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General eligibility for Long-term care
March 21, 2019
Purpose: WAC 182-513-1315 is the index roadmap WAC for the general eligibility of institutional and home and community based (HCB) waiver medicaid.
- See Filing
- Follow rules for Washington Apple Health (WAH) Eligibility requirements:
- Chapter 182-503 WAC describes:
- How to Apply
- Who can apply
- Interview requirements
- Verification requirements
- Application processing times
- When coverage begins
- Application denials and withdrawals
- Exceptions to rule
- Rights and responsibilities
- Limited English proficient (LEP) services
- Equal Access Services
- General eligibility requirements
- Program Summary
- Social Security number requirements
- Residency requirements-Persons who are not residing in an institution
- Residency requirements for an institutionalized person
- Citizenship and alien status- Definitions
- Assignment of rights and cooperation
- Age requirements for medical programs based on modified adjusted gross income (MAGI)
- Chapter 182-504 WAC describes:
- Retroactive certification period
- Certification periods for categorically needy (CN) programs
- Certification periods for noninstitutional medically needy (MN) programs
- Medicare Savings Programs certification periods
- Changes that must be reported
- When to report changes
- Effective dates of changes
- Effect of reported changes
- Continued coverage pending an appeal
- Monthly income standards based on the federal poverty level (FPL)
- Chapter 182-503 WAC describes:
- Follow rules in Chapter 182-506 WAC regarding assistance units
- Follow rules in Chapter 182-507 WAC for state funded LTC for noncitizens and AEM
- Follow rules in Chapter 182-508 WAC for Medicare Care Services (MCS) state funded medical
- Follow rules in Chapter 182-510 for SSI medical
- Follow rules in Chapter 182-511 for SSI related Health Care for Workers with Disabilities (HWD).
- Follow rules in Chapter 182-512 for SSI related medical
- For a nursing facility or state funded residential individual whose eligibility is established under the A01 program, waive the sequential evaluation process (SEP) for a client who is eligible to receive ADS services in a nursing facility or state funded residential, refer to the CSO disability specialist for a determination of ABD cash if potentially eligible for ABD cash. If not eligible for ABD cash, because of the duration requirement, open on A01 MCS that includes a referral for Housing Essential Needs (HEN).
- For a client with a potential long-term disability who is not eligible for ABD cash, submit a request to the Division of Disability Determination Services (DDDS).
- If a person is ineligible because of excess income or resources, or does not meet functional eligibility requirements, notify the client of the reasons why the application is denied. Determine eligibility for noninstitutional medical assistance as if the client were living at home.
- If notice is received that an individual no longer needs care provided in a medical facility, redetermine eligibility for other medical programs. Continue CN Medicaid during the redetermination process.
- If a client who is denied services for not meeting functional requirements requests an administrative hearing, notify the SW. The staff person who completed the assessment represents the agency at the hearing, unless someone else is designated for that responsibility.
- Clients who have insurance must complete 14-194 Medical Coverage Information form including LTC insurance. The Coordination of Benefits (COB) unit at HCA will receive the 14-194 Medical Coverage Information form. The COB unit enters information from the Medical Coverage Form into their system. The information is interfaced with ACES and the TPL screens are auto populated.
- Nursing facilities will be responsible for collecting payments from TPL carriers or obtaining a denial of benefits before the agency can pay the facilities. The agency will continue to assign participation, which the nursing facility may collect until the TPL party begins making payments. See Third party resources and LTC insurance.
- Admissions under 30 days into a medical facility is a Short stay.