Long-term services and supports (LTSS) manual

Overview - Long-term Services and Supports Program Administration chart

Revised Date: 
January 17, 2019

Purpose: To give an overview of program administration long- term services and supports (LTSS) for clients in medical institutions, receiving Home and Community based services authorized by either Developmental Disabilities Administration (DDA) or Home and Community Services (HCS), or Hospice services authorized by Health Care Authority.

The program responsibility chart gives most examples of which administration does what program.  

Program Responsibility Chart

HCS Programs HBE HCA HCS DDA/LTC specialty CSD Notes
HWD with HCS services (S08)     X     HCS maintains all ABD medical, MSP, ABD cash or food benefits for clients on HCS services. Note: If a spouse or dependent is also on an ABD medical program with/without food assistance, HCS maintains both the LTC and the SSI-related AUs and the basic food unless there is TANF cash.
ABD medical on HCS services (S01, S02, S08, G03, L01, L02, L04, L21, L22, L24, L31, L32, L51, L52)     X     Same as above
HCS HCB Waiver and Hospice (L21, L22) Single client     X     HCS maintains case as HCB Waiver under L21/L22 as a priority. Participation is always applied to the HCB Waiver program first.  HCS maintains hospice admissions into a SNF less than 30 days. The HCS worker sets a tickler for 30 days.  If the NF/HCC admission is 30 days or more, the case is updated as hospice and it will automatically transfer to 017. If the NF/HCC hospice admission is less than 30 days, the short stay screen is used to issue the NF/HCC hospice award letter and the case remains a L21/L22. NOTE: If HCS client is on CFC services and Hospice under the L31, L32 program, the case will transfer to 017 as Hospice is the priority program.    
ABD medicaid client on HCS services under L01, L02, L95, L99, L04, L24, L21, L22, or PACE and their spouse is on the Hospice program or DDA services under an ABD medical program.     X     HCS maintains both cases when one of the couple is on a HCS service under ABD medical and the other spouse is on any ABD medical program including DDA services.  HCS maintains the food benefits for the couple.   HCS maintains the food benefits for the couple.
One spouse on DDA Waiver the other spouse on HCS Waiver (L21/L22)     X     HCS maintains both cases when one spouse is on HCS services and the other spouse is on a DDA services.
ABD medical on HCS services, no family member on TANF cash. Request for food benefits or ABD cash.     X     HCS processes food benefits or ABD cash for persons on ABD medical or MCS medical and on HCS services. Rule: No TANF cash, and on HCS services via ABD medical or MCS 14-084 referral to CSD Incapacity/SSI facilitator is required for ABD cash request in R1 and R3 HCS.
State-funded 45 slot LTC program if preapproved by ALTSA. (L04, L24)     X     Coordinate with Sandy Spiegelberg, ALTSA, on preapprovals and any changes including hospitalizations over 30 days. HCS retains case during hospitalization unless notified by Sandy Spiegelberg that no slot is being held for HCS services in the community or nursing home.
MCS on HCS services with HEN or ABD cash (A01, A05)     X     Clients receiving MCS on HCS services. Case maintained by HCS. Region 1 and 3 HCS must have a duration determination by CSD for ABD cash. Case is referred to the CSD incapacity worker for the duration determination. MCS/HEN eligibility covers NF and State residential services. Not eligible for ABD cash because duration is not greater than 9 months. Application goes through CSD if client is in the hospital or home and no NF or ALF admission date is known. HCS brings in case once the client is in the NF or ALF on services.  NOTE:  MCS does not cover HCS in-home care.  

ABD cash-MCS application request. Client is either in a nursing facility or ALF or the admission date is known. (A01, A05)

NOTE: The only time HCS will be processing ABD cash is when the client needs MCS due to 5 year bar or PROCUL status and a NF or ALF admission date is known or already admitted into a NF or ALF on HCS services.

    X     HCS can authorize services and open MCS prior to an incapacity duration or disability determination by CSD only if the HCS social worker is authorizing a placement date into a NF or ALF. A client receiving NF or ALF HCS services authorized by an HCS social worker meets the criteria for incapacity. The case still needs to be referred to the CSD incapacity specialist for duration and incapacity for ABD cash in Region 1 and 3. HCS must refer applications for MCS/HEN/ABD cash to CSD if a social service authorization date is not known. Cases not on HCS services or NF or residential admit date is not known must go through CSD for MCS/HEN/ABD cash.
Transitional Food Assistance with L track or S track case on HCS services. No TANF cash. Note: In this scenario the case was previously shared between CSD and HCS and the TANF case closed.     X     Transitional Food Assistance (TFA) is 5 months of continuous eligibility once TANF cash is closed. TFA will be transferred to the office where the S or L track case is located after 30 days of no TANF. HCS maintains the L track and TFA and does the basic food review once the TFA has ended.
HCS clients admitted into the hospital less than 90 days.     X     Clients that are on HCS services and admitted into the hospital less than 90 days are retained by HCS as it is projected the client will receive HCS services upon discharge.  The HCS financial worker will set a tickler for 90 days to check the status.  
Roads to Community Living (RCL) L41 or L42     X     RCL uses waiver rules for eligibility if a client is not eligible for another CN or ABP program. If RCL is authorized by a HCS social worker, the HCS financial worker will determine eligibility, unless the client is active on CN or ABP.
Medicaid alternative care (MAC) Non-MAGI     X     Unless the client is active MAGI, clients whose unpaid caregiver are receiving MAC services, HCS maintains the client’s ABD medical. If HH is active TANF, the case will be shared with CSD.
Tailored supports for older adults (TSOA)     X    

