Eligibility Requirements
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Eligibility Requirements

Revised October 28, 2007

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

WAC 388-513-1315

WAC 388-513-1315

Effective October 20, 2007

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 institutional, waiver, or hospice services under the categorically needy (CN) program and institutional or hospice services in a medical institution under the medically needy (MN) program. 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.

  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(1), unless subsection (4) applies; or

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

    3. Be eligible for the CN children's medical program as described in WAC 388-505-0230; or

    4. Be eligible for the temporary assistance for needy families (TANF) program as described in WAC 388-505-0220.

  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 for COPES, New Freedom PACE, MMIP and WMIP services; or

    2. WAC 388-515-1510 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  (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. Reside in a state contracted and licensed alternate living facility and not on Waiver services and receives medical assistance described in WAC 388-513-1305 as they are paying the facility privately.

    6. Be eligible for institutional CN if residing in a medical institution 30 days or more. (Use institutional rules for eligibility when in a medical institutional 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 388-505-0230; or

    2. Related to the SSI program as described in WAC 388-475-0050(1) 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 (Use institutional rules for eligibility when in a medical institution 30 days or more).

  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 for: 

    1. Institutional services in a medical facility;

    2. Waiver services at home or in an alternate living facility; or

    3. Hospice services at home or in a medical facility. 

  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 facility; or

    2. Hospice services in a medical facility.

  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 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 less than twenty-one years old at application and approval; 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. The department considers the parents’ income and resources available as described in WAC 388-408-0055 (1) (c) for a minor who is less than eighteen years old and is receiving or is expected to receive inpatient chemical dependency and/or inpatient mental health treatment.

  16. The department considers the parents’ income and resources available only as contributed for a client who is less than twenty-one years old and has attained institutional status as described in WAC 388-513-1320.

  17. The department determines a client's participation in the cost of care for LTC services as described in WAC 388-513-1380 and WAC 388-515-1505 for long-term care services under COPES, New Freedom, PACE, MMIP and WMIP or WAC 388-515-1510 for DDD Waivers.

  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. 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.

CLARIFYING INFORMATION

  1. 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.

    2. The SIL  is equal to 300% of the annually adjusted SSI Federal Benefit Rate.

    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 388-513-1340. 

    4. Income disregards not allowed before doing the SIL comparison are the $20 disregard and 65 and 1/2 earned income deduction.

    5. The SIL is the maximum amount allowed by law as the CN income standard.

    6. The current SIL amount can be found on the institutional standards chart.

  2. 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. 

    1. 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.

    2. The department considers all of a client’s income to be available as described in WAC 388-513-1325 and WAC 388-513-1330, unless exceptional circumstances exist that include but are not limited to the following:

      1. When income is established as unavailable in a fair hearing as described in chapter 388-02 WAC .

      2. 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.

    3. 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 inWAC 388-513-1363, 388-513-1364  and  388-513-1365.

    4. If a period of ineligibility is required, the department uses only the value of the resource to determine the penalty period of ineligibility.

    5. If a period of ineligibility has been established, a client has a right to request a hardship waiver. 

  3. Private payments to facilities:

    1. The department does not count private payments in the form of a deposit or as part of a contract when determining a client’s eligibility.

    2. If eligibility is established for the period of time for which such payment was made, the facility must refund the amount that exceeds the client’s participation in the cost of care. The facility then bills the department and accepts payment as payment in full.

    3. If the refund belongs to the client and adding the payment amount to non-excluded resources results in an excess of the resource standard, the department uses it to establish the client’s spenddown liability as described in WAC 388-513-1395.

    4. The department does not count private payments made by relatives or others for amenities not provided by the facility when determining eligibility or participation in the cost of care. The definition of income as described in                            WAC 388-513-1325 and WAC 388-513-1330  does not include such payments.

  1. LTC/Private Insurance: 

    1. The department does not count LTC insurance payments when determining income eligibility or participation in the cost of care. LTC insurance is considered a third party resource. 

    2. The department refunds any amount to the client for whom it receives reimbursement as a third party payment when the payment exceeds what the department has paid for LTC services.

    3. The remaining portion of the refund becomes a resource the first of the month following the month of receipt.   

    4. Spenddown rules apply if addition of the refund results in an amount that exceeds the resource standard.

  2. 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. 

  3. Involuntary Treatment Act (ITA):  Under the ITA, clients of any age can be placed into certain institutions for mental diseases (IMD). No face to face interview is required when determining eligibility.

  4. 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.

  5. 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.
  6. 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.

  7. 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.

  8. Medicare payment for NF cost of care: 

    1. Medicare pays the full cost of care for NF services for up to 20 days per benefit period and partial costs for the remainder of 100 days when the client meets Medicare requirements. 

    2. If the client enters the NF under Medicare coverage, the department determines eligibility and participation the same as for any other institutionalized client. 

    3. The department considers any unused participation a resource if the client still has it on the first of the next month.

WORKER RESPONSIBILITIES

  1. See CITIZENSHIP/ALIEN STATUS, RESIDENCY, and SSN to determine whether a client meets the general eligibility requirements.

  2. Determine the program to which the client can be related to medical eligibility. See ADULT MEDICAL, FAMILY MEDICAL PROGRAMS, and INCAPACITY.

  3. See INCOME and RESOURCES to determine the program to which the client can be related to medical eligibility.

  4. For a client whose eligibility is established under the alien emergency medical (AEM), see WAC 388-438-0110.  The Alien medical (AEM) program including clarifying information  describing pre-approval of nursing home services. 

