Long-term services and supports (LTSS) manual

Available resources

Revised Date: 
February 10, 2014

Purpose: This section describes resource eligibility for institutional medicaid programs including HCBS Waiver programs.

WAC 182-513-1350 Defining the resource standard and determining resource eligibility for SSI-related long-term care (LTC) services.

Effective September 28, 2017

  1. General information.
    1. This section describes how the agency or its designee defines the resource standard and countable or excluded resources when determining a person's eligibility for SSI-related long-term care (LTC) services.
    2. "Resource standard" means the maximum amount of resources a person can have and still be resource eligible for program benefits.
    3. For a person not SSI-related, the agency applies program specific resource rules to determine eligibility.
  2. Resource standards.
    1. The resource standard for the following people is $2000:
      1. A single person; or
      2. An institutionalized spouse.
    2. The resource standard for a legally married couple is $3000, unless subsection (3)(b)(ii) of this section applies.
    3. The resource standard for a person with a qualified long-term care partnership policy under WAC 182-513-1400 may be higher based on the dollar amount paid out by a partnership policy.
    4. Determining the amount of resources that can be allocated to the community spouse when determining resource eligibility is under WAC 182-513-1355.
  3. Availability of resources.
    1. General. The agency or its designee applies the following rules when determining available resources for LTC services:
      1. WAC 182-512-0300 SSI-related medical—Resources eligibility;
      2. WAC 182-512-0250 SSI-related medical—Ownership and availability of resources; and
      3. WAC 182-512-0260 SSI-related medical—How to count a sponsor's resources.
    2. Married couples.
      1. When both spouses apply for LTC services, the resources of both spouses are available to each other through the month in which the spouses stopped living together.
      2. When both spouses are institutionalized, the agency or its designee determines the eligibility of each spouse as a single person the month following the month of separation.
      3. If the agency or its designee has already established eligibility and authorized services for one spouse, and the community spouse needs LTC services in the same month, but after eligibility has been established and services authorized for the institutionalized spouse, then the agency applies the standard under subsection (2)(a) of this section to each spouse. If doing this would make one of the spouses ineligible, then the agency applies subsection (2)(b) of this section for the couple.
      4. The resources of the community spouse are unavailable to the institutionalized spouse the month after eligibility for LTC services is established, unless (v) or (vi) of this subsection applies.
      5. When a single institutionalized individual marries, the agency or its designee redetermines eligibility applying the resource and income rules for a legally married couple.
      6. A redetermination of the couple's resources under this section is required if:
        1. The institutionalized spouse has a break of at least thirty consecutive days in a period of institutional status;
        2. The institutionalized spouse's countable resources exceed the standard under subsection (2)(a) of this section, and WAC 182-513-1355 (2)(b) applies; or
        3. The institutionalized spouse does not transfer the amount, under WAC 182-513-1355 (3) or (5), to the community spouse by either:
          1. The end of the month of the first regularly scheduled eligibility review; or
          2. A reasonable amount of time necessary to obtain a court order for the support of the community spouse.
  4. Countable resources.
    1. The agency or its designee determines countable resources using the following sections:
      1. WAC 182-512-0200 SSI-related medical—Definition of resources.
      2. WAC 182-512-0250 SSI-related medical—Ownership and availability of resources.
      3. WAC 182-512-0260 SSI-related medical—How to count a sponsor's resources.
      4. WAC 182-512-0300 SSI-related medical—Resources eligibility.
      5. WAC 182-512-0350 SSI-related medical—Property and contracts excluded as resources;
      6. WAC 182-512-0400 SSI-related medical—Vehicles excluded as resources;
      7. WAC 182-512-0450 SSI-related medical—Life insurance excluded as a resource; and
      8. WAC 182-512-0500 SSI-related medical—Burial funds, contracts and spaces excluded as resources.