T02 cases are maintained by HCS, even though Washington Apple Health coverage is not provided. The applicant is the person receiving care even though services may be authorized to the person providing care.

HCS maintains all S99, S95 or food benefits for clients on TSOA services.

If HH is active TANF, the case will be shared with CSD.

HCS/DDA LTC Specialty Unit Shared Cases HBE HCA HCS DDA/LTC Specialty CSD Notes
HCS/DDA specialty unit Shared Cases.  DDA minor child and HCS adult on ABD medical     X X   DDA minor child is on DDA services under ABD medical.  HCS parent or grandparent is on HCS services on ABD medical.  Food benefits are done by HCS unless there is TANF cash.  If HH member on TANF cash, the food and cash is done through CSD. HCS does not maintain L track/SSI related cases for minor children on DDA services.    
HCS/CSD Shared Cases HBE HCA HCS DDA/LTC specialty CSD Note: Whenever HCA authorizes services on an ABD medical case and an HH member is active on TANF cash will be a shared case.
HWD on HCS services. HH member on TANF cash and food. (S08 + cash/food)     X   X

HWD maintained by HCS HWD worker. TANF cash and Basic Food maintained by CSD.

SSI related S01, S02, S08, G03, L21, L22, L31, L32, L51 and L52 on HCS services and HH member receiving TANF cash.     X   X

ABD medical on HCS services is maintained by HCS.

TANF cash and basic food is maintained by CSD

DDA LTC Specialty Unit Case HBE HCA HCS DDA/LTC specialty CSD Notes

Health Care for Workers with Disabilities (HWD) not on HCS services. No HH member on TANF cash S08.

      X   DDA LTC specialty unit maintains all HWD cases not on HCS services.

SSI related in an ALF - BHO admissions or private pay when rules under 182-513-1205 are needed for eligibility. Not on HCS services (G03, G95, G99)

      X   DDA LTC specialty unit determines behavior health admissions into an ARTF if eligibility rules under the G03 program are needed for eligibility because the client is not eligible for another CN, ABP, MN program.  G95 and G99 private pay in a contracted ALF.
SSI related on DDA services. No TANF cash attached.        X   DDA specialty unit maintains cases for people receiving DDA services in both in-home and residential settings and their food benefits.  The exception is when the service is for a DDA minor child and the parent is HOH for the food benefits. CSD manages the food benefits for the HH when there is a DDA minor child in the household.
Roads to Community Living (RCL) L41 or L42       X   RCL uses waiver rules for eligibility if a client is not eligible for another CN or ABP program. If RCL is authorized by a DDA CRM, the LTC specialty unit will determine eligibility, unless the client is active on CN or ABP.
Hospice in a NF or home not on HCS services. (L31, L32)       X   DDA LTC specialty unit maintains hospice cases under the L31 and L32 program. If hospice rules are used as the primary eligibility, HCS CFC can be authorized as a service and the case remains with the DDA LTC specialty unit.  Hospice can be authorized as a service in the community for any non L track CN, MN or ABP program. These cases do not come to the DDA LTC specialty unit.
Children/Family institutional (K01, K03, K95, K99)   X       Eligibility for K track programs is determined by HCA. For persons not eligible for MAGI through the HBE and are in a hospital or institution 30 days or more. It is for under age 65, not on Medicare. MAGI based. Any family food benefits or TANF are done by CSD.
MCS on DDA services with ABD cash or HEN (A01, A05)       X   Clients on MCS or ABD cash on DDA services are maintained by the DDA LTC specialty unit. Duration determination for ABD cash must be referred to the CSD incapacity worker.
Transitional Food Assistance with L track or S track case on DDA services. No TANF cash. Note: In this scenario the case was previously shared between CSD and the LTC Specialty Unit and the TANF case closed. The DDA specialty unit only maintains if the head of household was on DDA services, not a child.       X   Transitional Food Assistance (TFA) is 5 months of continuous eligibility once TANF cash is closed. TFA will be transferred to the service office that the L track is located after 30 days of no TANF. DDA maintains the L track and TFA and does the basic food review once the TFA has ended
WASHCAP food AU associated with ABD medical and on DDA services       X   DDA Specialty Unit maintains
ABD medical on DDA services, no family member on TANF cash. Request for food benefits       X   DDA processes food benefits for ADULTS on ABD medical on DDA services. Spouse and/or children can be included in food AU. Food benefits are processed by CSD if the only client on DDA services is a minor child.  This would be a shared case. If the household is on TANF cash then CSD processes the food request too.
DDA LTC Specialty Unit/CSD Shared Case HBE HCA HCS DDA/LTC specialty CSD Notes
HWD not on HCS services. HH member on TANF cash and food.       X X Shared case. HWD maintained by LTC HWD specialty worker, TANF cash and Basic Food maintained by CSD.
SSI related on DDA CFC or MPC residential services. Spouse or child on SSI related program not on DDA services. No TANF cash attached (S01, S02, L51, L52)       X X LTC specialty unit manages the ABD MPC/CFC residential case not on HCS services. Since the family is not living under the same roof, CSD would maintain the ABD medical cases and the case would be separated
SSI related S01, S02 on DDA in home CFC or MPC services and HH member receiving TANF cash       X X Shared case. S01 or S02 cases on CFC or MPC maintained by the DDA LTC specialty unit. TANF cash and basic food attached is maintained by CSD.
Children on ABD medical on DDA services, active in parent's food AU, with or without other associated AU's for parents, other family members       X X DDA maintains ABD medical for child who is on DDA services. CSD maintains all other AU's in the household including food benefits.
CSD Cases HBE HCA HCS DDA/LTC specialty CSD Notes
ABD medical in an ALF - BHO admissions (S01, S02 and S95) cases placed in a behavioral health ALF remain with CSD because rules under Chapter 182-513 are not needed in eligibility. Client is not on HCS or DDA services.         X CSD determines eligibility and maintains cases for ABD medical (not G03, G95, or G99) when a client is placed in a behavioral health ARTF.
Medical Care Services (MCS) Not on HCS or DDA service or in a nursing facility (A01, A05)         X

