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Revised March 17, 2014


Long-term care


Purpose: This section describes resource eligibility for institutional medicaid programs including HCBS Waiver programs.

WAC 182-513-1350Defining the resource standard and determining resource eligibility for long-term care (LTC) services

WAC 182-513-1350

WAC 182-513-1350

Effective January 1, 2013

WAC 182-513-1350 Defining the resource standard and determining resource eligibility for long-term care (LTC) services

Emergency WAC effective 1-1-2014

This section describes how the department defines the resource standards  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.

  1. The resource standard used to determine eligibility for LTC services equals:
    1. Two thousand dollars for
      1. A single client; or
      2. A legally married client with a community spouse, subject to the provisions described in subsections (9) through (12) of this section; or
    2. Three thousand dollars for a legally married couple, unless subsection (4) of this section applies.
  2. Effective January 1, 2012 if an individual purchases a qualified long-term care partnership policy approved by the Washington Insurance Commissioner under the Washington long- term care partnership program, the department allows the individual with the long-term care partnership policy to retain a higher resource amount based on the dollar amount paid out by a partnership policy. This is described in WAC 182-513-1400.
  3. 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.
  4. 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.
  5. 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 subsection (1)(b) of this section for a couple.
  6. When a single institutionalized individual marries, the department will redetermine eligibility applying the rules for a legally married couple.
  7. The department applies the following rules when determining available resources for LTC services:
    1. WAC 182-512-0300, Resource eligibility;
    2. WAC182-512-0250, How to determine who owns a resource; and
    3. WAC 182-512-0260, Resources of an alien's sponsor.
  8. For LTC services the department determines a client's non-excluded resources as follows:
    1. The department determines countable resources for SSI-related clients as described in chapter 182-512 WAC and resources excluded by federal law with the exception of
      1. WAC 182-512-0550 pension funds owned by an
        1. Ineligible spouse. Pension funds are defined as fund held in an individual retirement account (IRA) as described by the IRS code; or
        2. Work-related pension plan (including plans for self-employed individuals, known as Keogh plans).
      2. WAC 182-512-0350 (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 182-513-1367.  Effective January 1, 2011, the excess home equity limits will increase to five hundred six thousand dollars.  On January 1, 2012 and on January 1 of each year thereafter, this standard may be increased or decreased by the the percentage increased or decreased in the consumer price index-urban (CPIU). For current excess home equity standard starting January 1, 2011 and each year thereafter see http://www.hca.wa.gov/medicaid/Eligibility/Pages/index.aspx
    2. 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
      1. For an SSI-related client with a community spouse, the value of one automobile is excluded regardless of its use or value.
      2. 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.
    3. For a SSI-related client, the department adds together the countable resources of both spouses if subsections (3), (6) and (9)(a) or (b) of this section apply, but not if subsection (4) or (5) of this section apply.
    4. For an SSI-related client, excess resources are reduced
      1. In an amount equal to incurred medical expenses such as
        1. Premiums, deductibles, and co-insurance/co-payment charges for health insurance and Medicare premiums;
        2. Medically necessary care recognized under state law, but not covered under the state's Medicaid plan;
        3. Medically necessary care covered under the state's Medicaid plan incurred prior to Medicaid eligibility. Expenses for nursing facility care are reduced at the state rate for the facility that the client owes the expense to.
      2. As long as the incurred medical expenses
        1. Were not incurred more than three months before the month of medicaid applications;
        2. Are not subject to third-party payment or reimbursement;
        3. Have not been used to satisfy a previous spend down liability;
        4. Have not previously been used to reduce excess resources;
        5. Have not been used to reduce client responsibility toward cost of care;