      9. Chapter 182-516 WAC, Trusts, annuities, life estates, and promissory notes—Effect on medical programs.
    2. The agency or its designee determines excluded resources based on federal law and WAC 182-512-0550, except:
      1. For institutional and HCB waiver programs, pension funds owned by a nonapplying spouse are counted toward the resource standard.
      2. For long-term services and supports (LTSS), based on the need for either nursing facility level of care or intermediate care facility for the intellectually disabled level of care, one home is excluded only if it meets the home equity limits of subsection (8) of this section. See WAC 182-512-0350 (1)(b).
    3. The agency or its designee adds together the countable resources of both spouses if subsections (3)(b)(i) and (iv) apply, but not if subsection (3)(b)(ii) or (iii) apply. For a person with a community spouse, see WAC 182-513-1355.
  5. Excess resources.
    1. For LTC programs, a person may reduce excess resources by deducting incurred medical expenses under subsection (6) of this section;
    2. The amount of excess resources is limited to the following amounts:
      1. For LTC services provided under the categorically needy (CN) program:
        1. In a medical institution, excess resources and available income must be under the state medicaid rate based on the number of days the person spent in the medical institution in the month.
        2. For HCB waiver eligibility, incurred medical expenses must reduce resources within allowable resource standards. The cost of care for the HCB waiver services cannot be allowed as a projected expense.
      2. For LTC services provided under the medically needy (MN) program, see:
        1. WAC 182-513-1395 for LTC programs; and
        2. WAC 182-513-1245 for hospice.
    3. Excess resources not otherwise applied to medical expenses will be applied to the projected cost of care for services in a medical institution under WAC 182-513-1380.
  6. Allowable medical expenses.
    1. The following incurred medical expenses may be used to reduce excess resources:
      1. Premiums, deductibles, coinsurance, or copayment charges for health insurance and medicare;
      2. Medically necessary care defined under WAC 182-500-0070, but not covered under the state's medicaid plan. Information regarding covered services is under chapter 182-501 WAC;
      3. Medically necessary care defined under WAC 182-500-0070 incurred prior to medicaid eligibility. Expenses for nursing facility care are reduced at the state rate for the specific facility that provided the services.
    2. To be allowed, the medical expense must:
      1. Have been incurred no more than three months before the month of the medicaid application;
      2. Not be subject to third-party payment or reimbursement;
      3. Not have been used to satisfy a previous spenddown liability;
      4. Not have been previously used to reduce excess resources;
      5. Not have been used to reduce participation;
      6. Not have been incurred during a transfer of asset penalty under WAC 182-513-1363; and
      7. Be an amount for which the person remains liable.
  7. ​Nonallowable expenses. The following expenses are not allowed to reduce excess resources:
    1. Unpaid adult family home (AFH) or assisted living facility expenses incurred prior to medicaid eligibility;
    2. Personal care cost in excess of approved hours determined by the CARE assessment under chapter 388-106 WAC; and
    3. Expenses excluded by federal law.
  8. Excess home equity.
    1. A person with an equity interest in a primary residence in excess of the home equity limit is ineligible for long-term services and supports (LTSS) that are based on the need for either nursing facility level of care or intermediate care facility for the intellectually disabled level of care, unless one of the following persons lawfully resides in the home:
      1. That person's spouse; or
      2. That person's dependent child under age twenty-one, blind child, or disabled child.
    2. The home equity provision applies to all applications for LTSS received on or after May 1, 2006.
    3. Effective January 1, 2016, the excess home equity limit is $552,000. On January 1, 2017, and on January 1st of each year thereafter, this standard may change by the percentage in the consumer price index-urban.
    4. A person who is denied or terminated LTC services due to excess home equity may apply for an undue hardship waiver under WAC 182-513-1367.
  9. Institutional resource standards are found at http://www.hca.wa.gov/free-or-low-cost-health-care/program-administration/program-standard-income-and-resources.