CSD maintains MCS for persons not on HCS or DDA services.

Note: HCS can only authorize services for a MCS client in a NF or in an alternate living facility under state residential services. HCS cannot authorize in-home services for a client applying or active on state-funded MCS. All applications for ABD/HEN/MCS for clients not in a nursing facility or a HCS social service imminent placement into an alternate living facility must go through CSD to complete an incapacity, duration and disability determination. An intake referral by CSD can be done to HCS social services for an assessment for an active MCS client. The HCS financial worker will transfer the case into the HCS office once a client is found eligible for HCS services.

ABD cash - Active N track Medical Care Services (MCS) not on HCS or DDA service or in a nursing facility (A01, A05)         X

ABD cash and food is a CSD program. The medical authorizing HCS/DDA MPC or NF services are in the N track, which is maintained by the Health Benefit Exchange (HBE). No medical program maintained by HCS or DDA. CSD maintains MCS for persons not on HCS or DDA services.

Note: HCS can only authorize services for a MCS client in a NF or in an alternate living facility under state residential services. HCS cannot authorize in-home services for a client applying or active on state-funded MCS. All applications for ABD/HEN/MCS for clients not in a nursing facility or a HCS social service imminent placement into an alternate living facility must go through CSD to complete an incapacity, duration and disability determination. An intake referral by CSD can be done to HCS social services for an assessment for an active MCS client. The HCS financial worker will transfer the case into the HCS office once a client is found eligible for HCS services.

TANF cases – Active N track medical ABD cash- Active N track         X TANF and associated food managed by CSD ABD cash and food is a CSD program. The medical authorizing HCS/DDA MPC or NF services are in the N track, which is maintained by the HBE. No medical program maintained by HCS or DDA.
Food benefits, either alone or with an active N track medical TANF cases – Active N track medical         X ABD cash and food is a CSD program. The medical authorizing HCS/DDA MPC or NF services are in the N track, which is maintained by the HBE. No medical program maintained by HCS or DDA. TANF and associated food managed by CSD
SSI related: S01, S02, S95, S99, not on HCS or DDA services Food benefits, either alone or with an active N track medical         X ABD medical cases with no HCS or DDA services attached is maintained by CSDABD cash and food is a CSD program. The medical authorizing HCS/DDA MPC or NF services are in the N track, which is maintained by the HBE. No medical program maintained by HCS or DDA.
Medicare Savings Programs not on HCS or DDA services (S03, S04, S05, S06) ABD medical: S01, S02, S95, S99, not on HCS or DDA services         X MSP when no HCS or DDA services are attached are managed by CSD. ABD medical cases with no HCS or DDA services attached is maintained by CSD
Basic Food benefits – not on HCS or DDA services Medicare Savings Programs not on HCS or DDA services (S03, S04, S05, S06)         X MSP when no HCS or DDA services are attached are managed by CSD.
Basic Food benefits for a MAGI client receiving CFC or MPC services through HCS or DDA. Basic Food benefits – not on HCS or DDA services         X The HCS or DDA financial worker is not maintaining a medical case; therefore food benefits are determined and maintained by CSD.
Childcare and Basic Food benefits for a MAGI client receiving CFC or MPC services through HCS or DDA         X All childcare is managed through CSD. The HCS or DDA financial worker is not maintaining a medical case; therefore food benefits are determined and maintained by CSD.
WASHCAP not on HCS or DDA services          X HCS will do courtesy nursing facility award letters for WASHCAP cases for nursing facility admissions under 30 days.
Childcare not on HCS or DDA services         X All childcare is managed through CSD
Hospital applications. No admission date to a NF or ALF is known.         X ABD medical hospital applications go through CSD unless there is a known NF or ALF placement date.  A client in the hospital is not on HCS or DDA services.
HCA Cases HBE HCA HCS DDA/LTC specialty CSD Notes
Children/Family institutional (K01, K03, K95, K99)   X      

