Long-term services and supports (LTSS) manual

HCS Home and Community based (HCB) waivers

Revised Date: 
July 1, 2015

This section is commonly referred as "The COPES chapter". It is used for the eligibility of the HCS HCB waiver programs. The medical coverage group is L22 and L21 for SSI recipients. The other HCS Waivers are New Freedom and the Residential Support Waiver (RSW). Some services use HCB Waiver rules for eligibility but are not considered HCB Waivers. These services are Hospice, Program of all-inclusive care for the elderly (PACE) and Roads to Community Living (RCL). This is described in the Overview of Home and Community Based (HCB) Waivers.

Purpose: This chapter describes the general and financial eligibility requirements for (HCB) services authorized by home and community services (HCS). These services are administered either in a home or residential (non medical institution) setting.

WAC 182-515-1505 Home and community based (HCB) waiver services authorized by home and community services (HCS).

WAC 182-515-1506 Home and community based (HCB) waiver services authorized by home and community services (HCS) general eligibility.

WAC 182-515-1507 Home and community based (HCB) waiver services authorized by home and community services (HCS) if a person is eligible for an SSI-related noninstitutional categorically needy (CN) medicaid program.

WAC 182-515-1508 Home and community based (HCB) waiver services authorized by home and community services (HCS) -Financial eligibility using SSI-related institutional rules.

WAC 182-515-1505 Home and community based (HCB) waiver services authorized by home and community services (HCS).

Effective February 20, 2017

This chapter describes the general and financial eligibility requirements for categorically needy (CN) home and community based (HCB) waiver services authorized by home and community services (HCS). The definitions in WAC 182-513-1100 and chapter 182-500 WAC apply throughout this chapter.

  1. The HCS waivers are:
    1. Community options program entry system (COPES);
    2. New Freedom consumer-directed services (New Freedom); and
    3. Residential support waiver (RSW).
  2. WAC 182-515-1506 describes the general eligibility requirements for HCB waiver services authorized by HCS.
  3. WAC 182-515-1507 describes financial requirements for eligibility for HCB waiver services authorized by HCS when a person is eligible for a noninstitutional SSI-related categorically needy (CN) medicaid program.
  4. WAC 182-515-1508 describes the financial eligibility requirements for HCB waiver services authorized by HCS when a person is not eligible for SSI-related noninstitutional CN medicaid under WAC 182-515-1507.
  5. WAC 182-515-1509 describes the rules used to determine a person's responsibility for the cost of care and room and board for HCB waiver services if the person is eligible under WAC 182-515-1508.

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 182-515-1506 Home and community based (HCB) waiver services authorized by home and community services (HCS) general eligibility.

Effective February 20, 2017

  1. To be eligible for home and community based (HCB) waiver services a person must:
    1. Meet the program and age requirements for the specific program:
      1. Community options program entry system (COPES), under WAC 388-106-0310;
      2. Residential support waiver (RSW), under WAC 388-106-0310; or
      3. New Freedom, under WAC 388-106-0338.
    2. Meet the disability criteria for the supplemental security income (SSI) program under WAC 182-512-0050;
    3. Require the level of care provided in a nursing facility under WAC 388-106-0355;
    4. Reside in a medical institution as defined in WAC 182-500-0050, or be likely to be placed in one within the next thirty days without HCB waiver services provided under one of the programs listed in (a) of this subsection;
    5. Attain institutional status under WAC 182-513-1320;
    6. Assessed for HCB waiver services, be approved for a plan of care, and receiving an HCB waiver service under (a) of this subsection;
    7. Be able to live at home with community support services and choose to remain at home, or live in a department-contracted alternate living facility under WAC 182-513-1100.
  2. A person is not eligible for home and community based (HCB) waiver services if the person:
    1. Is subject to a penalty period of ineligibility for the transfer of an asset under WAC 182-513-1363; or
    2. Has a home with equity in excess of the requirements under WAC 182-513-1350.
  3. See WAC 182-513-1315 for rules used to determine countable resources, income, and eligibility standards for long-term care (LTC) services.
  4. Current income and resource standards are found at https://www.hca.wa.gov/health-care-services-and-supports/program-standar....

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 182-515-1507 Home and community based (HCB) waiver services authorized by home and community services (HCS) — Financial eligibility if a client is eligible for an SSI-related noninstitutional categorically needy (CN) medicaid program.

Effective January 1, 2018

  1.  A client is financially eligible for home and community based (HCB) waiver services if the client:
    1. Is receiving coverage under one of the following categorically needy (CN) medicaid programs:
      1. SSI program under WAC 182-510-0001. This includes SSI clients under Section 1619(b) of the Social Security Act;
      2. SSI-related noninstitutional CN program under chapter 182-512 WAC; or
      3. Health care for workers with disabilities program (HWD) under chapter 182-511 WAC.
    2. Does not have a penalty period of ineligibility for the transfer of an asset under WAC 182-513-1363; and
    3. Does not own a home with equity in excess of the requirements under WAC 182-513-1350.
  2. A client eligible under this section does not pay toward the cost of care, but must pay room and board if living in an alternate living facility (ALF) under WAC 182-513-1100.
  3. A client eligible under this section who lives in a department-contracted ALF described under WAC 182-513-1100 :
    1. Keeps a personal needs allowance (PNA) under WAC 182-513-1105; and
    2. Pays towards room and board under WAC 182-513-1105
  4. A client who is eligible under the HWD program must pay the HWD premium under WAC 182-511-1250, in addition to room and board, if residing in an ALF.
  5. Current resource, income, PNA, and room and board standards are found at 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 182-515-1508 Home and community based (HCB) waiver services authorized by home and community services (HCS) — Financial eligibility using SSI-related institutional rules.