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.

WAC 182-513-1355 Allocating resources to a community spouse when determining resource eligibility for SSI-related long-term care services

Effective February 20, 2017

  1. The agency or its designee uses this section to calculate the resource allocation from the institutionalized spouse to the community spouse for the determination of the institutionalized spouse's resource eligibility under WAC 182-513-1350 (2)(a)(ii).
  2. If the institutionalized spouse's most recent continuous period of institutionalization (MRCPI) began:
    1. Before October 1, 1989, the agency adds together one-half the total amount of countable resources, as determined under WAC 182-513-1350(4), held in the name of:
      1. The institutionalized spouse; and
      2. Both spouses.
    2. On or after October 1, 1989, the agency or its designee adds together the total amount of countable resources, as determined under WAC 182-513-1350(4), held in the name of:
      1. Either spouse; and
      2. Both spouses.
  3. If subsection (2)(b) of this section applies, the agency or its designee determines the amount of resources allocated to the community spouse, before determining the amount of countable resources used to establish eligibility for the institutionalized spouse under WAC 182-513-1350:
    1. If the institutionalized spouse's MRCPI began on or after October 1, 1989, and before August 1, 2003, the agency or its designee allocates the federal spousal resource maximum;
    2. If the institutionalized spouse's MRCPI began on or after August 1, 2003, the agency or its designee allocates the greater of:
      1. A spousal share equal to one-half of the couple's combined countable resources, up to the federal spousal resource maximum; or
      2. The state spousal resource standard.
  4. Countable resources under subsection (3)(b) of this section determined as of the first day of the month in which MRCPI began.
  5. The agency or its designee uses a community spouse evaluation to determine the amount of the spousal share under subsection (3)(b)(i) of this section.
  6. The agency or its designee completes a community spouse resource evaluation:
    1. Upon request by the institutionalized spouse, or the institutionalized spouse's community spouse;
    2. At any time between the date that the MRCPI began and the date that eligibility for long-term care (LTC) is determined; and
    3. Upon receipt of any verification required to establish the amount of the couple's resources in the month of MRCPI.
  7. The community spouse resource evaluation can be completed prior to an application for LTC or as part of the LTC application if:
    1. The beginning of the MRCPI was prior to the month of application; and
    2. The spousal share exceeds the state spousal resource standard.
  8. The amount of allocated resources under subsection (3) of this section can be increased, but only if:
    1. A court has entered an order against the institutionalized spouse for the support of the community spouse or a dependent of either spouse; or
    2. A final order is entered under chapter 182-526 WAC, ruling that the institutionalized spouse or community spouse established that the income generated by the resources allocated under subsection (3) of this section is insufficient to raise the community spouse's income to the monthly maintenance needs allowance (MMNA) determined under WAC 182-513-1385, but only after the application of the income-first rule under 42 U.S.C. 1396r–5(d)(6).
  9. If a final order establishes that the conditions identified in subsection (8)(b) of this section have been met, then an amount of allocated resources under subsection (3) of this section will be substituted by an amount adequate to provide such an MMNA.
  10. The institutionalized spouse has until the end of the month of the first regularly scheduled eligibility review to transfer countable resources in excess of $2000 to the community spouse.
  11. Standards in this section are found at http://www.hca.wa.gov/free-or-low-cost-health-care/program-administration/program-standard-income-and-resources.

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

Resource ownership and availability describes how the department defines resources, determines ownership and availability of resources, property and contracts, vehicles, life insurance, burial funds and other excluded resources.

Resource eligibility and excess resource eligibility specific to long-term care is described in WAC 182-513-1350.

Standards - LTSS

The individual must be resource eligible on the first day of the month to be eligible for any day or days of that month. A resource determination is made on the first moment of the first day of the month. Changes in the amount of an individual's countable resources during a month do not affect eligibility or ineligibility for that month. WAC 182-512-0300 (1)

Excess Resources

182-513-1350 (8) (d) (e) and (f)

Excess resources for any historical month will first be reduced by qualifying medical expenses coded on the LTCX screen. Then, for individuals in a medical institution, any remaining excess resources will be applied to the individual's participation. If the individual's resources cannot be reduced to the program limit through this process, the assistance unit will be terminated or denied. The remaining excess resources do not carry forward for use in any months beyond the months in which they are entered.

Excess Resources will not be reduced by medical expenses or applied to the individual's participation in any month beyond the current calendar month. When excess resources exist in any benefit month beyond the current calendar month, the assistance unit will be terminated or denied.