Eligibility for K track programs is determined by HCA. For persons not eligible for MAGI through the HBE and are in a hospital or institution 30 days or more. It is for under age 65, not on Medicare. MAGI based.

Breast and Cervical Cancer (S30)   X       May be on HCS or DDA MPC or CFC services. Medical case maintained by HCA
Pregnant Teen (N03)   X       Medical case maintained by HCA
Take Charge & Family Planning (P05/P06)   X       Does not have a LTSS in benefit package
Foster Care (D01, D02, D26)   X       Medical case maintained by HCA. May receive MPC, CFC or short stay NF services authorized by HCS or DDA. Note: requires coordination and disability determination if approved for LTC waiver services.
Post-enrollment quality assurance for MAGI cases   X       HCA does post-enrollment review of MAGI cases.
AEM for emergent hospitalization, kidney dialysis, cancer treatment (N21/N25)   X       AEM must be preapproved by HCA. AEM does not cover LTSS services.
F99/P99 Spenddown cases   X       HCA pulls reports of clients denied MAGI pregnancy & children's coverage and offers MN spenddown coverage as an option
CASE actions across multiple administrations, WASHCAP not on HCS or DDA services HBE HCA HCS DDA/LTC specialty CSD Notes: HCS will do a courtesy nursing facility award letters for WASHCAP cases for nursing facility admissions under 30 days
Short stay nursing facility award letters. (Admission into a nursing facility under 30 days, not covered by managed care or Medicare) Case actions across multiple administrations   X X X X A short stay NF award letter is completed by agency has the active ABD medical program. See short stays. This responsibility could be HCA (for active foster care or breast and cervical cancer), CSD (for active ABD medical not on HCS or DDA services) or clients receiving services by DDA or HCS. Active MAGI cases in a NF do not require a NF award letter for the facility to bill ProviderOne. If it is a short stay CSO needs to complete, please send all documents to @MER/157.
LTC L track cases (L01, L02, L95, L21, L22, L04, L24) on HCS services and HH member receiving TANF/SFA cash and food. HH members on N track medical State-funded 45 slot LTC program if preapproved by ALTSA. (N21*, N25*) X X X   X

Shared case. HCS maintains the L track program and any related SSI related medical program for other HH members.

CSD maintains TANF cash and food.

HBE manages the MAGI coverage. MAGI cases are maintained by CSD but opened by specialized workers at HCA. N21 and N25 clients are eligible for the ALTSA 45 slot program if preapproved so functional eligibility is determined by the HCS social worker.

SL Track (L01, L02, L95, L21, L22) on DDA services and HH member receiving TANF/SFA cash and food. HH members on N track medical LTC L track cases (L01, L02, L95, L21, L22, L04, L24) on HCS services and HH member receiving TANF/SFA cash and food. HH members on N track medical X   X X X Shared case. DDA LTC specialty unit maintains the L track case and any related SSI related medical program for other HH members.

CSD maintains TANF cash and Food. HBE manages the MAGI coverage. Shared case. HCS maintains the L track program and any related SSI related medical program for other HH members. CSD maintains TANF cash and food. HBE manages the MAGI coverage

L Track (L01, L02, L95, L21, L22) on DDA services and HH member receiving TANF/SFA cash and food. HH members on N track medical X     X X Shared case. DDA LTC specialty unit maintains the L track case and any related SSI related medical program for other HH members. CSD maintains TANF cash and Food. HBE manages the MAGI coverage.
Hospice L track case with a spouse that is on HCS services     X X   This is a shared case between the DDA LTC Specialty unit and HCS.  The Hospice case is under 017 and HCS retains the spouse that is on HCS services.  The ACES system is programmed to always assign a hospice case to 17, even if the other spouse is on HCS services.
HBE Cases HBE HCA HCS DDA/LTC specialty CSD Notes
MAGI N track Medical (parents, caretaker relatives, single adults, pregnant women and children) X         Medical case maintained by HBE. May receive MPC, CFC or NF services.
Children's Health Insurance Program (CHIP) N13/N33 X         Maintained by HBE.