Effective February 20, 2017

  1. If a person is not eligible for a categorically needy (CN) program under WAC 182-515-1507, the agency determines eligibility for home and community based (HCB) waiver services authorized by home and community services (HCS) using institutional medicaid rules. This section explains how a person may qualify using institutional rules.
  2. A person must meet:
    1. General eligibility requirements under WAC 182-513-1315 and 182-515-1506;
    2. The resource requirements under WAC 182-513-1350;
    3. The following income requirements:
      1. Available income must be at or below the special income level (SIL), defined under WAC 182-513-1100;
      2. If available income is above the SIL, net available income is no greater than the effective one-person medically needy income level (MNIL). Net income is calculated by reducing available income by:
        1. Medically needy (MN) disregards found under WAC 182-513-1345;
        2. The average monthly nursing facility state rate;
        3. Health insurance premiums, other than medicare; and
        4. Outstanding medical bills, prorated monthly over a twelve-month certification period, that meet the requirements of WAC 182-513-1350.
  3. The agency determines available income and income exclusions under WAC 182-513-1325, 182-513-1330, and 182-513-1340.
  4. A person eligible under this section is responsible to pay toward the cost of care and room and board, as described under WAC 182-515-1509.
  5. Current resource, income standards, and the average state nursing facility rate for long-term care are found at https://www.hca.wa.gov/health-care-services-and-supports/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.

This section contains the following HCB Waiver services:

  1. Community options program (COPES)
  2. New Freedom consumer directed services (New Freedom)
  3. Program of all-inclusive care for the elderly (PACE)

Institutional standards used in determining initial and post eligibility (participation) in long term care change annually. Depending on the standard, these changes occur in January, April, July and August. See the Institutional standard chart for current standards used in long term care. This chart indicates the formula for the standard and when the standard last changed.

Personal needs allowance (PNA) for clothing, personal items and incidentals (CPI):

Personal needs allowance (PNA) for clothing, personal items and incidentals (CPI). Client's are allowed the highest personal needs allowance in a given month based on living arrangement, authorized service and marital status. If a client resided at home the first day of the month and went into a nursing home the same day, we would allow the in home PNA because they were residing in a home setting at least one moment during that given month. If a client went from a nursing home to an adult family home on HCB waiver services the first day of the month, we would allow the ALF PNA as it is the highest allowed. If that client were then discharged home from the ALF on the last day of the month, the benefit would be recalculated allowing the in home PNA

Medical Expenses used to reduce participation

To reduce participation, deduct medical expenses not already used to reduce excess resources as described in WAC 182-513-1350.

Income and Deduction changes in HCB Waivers. Method 3 effective 8/29/2014

WAC 182-504-0120 (12) Effective 8/29/2014 a change in income or deductions is effective the first of the month following the date the change was reported rather than the month the income or deduction changed (Method 1). Method 1 is used for clients residing in medical institutions. Method 3 is used for HCB Waivers.

When a change in income, or allowable expenses, changes the amount the client pays toward participation for a home and community-based waiver or service, we calculate the new participation amount effective the first of the month following the date the change was reported. The exception is if the change occurs due to the loss of an income source that is to last 2 months or longer and is reported timely.

Any change to an HCB Waiver client's income or post eligibility deductions that affect cost of care take effect in the ongoing month in ACES.

  • With the exception of loss of an income source or the lowering of income
    • The change takes effect the actual month of change.
    • We will make these historical changes in ACES.
    • To be considered a loss or reduction of income:
      • We must have a timely report of the change to income
      • We must have verification that this change is to last two months or longer;
      • Otherwise, it is a "change" in income that takes effect the following month.

What if a loss or lower of income is not reported timely?

  • Financial will not make historical adjustments in ACES.
  • Treat as an underpayment, or "client reimbursement".
  • Send the DSHS 07-104 in barcode to let the case manager know what the client's income or deduction actually was, and what we had in ACES. Indicate what the correct participation should have been for each month and that change was not reported timely.
  • The case manager/social worker will determine if the provider is to be paid more, if the client is owed any money or if there is a client overpayment.

Training information on Method 3 can be found on the financial program SharePoint under training, policy changes.

Note: Facility daily rates reported to financial by the social worker need to be made effective in the month the daily rate change occurred. Make these changes historical as it will affect the calculation in Provider One if there is a split participation month.

Overview of HCB Waivers

DDA home and community based (HCB) waivers

Additional clarification and worker responsibilities can be found in the Participation in a medical facility section.

See General eligibility for Long Term Care