Long-term services and supports (LTSS) manual

Overview - Long-term Services and Supports chart

Revised Date: 
October 13, 2016

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

ACES is programmed for shared cases based on this chart.

ACES is programmed to assign Hospice cases and HWD cases that are not on HCS services to 017.

Basic rule of thumb:

  • HCA and DDA LTC specialty financial workers do not maintain MAGI or TANF/Refugee cash assistance and the related food benefits.
  • HCS and DDA LTC specialty workers always maintain classic Medicaid programs for clients receiving HCS and DDA services.  They also maintain the classic Medicaid program for a spouse when the other spouse is on LTSS.  If the client on LTSS is not a child, the HCA and DDA financial worker maintains the WASHCAP or food benefits for the HH.
  • DDA specialty financial workers do not do food benefits when the only client on DDA services is a child.
  • TANF cash and related food benefits are always maintained by CSD.

“Classic Medicaid” programs are the Aged, Blind, Disabled (SSI-related) medical programs that are not the modified adjusted gross income (MAGI) methodology.  MAGI medical is done through the Health Plan Finder/Health Benefit Exchange. 

The program responsibility chart gives most examples of which entity 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 classic medical, MSP, ABD cash or food benefits for clients on HCS services. Note: If a spouse or dependent is also on a Classic Medicaid program with/without food assistance, HCS maintains both the LTC and the SSI-related AUs and the basic food unless there is TANF cash.
SSI related 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 NF 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.    
Classic 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 a classic Medicaid program.     X     HCS maintains both cases when one of the couple is on a HCS service under classic Medicaid and the other spouse is on any classic Medicaid program including Hospice or DDA services.  HCS maintains the food benefits for the couple.   If one of the couple is on HCS Services and the other is on Hospice as a program under the L31 or L32 program, it is a shared case with the DDA LTC Specialty unit. 
One spouse on DDA Waiver the other spouse on HCS Waiver (L21/L22)     X     HCS maintains both cases when one of the couple is on HCS services and the other is on a DDA services.
Classic Medicaid 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 classic Medicaid or MCS medical and on HCS services. Rule: No TANF cash, and on HCS services via classic Medicaid 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     Individuals 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.  
HCS/DDA specialty unit SHARED CASES HBE HCA HCS DDA/LTC Specialty CSD Notes
HCS/DDA specialty unit Shared Cases.  DDA child and HCS adult on classic Medicaid     X X   DDA child is on DDA services under classic Medicaid.  HCS parent or grandparent is on HCS services on classic Medicaid.  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 children on DDA services.    
HCS/CSD Shared Cases HBE HCA HCS DDA/LTC specialty CSD Note: Whenever HCA authorizes services on a classic medical case and an H/H 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

Classic medicaid on HCS services is maintained by HCS.

TANF cash and basic food is maintained by CSD

LTC Specialty Units cases 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)

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.

      X   DDA specialty unit determines behavior health admissions into an ALF 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 child and the parent is HOH for the food benefits. CSD manages the food benefits for the HH when there is a DDA child in the household.
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   K track programs are requested directly to the DDA LTC specialty unit. 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 are done by CSD.
MCS on DDA services with ABD cash or HEN (A01, A05)       X   Individuals 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. (R1 and R3 HCS only)
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. HCS maintains the L track and TFA and does the basic food review once the TFA has ended
WASHCAP food AU associated with classic medical and on DDA services       X   DDA Specialty Unit maintains
Classic medicaid on DDA services, no family member on TANF cash. Request for food benefits       X   DDA processes food benefits for ADULTS on classic Medicaid 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 child.  This would be a shared case. If the household is on TANF cash then CSD processes the food request too.
LTC/Specialty Unit/CSD Shared Cases 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 classic MPC/CFC residential case not on HCS services. Since the family is not living under the same roof, CSD would maintain the classic 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 Classic Medicaid 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 classic 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
Medical Care Services (MCS) Not on HCS/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 can't 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/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 DDACSD 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 can't 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
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 DDATANF 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 Classic Medicaid 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
Medicare Savings Programs not on HCS or DDA services (S03, S04, S05, S06)SSI related: S01, S02, S95, S99, not on HCS or DDA services         X MSP when no HCS or DDA services are attached are managed by CSD. Classic Medicaid 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/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/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 Childcare not on HCS or DDA services Childcare         X HCS will do courtesy nursing facility award letters for WASHCAP cases for nursing facility admissions under 30 days. All childcare is managed through CSD
Hospital applications. No admission date to a NF or ALF is known.         X Classic 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
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 whatever agency has the active Classic Medicaid program. See short stays. This responsibility could be HCA (for active foster care or breast and cervical cancer, CSD (for active classic medicaid 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.
LTC L track cases (L01, L02, L95, L21, L22, L04, L24) on HCS services and HH member receiving TANF/SFA cash and food. H/H 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.

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 LTC L track cases (L01, L02, L95, L21, L22, L04, L24) on HCS services and HH member receiving TANF/SFA cash and food. H/H 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.

What is an institutional Medicaid program and what are long term care services?

The term "institutional" Medicaid means institutional medicaid rules are used in eligibility. This group has initial eligibility for the Medicaid and post-eligibility that determines if the client pays toward the cost of care. These clients are either residing in a medical institution or on a HCB Waiver. Some programs may use the same rules as a HCB Waiver such as Hospice, PACE and RCL and may pay toward the cost of care.  

In ACES the institutional medical programs are under the L01, L02, L95, L99, L21, and L22 (ABD) programs, L04 and L24 state-funded long term care or Health care for children. PACE and Hospice as a program is under the L31 and L32 program.  RCL is under the L41 and L42 program.  MAGI, clients can be on the Hospice or RCL program.  Institutional rules are only used if the client isn’t eligible for another CN or ABP program.  