Home & Community Based Services

Home and community-based services, provided under a medicaid waiver granted by the federal government, enable a client to live in a residential setting outside of a nursing or other medical facility or in their own home. Such services are referred to as waiver services or use HCB Waiver rules in eligibility. The HCB services currently provided include:

  • Community Options Program Entry System (COPES) authorized by HCS
  • New Freedom authorized by HCS
  • Program for All-Inclusive Care to the Elderly (PACE) is not a Waiver, but uses waiver rules for eligibility if a client is not eligible for another CN or ABP program. Can be authorized by HCS.
  • Roads to Community Living (RCL) Not a Waiver, but uses waiver rules for eligibility if a client is not eligible for another CN or ABP program.  Can be authorized by HCS, DDA or BHA.
  • Core authorized by DDA 
  • Basic Plus authorized by DDA.
  • Community Protection authorized by DDA.
  • Children's Intensive In-home Behavioral Support (CIIBS) authorized by DDA.

Individual Family Services (IFS) authorized by DDA.

HCB Waiver services cannot be authorized under a MAGI or N track program. Eligibility for the L22 program must be done through the DDA/HCS financial worker. An HCA 18-005 or Washington Connections application are needed to apply for HCB Waiver, Institutional Medicaid or ABD medical program.

1115 Medicaid Transformation Demonstration Project (currently funded through 2022)

  • MAC (Medicaid Alternative Care) MAC services are person-centered LTSS provided to unpaid caregivers caring for a Medicaid eligible person who meets NFLOC.
  • TSOA (Tailored Supports for Older Adults) TSOA services are person-centered LTSS to unpaid caregivers caring for a person who meets NFLOC, but is not active on medicaid.

Institutional Services

Some clients require institutional services that can be provided only in a medical facility. Institutional medicaid rules must be used for clients who live in a medical facility for 30 days or more.

Hospice Services

Some clients receive Hospice index services in addition to or instead of services in their home or a medical facility. Hospice provides palliative care for clients dealing with a terminal illness or end-of-life issues. Hospice services are described in more detail in the Hospice section of the manual and in Chapter 182-551 WAC. Hospice services can be authorized as a service under any CN or ABP program. Hospice program rules are only used if a client outside an institution is not eligible for a noninstitutional CN or ABP program.  Institutional rules are used for Hospice clients residing in a medical institution 30 days or more. 

Hospice agencies must send notices within 5 business days of election. If the agency receives a ‘late’ hospice election notice for a client in a SNF, do not backdate services. Please contact Lori Rolley at HCS HQ, as HCA will need to adjust the provider payment.

Institutional Status

All clients approved for DDA Home and Community Based (HCB) waivers or ​​HCS Home and Community based (HCB) waivers Waiver services, Hospice services or in a medical institution 30 days or more have attained institutional status and are considered to be institutionalized as described in Medicaid law and the regulations used to implement these programs. A key difference for an institutionalized person is that eligibility is determined using only that person's income, and not the income of their spouse or children. Institutional status is described under WAC 182-513-1320.

Community First Choice (CFC)

Home & Community Services (HCS) and Developmental Disabilities Administration (DDA) can authorize Community First Choice (CFC) for clients eligible to receive a noninstitutional CN Medicaid program and assessed to be eligible for CFC. This includes clients under the adult medicaid expansion group who receive coverage under the Alternative Benefit Plan (ABP) scope of care (N05).

Medicaid Personal Care (MPC)

Home & Community Services (HCS) and Developmental Disabilities Administration (DDA) can authorize Medicaid Personal Care (MPC) for clients eligible to receive a noninstitutional CN Medicaid program and assessed to be eligible for MPC. This includes clients under the adult medicaid expansion group who receive coverage under the Alternative Benefit Plan (ABP) scope of care (N05).

MPC clients are not considered institutionalized. The financial eligibility for MPC is eligibility for a "noninstitutional" CN Medicaid program.

This category also describes the rules and procedures used to determine a person's eligibility for noninstitutional medical assistance provided in an ALF. This is a SSI related noninstitutional program under WAC 182-513-1205.  For behavioral health placements or MPC in an ALF, the ACES program is a G03.

Eligibility Determinations

The department must determine a person's eligibility for LTC services according to both functional and financial requirements. Both financial and functional eligibility must be established concurrently. Coordination between financial and social service/case management staff is required to process applications and provide services.

Functional Eligibility

A department-designated social service specialist establishes functional eligibility for nursing home placement or long-term services and supports in the community or residential setting.

The HCS SW must authorize all nursing facility admissions before a nursing home award letter can be issued. (See applications for nursing facility care on the bottom of this clarifying page). For active Medicaid clients with short stay admissions (under 30 days) see Short stays. The exception to this is an admission into a State Veteran's Nursing Facility where a Veteran's Affairs Registered Nurse (VARN) determines NFLOC for admissions into a State Veteran's Nursing Facility. A NFLOC determination is not needed when a client enters a NF and is active on a HCB Waiver under a L21 or L22.

