Eligibility Requirements
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Eligibility Requirements


Revised September 8, 2014


Long-term care


Purpose: WAC 182-513-1315 is considered the index roadmap WAC for the general eligibility of institutional and home and community based (HCB) Waiver medicaid

WAC 182-513-1315Eligibility for long-term care (institutional, home and community based (HCB) waiver, and hospice) services
WAC 182-513-1316General Eligibility requirements for WAH long-term care programs
WAC 182-513-1317Income and resource criteria for an institutionalized client
WAC 182-513-1318Income and resource criteria for home and community based (HCB) waiver programs and hospice clients
WAC 182-513-1319State-funded programs for noncitizen clients

WAC 182-513-1315

WAC 182-513-1315

Effective January 1, 2014

WAC 182-513-1315 Eligibility for long-term care (institutional, home and community based (HCB) waiver, and hospice) services

Emergency WAC effective 1-1-2014

This section describes how the medicaid agency or its designee determines a client's eligibility for Washington apple health (WAH) long-term care coverage for clients residing in a medical institution, receiving home and community based waiver services, or receiving hospice services under the categorically needy (CN) or medically needy (MN) programs.  Also described are the eligibility requirements for these services under state-funded medical care services (MCS) program and the state funded long-term care services program. 

This chapter includes the following sections;

  1. WAC 182-513-1316, General eligibility requirements for WAH long-term care programs.
  2. WAC 182-513-1317, Income and resource criteria for an institutionalized client.
  3. WAC 182-513-1318, Income and resource criteria for home and community based (HCB) waiver programs and hospice clients.
  4. WAC 182-513-1319, State-funded programs for noncitizen clients.

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.

WAC 182-513-1316

WAC 182-513-1316

Effective January 1, 2014

WAC 182-513-1316 General Eligibility requirements for WAH long-term care programs

Emergency WAC effective 1-1-2014

  1. To be eligible for long-term care (LTC) services, a client must:
    1. Meet the general eligibility requirements for medical programs described in WAC 182-503-0505;
    2. Attain institutional status as described in WAC 182-513-1320;
    3. Meet the functional eligibility described in:
      1. Chapter 388-106 WAC  for a home and community services (HCS) waiver or nursing facility coverage; or
      2. Chapter 388-828  WAC for DDA waiver or institutional services; and
    4. Meet either:
      1. SSI-related WAH criteria as described in WAC 182-512-0050; or
      2. MAGI-based WAH criteria as described in WAC 182-503-0510  (2).  A client who is eligible for MAGI-based WAH is not subject to the provisions described in subsection (2) of this section. 
  2. An SSI-related client, including supplemental security income (SSI) recipients, who needs LTC services must also:
    1. Not have a penalty period of ineligibility as described in WAC 182-513-1363, 182-513-1364, or 182-513-1365;
    2. Not have equity interest in their primary residence great than the home equity standard described in WAC 182-513-1350;
    3. Disclose to the state any interest the applicant or spouse has in an annuity and meet annuity requirements described in chapter 182-516 WAC.
  3. An SSI recipient must submit a signed health care coverage application form attesting to the provisions described in subsection (2) of this section.  A signed and completed eligibility review for long-term care benefits can be accepted for SSI clients applying for long-term care services. 
  4. To be eligible for WAH LTC waiver services, a client must also meet program requirements described in:
    1. WAC 182-515-1505 through 182-515-1509  for COPES, New Freedom, PACE and WMIP services; or
    2. WAC 182-515-1510 through 182-515-1514  for DDA Waivers
  5. A client who is eligible for categorically needy WAH coverage is certified for twelve months.
  6. A client who is eligible for medically needy WAH coverage is approved for a period of months described in WAC 182-513-1395  (6) for:
    1. Institutional services in a medical institution; or
    2. Hospice services in a medical institution.
  7. The medicaid agency or its designee determines a client's eligibility as it does for a single person when the client's spouse has already been determined eligible for LTC services.

 

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.

