General eligibility requirements that apply to all Apple Health programs

Hospice eligibility (with institutional Medicaid rules)

Revised Date: 
February 14, 2018

Eligibility for the L32 Hospice program utilizing institutional rules

The L32 hospice program should be used for a client who receives hospice services and who resides in a medical institution (nursing facility, hospice care center). ACES will trickle to an L95 or L99 medically needy (MN) program if the gross income is over the medicaid special income level (SIL) when the client is in a medical institution.

For some clients who do not reside in medical institutions, it could be to their benefit to follow institutional rules when determining eligibility for hospice services. Institutional rules allow the spend-down of excess resources towards the cost of care, a higher resource standard for married couples, a higher income allocation amount for a spouse and a higher income standard for a single person. Clients need to meet aged, blind, or disabled criteria to be eligible for the L32 hospice program. Examples of cases that should be considered for L32 coverage are listed below:

L32 is a categorically needy (CN) program and has advantages over a MN program.

  1. SSI related medically needy. A client should always be considered for a L32 program before authorizing benefits or services under MN for the following reasons:
    • Clients will not have to meet a spend-down amount prior to becoming eligible. They may have to pay toward the cost of care each month; participation is paid directly to the hospice provider).
    • Once the client is found eligible, medicaid is backdated to the first of the month and CN scope of care.
    • The CN income limit is the SIL which is higher than the CN income limit for noninstitutional medical.
    • For a single client at home, the personal needs allowance standard is higher (100% FPL), as opposed to the Medically Needy Income Limit (MNIL) used for noninstitutional medical.
    • A community spouse’s income is not counted when determining hospice participation. The personal needs allowance (PNA) is the MNIL when there is a community spouse.
    • A dependent’s income is not counted when determining hospice participation.
    • Higher income allocation to a community spouse and dependents when living with a community spouse.
  2. A single Apple Health for Workers with Disability (HWD) client with income below 100% of the FPL. They would not have to pay a premium for medical coverage and would have no participation.

  3. A minor child with a disability who is not eligible for a children’s health care program due to the income of their parents.

For clients receiving waiver services through Aging and Long-term Supports Administration (ALTSA), see additional instructions under Worker Responsibilities - ALTSA HCB Waiver Programs.

HCB Waiver rules for Home and Community Services (HCS) clients are described in WAC 182-515-1505.

HCB Waiver rules for Development Disabilities Administration (DDA) clients are described in WAC 182-515-1510.

A client can be on an HCB waiver program (L21, L22) with HCS or DDA and receive hospice services, if functionally and financially eligible. Both waiver and hospice services are coded on the Institutional Care screen under Services. The Waiver program is the priority program over Hospice. All participation is applied to the waiver program.

For a hospice client in a medical institution with income over the SIL, see WAC 182-513-1395 Determining eligibility for institutional services for people living in a medical institution under the SSI-related medically needy program.