  • The HCS social service specialist Area Agency on Aging (AAA) case resource manager, DDA case manager (CRM) or the Veterans Affairs registered nurse (VARN) determines functional eligibility for HCB waivers and MPC based on the client's assessment which takes into account the client's place of residence and services that are appropriate for the plan of care.
  • The client admits into Providence Children's Hospital in Portland Oregon.  A letter is issued upon admission.  No NFLOC is needed.

Financial Eligibility

Financial Staff determines financial eligibility by comparing the person's income, resources, and circumstances to program requirements

The amount of income and excess resources a client must contribute to the cost of care for services received is established in what is called the post-eligibility determination (participation).

Financial staff must also determine eligibility for noninstitutional medical assistance at the same time they determine eligibility for institutional, waiver, or hospice services.

When determining eligibility and the cost of care for LTC services, program policy requires an allocation of income and resources from the institutionalized spouse (the applicant for LTC services) to the community spouse.(The spouse of an LTC applicant who is not applying for or receiving LTC services). This is to allow the community spouse to keep some assets and income necessary to maintain their home without requiring that the couple spend down all their assets to the individual resource limit of $2000. The Medicare Catastrophic Care Act in 1988 began the spousal allocation process used to discourage the impoverishment of a spouse due to the need for LTC services by their husband or wife. That law and those that have extended and/or amended it are referred to as spousal impoverishment legislation. (Section 1924 of the Social Security Act).

The rules used to determine eligibility and participation costs for waiver services are similar to those for institutional services, but there are important differences. These differences, in addition to those related to hospice services, are described in 182-551 WAC

A client may be eligible for both health care coverage and institutional services, or be eligible for one but not the other.

Agency/Department Responsibilities

Aged, Blind or Disabled medicaid (ABD) or Modified Adjusted Gross Income medicaid (MAGI)?

ALTSA is responsible for managing all the long-term care programs offered in the State of Washington. LTC programs are managed by both Home and Community Services (HCS) staff and by financial staff in the DDA/LTC specialty unit. The breakup of duties is defined below;

  1. DDA/LTC Specialty Unit financial service specialist (FSS) staff determine financial eligibility for the following long-term care (LTC) client:
    • Developmental Disabilities administration (DDA) clients receiving LTC services in a DDA medical institution, ​DDA Home and Community Based (HCB) waivers or Medicaid Personal Care (MPC) residential services paid for by DDA and authorized under a ABD medical assistance unit. (Unless the DDA client is married and spouse is on HCS services, see HCS responsibility below).
    • DDA LTC medical institutions are:
    • Residential Habilitation Centers (RHC)
    • Intermediate Care Facilities for individuals with the Intellectual Disabilities (ICF/IID)
    • Mental health clients receiving residential services paid for by Mental Health / Behavioral Health Organization (MH/BHO) in an ARTF. Client not eligible for a MAGI, S01 or S02 and G03 rules need to be used for eligibility.
    • Hospice program rules are needed for eligibility because the client is not on a CN, MN or ABP program living outside a medical institution, unless the client is receiving an HCS HCB waiver service in home. 
    • Hospice program rules because a client is in a Nursing facility or Hospice Care Center 30 days or more and client is not eligible under MAGI.
    • Hospice services are paid by Health Care Authority (HCA).
    • NF admits for clients who receive DDA services. If discharge date is unknown or anticipated to be longer than six months, the case will be transferred to HCS for ongoing maintenance. HCS will complete exit maintenance at discharge, including updating HCB services authorized by DDA, prior to transferring back to DDA.  
    • Health Care for Workers with Disabilities (HWD) unless on HCS services.
    • Basic food eligibility when associated with a DDA LTC case unless the DDA recipient is a minor child.
    • Medicare Savings Program eligibility when associated with a DDA LTC case.
  2. Home and community services (HCS) FSS staff determine financial eligibility for LTC clients who receive the following services from HCS:
    • Nursing facility (NF) care;
      • NF applications and maintenance for nursing facility (NF) care under the L track program.
      • Active ABD medical clients when NF care is 30 days or longer.
      • Active WASHCAP (CSO 130) when NF care is under 30 days and a NF short stay award letter is needed.
    • HCS services either in home or in an alternate living facility. This includes:
    • Food stamp eligibility (associated with LTC services) when the non-LTC clients in the household do not receive TANF cash.
    • ABD cash for clients receiving services authorized by HCS and eligible for HEN/MCS. ABD cash requires a 9 month disability duration determination by CSD for clients under age 65.
    • Medical Care Services (MCS) for clients receiving services authorized by HCS if there is no TANF cash
    • Married couple, one client is on HCS services ( ABD medical MAC/MPC or CFC or HCS Waiver or nursing home) the other spouse is on active DDA services. (ABD medical MAC/MPC or CFC or DDA Waiver).
    • Married couple, one client is on HCS services (MAC/MPC or CFC or HCS Waiver or nursing home). The other spouse is not on institutional medical, but is applying for an ABD medical program HCS is responsible for the application and maintenance of the community spouse's application for ABD medical.
    • The HCS SW is responsible to gather the information needed to submit a disability determination (NGMA) packet and referral if needed for the community spouse ABD medical application even if the institutional spouse is receiving COPES and is being case managed by the Area Agency on Aging