        6. Were not incurred during a transfer of asset penalty described in WAC 182-513-1363, 182-513-1364, and   182-513-1365; and
        7. Are amounts for which the client remains liable.
    5. Expenses not allowed to reduce excess resources or participation in personal care are
      1. Unpaid expense(s) prior to Waiver eligibility to an adult family home (AFH) or assisted living facility is not a medical expense.
      2. Personal care cost in excess of approved hours determined by the CARE assessment described in 106 WAC  is not a medical expense.
    6. The amount of excess resources is limited to the following amounts
      1. For LTC services provided under the categorically needy (CN) program
        1. Gross income must be at or below the special income level (SIL) 300% of the federal benefit rate( FBR).
        2. In a medical institution excess resources and income must be under the state Medicaid rate based on the number of days in the medical institution in the month.
        3. 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.
      2. For LTC services provided under the medically needy (MN) program when excess resources are added to countable income, the combined total is less than the
        1. State medical institution rate based on the number of days in the medical institution in the month, plus the amount of recurring medical expenses; or
        2. State hospice rate based on the number of days in the medical institution in the month, plus the amount of recurring medical expenses; in a medical institution.
        3. 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.
    7. For a client not related to SSI, the department applies the resource rules of the program used to relate the client to medical eligibility.
  9. 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:
    1. Before October 1, 1989, the department adds together one-half the total amount of countable resources held in the name of
      1. The institutionalized spouse; or
      2. Both spouses.
    2. On or after October 1, 1989, the department adds together the total amount of non-excluded resources held in the name of
      1. Either spouse; or
      2. Both spouses.
  10. If subsection (9)(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:
    1. 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 may change 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.hca.wa.gov/medicaid/Eligibility/Pages/index.aspx ; or 
    2. If the client's current period of institutional status began on or after August 1, 2003, the department allocates the greater of
      1. A spousal share equal to one-half of the couple's combined countable resources as of the first day of the month of the current period of institutional status, up to the amount described in subsection (10)(a) of this section; or
      2. 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.
    3. Resources are verified on the first moment of the first day of the month institutionalization began as described in WAC 182-512-0300 (1).
  11. The amount of the spousal share described in subsection (10)(b)(i) of this section 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:
    1. 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
    2. 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.
  12. The amount of allocated resources described in subsection (10) of this section can be increased, only if:
    1. A court transfers additional resources to the community spouse; or
    2. An administrative law judge establishes in an administrative hearing described in chapter 182-526 WAC, that the amount is inadequate to provide a minimum monthly maintenance needs amount for the community spouse.
  13. The department considers resources of the community spouse unavailable to the institutionalized spouse the month after eligibility for LTC services is established, unless subsection (6) or (14)(a), (b), or (c) of this section applies.
  14. A redetermination of the couple's resources as described in subsection (8) of this section is required, if:
    1. The institutionalized spouse has a break of at least thirty consecutive days in a period of institutional status;
    2. The institutionalized spouse's countable resources exceed the standard described in subsection (1)(a) of this section, if subsection (9)(b) applies; or
    3. The institutionalized spouse does not transfer the amount described in subsections (10) or (12) of this section to the community spouse by either
      1. The end of the month of the first regularly scheduled eligibility review; or
      2. The reasonable amount of additional time necessary to obtain a court order for the support of the community spouse.