WAC 182-513-1317

WAC 182-513-1317

Effective January 1, 2014

WAC 182-513-1317 Income and resource criteria for an institutionalized client

Emergency WAC effective 1-1-2014

  1. This section provides an overview of the income and resource eligibility rules for a client who lives in an institutional setting.  The term "institution" is defined in WAC 182-500-0050. To determine income eligibility for an SSI-related WAH long-term care (LTC) client under the categorically needy (CN) program, the medicaid agency or its designee:
    1. Considers income available as described in WAC 182-513-1325 and 182-513-1330;
    2. Excludes income as described in WAC 182-513-1340;
    3. Compares remaining gross nonexcluded income to the special income level (SIL) (three hundred percent of the federal benefit rate (FBR)). A client's gross income must be equal to or less than the SIL to be eligible for CN coverage.
  2. To determine income eligibility for an SSI-related WAH LTC client under the medically needy (MN) program, the agency or its designee:
    1. Considers income available as described in WAC 182-513-1325 and 182-513-1330;
    2. Excludes income as described in WAC 182-513-1340;
    3. Disregards income as described in WAC 182-513-1345; and
    4. Follows the income standards and eligibility rules described in WAC 182-513-1395
  3. To be resource eligible under the SSI-related WAH LTC CN or MN program, the client must::
    1. Meet the resource eligibility requirements and standards described in WAC 182-513-1350;
    2. Not have a penalty period of ineligibility due to a transfer of asset as described in WAC 182-513-1363 or 182-513-1364;
    3. Disclose to the state any interest the client or the client's spouse has in an annuity and meet the annuity requirements described in chapter 182-516 WAC.
  4. the agency or its designee allows an institutionalized client to reduce countable resources in excess of the standard.  This is described in WAC 182-513-1350.
  5. A client is eligible for medicaid as a resident in a psychiatric facility, if the client:
    1. Has attained institutional status as described in WAC 182-513-1320; and
    2. Is under the age of twenty-one at the time of application; or
    3. Is receiving active psychiatric treatment just prior to their twenty-first birthday and the services extend beyond this date and that client has not yet reached age twenty-two; or
    4. Is at least sixty-five years old.
  6. To determine CN or MN income eligibility for a MAGI-based WAH LTC client, the medicaid agency or its designee follows the rules described in WAC 182-514-0230 through 182-514-0265.
  7. There is no asset test for MAGI-based WAH LTC programs as described in WAC 182-514-0245.
  8. The agency or its designee determines a client's total responsibility to pay toward the cost of care for LTC services as follows:
    1. For SSI-related WAH clients residing in a medical institution see WAC 182-513-1380;
    2. For MAGI-based WAH clients residing in a medical institution see WAC 182-514-0265.  Clients who are eligible for the MAGI-based WAH adult medical program described in WAC 182-505-0250  are not required to contribute toward the cost of care.  Nursing home care is included scope of care for these clients.

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.

WAC 182-513-1318

WAC 182-513-1318

Effective January 1, 2014

WAC 182-513-1318 Income and resource criteria for home and community based (HCB) waiver programs and hospice clients

