluation is not required when:
The current period of institutional status began prior to 8/1/03
The total non-excluded resources are at or below the state spousal resource share for the community spouse plus the $2,000 resource limit allowed for the institutional spouse
Spousal Share: The spousal share is one-half of the total non-excluded community resources owned by the couple as of the first day of the month the applying institutional spouse first become institutionalized. The spousal share can be used as the Community Spouse Resource Allocation when the amount of spousal share exceeds the State Spousal Resource Standard. However, if the spousal share exceeds the federal Community Spouse Resource Allocation maximum standard, then we can allow only up to the federal maximum standard that is in place at the time the institutional client applies for LTC Medicaid.
Resources of a married couple – both institutionalized: The spousal impoverishment rules do not apply if both spouses are institutionalized. If both spouses apply for LTC services during the same month, the department considers all non-excluded resources available to both spouses when establishing eligibility. If one spouse applies for LTC services in a month after eligibility for the other spouse has been established, or if both were denied in the previous month because of excess resources, the department considers one-half of community resources and separate resources respectively when determining the eligibility of each spouse.
A client can establish a patient trust account in a medical facility, if the client is not capable of handling personal funds or has requested in writing that one be established. The Nursing Facility is required to:
Maintain an interest bearing account for balances above $49.99
Keep a ledger of the trust account balance of each client
Notify the HCS/CSO FSS when the trust account is close to the resource standard.
f the client leaves a medical facility, the facility returns these funds to the client. If the client dies, the facility sends these funds to the Office of Financial Recovery for estate recovery. If the client leaves and his/her whereabouts are unknown, the facility sends these funds to the Department of Revenue.
Excess Resources:
A client may reduce excess resources in either the month of application or an eligibility review, if they are used to determine participation in the cost of institutional care or a spenddown liability for non-institutional medical assistance. The client’s non-excluded resources cannot exceed the program standard in other months, in order for the client to remain eligible for LTC services.
A client may also reduce excess resources by paying medical bills or using funds to establish a burial fund, if appropriate. Care must be taken to ensure that excess resources are spent during the month of application. If a client remains resource ineligible during the month of application, the department cannot pay for services received that month, even if the client becomes eligible in the next month.
The department considers the client's home with equity less than $500,000 an excluded resource, if one of the following applies:
The client expresses an intent to return to the home, and the home is considered the principal place of residence, or
The client's spouse or other dependent relative lives in the home.
When the home cannot be exempted the client must make a reasonable attempt to convert the property to an available resource. Providing one of the following does this:
Current real estate listing
Advertisement showing property is for sale
Other verification to show reasonable effort to sell the property.
When the current period of institutional status began before October 1, 1989:
Consider resources in both spouses’ names as community resources (jointly owned).
Do not count separate resources of each spouse as a community resource. In order to be considered separate, these resources must belong to one spouse and be maintained separately from community resources.
Count one-half of the community resources and one-half of the resources owned by the institutionalized spouse toward the Medicaid resource standard for one person of $2,000 to determine resource eligibility.
Follow necessary supplemental accommodation (NSA) procedures described in WAC 388-200-1300 when appropriate.
When the current period of institutional status began on or after October 1, 1989:
Determine the value of the community resources as of the first day of the month of application. Include all non-excluded resources of both spouses. Do not consider whether or not the resources are separate or jointly owned.
Allocate non-excluded community resources to the community spouse up to:
The maximum amount if the client’s institutional status onset was before 8/1/03;
The state spousal resource standard or the spousal share up to the federal maximum if the client’s institutional status onset was on or after 8/1/03; or
An amount ordered by the court or ALJ
Count the remaining resources toward the Medicaid resource standard for one person.
If below the standard, the institutionalized spouse is resource eligible
If above the standard, consider whether the excess amount can be used to satisfy any spenddown liability for the cost of care in the initial month
If you deny the application for excess resources and the client disputes the value assigned to the resources, send the client a letter to gain verification of the value of the couples’ resources. Allow ten days, and send a confirmation of denial, if the client does not respond or provide the information requested. If the information is provided and the client is ineligible, send a confirmation of denial that itemizes resources and their values.
If the institutionalized spouse is eligible after allocating resources to the community spouse, inform the client that the names must be changed to that of the community spouse on documents of ownership for the allocated resources by the end of one year. Start this protected period on the date you open LTC services and end this period on the last day of the month in which the first eligibility review is due.
When completing the first eligibility review, determine if the resources have been transferred to the community spouse.
