Partial federal government shutdown
HCA does not anticipate any immediate impacts to our services or disruption to provider payments at this time. We will continue to monitor the situation and share updates if anything changes.
HCA does not anticipate any immediate impacts to our services or disruption to provider payments at this time. We will continue to monitor the situation and share updates if anything changes.
This section explains how long term care insurance and third party resources apply to long term care programs.
Policies covering long-term care are considered a third party resource.
See rules regarding additional assets allowed under the Long-term care partnership program.
The agency 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.
When LTC insurance payments exceed the private cost of care in a medical facility the amount refunded to the client is:
Consult HCS Management Bulletin H06-076 dated October 30, 2006 for additional information on Third Party Liability (TPL) and Nursing Facility Billing Policy Update. This MB includes Provider Q and A attachments regarding insurance billing. The provider is expected to bill the primary insurance first before medicaid.
The agency 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 individual for the months paid by the TPL party. If the TPL insurance is less than the Medicaid rate, the NF can only collect up to the Medicaid rate as the total payment. The NF must refund any excess participation collected to the individual. The NF should report the amount of the individual's refund to the local HCS office at the time it is refunded.
The NF 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. Individuals will not be reimbursed the difference between the Medicaid rate and the TPL insurance payment amount.
Effective October 16, 2006 the long-term care (LTC) ACES award letter has text advising individuals to let case managers, financial workers, facilities and providers know when they have LTC insurance.
Financial workers must inform new applicants with TPL insurance that pays for NF care that the NF must bill the insurance company directly and the state will not pay for services until the TPL insurance company has either paid or denied payment.
If the NF reports a refund of participation to the individual, review eligibility to ensure that the individual’s resources are not over the standard. The refund is considered a new resource and not income. Follow advance and adequate notice and reporting requirements criteria if making changes in participation or eligibility.
The NF should contact the insurance carrier to determine if they will pay a nonnetwork provider, or can decide to become a network provider if possible.
If neither of these options is possible, the NF needs to contact the HCS social worker to see if it is possible to relocate the resident to a network provider or if there is good cause not to relocate a resident.
The HCS social worker determines if there is good cause not to relocate a resident and notifies the Coordination of Benefits (COB) unit at Health Care Authority (HCA):
Complete instructions for the HCS social worker can be found in the LTC manual - Nursing Facility Case Management & Relocation under Home & Community Services Private Health Insurance and Good Cause Determinations.
Don't consider the value of extras purchased by relatives or others for NF individuals (such as telephone, television set, radio, private room) as income if the following criteria is met:
Example: Jane Doe, a NF resident is eligible for CN and institutional care. Her daughter pays the NF directly for a telephone in Jane's room. Don't consider this payment as income to Jane since neither the medical care nor institutional care cover this service and the daughter pays directly to the NF
Medicaid supplementation in long-term settings from Washington LawHelp
Report long-term care insurance for those applying or receiving in-home or residential long term services and supports on the Home and Community Services (HCS) Financial Eligibility and Policy (FEP) SharePoint page under the Notify Us tab LTC insurance workarounds.
Report long-term care insurance for those applying or receiving nursing facility or hospice as a program care to Mark Benya, Health Care Authority (HCA), Coordination of Benefits.
WAC 182-501-0200 Third-party resources
WAC 182-502-0100 (2) General conditions of payment (Medicaid the payer of last resort).
Payments from the Veteran's administration for aid and attendant care or unusual medical expenses (UME) are considered a third party resource. This applies to long-term care services such as nursing home or personal care services. Payments from the VA for aid and attendance or UME are not considered as income in initial or post eligibility. These payments are excluded from SSI related Medicaid eligibility per WAC 182-512-0840. It is essential to code these payments correctly in ACES so the payments aren't used to determine eligibility but applied as a third party resource toward long term care services.
Any health, dental, long-term care insurance or some other type of third-party insurance must be reported to coordination of benefits (COB) at Health Care Authority (HCA). This can be done by providing a:
The COB will receive an automatic assignment of the medical coverage information form, health insurance card or insurance policy once the document is imaged into the electronic case record (ECR).
Monitor resource eligibility on cases where LTC insurance payments exceed the cost of care.