Emergency WAC effective 1-1-2014

  1. This section provides an overview of the income and resource eligibility rules for a client to be eligible for a home and community based (HCB) waiver program or the Washington apple health (WAH) hospice program.
  2. To determine income eligibility for an SSI-related WAH long-term care (LTC) waiver client under the categorically needy (CN) program, the medicaid agency or its designee:
    1. Considers income available as described in WAC 182-513-1325 and 182-513-1330;
    2. Excludes income as described in WAC 182-513-1340;
    3. Compares remaining gross non excluded income to:
      1. The special income level (SIL) (three hundred percent of the federal benefit rate (FBR)); or
      2. For home and community based (HCB) service programs authorized by aging and long-term supports administration (ALTSA), a higher standard is determined following the rules described in WAC 182-515-1508  if a client's income is above the SIL but net income is below the medically needy income level (MNIL).
  3. A client who receives MAGI-based WAH is not eligible for HCB waiver services unless found eligible based on program rules in chapter 182-515  WAC.
  4. There is not WAH HCB Waiver medically needy program.
  5. To be resource eligible under the SSI-related WAH LTC CN waiver programs, the client must:
    1. Meet the resource eligibility requirements and standards described in WAC 182-513-1350;
    2. Not have a penalty period of ineligibility due to a transfer of asset as described in WAC 182-513-1363182-513-1364, or 182-513-1365;
    3. Disclose to the state any interest the client or the client's spouse has in an annuity and meet the annuity requirements described in chapter 182-516
  6. The agency or its designee allows an HCB waiver client to use verified unpaid medical expenses to reduce countable resources in excess of the standard.  This is described in WAC 182-513-1350.
  7. The agency or its designee determines a client's total responsibility to pay toward the cost of care for LTC services as follows:
    1. For clients receiving HCS CN waiver services see WAC 182-515-1509;
    2. For clients receiving DDA CN waiver services see WAC 182-515-1514.
  8. HCB waiver clients who are "deemed eligible" for SSI benefits as described in WAC 182-512-0880 do not pay service participation toward their cost of personal care.  Clients living in a residential setting do pay room and board as described in WAC 182-515-1505 through 182-515-1509 or 182-515-1514.
  9. To be eligible for hospice services under the CN program, a client must:
    1. Meet the program requirements described in chapter 182-551 WAC  governing client eligibility for hospice care; and
    2. Be eligible for a noninstitutional CN program if not residing in a medical institution thirty days or more.
  10. A client who is not eligible for a noninstitutional CN program who needs hospice care is eligible for the WAH hospice program if they meet the following criteria:
    1. Meet the hospice program requirements described in chapter 182-551 WAC; and
    2. Reside at home and would be eligible for coverage by using home and community services waiver rules described in WAC 182-515-1505 through 182-515-1509  (SSI related clients with income over the effective one-person MNIL and gross income at or below the three hundred percent of the FBR or clients with a community spouse); or
    3. Receive WAH HCB waivers services in addition to hospice services.  The client's responsibility to pay toward the cost of care (participation) is applied to the waiver service provider first; or
    4. Be eligible for institutional CN if residing in a medical institution (including a hospice care center) for thirty days or more.
  11. To be eligible for hospice services under the MN program, a client must be:
    1. Eligible for the MN SSI-related program described in WAC 182-512-0150  for hospice clients residing in a home setting; or
    2. Eligible for the MN SSI-related program described in WAC 182-513-1305  for hospice clients not receiving HCB waiver services who reside in an alternate living facility.
    3. Be eligible for institutional MN if residing in a medical institution thirty days or more described in WAC 182-513-1395.  

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.

WAC 182-513-1319

WAC 182-513-1319

Effective January 1, 2014

WAC 182-513-1319 State-funded programs for noncitizen clients

Emergency WAC effective 1-1-2014

  1. This section describes the programs that are available for noncitizen clients who do not meet the citizenship criteria described in WAC 182-503-0530  to be eligible for federally funded Washington apple health (WAH) coverage.
  2. Lawfully residing noncitizen clients who need nursing facility care or care in an alternate living facility may receive long-term care (LTC) coverage if the client meets the eligibility and incapacity criteria of the medical care services (MCS) program described in WAC 182-508-0005.
  3. Clients who receive MCS coverage are not eligible for home and community based (HCB) waiver programs or hospice care.
  4. Noncitizen clients under the age of nineteen who are eligible for the WAH for kids program described in WAC 182-505-0210 are eligible for LTC services if the client is admitted to a medical institution for less than thirty days.  Once the client resides or is likely to reside in a medical institution for thirty days or more, the medicaid agency or its designee determines eligibility under WAC 182-514-0260, subject to being preapproved for coverage by aging and long-term supports administration (ALTSA) as described in WAC 182-507-0125
  5. Noncitizen clients age nineteen or older may be eligible for the state-funded long-term care services WAH program described in WAC 182-507-0125.  These clients must be preapproved by ALTSA as the program has enrollment limits.  When the program is full, a client who needs LTC services is place on a waiting list for services.  Such an individual is not eligible for WAH waiver programs described in chapter 182-515 WAC.

 

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



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 182-515-1508 ). 
  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 182-513-1340

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 182-513-1325 and WAC 182-513-1330, unless exceptional circumstances exist that include but are not limited to the following:
    1. When income is established as unavailable in an administrative hearing as described in chapter 182-526 WAC.   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 in WAC 182-513-1363182-513-1364  and 182-513-1365.

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

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.
  4. Persons who come to Washington solely for medical care in a nursing facility may be considered residents of Washington. They can even maintain a residence in another state if they hope to return. However if a person is placed in a nursing facility by another state, the person is considered a resident of the state that placed them. The department will not deny or terminate Medicaid eligibility for a Washington resident who is absent temporarily and will return. For example, a client who goes to a border facility for rehabilitation for 4 to 6 weeks and will return to Washington is not considered a resident of the border state and Washington will provide Medicaid benefits.

