Tailored supports for older adults (TSOA) presumptive eligibility

Revised Date:

July 16, 2019

Purpose: This section describes how the presumptive eligibility process works.

WAC 182-513-1620 Tailored Supports for Older Adults (TSOA) - Presumptive Eligibility

WAC 182-513-1620 Tailored Supports for Older Adults (TSOA) - Presumptive Eligibility (PE).

Effective June 22, 2019

A person may be determined presumptively eligible for tailored supports for older adults (TSOA) services upon completion of a prescreening interview.
The prescreening interview may be conducted by either:
1. The area agency on aging (AAA); or
2. By a home and community services intake case manager or social worker.
To receive services under presumptive eligibility (PE), the person must meet:
1. Nursing facility level of care under WAC 388-106-0355;
2. TSOA income limits under WAC 182-513-1635; and
3. TSOA resource limits under WAC 182-513-1640.
The presumptive period begins on the date the determination is made and:
1. Ends on the last day of the month following the month of the presumptive eligibility (PE) determination if a full TSOA application is not completed and submitted by that date; or
2. Continues through the date the final TSOA eligibility determination is made if a full TSOA application is submitted before the last day of the month following the month of the PE determination.
If the person applies and is not determined financially eligible for TSOA, there is no overpayment or liability on the part of the applicant for services received during the PE period.
The medicaid agency or the agency's designee sends written notice as described in WAC 182-518-0010 when PE for TSOA is approved or denied.
A person may receive only one PE period within a consecutive twenty-four-month period.
If the department of social and health services establishes a waitlist for TSOA services under WAC 388-106-1975, PE does not apply.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

Clarifying Information

People who are interested in applying for TSOA or MAC may do so by contacting their local AAA or HCS office. A person may be found presumptively eligible and services may be approved for eligible people pending completion of the application process.

Both TSOA and MAC have a presumptive eligibility component that allows services to be authorized based on a quick prescreening of financial and functional eligibility criteria. The goals of both programs are to get services in place quickly to support the person and caregivers taking care of them. If the person is found presumptively eligible (PE) they can receive services for a period of up to about 60 days while the financial application is being processed and while DSHS confirms that the person meets the functional criteria for the programs.

As long as a financial application has been filed the PE period continues until the application is completed.

If an application isn’t filed, the PE period will end at the end of the month after the month in which services were first authorized.

For example:

Mary is a caregiver to her father Joe. She talks with the local AAA office about getting some help with a bath bench for Joe. She asks about some possible training on how to safely lift him out of his bed in the morning and from his chair at night. Joe is found presumptively eligible for services under TSOA on 8/10 and is authorized to receive a bath bench. Mary is scheduled for a local caregiver training class. Mary and Joe have until 9/30 to file an HCA 18-008 Application for TSOA if they wish to continue to receive services. If they don’t apply by that date, the TSOA services ends on 09/30.

Mary indicates she would also like respite services so she can get some shopping done for her family once a week. She agrees to complete a TCARE Assessment and files the TSOA application form on 8/25. Because Mary filed the application before the PE period ended, she can continue to receive services, including respite services, until a final decision is made on Joe’s application, even if the final decision takes longer than 09/30.

If it is later determined that the person wasn’t eligible for services, there is no requirement to repay any of the services that were received during the PE period. TSOA and MAC can’t be back-dated and won’t cover services provided before the date of the authorization.

Worker Responsibilities

The PE process is determined and authorized by the AAA and HCS social services staff. Unlike Fast Track, financial staff don’t need to send a 07-104 communication to the authorizing case manager, approving PE.

For MAC: PE is only authorized for people who are currently eligible for CNP or ABP coverage, therefore the PE determination is only for the functional eligibility criteria. Staff should document the PE approval in the person’s case. If NFLOC is approved and MAC services are authorized, HCS will need to transfer the medicaid case into their HCS office to manage.

For TSOA: The PE determination may be for both functional and financial eligibility criteria. In most cases, the TSOA applicant will not be eligible for medicaid so the HCS financial worker doesn’t need to do anything at the time of the PE approval. Once a TSOA application is received and a case is screened into ACES, the worker should document that PE was authorized and send the case manager a 07-104 communication notifying them that the application was filed so that the PE authorization period can be extended until the application is processed. There is no requirement to open T02 coverage in months prior to the application month to cover the PE period.

Once the TSOA application is approved or denied, send another 07-104 communication to the case manager to notify them of the final decision.

Note: If the PE determination is made by AAA staff, the worker must select the correct AAA location in Barcode in order to send the 07-104 form to AAA staff responsible for the Medicaid Transformation Project, and not to AAA Medicaid Case Management staff.