Long-term care (LTC) programs provide services for the elderly and disabled in need of institutional care. Some individuals who receive LTC services are able to continue living in their home or in an alternate living facility (ALF) on a Home and Community based (HCB) Waiver authorized by Home and Community Services (HCS) or the Development Disabilities Administration (DDA). LTSS programs that are not considered “institutional” programs are Medicaid Personal Care (MPC) and Community First Choice (CFC).  

Home & Community Based Services

Home and community-based services, provided under a Medicaid waiver granted by the federal government, enable an individual 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:

  • COPES (Community Options Program Entry System) authorized by HCS.
  • New Freedom authorized by HCS.
  • PACE (Program for All-Inclusive Care to the Elderly) 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 DDA or 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 DDA or HCS.
  • Core authorized by DDA 
  • Community Protection authorized by DDA.
  • CIIBS (Children's Intensive In-home Behavioral Support) authorized by DDA.

Individual Family Services (IFS) authorized by DDA.

HCB Waiver services L22 cannot be authorized under a MAGI "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 any "Classic Medicaid" program.

Institutional Services

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

Hospice Services

Some individuals receive Hospice index services in addition to or instead of services in their home or a medical facility. Hospice provides palliative care for individuals 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. 

Institutional Status

All individuals 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.

Medicaid Personal Care (MPC)

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

MPC individuals 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 an individual'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 an individual'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 individuals 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 an individual 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 manager, DDA case manager (CM) or the Veterans Affairs registered nurse (VARN) determines functional eligibility for HCB waivers and MPC based on the individual's assessment which takes into account the individual'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 individual's income, resources, and circumstances to program requirements

The amount of income and excess resources an individual 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

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

Agency/Department Responsibilities

Aging and Long Term Supports Administration (ALTSA)

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 break up 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) individuals:
    • Developmental Disabilities administration (DDA) individuals receiving LTC services in a DDA medical institution, ​DDA Home and Community Based (HCB) waivers or Medicaid Personal Care residential services paid for by DDA and authorized under a "Classic Medicaid" assistance unit. (Unless the DDA individual is married and spouse is on HCS services, see HCS responsibility below).
    • DDA LTC medical institutions are:
    • Residential Habilitation Centers (RHC)
      • Fircrest School
      • Lakeland Village
      • Rainier School
      • Yakima Valley School
    • Intermediate Care Facilities for the Intellectually Disabled (ICF/ID)
      • Barclay Group Home
      • Chelsea
      • Brookhaven
      • Bedford
      • Camelot Group Home
      • Carlton
    • Mental health individuals receiving residential services paid for by Mental Health / Behavioral Health Organization (MH/BHO) in an ALF. Client not eligible for a MAGI, S01 or S02 and G03 rules need to be used for eligibility.
    • Institutional children or family medical (K track)
    • Hospice program rules are needed for eligibility because the client is not on a CN, MN or ABP program living outside a medical institution.
    • 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).
    • 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 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 individuals who receive the following services from HCS:
    • Nursing facility (NF) care;
      • New applications and maintenance for nursing facility (NF) care under the L track program.
      • Active classic Medicaid individuals 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 individuals in the household do not receive TANF cash.
    • ABD cash for individuals receiving services authorized by HCS and eligible for HEN/MCS. ABD cash requires a 9 month disability duration determination by CSD for individuals under age 65.
    • Medical Care Services (MCS) for individuals receiving services authorized by HCS if there is no TANF cash
    • Married couple, one individual is on HCS services ( Classic Medicaid MPC or HCS Waiver or nursing home) the other spouse is on active DDA services.(Classic Medicaid MPC or DDA Waiver).
    • Married couple, one individual is on HCS services (MPC, HCS Waiver or nursing home). The other spouse is not on institutional medical, but is applying for a classic medical program HCS is responsible for the application and maintenance of the community spouse's application for classic 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 classic medicaid 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:

  • 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 individual 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 individual 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 individual will remain on the 'D' track program.
    • Email Lori Rolley HCS HQ to coordinate with HCA-Foster Care Unit. Include client name and client ID.
    • D02/D26 Foster Care cases remain with 076 until they age out, usually at age 26.
  • Individual is active on S30 breast and cervical cancer case. Individuals on this program are eligible for MPC services if found functionally eligible. Active S30 cases will remain with the MEDS unit. S30 individuals are not eligible for waiver services or nursing home coverage 30 days or longer. The individuals 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
  • Individual 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.
  • Childcare Assistance
  • Classic 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 a classic 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 individuals need to be referred to the HBE call center (1-855-923-4633).

Classic Medicaid or Modified Adjusted Gross Income (MAGI)?

Effective 10/1/2013, children, parents and pregnant women will be converted over to medical determined under the Modified Adjusted Gross Income (MAGI) methodology starting with the 11/2013 renewals.

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 and K track is always maintained by HCS or DDA Specialty Unit financial workers.
  • 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 Health Care Authority (HCA).

Basic Program Division:

  • HCS maintains Classic Medicaid cases when a HH member is receiving HCS services or a classic Medicaid client residing in a NF 30 days or more.
  • DDA LTC specialty unit maintains Classic Medicaid cases when a HH member is receiving DDA HCB Waiver services, Classic CN Medicaid for MPC in DDA residential settings and DDA institutions. In addition this unit does:
    • All HWD cases with the exception of HWD individuals 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).
    • All K track cases (Institutional children and families).
  • L track hospitalization 30 days or more ONLY if the individual 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 maintains any Medicare Savings program associated with an LTC case under the 'L' track.

CSD Cases:

  • Classic Medicaid 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 individuals:
    • Age 21 or under at discharge.
    • 65 or older
    • Individuals needing classic medicaid 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 classic 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