If the transfer has been completed, the institutionalized spouse remains eligible.
If the transfer has not been completed, determine if legal proceedings to transfer the resources have begun. If not, terminate the case after giving the client advance and adequate notice. Do not allow an additional protected period if the client reapplies unless there is a 30 day break in services. A re-application after a 30 day break is treated like a new application.
If legal proceedings are under way, tickle the case to review the status of the resources based on the expected date of transfer.
Do not reassess community resources unless the institutionalized spouse has a break of at least thirty consecutive days in the current period of institutional status or acquires resources above the program standard.
When both spouses are institutionalized during the same month, count all non-excluded resources during the first month of separation. Consider all resources as available to both and compare total resources to the couple institutional standard. If resources are above this standard, both are ineligible for that month. For the month following the month of separation, refer to number 9.
When eligibility has already been established for one spouse, and the other spouse becomes institutionalized in a following month, consider one-half of all community resources jointly held as available to both spouses. Add to that amount the separate resources of each spouse when determining eligibility for each of them. Establish eligibility for each spouses as you do for a single client. If resources of a spouse are above the standard for one person, that spouse is ineligible.
Use the Inidividual Annuity (Life Expectancy) Tables in Appendix IV to determine whether annuity payments will exceed a time frame based on the actuarial life expectancy of the client. If they do, establish a period of ineligibility described in the transfer of asset section. Determine whether a life estate can be excluded as a resource. If not, determine its value as a non-excluded resource by using Appendix II - Determining the Value of Life Estates. If the life estate is jointly owned, divide the value by the number of joint owners to determine the client’s share.
Follow necessary supplemental accommodation (NSA) procedures when appropriate.
Use the following guidelines when completing an evaluation of the community resources when the client becomes institutionalized on or after 8/1/03:
Resource evaluations can be completed prior to the application or at the same time as the application.
An evaluation is not necessary if the client’s community resources do not exceed the state spousal resource standard plus the resource standard for a single individual (total of $42,000 for time period 8/1/03 through 6/30/05. Effective 7/1/2005, total increased to $43,943).
Determine the value of the community resources as of the first day of the month that institutionalization began.
Obtain verification of the resource values. Allow 10 days for a response.
If the client does not provide requested verification when completing evaluations prior to the application, send a letter that explains we cannot determine the spousal share without this verification. A letter template is available to DSHS staff from the ADSA homepage.
When completing evaluations prior to the application, send the client and spouse the results. In addition, inform the couple that the spousal share determination may change if there is a break in institutional status of 30 or more consecutive days. A letter template is available to DSHS staff from the ADSA homepage.
A new evaluation is needed only if there has been a break in institutional status of 30 or more consecutive days prior to the Medicaid application. If needed, this evaluation can be completed in conjunction with the Medicaid application.
After completing the evaluation, do not require married couples to report changes in institutional status prior to applying for Medicaid. However, when the institutional client applies, always confirm that there has not been a break in institutional status since completing the evaluation.
If a Community Resource evaluation was completed prior to the Medicaid application, determine if there has been a break in the institutional status of 30 or more consecutive days since the onset of the current period of institutionalization.
When the client applies, a new evaluation will be needed If there was a break in the client’s institutional status of 30 or more consecutive days and the client’s current community resources exceed the state spousal resource standard plus the resource standard for a single person.
When processing the long term care application, if the client does not provide verification of resources to determine the spousal share:
Use the state spousal resource standard to determine eligibility;
Do not deny the application for failure to provide this information; and
If the client is over the resource limit after allowing the state spousal resource standard and applying excess resources towards the cost of care, deny the application and explain in the ACES denial letter that we cannot determine the spousal share without the missing verification.
While following these procedures, the information below is important to remember.
Until the policy for Community Spouse Resource Allocations is fully supported in ACES, a parameter change has been implemented. The maximum community resource standard is updated on the LTC standards chart. Enter resource amounts on the RES1, RES2, and RES3 screens. ACES supports policy that states married clients must transfer all but $2,000 of non-excluded resources to the non-applying spouse by the time the first eligibility review is completed.
For a married client with a community spouse, code up to $45,104 (7/1/07 spousal resource amount) on the client’s RES1, RES2, and RES3 screens. Code any excess based on the spousal share determination on the spouse’s RES1 screen. Document this action on the client’s RES1 screen in F9 remarks. For current community spouse resource amounts, consult the LTC standards chart.
Modification Date: September 2, 2009
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