Note: Effective 11/1/2009 there is no nursing home coverage under the AEM program. The legislature gave limited funding for a state funded long-term care program to cover services authorized under AEM prior to 11/1/2009.
WAC 182-507-0125 describes the state-funded long-term care program.
New admissions into nursing facilities, residential or home settings under the state-funded long-term care program for noncitizens must be preapproved by Natalie Lehl, Residential Policy Program Manager at Home & Community Services Headquarters. This program has limited 45 slots for coverage based on legislative funding.
Other programs should always be considered before the state-funded long-term care program for noncitizens.
Many legally admitted noncitizens in their five-year bar for Medicaid or other eligible non-federally qualified status can be considered for the ABD cash/HEN program. State-funded Medical Care Services (MCS) should be considered for legally admitted noncitizens who do not qualify for federal Medicaid.
State funded medical care services (MCS) program is described in WAC 182-508-0005.
ABD cash is described in WAC 388-400-0060.
For nursing facility coverage under MCS the client must meet income and resource criteria and be assessed as nursing facility level of care (NFLOC) by an HCS social worker.
An active A01/A05 (MCS) does not require a preapproval by HCS HQ prior to nursing facility admission.
Long-term care services under State Funds for noncitizens
Aging and Long Term Supports Administration (ALTSA) has a limited amount of state funding available for noncitizens who have been denied or terminated from AEM coverage and are in need of long-term care services outside of a hospital. These noncitizens are not eligible for the MCS program
An L04 is used in ACES for nursing facility cases. An L24 is used for in home or residential services preapproved by HCS HQ in a residential or home setting.
An L04 client that has income over the medicaid special income level (SIL) will trickle to a L95.
ALTSA/HCS headquarters must track each case using the state funds to pay for long-term care services under this program.
The following must be reported to Natalie Lehl, Residential Policy Program Manager Natalie.Lehl@dshs.wa.gov:
- New admits. Include the date and facility.
- Discharges. Include the date and circumstances.
- Any closures. Include the date and circumstances.
Specialty Hospital Unit for AEM coverage
Most admissions into the state-funded long-term care program start out in a hospital. Hospital applications are completed by a specialty hospital unit at CSD for a determination of AEM.
The HBE determines the eligibility for individuals receiving Health Care Coverage under the Modified Adjusted Gross Income (MAGI) method.
This unit refers to HCA medical consultant for possible AEM coverage in the hospital.
Prior to admission into a NF, a prior approval by ADS-HCS is needed. Even if there is an approval of AEM in the hospital, AEM does not cover NF admissions.
Once an AEM Hospital case has been approved a NF slot by HCS HQ, HCS financial staff will transfer the case into HCS for maintenance and tracking.
Example #1: Joe Smith is approved through 10/31/2009 under the federal AEM program. The federal AEM program for nursing home ended on 10/31/2009. Effective 11/1/2009, this client was grandfathered into the state-funded nursing facility program as Mr. Smith is still in need of nursing home care. The medical coverage group in ACES is an L04.
Example #2: Jane Smith has been in a hospital for six months. All options for alternative settings has been explored by the hospital. She must either remain in the hospital indefinitely or be placed in a nursing home.
She is assessed by the HCS social worker and meets NFLOC. The HCS office handling the assessment contacts HCS headquarters for an available slot under the state-funded long-term care program. Once headquarters approves a slot and the client is financially and resource eligible, an L04 is opened in ACES. The nursing home will be able to admit Jane and bill under the state-funded nursing facility program.
Example #3: Jayna Smith is a legally admitted alien in the 5-year bar.
Jayna is over 65, has been hospitalized, and is in need of nursing home care due to a stroke. She has been assessed by the HCS SW and meets NFLOC.
Jayna can be opened on ABD cash and state funded MCS medical. There is no need to refer for the state-funded funded nursing home program. MCS covers nursing facility coverage.
MCS placements do not need a preapproval by HCS HQ.
If this individual is a candidate for SSI, submit a packet to the SSI facilitator.
Example #4: John Doe has been hospitalized and is in need of LTC. Mr. Doe's needs can be met in an adult family home setting. Mr. Doe is financially eligible for the L24 program and there has been a preapproval from HCS HQ.
L04 is used for state funded long-term care nursing facility admissions.
L24 is used for state funded residential admissions and in-home services. Eligibility for residential settings and in home care is the same as the COPES program. The determination of room and board and participation would follow the calculation described in WAC 182-515-1509.