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

SSI related medical resources describes how the department defines resources, determines ownership and availability of resources, property and contracts, vehicles, life insurance, burial funds and other excluded resources.

Resource eligibility  and excess resource eligibility specific to long-term care is described in WAC 182-513-1350. 

Institutional resource standards 

The client must be resource eligible on the first day of the month to be eligible for any day or days of that month. A resource determination is made on the first moment of the first day of the month. Changes in the amount of a client's countable resources during a month do not affect eligibility or ineligibility for that month.  WAC 182-512-0300 (1)

Senior Bulletin: Bank accounts and SSI or Medicaid


Excess Resources

182-513-1350   (8) (d) (e) and (f)

Excess resources for any historical month will first be reduced by qualifying medical expenses coded on the LTCX screen.  Then, for clients in a medical institution, any remaining excess resources will be applied to the client's participation.  If the client's resources cannot be reduced to the program limit through this process, the assistance unit will be terminated or denied.  The remaining excess resources do not carry forward for use in any months beyond the months in which they are entered.

Excess Resources will not be reduced by medical expenses or applied to the client's participation in any month beyond the current calendar month.  When excess resources exist in any benefit month beyond the current calendar month, the assistance unit will be terminated or denied.

The following long term care expense types are considered incurred medical expenses and will be used to reduce excess resources in this order:

 

·         UB – OUTSTANDING NURSING HOME BILL

·         UO – Old Medical Bill

·         UA – Adult Day Health

·         UM – Medical Necessity MA Not Covered

·         UH – Hearing Aids

·         OH – Health Insurance

·         UD – Prescription Expenses Not Covered By Medicare Part D

·         OP – Medicare Part D Co-Payments

·         OL – LTC Insurance

·         OD – Medicare Part D Premiums

·         OC – Medicare Part C Premiums

·         OB – Medicare Part B Premiums

·         OA – Medicare Part A Premiums

 

Multiple expenses of the same type are deducted in order of highest amount to lowest amount. 

All other expense types are not considered medical expenses and can't be used to reduce excess resources.

 

Excess Resources and Medical Institutions

 

ACES will compare the client's income plus excess resources to the cost of care

  • In a full calendar month it will use the state daily rate x 30.42
  • In a partial month, it will use the state daily rate x the actual number of days

If the income plus the remaining excess resources is not more than the cost of care, the case will open and assign the excess.

If the income plus remaining income is more than the cost of care, the case will deny. 

 

Income only determines CN versus MN.  Excess resources do not affect the scope of care the individual is eligible to receive. 

 

If excess resources causes a case to go into L99 spenddown, the case needs to be denied. 

 

Excess Resources and HCB Waiver (COPES)

For CN Waiver eligibility, incurred medical expenses must reduce resources within the allowable resource limits for CN-Waiver eligibility.  The cost of care for waiver services cannot be allowed as a projected expense. 

  • If medical expenses do not reduce the excess to the applicable resource standard, the case will deny.
  • If medical expenses do reduce the excess to the applicable resource standard, the case will open. 

Set a barcode tickler to check resource eligibility on the first of the month when appropriate. 

Excess Resources in the application month

  •  Ensure the excess is in the first month of eligibility only
  • Adjust the resource amount in the remaining processing months to the applicable standard
  • ACES will deny if excess is coded in the ongoing month. 

Active Cases

  •  A review does not need to be initiated
  • Update the resource information in the current or historical month
  • Case will process as described

Short stays-Medical Institution

  • Excess will not be assigned to the cost of care for days coded on the STAY screen
  • Excess will be applied if the facility is coded using INST

Burial Fund

A client may also reduce excess resources by 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.  See SSI related rules regarding burial funds


Assignment of excess resources when Medicare pays 100%

A client is not eligible if they have excess resources that must be assigned toward cost of care (medical institution) when there is no obligation to pay the facility for that month because Medicare or another TPL source is covering 100% of the cost. Deny eligibility for that month as there isn't a cost of care the client is obligated to pay. Consider eligibility for the following month.

This is only for issues where the client has excess resources and other coverage. If the client doesn't have excess resources, Medicare or other TPL coverage does not affect eligibility.

For months where there is other coverage for only a part of a month, eligibility with excess resources will be based on the coast for the number of days the client is obligated to pay, similar to a partial month with excess resources:

  • If the assigned excess plus income is greater than the cost for the number of days of client obligation, the client isn't eligible.
  • If the assigned excess plus income is no greater than the cost for the number of days of client obligation, the client is eligible and must pay the excess toward care.
  • Code the date the client starts having an obligation to pay as the payment authorization date.

EXAMPLE

Example #1:  Excess, not eligible:

Arlo is single and his monthly income is $2,000. On 2/1 his resources were $2500 after reducing for out of pocket medical expenses. He admits to the nursing home under Medicare on 2/19 and applies for Medicaid. Medicare is paying the cost at $100%. Because he has no obligation toward his cost of care, his excess resources cannot be assigned to an actual medical obligation. He is not resource eligible . Deny February for being over resources and consider eligibility for March.


EXAMPLE

Example #2. Excess, is eligible:

Milly is single and her monthly income is $2,000. On 2/1 her resources were $2,000 after reducing for out of pocket medical expenses. She enters the nursing home under Medicare on 2/19 and applies for Medicaid. Medicare is paying the cost at 100%. She is eligible because her resources do not need to be assigned toward the cost of care.


Active cases and excess resources

If excess resources were assigned but never paid and the client is still over resources in a subsequent month, you cannot assign the same excess again. The only alternative is to terminate the case.

