WAC 388-513-1315

Effective April 10, 2009

WAC 388-513-1315 Eligibility for long-term care (institutional, waiver, and hospice) services

This section describes how the department determines a client's eligibility for medical for clients residing in a medical institution, on a waiver, or receiving hospice services under the categorically needy (CN) or medically needy (MN) programs. Also described are the eligibility requirements for these services under the general assistance (GA) program in subsection (12) and the alien emergency medical programs described in subsection (11).

  1. To be eligible for long-term care (LTC) services described in this section, a client must:

    1. Meet the general eligibility requirements for medical programs described in WAC 388-503-0505 (2) and (3) (a) through (f);

    2. Attain institutional status as described in WAC 388-513-1320;

    3. Meet functional eligibility described in WAC 388-106  for waiver and nursing facility coverage; and

    4. Not be subject to a penalty period of ineligibility as described in WAC 388-513-1363, WAC 388-513-1364, WAC 388-513-1365 and WAC 388-513-1366.

    5. Not have equity interest greater than five hundred thousand dollars in their primary residence as described in WAC 388-513-1350; and

    6. Must disclose to the state any interest the applicant or spouse has in an annuity and meet annuity requirements described in chapter 388-561  WAC.

      1. This is required for all institutional or waiver services and includes those individuals receiving supplemental security income (SSI).

      2. A signed and completed eligibility review for long term care benefits or application for benefits form can be accepted for SSI individuals applying for long-term care services.

  2. To be eligible for institutional, waiver, or hospice services under the CN program, a client must either:

    1. Be related to the Supplemental Security Income (SSI) program as described in WAC 388-475-0050(1), (2) and (3) or and meet the following financial requirements by having:

      1. Gross nonexcluded income described in subsection (8)(a) that does not exceed the special income level  (SIL); and

      2. Countable resources described in subsection (7) that do not exceed the resource standard described in WAC 388-513-1350; or

    2. Be approved and receiving the general assistance expedited Medicaid disability (GA-X) or general assistance aged (GA-A) or general assistance disabled (GA-D) described in WAC 388-505-0110(6); or

    3. Be eligible for the CN apple health for kids described in WAC 388-505-0210; or CN family medical described in WAC 388-505-0220; or family and children's institutional medical described in WAC 388-505-0230 through 388-505-0260.  Clients not meeting the citizenship requirements for federally funded medicaid described in WAC 388-424-0010  are not eligible to receive waiver services;  or

    4. Be eligible for the temporary assistance for needy families (TANF) program as described in WAC 388-400-0005. Clients not meeting disability criteria described in WAC 388-475-0050  are not eligible for waiver services.

  3. The department allows a client to have countable resources in excess of the standard described in WAC 388-513-1350 when meeting the conditions of reducing excess resources described in WAC 388-513-1350.

  4. To be eligible for waiver services, a client must also meet the program requirements described in:

    1. WAC 388-515-1505 through 388-515-1509   for COPES, New Freedom PACE, and WMIP services; or

    2. WAC 388-515-1510 through 388-515-1514  for DDD waivers; or

    3. WAC 388-515-1540 for the medically needy residential Waiver (MNRW); or

    4. WAC 388-515-1550 for the medically needy in-home waiver (MNIW).

  5. To be eligible for hospice services under the CN program, a client must:

    1. Meet the program requirements described in WAC 388-551 client eligibility for Hospice care; and

    2. Be eligible for a non institutional categorically needy program (CN-P) if not residing in a medical institution thirty days or more; or

    3. Reside at home and benefit by using home and community waiver rules described inWAC 388-515-1505  through 388-515-1509 (SSI related clients with income over the MNIL  and at or below the 300 percent of the FBR or clients with a community spouse); or

    4. Receive Home and Community Waiver (HCS) or DDD Waiver 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

    5. Be eligible for institutional CN if residing in a medical institution 30 days or more.

  6. To be eligible for institutional or hospice services under the MN program, a client must be:

    1. Eligible for MN children's medical program described in WAC 388-505-0210, 388-505-0255 or 388-505-0260; or

    2. Related to the SSI program as described in WAC 388-475-0050  and meet all requirements described in WAC 388-513-1395; or

    3. Eligible for the MN SSI related program described in WAC 388-475-0150 for Hospice clients residing in a home setting; or

    4. Eligible for the MN SSI related program described in WAC 388-513-1305 for Hospice clients not on a medically needy waiver and residing in an alternate living facility.

    5. Be eligible for institutional MN if residing in a medical institution 30 days or more described in WAC 388-513-1395.

  7. To determine resource eligibility for an SSI-related client under the CN or MN program, the department:

    1. Considers resource eligibility and standards described in WAC 388-513-1350;

    2. Evaluates the transfer of asset as described in WAC 388-513-1363, 388-513-1364, 388-513-1365 and 388-513-1366.

  8. To determine income eligibility for an SSI-related client under the CN or MN program, the department:

    1. Considers income available as described in WAC 388-513-1325 and WAC 388-513-1330;

    2. Excludes income for CN and MN programs as described in WAC 388-513-1340;

    3. Disregards income for the MN program as described in WAC 388-513-1345; and

    4. Follows program rules for the MN program as described in WAC 388-513-1395.

  9. A client who meets the requirements of the CN program is approved for a period of up to twelve months.

  10. A client who meets the requirements of the MN program is approved for a period of months described in WAC 388-513-1395 (6) for:

    1. Institutional services in a medical institution; or

    2. Hospice services in a medical institution .

  11. The department determines eligibility for nursing facility and Hospice services under the alien emergency medical (AEM) program described in WAC 388-438-0110 for a client age nineteen or over who meets all other requirements for such services but does not meet citizenship requirements. Nursing facility and Hospice services under the AEM program must be pre approved by the department's medical consultant.

  12. The department determines eligibility for institutional services under the GA program described in WAC 388-448-0001 for a client who meets all other requirements for such services but is not eligible for programs described in subsections (9) through (11).

  13. 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 388-513-1320; 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 the client has not yet reached age twenty-two; or

    4. Is at least sixty-five years old.

  14. The department 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.

  15. If an individual under age twenty one is not eligible for medicaid under SSI related in WAC 388-475-0050 or general assistance (GA) described in WAC 388-448-0001 and 388-505-0110(6) consider eligibility under WAC 388-505-0255 or 388-505-0260.

  16. Noncitizen individuals under age nineteen can be considered for the apple health for kids program described in WAC 388-505-0210 if they are admitted to a medical institution for less than thirty days.  Once an individual resides or is likely to reside in a medical institution for thirty days or more, the department determines eligibility under WAC 388-505-0260.

  17. The department determines a client's total responsibility to pay toward the cost of care for LTC services as follows: 

    1. For SSI-related clients residing in a medical institution see WAC 388-513-1380;

    2. For clients receiving HCS CN waiver services see WAC 388-515-1509;

    3. For clients receiving DDD CN waiver services see WAC 388-515-1514;

    4. For clients receiving HCS MN waiver services see WAC 388-515-1540 or 388-515-1550; or

    5. For TANF related clients residing in a medical institution see WAC 388-505-0265.

  18. Clients not living in a medical institution who are considered to be receiving SSI benefits for the purposes of Medicaid do not pay service participation toward their cost of care. Clients living in a residential setting do pay room and board as described in WAC 388-515-1505. through 388-515-1509 or WAC 388-515-1514. Groups deemed to be receiving SSI and for Medicaid purposes are eligible to receive CN-P Medicaid. These groups are described in WAC 388-475-0880.  

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.