When am I eligible for C01 Hospice program following institutional Medicaid rules?

Revised June 16, 2011

When am I eligible for the L22 Hospice program following institutional Medicaid rules?

Use the L22 hospice program for a client who receives hospice services  and who resides in a medical institution (nursing home, hospice care center).  (ACES will trickle to a L95, L99 medically needy program depending on income when the client is in a medical institution ).  

For some clients who do not reside in medical institutions, it could be to their benefit to follow institutional rules when determining eligibility for Hospice services.   Institutional rules allow the spend-down of excess resources towards the cost of care, a higher resource standard  for married couples, a higher income allocation amount for a spouse and a higher income standard for a single person.  Clients need to meet aged, blind or disabled criteria to be eligible for the L22 hospice program.  Examples of cases that should be considered for L22 coverage are listed below:

L22 is a categorically needy (CN) program and has advantages over a MN program.

1. SSI related medically needy.   A client should always be considered for a L22 program before authorizing benefits or services under MN for the following reasons:  

• Clients will not have to meet the spend-down amount prior to becoming eligible.  (They may have to pay toward the cost of care each month. This is paid directly to the Hospice provider).   
• Once eligible, Medicaid is backdated to the first of the month and CN scope of care.
• The CN income limit is the Special Income Limit  (SIL) which is higher than the CN income limit for non-Institutional medical. 
• The personal needs allowance standard is higher for a single person (100% FPL) as opposed to the MNIL  used for non-institutional medical. 
• A community spouse’s income is not counted when determining hospice participation. The personal needs allowance (PNA) is theMNIL  when there is a community spouse.
• A dependent’s income is not counted when determining hospice participation. 
• Higher income allocation to a community spouse and dependents when living with a community spouse. 

See:  LTC income and standards chart

2. Single Healthcare for Workers with Disability  (HWD) clients with income below 100% of the FPL. They would not have to pay a premium for medical coverage and would have no participation.  
3. Children with disabilities who are not eligible for a children’s healthcare program due to the income of their parents.

For clients receiving waiver services  through Aging and Disability Services Administration (ADSA), see additional instructions under Worker Responsibilities - ADSA Waiver Programs. 

Waiver rules are described in WAC 388-515-1505  for HCS clients with income under the special income level (SIL).

WAC 388-513-1395 Determining eligibility for institutional or hospice services and for facility care only under the medically needy (MN) program for clients with income over the SIL. (hospice clients in a medical institution with income over the SIL).

Waiver rules are described in WAC 388-515-1510 through 388-515-1514  for DDD clients on the L22 Waiver program.

A client can be on a waiver program with HCS or DDD and receive Hospice services.  Both Waiver and Hospice service eligibility is coded on the INST screen.  The Waiver program is the priority program over Hospice.  All participation is applied to the waiver program.