The following long term care expense types are considered incurred medical expenses and will be used to reduce excess resources in this order:

  • UB – Outstanding Nursing Home Bill
  • UO – Old Medical Bill
  • UA – Adult Day Health
  • UM – Medical Necessity MA Not Covered
  • UH – Hearing Aids
  • OH – Health Insurance
  • UD – Prescription Expenses Not Covered By Medicare Part D
  • OP – Medicare Part D Copayments
  • OL – LTC Insurance
  • OD – Medicare Part D Premiums
  • OC – Medicare Part C Premiums
  • OB – Medicare Part B Premiums
  • OA – Medicare Part A Premiums

Multiple expenses of the same type are deducted in order of highest amount to lowest amount.

All other expense types are not considered medical expenses and can't be used to reduce excess resources.

Excess Resources and Medical Institutions

ACES will compare the individual's income plus excess resources to the cost of care

  • In a full calendar month it will use the state daily rate x 30.42
  • In a partial month, it will use the state daily rate x the actual number of days

If the income plus the remaining excess resources is not more than the cost of care, the case will open and assign the excess.

If the income plus remaining excess resources is more than the cost of care, the case will deny.

Income only determines CN versus MN. Excess resources do not affect the scope of care the individual is eligible to receive.

If excess resources causes a case to go into L99 spenddown, the case needs to be denied.

Excess Resources and HCB Waiver (COPES)

For CN Waiver eligibility, incurred medical expenses must reduce resources within the allowable resource limits for CN-Waiver eligibility. The cost of care for waiver services cannot be allowed as a projected expense.

  • If medical expenses do not reduce the excess to the applicable resource standard, the case will deny.
  • If medical expenses do reduce the excess to the applicable resource standard, the case will open.

Set a barcode tickler to check resource eligibility on the first of the month when appropriate.

Excess Resources in the application month

  • Ensure the excess is in the first month of eligibility only
  • Adjust the resource amount in the remaining processing months to the applicable standard
  • ACES will deny if excess is coded in the ongoing month.

Active Cases

  • A review does not need to be initiated
  • Update the resource information in the current or historical month
  • Case will process as described

Short stays-Medical Institution

  • Excess will not be assigned to the cost of care for days coded on the STAY screen
  • Excess will be applied if the facility is coded using INST

Burial Fund

An individual may also reduce excess resources by using funds to establish a burial fund, if appropriate. Care must be taken to ensure that excess resources are spent during the month of application. See SSI related rules regarding burial funds.

Assignment of excess resources when Medicare pays 100%

An individual is not eligible if they have excess resources that must be assigned toward cost of care (medical institution) when there is no obligation to pay the facility for that month because Medicare or another TPL source is covering 100% of the cost. Deny eligibility for that month as there isn't a cost of care the individual is obligated to pay. Consider eligibility for the following month.

This is only for issues where the individual has excess resources and other coverage. If the individual doesn't have excess resources, Medicare or other TPL coverage does not affect eligibility.

For months where there is other coverage for only a part of a month, eligibility with excess resources will be based on the cost for the number of days the individual is obligated to pay, similar to a partial month with excess resources:

  • If the assigned excess plus income is greater than the cost for the number of days of individual's obligation, the individual isn't eligible.
  • If the assigned excess plus income is no greater than the cost for the number of days of individual's obligation, the individual is eligible and must pay the excess toward care.
  • Code the date the client starts having an obligation to pay as the payment authorization date.

Example #1: Excess, not eligible:
Arlo is single and his monthly income is $2,000. On 2/1 his resources were $2500 after reducing for out-of-pocket medical expenses. He admits to the nursing home under Medicare on 2/19 and applies for Medicaid. Medicare is paying the cost at $100%. Because he has no obligation toward his cost of care, his excess resources cannot be assigned to an actual medical obligation. He is not resource eligible. Deny February for being over resources and consider eligibility for March.

Example #2: Excess, is eligible:
Milly is single and her monthly income is $2,000. On 2/1 her resources were $2,000 after reducing for out-of-pocket medical expenses. She enters the nursing home under Medicare on 2/19 and applies for Medicaid. Medicare is paying the cost at 100%. She is eligible because her resources do not need to be assigned toward the cost of care.