    1. Redetermine eligibility every three months.

    2. Do not limit eligibility to three months in a calendar year.

  5. For a client whose eligibility is established under the general assistance (GA) program:

    1. Waive the progressive evaluation process (PEP) for a client who meets program requirements described in WAC 388-448-0001;


NOTE: To be eligible for waiver services, a GA client must be approved for the GA expedited Medicaid disability (GAX) program.

  1. Determine whether the client should be referred to the CSO SSI facilitator
  2. (SSIF) for a determination of eligibility for the GAX program
  3. Include a copy of the comprehensive assessment (CA) when submitting other information as described in the INCAPACITY category to the SSIF.

  1. For a client with a potential long-term disability who is not eligible for GA, submit a request to the division of disability determination services (DDDS) as described in the ADULT MEDICAL – SSI-Related Medical section and include a copy of the CA.

  2. See WAC 388-513-1350  to establish a client’s resource eligibility. Institutional standards.

  3. See WAC 388-513-1325, WAC 388-513-1330, WAC 388-513-1340, and WAC 388-513-1345 to establish a client’s income eligibility. Refer also to WAC 388-506-0620  and the ADULT MEDICAL – SSI-related Medical section for a client who is married.

  4. 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.

  5. If notice is received that a client no longer needs care provided in a medical facility, redetermine eligibility for other medical programs. CN-P Medicaid is continued during the redetermination process. 

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

  7. A DSHS 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 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. For offices not in the DMS system, submit the 14-194 Medical Coverage form to the Coordination of Benefits (COB) Section of H.R.S.A at MS 45561. Link to DSHS 14-194 and instructions: http://www1.dshs.wa.gov/word/ms/forms/14_194.doc

     

    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.  If the TPL insurance payment is equal to or more than the Medicaid rate, the total participation must be refunded to the client for the months paid by the TPL party.  If the TPL insurance is less than the Medicaid rate, the NF can only collect participation up to the Medicaid rate as the total payment.  If the total of the

    insurance payment and the participation amount collected would be more than the Medicaid rate; the NF must refund the amount that exceeds the Medicaid rate to the resident.

     


EXAMPLE

Private rate is $180 per day.  State rate is $155 per day.  Insurance will pay full private rate.  Nursing Facility is paid at the $180 per day. Client does not pay participation toward the cost of care.  Resource eligibility must be monitored

EXAMPLE

Private rate is $180 per day.  State rate is $155 per day.  Insurance will pay $160 per day.  Nursing facility keeps the entire $160 per day and because it is over the state rate, they cannot charge the client participation.  Resource eligibility must be monitored

EXAMPLE

Private rate is $180 per day.  State rate is $155 per day.  Insurance will pay $145 per day.  Client’s participation has been determined at $800 per month.  Nursing facility bills the state for additional $10 per day and collects that amount from the client in the nursing home.  If this were a 31 day month, the client would pay $310 in participation to the facility as the facility cannot charge over the state rate.  Resource eligibility must be monitored.

The nursing facility should report the amount of the client refund to the local HCS office at the time it is refunded.  If the nursing facility reports a refund of participation to the client, review eligibility to ensure that the client’s resources are not over the standard.

 

The nursing facilities will be allowed to charge the TPL insurance companies the private rate and keep the amount paid by the TPL insurance, even if it is over the Medicaid rate. 

   

Submit any insurance payments received at the HCS or CSO to OFR at MS 45862. Attach insurance information. Tell the client or facility to do the same with any insurance payments received

  1. Follow necessary supplemental accommodation (NSA) procedures described in WAC 388-200-1300 when appropriate.

  2. 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.

  1. All allowable deductions found in WAC 388-515-1505(4)(b) for COPES and WAC 388-513-1380 for nursing home.
  2. 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 1/06-3/06. Spenddown was met in February and case was certified effective 2/1/06. Client has monthly income of $825 per month. He enters the nursing home from home on 3/5/06.

His MN spenddown was computed as follows:

$825.00

monthly income

-$20.00

 

-603.00

MNIL

$202.00

per month available for spenddown use as a deduction.

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

$825.00

monthly income

-603.00

MNIL (at home 3/1/2006)

-$202.00

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.


  1. 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 in 13. for guidance once a spenddown has been met.

  2. Short Stay-Less than 30 days in a Nursing Facility.

    For clients who do not meet institutional status described in WAC 388-513-1320 but meet the functional eligibility requirement and are eligible for Medicaid.


Inpatient Mental Health and Retardation Facilities

  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 CSO 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 CSO. An application is not necessary for a client who is eligible for SSI.

  3. Facility staff make referrals as appropriate to the SSIF for a determination of eligibility for the GAX program.

  4. When written notification of admission from the facility is received in the CSO, document whether the client intends to return home upon discharge, if the client is a member of a TANF/SFA household (H/H). If so, obtain an estimated length of stay. If not, remove the client from the H/H assistance unit (AU), and determine eligibility for all program benefits as appropriate upon the client’s discharge from the facility.

  5. If the client intends to return to the TANF/SFA H/H, family members are responsible for the client’s personal needs. If the client’s length of stay will be:

    1. Ninety days or less, continue the full grant amount for the client to the AU.

    2. More than ninety days, reduce the grant amount for the client to the CPI.

  6. 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.

  7. If a client who was expected to be inpatient for ninety days or less end up staying longer, reduce the client’s grant to the H/H to the CPI amount. This does not create an overpayment.

  8. 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 in the coverage group and living arrangement. Determine eligibility for all program benefits as appropriate upon the client’s discharge from the facility.

  9. 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.

  10. Follow necessary supplemental accommodation (NSA) procedures.   

ACES PROCEDURES

See Long Term Care and Waiver Services - Interview

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Modification Date: October 28, 2007
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