Health Care Authority

3. The Health Care Authority staff are responsible for managing the following cases:

  • MAGI based institutional (K01, K03, K95, K99)
  • Foster Care/Adoption Support cases (D01/D02/D26)
  • Breast and Cervical Cancer cases (S30)
  • Take Charge Family Planning (P06)
  • MAGI-based Alien Emergency medical cases (N21-/N25) (updating the case with the medical consultant approval-initial eligibility is done through the Health Benefit Exchange)
  • Pregnant Teens program (not in ACES)

When an LTC client is active on a case managed by HCA, special handling of the case may be necessary. Here are some examples of when additional coordination activities are required:

  • An client that is approved for DDA waiver or COPES waiver services who is active on a foster care or adoption support program through the 076 ​Foster Care Relative Placement Adoption Support Juvenile Rehabilitation Unaccompanied Minor Program. (Active D01/D02/D26) is not managed by ALTSA staff. The client will remain on the 'D' track program.
    • For HCS services email Lori Rolley HCS HQ to coordinate with HCA-Foster Care Unit. Include client name and client ID.
    • For DDA services, DDA financial workers will coordinate with the 076 FCMT Unit for client’s 18 and older, with support from DDA Unit Manager Marcie Birdsall if applicable.
    • D02/D26 Foster Care cases remain with 076 until they age out, usually at age 26.
  • Client is active on S30 breast and cervical cancer case. Clients on this program are eligible for CFC or MPC services if found functionally eligible. Active S30 cases will remain with the MEDS unit. S30 clients are not eligible for waiver services or nursing home coverage 30 days or longer. The clients will need to submit an applications for LTC services to HCS. These cases will need to be coordinated between MEDS and HCS offices. Contact Kim Moore 360-725-1469
  • Client is active on N25 AEM medical in a hospital setting requiring discharge to a nursing home. A slot is approved for the state-funded nursing facility program by ALTSA HQ. Staff will need to contact the HCA MEDS unit to update the AEM approval coding on the ALAS screen to reflect the institutional placement

4. CSD financial staff are responsible for managing the following programs:

  • TANF/SFA cash assistance
  • ABD (Aged, blind disabled) cash assistance including those on a N track MAGI program through the Health Benefit Exchange and receiving MPC or NF services.
  • PWA (Pregnant Women's Assistance)
  • HEN (Housing & Essential Needs)
  • RCA (Refugee Cash Assistance)
  • Medical Care Services (MCS)
  • Basic Food for non-LTC recipients unless the only household member receiving LTSS is a DDA child.
  • WASHCAP for non-LTC recipients
  • Childcare Assistance
  • ABD non-LTC medical cases including, SSI-related (S02), medically needy/spenddown cases (S95/S99, Medicare Savings Program (S03, S04, S05, S06) and refugee medical (R03). This includes hospital applications with no plan of discharge.
  • Medicare Savings Programs (MSP)

Health Benefit Exchange (HBE)

Effective 10/1/2013, children, parents and pregnant women must be converted over to health care coverage determined under the Modified Adjusted Gross Income (MAGI) methodology starting with the 11/2013 renewals. In January 2014, under the Medicaid expansion, single adults and parents with income at or below 138% FPL will also be eligible for health care coverage using MAGI methodologies. Eligibility for these coverage groups is determined by the Health Benefit Exchange through the Washington Healthplanfinder portal. The HBE is responsible for all 'N' Track programs as listed below, and determinations of eligibility for the Health Insurance Premium Tax Credit and Cost-Sharing reductions

  • WAH for parents and caretaker relatives (N01)
  • WAH transitional medical (N02)
  • WAH Pregnancy coverage (N03)
  • WAH MAGI-based adult coverage (N05)
  • WAH Newborn coverage (N10)
  • WAH Children's coverage (0 - 210%) - citizen and federally qualified noncitizens
  • WAH Premium based children's coverage (210% - 312% FPL) - citizen and federally qualified noncitizens (N13)
  • WAH Alien Emergency Medial for parents/caretaker relatives with income <= 53% FPL (N21)
  • WAH Pregnancy coverage (noncitizens) (N23)
  • WAH Alien Emergency Medical for single adults and parents/caretaker relatives with income <= 138% FPL (N25)
  • WAH Children's coverage - noncitizen state-funded program (N31)
  • WAH Premium based children's coverage - noncitizen state-funded program (N33)

ALTSA staff have limited ability to determine eligibility for cases managed through Washington Healthplanfinder limited to cases which require redetermination when an ABD medical case maintained by ALTSA closes. Contact your region designated staff if you have a case that needs redetermination through the Healthplanfinder. For all other changes and applications the person needs to be referred to the HBE call center (1-855-923-4633).