Active cases and excess resources

If excess resources were assigned but never paid and the client is still over resources in a subsequent month, you cannot assign the same excess again. The only alternative is to terminate the case.

  • Determine if the excess is the same funds previously assigned
  • If it is the same funds, do not assign them again
  • Find out if they have paid but it is not yet reflected in the accounts by discussing with the institution bookkeeper
  • If it has not been paid, advise the individual they are not eligible as their eligibility was contingent upon them paying that excess toward care
  • Determine if/when they are going to pay it and follow up
  • If individual fails to pay it after allowing a reasonable time (10 days) propose termination

Advise HQ there is a situation where an active medical institution case starts receiving Medicare coverage at 100% (nursing home readmit after a hospital stay) and has excess resources. This will be very rare and most likely will be an overpayment.

When a client becomes ineligible due to excess resources and notifies the agency timely, and the notification is beyond the time for 10 day notice to be given. We do not terminate the case. We must give 10 day notice, unless the client verbally waives the notice to prevent an overpayment. See WAC 182-518-0025

Example #1: 10 day notice
Client received a lump sum on 4/25/2015. They have 30 days to report and report the change of 5/10/2015. Their combined resources on 5/1/2015 were $4000. In this example we would propose termination effective 5/31/2015 and indicate if the client's resources are at or below $2000. We would need verification, see Verification requirements. We could reinstate eligibility if reported within 30 days

Annuities, Trusts and Life Estates

See How annuities affect eligibility for information on how annuities, trusts and life estates affect SSI related and LTC eligibility.

Definitions related to trusts, annuities and life estates.

Use the Individual Annuity (Life Expectancy) Tables in Appendix IV to determine whether annuity payments will exceed a time frame based on the actuarial life expectancy of the individual. If they do, establish a period of ineligibility described in the transfer of asset section.

Determine whether a life estate can be excluded as a resource. If not, determine its value as a nonexcluded resource by using Appendix II - Determining the Value of Life Estates. If the life estate is jointly owned, divide the value by the number of joint owners to determine the individual’s share.

Reverse mortgage, Promissory Notes and Loans

Reverse mortgage, promissory notes, and loans

Vehicles

WAC 182-513-1350 (8) (b) states:

  1. For an SSI-related client one automobile per household is excluded regardless of value if it is used for transportation of the eligible individual/couple.
    1. For an SSI-related individual with a community spouse, the value of one automobile is excluded regardless of its use or value.
    2. Vehicles not meeting the definition of automobile is a vehicle that has been junked or a vehicle that is used only as a recreational vehicle.

What this means is 1 vehicle is excluded for SSI related programs if used for transportation. For institutional programs with a community spouse a vehicle is excluded regardless of it's use.

This does not mean there are 2 vehicle exclusions for institutional medicaid.

Example #1. Single individual in a nursing home has a vehicle that is not being used to transport the individual. In this example the vehicle is not excluded as it is not used to transport the individual.

Example #2. Married individual in a nursing home. Community spouse cannot drive. The vehicle is still excluded because the value of one automobile is excluded regardless of use.

The exclusion for SSI-related individuals with a community spouse supersedes the exclusion for an SSI related individual being transported described in WAC 182-512-0400 (2). You cannot get both exclusions. There is 1 vehicle exclusion for institutional SSI related medical.

Patient trust account

  1. An individual can establish a patient trust account in a nursing facility, if the individual is not capable of handling personal funds or has requested in writing that one be established.
  2. The Nursing Facility is required to:
    1. Maintain an interest bearing account for balances above $49.99
    2. Keep a ledger of the trust account balance of each individual
    3. Notify the HCS/CSO FSS when the trust account is close to the resource standard
  3. If the individual leaves a medical facility, the facility returns these funds to the individual. If the individual dies, the facility sends these funds to the Office of Financial Recovery. If the individual leaves and his/her whereabouts are unknown, the facility sends these funds to the Department of Revenue.

