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

Effective January 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 188-512-0300, Resource eligibility;

    2. WAC 182-512-0250, 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 nonexcluded 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

    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 (8)(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 nonexcluded 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; 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 at http://www.hca.wa.gov/medicaid/Eligibility.

    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 subsections (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) of this section applies; or

    3. The institutionalized spouse does not transfer the amount described in subsection (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.