  • Determine if the excess is the same funds previously assigned
  • If it is the same funds, do not assign them again
  • Find out if they have paid but it is not yet reflected in the accounts by discussing with the institution bookkeeper
  • If it has not been paid, advise the client they are not eligible as their eligibility was contingent upon them paying that excess toward care
  • Determine if/when they are going to pay it and follow up
  • If client fails to pay it after allowing a reasonable time (10 days) propose termination

Advise HQ there is a situation where an active medical institution case starts receiving Medicare coverage at 100% (nursing home readmit after a hospital stay) AND has excess resources. This will be very rare and most likely will be an overpayment.


Annuities, Trusts and Life Estates

SeeTRUSTS,ANNUITIES and LIFE ESTATES for information on how annuities, trusts and life estates affect SSI related and LTC eligibility.  

Definitions related to trusts, annuities and life estates.

Use the Individual 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.


Reverse mortgage, Promissory Notes and Loans

Reverse mortgage, Promissory Notes and Loans


Vehicles

WAC 182-513-1350  (8) (b) states:

  1. 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.
    1. For an SSI-related client with a community spouse, the value of one automobile is excluded regardless of its use or value.
    2. 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.

What this means is 1 vehicle is excluded for SSI related programs if used for transportation.  For institutional programs with a community spouse a vehicle is excluded regardless of it's use.   

This does not mean there are 2 vehicle exclusions for institutional medicaid. 

Example #1. Single client in a nursing home has a vehicle that is not being used to transport the client.  In this example the vehicle is not excluded as it is not used to transport the client.

Example #2. Married client in a nursing home.  Community spouse cannot drive.  The vehicle is still excluded because the value of one automobile is excluded regardless of use.  

The exclusion for SSI-related individuals with a community spouse supersedes the exclusion for an SSI related individual being transported described in WAC 182-512-0400 (2).  You cannot get both exclusions.  There is 1 vehicle exclusion for institutional SSI related medical. 

 


Patient trust account

  1. A client can establish a patient trust account in a nursing facility, if the client is not capable of handling personal funds or has requested in writing that one be established.
  2. The Nursing Facility is required to:
    1. Maintain an interest bearing account for balances above $49.99
    2. Keep a ledger of the trust account balance of each client
    3. Notify the HCS/CSO FSS when the trust account is close to the resource standard
  3. If 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.  If the client leaves and his/her whereabouts are unknown, the facility sends these funds  to the Department of Revenue.

Home as an excluded resource

WAC 182-513-1350

The client's home with equity less than $500,000 is an excluded resources.  This includes the land on which the dwelling is located and all contiguous property and related out buildings in which the client has ownership interest, when:

  1. The client uses the home as his or her primary residence; or
  2. The client's spouse lives in the home; or
  3. The client does not currently live in the home but the client or his/her representative has stated the client intends to return to the home

When the home cannot be excluded the client must make a reasonable attempt to convert the property to an available resource.  Providing one of the following does this:

  1. Current real estate listing
  2. Advertisement showing property is for sale
  3. Other verification to show reasonable effort to sell the property.

Excess Home Equity is an eligibility factor for payment of long-term care services

Excess home equity value over the excess home equity standard is a provision specific to long-term care services.  If an individual has excess home equity, there is no eligibility for payment of long-term care services. 

 

See: Excess home equity


Primary Residence Placed into a Trust

  • Once placed into a trust, the primary residence cannot be excluded.
  • Count as you would any other trust asset.
    • If the trust is excluded, then the house is excluded
    • If the trust is not excluded, then the equity is counted as a resource unless it is in a portion of the trust that cannot be disbursed.  Then it is a resource transfer.  Allow the client or representative to remove the house from the trust:
      • If the beneficiary lives in the house
      • If the beneficiary is a Medicaid recipient and intends to return home; or
      • When the beneficiary's spouse or minor/disabled child reside in the house
    • If the home remains in the trust it can be considered unavailable if the client or representative take all necessary actions to make it available by listing it for sale and taking the first reasonable offer.  When granting conditional eligibility, the first reasonable officer is 2/3 the value. 