Home as an excluded resource

WAC 182-513-1350

The individual's home with equity less than $500,000 is an excluded resources. This includes the land on which the dwelling is located and all contiguous property and related out buildings in which the individual has ownership interest, when:

  1. The individual uses the home as his or her primary residence; or
  2. The individual's spouse lives in the home; or
  3. The individual does not currently live in the home but the individual or his/her representative has stated the individual intends to return to the home

When the home cannot be excluded the individual must make a reasonable attempt to convert the property to an available resource. Providing one of the following does this:

  1. Current real estate listing
  2. Advertisement showing property is for sale
  3. Other verification to show reasonable effort to sell the property.

Excess Home Equity is an eligibility factor for payment of long-term care services

Excess home equity value over the excess home equity standard is a provision specific to long-term care services. If an individual has excess home equity, there is no eligibility for payment of long-term care services.

See: Excess home equity

Resources of a married couple

  1. Resources of a married couple-one spouse institutionalized. The rules regarding resources for married couples are different depending on when the institutionalized spouse began the current period of institutional status.
    1. If the current period of institutional status began before October 1, 1989, the determination of eligibility does not include any resources of the community spouse that are owned and maintained separately from community resources. Once eligibility has been established, this rule remains in effect unless a break of at least thirty consecutive days occurs.
    2. If the current period of institutional status began on or after October 1, 1989, the spousal impoverishment count all nonexcluded resources owned by either or both spouses, separately or jointly. The department then allocates the amount set aside for the community spouse
    3. The amount that is allocated is based upon the onset date of the current period of institutional status. One set of rules covers married clients who become institutionalized before 8/1/03. A separate set of rules covers married individuals who become institutionalized on or after 8/1/03.
    4. The amount of allocation allowed, based on the appropriate set of rules, can be increased only as described in WAC 182-513-1350 :
      1. Pursuant to a court order for spousal support
      2. When an administrative law judge (ALJ) approves a determination by Home and Community Services (HCS) that the excess resources are needed to produce income to provide the community spouse the minimum maintenance allocation.
    5. Once eligibility has been established, this resource determination remains in effect unless a break of at least thirty consecutive days occurs, or if the institutionalized spouse acquires resources above the program standard.
    6. If the onset date of the current period of institutional status is after October 1, 1989 and before August 1, 2003, the federal Community Spouse Resource maximum that was in place at the time of the application is used as the Community Spouse Resource Allocation. See Example #1.
    7. If the onset date of the current period of institutional status is on or after August 1, 2003, the State Spousal Resource Standard that was in place at the time of the application is used as the Community Spouse Resource Allocation, unless:
      1. The individual or community spouse requests an evaluation of their community resources; and
      2. The results of the evaluation show the spousal share of the community resources at the onset of institutional status, or 1/2 of the couple’s total nonexcluded resources, was greater than the State Spousal Resource Standard. See Example #2
  2. Resource Evaluations: Married clients who become institutionalized on or after 8/1/03 and have a community spouse can request HCS to evaluate their resources. This evaluation is used to determine if they are eligible for a higher spousal resource allocation than the State Spousal Resource Allocation standard. When evaluating community resources, consider the value of all nonexcluded resources owned by either spouse separately or jointly as of the first day of the month that institutionalization began. Resource Evaluations can be requested and completed prior to the LTC Medicaid application or at the time of the LTC Medicaid application. Verification of all resources is required to complete the evaluation.
    1. HCS Community Resource Declaration: The HCS Community Resource Declaration form has been developed for individuals to use when requesting an evaluation. The DSHS 14-501 Community Resource Declaration is available on the DSHS forms website.
    2. Evaluation letter templates: In addition to the HCS Community Resource Declaration form, four letter templates are available for staff use when communicating with individuals when resource evaluations are requested prior to receiving the Medicaid application. These forms are available to DSHS staff on the ADSA forms page.
      1. Request for Verification - This letter is sent to request resource verification. Allow 10 days for the client or spouse to provide the information.
      2. Community Resource Evaluation Completed - This letter is sent to advise the individual and spouse that the community resource evaluation is completed. A copy of the completed HCS Community Declaration form that includes the amount of the spousal share is sent with this letter.
      3. Unable to Complete the Community Resource Evaluation - This letter is sent when the individual or spouse does not provide resource verification. This letter advises them that the evaluation cannot be completed without the verification. It will also tell the individual that the evaluation will be completed when the verification is received.
      4. Evaluation is not Required -This letter is sent when a couple requests an evaluation of community resources but it is not required. An evaluation is not required when:
        1. The current period of institutional status began prior to 8/1/03
        2. The total nonexcluded resources are at or below the state spousal resource share for the community spouse plus the $2,000 resource limit allowed for the institutional spouse
    3. Spousal Share: The spousal share is one-half of the total nonexcluded community resources owned by the couple as of the first day of the month the applying institutional spouse first become institutionalized. The spousal share can be used as the Community Spouse Resource Allocation when the amount of spousal share exceeds the State Spousal Resource Standard. However, if the spousal share exceeds the federal Community Spouse Resource Allocation maximum standard, then we can allow only up to the federal maximum standard that is in place at the time the institutional client applies for LTC Medicaid.
    4. Resources of a married couple – both institutionalized: The spousal impoverishment rules do not apply if both spouses are institutionalized. If both spouses apply for LTC services during the same month, the department considers all nonexcluded resources available to both spouses when establishing eligibility. If one spouse applies for LTC services in a month after eligibility for the other spouse has been established, or if both were denied in the previous month because of excess resources, the department considers one-half of community resources and separate resources respectively when determining the eligibility of each spouse.

