General eligibility requirements that apply to all Apple Health programs

Hospice applications - clients not eligible for a noninstitutional CN program

Revised Date: 
February 14, 2018

Purpose: HCB Waiver rules can be used to provide hospice services for clients in the community who are not otherwise eligible for any other CN, MN, or ABP program. The HCB Waiver rules may be more beneficial spenddown rules. When these rules are used, there is post eligibility treatment of income, also known as participation toward the cost of care. 

If a client is in a nursing facility or hospice care center:

  • For the Aged/Blind/Disabled group, use the hospice institutional rules if in the institution 30 days or more.
  • For a MAGI coverage group, the client remains on the MAGI program.

Hospice - applications - client is not otherwise eligible for a noninstitutional CN program.

In ACES, screen in a L32 medical coverage group. If the hospice election date is within 90 days of the application date and the hospice election notice was received timely (within 5 business days of election), consider retro coverage under the L32 program back to the election date as long as the client is income and resource eligible in each of the prior months and is related to the L32 program.

  1. How the client is related to an L32 program?
    1. Refer to WAC 182-515-1505 Financial Eligibility Requirements for long- term care services under COPES when L32/hospice rules are used to determine eligibility and the client is not residing in a medical institution. For those residing in a medical institution, follow the rules in WAC 182-513-1315.
    2. A client must be aged, blind or disabled to be eligible for this program. Follow office procedures to request a Non-Grant Medical Assistance (NGMA) determination from DDDS if no disability has been established.
  2. Household Composition
    1. The ineligible spouse is coded as a spouse on the household composition screen using the SP code. Update the spouse's income and resources on their own screens. The shelter costs are coded on the spouse's shelter screen.
    2. If there are dependents, they should be coded in the household as NM if the client has dependents in household. The dependents are counted on long term care expenses screen with the number of dependents, their income, and whether they are residing with the community spouse.
  3. Resources
    1. Resource standards for the L22/Hospice program follow institutional SSI related rules. The application should list all assets owned by the client including their primary residence; the client may be subject to estate recovery. Applications should not be denied when resource limits exceed $2000 for a single client or $3000 for a married client.
    2. A client may reduce their excess resources in the month of application by any unpaid medical expenses for which they are liable. This can include health insurance, Medicare premiums, deduction and coinsurance charges and any necessary medical care recognized under state law, but not covered under the state's Medicaid plan. The amount of excess resources is limited to the amounts indicated in WAC 182-513-1350.

Refer to WAC 182-513-1350 for more information on resource eligibility for institutional programs.

Example: A married couple one applying for hospice. Their combined available resources total $35,000. In this example, the community spouse* is allowed the Spousal Resource Transfer Maximum under institutional Medicaid rules.
*A community spouse is a person who does not receive institutional, waiver or hospice services and who is legally married to an institutionalized client.

The L95 and L99 MN program for Hospice is only used in medical institutions such as a nursing facility or a hospice care center. There is no MN Hospice program under the L95 and L99 outside of a medical institution.

See LTC income and resource standards chart

Follow Equal Access - Necessary Supplemental Accomodation (NSA) and long-term service and supports procedures.