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.


NOTE:

The spenddown liability deduction is coded on the INST screen in ACES with notation in remarks. The determination of the MNIL/PNA is based on the information coded on the INST screen and DEM1 screen in ACES.


3. All allowable deductions are found in WAC 182-515-1509 for HCS CN Waivers, WAC 182-515-1514  for DDA CN Waivers and WAC 182-513-1380  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.


EXAMPLE

Single client onMedicaid MN program with base period 1/01/06-3/06. Spenddown was met in February and case was certified effective 2/1/06. Client has monthly income of $848 per month. He enters the nursing home from home on 3/5/06.

His MN spenddown was computed as follows:

$848.00

monthly income

-$20.00

 

-721.00

MNIL

$107.00

per month available for spenddown use as a deduction.

Nursing Home Participation for 3/06 is computed as follows:

$848.00

monthly income

-721.00

MNIL

-$107.00

spenddown liability

$20.00

participation to the nursing facility.

The spenddown base period ended in March. This deduction can only be used through the last month of the original MN base period.

For current MNIL standards, see LTC standard chart


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 182-513-1320 but meet the functional eligibility requirement and are eligible for Medicaid.

Inpatient Mental Health and DDA institutional admissions (ICF-ID and RHC)

  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 DDA LTC speciality unit  or CSD IMD financial staff 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 DDA LTC speciality unit or CSD IMD financial staff. Facility staff make referrals as appropriate to the division of disability determination (DDDS) staff. 

  3. When written notification of admission from the facility is received, document whether the client intends to return home upon discharge.

  4. 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.

  5. 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 to an institutional (L-track)  coverage group and living arrangement. Determine eligibility for all program benefits as appropriate upon the client’s discharge from the facility.

  6. 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.

  7. Follow necessary supplemental accommodation (NSA) procedures.   


WORKER RESPONSIBILITIES

  1. See Application processes for LTC services

  2. Follow rules for  Washington Apple Health (WAH) Eligibility requirements:

    1. Chapter 182-503 WAC describes:

      1. How to Apply

      2. Who can apply

      3. Interview requirements

      4. Verification requirements

      5. Application processing times

      6. When coverage begins

      7. Application denials and withdrawals

      8. Exceptions to rule

      9. Rights and responsibilities

      10. Limited English proficient (LEP) services

      11. Equal Access Services

      12. General eligibility requirements

      13. Program Summary

      14. Social Security number requirements

      15. Residency requirements-Persons who are not residing in an institution

      16. Residency requirements for an institutionalized person

      17. Citizenship and alien status- Definitions

      18. Assignment of rights and cooperation

      19. Age requirements for medical programs based on modified adjusted gross income (MAGI)

    2. Chapter 182-504 WAC describes:

      1. Retroactive certification period

      2. Certification periods for categorically needy (CN) programs

      3. Certification periods for noninstitutional medically needy (MN) programs

      4. Medicare Savings Programs certification periods

      5. Renewals

      6. Changes that must be reported

      7. When to report changes

      8. Effective dates of changes

      9. Effect of reported changes

      10. Continued coverage pending an appeal

      11. Monthly income standards based on the federal poverty level (FPL)

  3. Follow rules in Chapter 182-506 WAC regarding assistance units

  4. Follow rules in Chapter 182-507 WAC for state funded LTC for non citizens and AEM

  5. Follow rules in Chapter 182-508 WAC for Medicare Care Services (MCS) state funded medical

  6. Follow rules in Chapter 182-510 for SSI medical

  7. Follow rules in Chapter 182-511 for SSI related Healthcare for Workers with Disabilities (HWD).

  8. Follow rules in Chapter 182-512 for SSI related medical

  9. 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 ADS services in a nursing facility or state funded residential, refer to the CSO disability specialist for a determination of ABD cash if potentially eligible for ABD cash.  If not eligible for ABD cash, because of the duration requirement, open on G01 MCS which includes a referral for HEN.

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

  11. 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).

  12. 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.

  13. 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. 

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

  15. 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.

  16. 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.    

  17. Admissions under 30 days into a medical facility is considered a short stay


ACES PROCEDURES

Long Term Care and Waiver Services - Interview

Long Term Care, Alternate Care and Waiver Services

Modification Date: September 8, 2014