Worker Responsibilities - Resources of a Couple

When the current period of institutional status began before October 1, 1989:

  1. Consider resources in both spouses’ names as community resources (jointly owned).
  2. Do not count separate resources of each spouse as a community resource. In order to be considered separate, these resources must belong to one spouse and be maintained separately from community resources.
  3. Count one-half of the community resources and one-half of the resources owned by the institutionalized spouse toward the Medicaid resource standard for one person of $2,000 to determine resource eligibility.

When the current period of institutional status began on or after October 1, 1989:

  1. Determine the value of the community resources as of the first day of the month of application. Include all nonexcluded resources of both spouses. Do not consider whether or not the resources are separate or jointly owned.
  2. Allocate nonexcluded community resources to the community spouse up to:
    1. The maximum amount if the client’s institutional status onset was before 8/1/03;
    2. The state spousal resource standard or the spousal share up to the federal maximum if the client’s institutional status onset was on or after 8/1/03; or
    3. An amount ordered by the court or ALJ
  3. Count the remaining resources toward the Medicaid resource standard for one person.
    1. If below the standard, the institutionalized spouse is resource eligible
    2. If above the standard, consider whether the excess amount can be used to satisfy any spenddown liability for the cost of care in the initial month
  4. If you deny the application for excess resources and the individual disputes the value assigned to the resources, send the individual a letter to gain verification of the value of the couples’ resources. Allow ten days, and send a confirmation of denial, if the individual does not respond or provide the information requested. If the information is provided and the individual is ineligible, send a confirmation of denial that itemizes resources and their values.
  5. If the institutionalized spouse is eligible after allocating resources to the community spouse, inform the individual that the names must be changed to that of the community spouse on documents of ownership for the allocated resources by the end of one year. Start this protected period on the date you open LTC services and end this period on the last day of the month in which the first eligibility review is due.
  6. When completing the first eligibility review, determine if the resources have been transferred to the community spouse.
    1. If the transfer has been completed, the institutionalized spouse remains eligible.
    2. If the transfer has not been completed, determine if legal proceedings to transfer the resources have begun. If not, terminate the case after giving the client advance and adequate notice. Do not allow an additional protected period if the individual reapplies unless there is a 30 day break in services. A reapplication after a 30 day break is treated like a new application.
    3. If legal proceedings are under way, tickle the case to review the status of the resources based on the expected date of transfer.
  7. Do not reassess community resources unless the institutionalized spouse has a break of at least thirty consecutive days in the current period of institutional status or acquires resources above the program standard.
  8. When both spouses are institutionalized during the same month, count all nonexcluded resources during the first month of separation. Consider all resources as available to both and compare total resources to the couple institutional standard. If resources are above this standard, both are ineligible for that month. For the month following the month of separation, refer to number 9.
  9. When eligibility has already been established for one spouse, and the other spouse becomes institutionalized in a following month, consider one-half of all community resources jointly held as available to both spouses. Add to that amount the separate resources of each spouse when determining eligibility for each of them. Establish eligibility for each spouses as you do for a single individual. If resources of a spouse are above the standard for one person, that spouse is ineligible.