Trusts

Transfer of an asset


Resources of a married couple

  1. 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.
    1. 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.
    2. If the current period of institutional status began on or after October 1, 1989, the spousal impoverishment 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
    3. 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.
    4. The amount of allocation allowed, based on the appropriate set of rules, can be increased only as described in WAC 182-513-1350  : 
      1. Pursuant to a court order for spousal support
      2. 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.
    5. 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.
    6. 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.
    7. 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:
      1. The client or community spouse requests an evaluation of their community resources; and
      2. 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
  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.
    1. HCS Community Resource Declaration: The HCS Community Resource Declaration form has been developed for clients to use when requesting an evaluation. The DSHS 14-501 Community Resource Declaration is available on the DSHS forms website. 
    2.  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.
      1. Request for Verification  - This letter is sent to request resource verification. Allow 10 days for the client or spouse to provide the information.
      2. 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.
      3. 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.
      4. 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:
        1. The current period of institutional status began prior to 8/1/03
        2. 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  
    3. 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.
    4. Resources of a married coupleboth 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.

WORKER RESPONSIBILITIES-Resources of a Couple

When the current period of institutional status began before October 1, 1989:
  1. Consider resources in both spouses’ names as community resources (jointly owned).

  2. 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.

  3. 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.

When the current period of institutional status began on or after October 1, 1989:

  1. 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.

  2. Allocate non-excluded community resources to the community spouse up to:

    1. The maximum amount if the client’s institutional status onset was before 8/1/03;

    2. 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

    3. An amount ordered by the court or ALJ

  3. Count the remaining resources toward the Medicaid resource standard for one person.

    1. If below the standard, the institutionalized spouse is resource eligible

    2. 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

  4. 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.

  5. 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.

  6. When completing the first eligibility review, determine if the resources have been transferred to the community spouse.

    1. If the transfer has been completed, the institutionalized spouse remains eligible.

    2. 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. 

    3. If legal proceedings are under way, tickle the case to review the status of the resources based on the expected date of transfer.

  7. 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.

  8. 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.

  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 following guidelines when completing an evaluation of the community resources when the client becomes institutionalized on or after 8/1/03:
  1. Resource evaluations can be completed prior to the application or at the same time as the application.
  2. 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).
  3. Determine the value of the community resources as of the first day of the month that institutionalization began.

  4. Obtain verification of the resource values. Allow 10 days for a response.

  5. 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.

  6. 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.

  7. 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.

  8. 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.

  9. 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.

  10. 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.

  11. When processing the long term care application, if the client does not provide verification of resources to determine the spousal share:

    1. Use the state spousal resource standard to determine eligibility;

    2. Do not deny the application for failure to provide this information; and

    3. 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.


EXAMPLE

#1

A married client applies for nursing home care on 8/15/03.  The client first entered the hospital on 7/2/03 and discharged to the nursing home on 8/14/03.  Because the client became institutionalized before 8/1/03, use the Federal Community Spouse Resource Allocation maiximum standard.


EXAMPLE

#2

A married client applies for LTC on 3/15/04.  The client first became institutionalized 8/1/03 and has remained institutionalized without a break.  Because the client first became institutionalized on or after 5/1/03, use the State Spousal Resource Standard of $40,000 for the time period 8/1/03 through 6/30/05. (Effecitive July 1, 2013 State Spousal Resource shared increase to $53,016.) unless the client or the client's spouse requests an evaluation of the community resources.

If the client or the client's spouse requests an evaluation of the community resources, determine the amount of the spousal share as of the first day of the month the client became institutionalized.

The client and spouse had a total of $90,000 of non-excluded resources on 8/01/03 (the first day of the month that the client became institutionalized) One-half of the total was $45,000. This is the spousal share. For this client we would use the spousal share of $45,000 as the Community Spouse Resource allocation because it is higher than the State Spousal Resource Standard and less than the Federal Community Spouse Resource Allocation maximum

The most we can allow is the Federal Community Spouse Resource Allocation maximum.  As of 8/1/03 $90,660.  If we evaluated the couple's resources and found they had a total of $200,000 in non-excluded resources as of 8/1/03, then we would use the Federal Community Spouse Allocation maximum in place at the time of application. This is because the spousal share of $100,000 is greater than both the State Spousal Resource Allocation standard and the Federal Community Resource Allocation maximum. 


ACES PROCEDURES

See Interview - (LTC) screens

       Resources-ACES including resource transfer

 

Modification Date: March 17, 2014