Shared Cases

A shared case is when cash, food and medical may be maintained by more than one agency or administration

  • TANF and Refugee cash is always maintained by Community Service Division (CSD)
  • HCB Waiver and institutional under the L track is always maintained by HCS or DDA Specialty Unit financial workers.
  • Institutional under the K track is approved through the Health Care Authority (HCA), but maintained by DDA LTC Specialty Unit until upcoming ACES release.

  • N track medical under MAGI is always maintained by the Health Benefit Exchange (HBE)
  • Breast and Cervical Cancer and Foster Care medical is always maintained by the HCA.

Basic Program Division:

  • HCS maintains ABD medical cases when a HH member is receiving HCS services or an ABD medical client residing in a NF 30 days or more.
  • HCS maintains TSOA clients. HCS maintains MAC clients when active ABD medicaid.
  • DDA LTC specialty unit maintains ABD medical cases when a HH member is receiving DDA HCB Waiver services, ABD CN medical for MPC in DDA residential settings and DDA institutions. In addition this unit does:
    • All HWD cases with the exception of HWD clients on HCS services.
    • Hospice eligibility under the L track program if the client is not eligible for any other CN or ABP program. 
    • BHO placements in Mental Health residential facilities (G03 programs), unless otherwise eligible for CN or ABP medicaid.
  • L track hospitalization 30 days or more ONLY if the person is not eligible for another CN, MN or ABP medical program including S99. L track medical for hospitalization 30 days or more may need to be considered under L track because of higher resource allowances for a married couple.
  • HCS or DDA maintain any Medicare Savings program associated with an LTC case under the 'L' track.

Hospital Admits from NF or active HCB waiver

For SNF clients:

  • Update living arrangement and institutional setting after client has been in the hospital for 30 days; medical will trickle to an institutional program and the case will stay with HCS or DDA office. 
  • If client is still in hospital at 90 days, check with SW or CRM to see if there is a discharge plan.  If not, redetermine coverage under appropriate program (MAGI or classic). Individual regions may choose to keep these cases or transfer them out to CSD.

For active HCB waiver:

  • If a hospital admit is less than 30 days, update as a short stay.
  • If client is still in hospital at 90 days, check with SW or case manager to see if there’s a discharge plan.  If not, redetermine coverage under appropriate program (MAGI or classic). Individual regions may choose to keep these cases or transfer them out to CSD.

CSD Cases:

  • ABD medical cases when no HH member is receiving DDA or HCS services including hospital applications under S track medical programs. The exception to this is HWD (S08), BHO placements in residential (G03), institutional children (K track) and Hospice where L track is needed for eligibility.
  • Food benefits if a medical program under N track (MAGI) maintained by HBE even if there is MPC services authorized by HCS or DDA
  • Medicare Savings Program
  • TANF, SFA and Refugee cash assistance
  • CSD has out-stationed workers at Eastern and Western State hospital that determine eligibility for clients:
    • Age 21 or under at discharge.
    • 65 or older
    • Clients needing ABD medical upon discharge

Example # 1

Parent is on L21 receiving HCS HCB Waiver services. The parent is also receiving TANF cash for 3 children. The children are receiving N track medical through the HBE. The entire household is on basic food.

The L21/HCB Waiver case will be maintained by the HCS financial worker;

The TANF cash and basic food will be maintained by the CSD financial worker; and

The children's medical will be maintained by the Health Benefit Exchange (HBE).

Example # 2

Parent A is on CFC L51 authorized by DDA.

Parent B is on CFC L52 authorized by HCS.

2 children are on MAGI medical through the HBE.

The L51 and L52 are maintained by HCS.  If the family applies for food benefits, it goes through HCS.

Example #3

Parent A is on CFC L51 authorized by DDA.

Parent B is on CFC L52 authorized by HCS.

2 children are on MAGI medical through the HBE.

The 2 children are on TANF cash through CSD.

In this example, since there is TANF cash involved it is a shared case.  HCS maintains the 2 ABD CFC L51 and L52 programs and CSD maintains the TANF cash and associated food. 

Example #4

Child is on L22 DDA Waiver.

Parent is on L22 HCS Waiver.

The L22 waiver for a minor child is always maintained by the DDA LTC specialty unit.  In this example it is a shared case between the DDA specialty unit and HCS.  Food benefits would be maintained by HCS as the adult is the head of household.

Example #5

Child is on L22 DDA Waiver.

Parents are on MAGI/N track through the HBE.

Family is on food benefits.

In this example, the DDA LTC specialty unit maintains the L22/DDA Waiver, HBE maintains the MAGI and food benefits are done through CSD as the adults are not on LTSS through DDA.  

Forms, WACs, Rule Making and useful LTC links

DSHS and HCA forms, WACs, Rule Making and Useful Links

Washington State Health Care Authority income and resource standards for Medicaid

HCA ​Program standard for income and resources