Use the following guidelines when completing an evaluation of the community resources when the individual becomes institutionalized on or after 8/1/03:

  1. Resource evaluations can be completed prior to the application or at the same time as the application.
  2. An evaluation is not necessary if the individual’s community resources do not exceed the state spousal resource standard plus the resource standard for a single individual (total of $42,000 for time period 8/1/03 through 6/30/05. Effective 7/1/2005, total increased to $43,943).
  3. Determine the value of the community resources as of the first day of the month that institutionalization began.
  4. Obtain verification of the resource values. Allow 10 days for a response.
  5. If the individual does not provide requested verification when completing evaluations prior to the application, send a letter that explains we cannot determine the spousal share without this verification. A letter template is available to DSHS staff from the ADSA home page.
  6. When completing evaluations prior to the application, send the individual and spouse the results. In addition, inform the couple that the spousal share determination may change if there is a break in institutional status of 30 or more consecutive days. A letter template is available to DSHS staff from the ADSA home page.
  7. A new evaluation is needed only if there has been a break in institutional status of 30 or more consecutive days prior to the Medicaid application. If needed, this evaluation can be completed in conjunction with the Medicaid application.
  8. After completing the evaluation, do not require married couples to report changes in institutional status prior to applying for Medicaid. However, when the institutional individual applies, always confirm that there has not been a break in institutional status since completing the evaluation.
  9. If a Community Resource evaluation was completed prior to the Medicaid application, determine if there has been a break in the institutional status of 30 or more consecutive days since the onset of the current period of institutionalization.
  10. When the individual applies, a new evaluation will be needed If there was a break in the individual’s institutional status of 30 or more consecutive days and the individual’s current community resources exceed the state spousal resource standard plus the resource standard for a single person.
  11. When processing the long term care application, if the individual does not provide verification of resources to determine the spousal share:
    1. Use the state spousal resource standard to determine eligibility;
    2. Do not deny the application for failure to provide this information; and
    3. If the individual is over the resource limit after allowing the state spousal resource standard and applying excess resources towards the cost of care, deny the application and explain in the ACES denial letter that we cannot determine the spousal share without the missing verification.

Example #1
A married individual applies for nursing home care on 8/15/03. The individual first entered the hospital on 7/2/03 and discharged to the nursing home on 8/14/03. Because the individual became institutionalized before 8/1/03, use the Federal Community Spouse Resource Allocation maximum standard.

Example #2
A married individual applies for LTC on 3/15/04. The individual first became institutionalized 8/1/03 and has remained institutionalized without a break. Because the individual first became institutionalized on or after 5/1/03, use the State Spousal Resource Standard of $40,000 for the time period 8/1/03 through 6/30/05. (Effective July 1, 2013 State Spousal Resource shared increase to $53,016.) unless the individual or the individual's spouse requests an evaluation of the community resources.

If the individual or the individual's spouse requests an evaluation of the community resources, determine the amount of the spousal share as of the first day of the month the individual became institutionalized.

The individual and spouse had a total of $90,000 of nonexcluded resources on 8/01/03 (the first day of the month that the individual became institutionalized) One-half of the total was $45,000. This is the spousal share. For this individual we would use the spousal share of $45,000 as the Community Spouse Resource allocation because it is higher than the State Spousal Resource Standard and less than the Federal Community Spouse Resource Allocation maximum

The most we can allow is the Federal Community Spouse Resource Allocation maximum. As of 8/1/03 $90,660. If we evaluated the couple's resources and found they had a total of $200,000 in nonexcluded resources as of 8/1/03, then we would use the Federal Community Spouse Allocation maximum in place at the time of application. This is because the spousal share of $100,000 is greater than both the State Spousal Resource Allocation standard and the Federal Community Resource Allocation maximum.

ACES Procedures

Resources-ACES including resource transfer