General eligibility requirements that apply to all Apple Health programs

Hospice index

Revised Date: 
July 1, 2015

Purpose: To provide an overview of the Hospice program and explain how to correctly determine eligibility for Hospice.

WAC 182-513-1240 The hospice program

Effective February 20, 2017

  1. General information.
    1. The hospice program provides palliative care to people who elect to receive hospice services and are certified as terminally ill by their physician.
    2. Program rules governing election of hospice services are under chapter 182-551 WAC.
    3. A person may revoke an election to receive hospice services at any time by signing a revocation statement.
    4. Transfer of asset rules under WAC 182-513-1363 do not apply to the hospice program in any setting, regardless of which apple health program the person is eligible to receive.
  2. When hospice is a covered service.
    1. A person who receives coverage under a categorically needy (CN), medically needy (MN), or alternative benefits plan (ABP) program is eligible for hospice services as part of the program specific benefit package.
    2. A person who receives coverage under the alien emergency medical (AEM) program under WAC 182-507-0110 may be eligible for payment for hospice services if preapproved by the agency.
    3. A person who receives coverage under the medical care services (MCS) program is not eligible for coverage of hospice services.
  3. When HCB waiver rules are used to determine eligibility for hospice.
    1. A person who is not otherwise eligible for a CN, MN, or ABP noninstitutional program who does not reside in a medical institution, may be eligible for CN coverage under the hospice program by using home and community based (HCB) waiver rules under WAC 182-515-1505 to determine financial eligibility.
    2. When HCB waiver rules are used, the following exceptions apply:
      1. A person on the hospice program may reside in a medical institution, including a hospice care center, thirty days or longer and remain eligible for hospice services; and
      2. A person residing at home on the hospice program who has available income over the special income limit (SIL), defined under WAC 182-513-1100, is not eligible for CN coverage. If available income is over the SIL, the agency or its designee determines eligibility for medically needy coverage under WAC 182-519-0100.
    3. When HCB waiver rules are used, a person may be required to pay income and third-party resources (TPR) as defined under WAC 182-513-1100 toward the cost of hospice services. The cost of care calculation is described under WAC 182-515-1509.
    4. When a person already receives HCB waiver services and elects hospice, the person must pay any required cost of care towards the HCB waiver service provider first.
  4. Eligibility for hospice services in a medical institution:
    1. A person who elects to receive hospice services, resides in a medical institution for thirty days or longer, and has income:
      1. Equal to or less than the SIL is income eligible for CN coverage. Eligibility for institutional hospice is determined under WAC 182-513-1315; or
      2. Over the SIL may be eligible for MN coverage under WAC 182-513-1245.
    2. A person eligible for hospice services in a medical institution may have to pay toward the cost of nursing facility or hospice care center services. The cost of care calculation is under WAC 182-513-1380.
  5. Changes in coverage. The agency or its designee redetermines a person's eligibility under WAC 182-504-0125 if the person:
    1. Revokes the election of hospice services and is eligible for coverage using HCB waiver rules only, described in subsection (3) of this section; or
    2. Loses CN, MN, or ABP eligibility.
  6. Personal needs allowance and income and resource standards for hospice and home and community based (HCB) waiver programs 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 182-513-1245 Medically needy hospice in a medical institution.

Effective February 20, 2017

  1. General information.
    1. When living in a medical institution, a person may be eligible for medically needy coverage under the hospice program. A person must:
      1. Meet program requirements under WAC 182-513-1315;
      2. Have available income that exceeds the special income level (SIL), defined under WAC 182-513-1100, but is below the institution's monthly state-contracted rate;
      3. Meet the financial requirements of subsection (4) or (5) of this section; and
    2. Elect hospice services under chapter 182-551 WAC.
  2. Financial eligibility.
    1. The agency or its designee determines a person's resource eligibility, excess resources, and medical expense deductions using WAC 182-513-1350.
    2. The agency or its designee determines a person's countable income by:
      1. Excluding income under WAC 182-513-1340;
      2. Determining available income under WAC 182-513-1325 or 182-513-1330;
      3. Disregarding income under WAC 182-513-1345; and
      4. Deducting medical expenses that were not used to reduce excess resources under WAC 182-513-1350.
  3. Determining the state-contracted daily rate in an institution, and the institutional medically needy income level (MNIL).
    1. The agency or its designee determines the state-contracted daily rate in an institution and the institutional MNIL based on the living arrangement, and whether the person is entitled to receive hospice services under medicare.
    2. When the person resides in a hospice care center:
      1. If entitled to medicare, the state-contracted daily rate is the state-contracted daily hospice care center rate. The institutional MNIL is calculated by multiplying the state-contracted daily rate by 30.42.
      2. If not entitled to medicare, the state-contracted daily rate is the state-contracted daily hospice care center rate, plus the state-contracted daily hospice rate. To calculate the institutional MNIL, multiply the state-contracted daily rate by 30.42.
    3. When the person resides in a nursing facility:
      1. If entitled to medicare, the state-contracted daily rate is ninety-five percent of the nursing facility's state-contracted daily rate. The institutional MNIL is calculated by multiplying the state-contracted daily rate by 30.42.
      2. If not entitled to medicare, the state-contracted daily rate is ninety-five percent of the nursing facility's state-contracted daily rate, plus the state-contracted daily hospice rate. The institutional MNIL is calculated by multiplying the state-contracted daily rate by 30.42.
  4. Eligibility for agency payment to the facility for institutional hospice services and the MN program.
    1. If a person's countable income plus excess resources is less than or equal to the state-contracted daily rate under subsection (3) of this section times the number of days the person has resided in the medical institution, the person:
      1. Is eligible for agency payment to the facility for institutional hospice services;
      2. Is approved for MN coverage for a twelve-month certification period;
    2. Pays excess resources under WAC 182-513-1350; and
    3. Pays income towards the cost of care under WAC 182-513-1380.
  5. Eligibility for institutional MN spenddown.
    1. If a person's countable income is more than the state-contracted daily rate times the number of days the person has resided in the medical institution, but less than the institution's private rate for the same period, the person:
      1. Is not eligible for agency payment to the facility for institutional hospice services; and
      2. Is eligible for the MN spenddown program for a three-month or six-month base period when qualifying medical expenses meet a person's spenddown liability.
    2. Spenddown liability is calculated by subtracting the institutional MNIL from the person's countable income for each month in the base period. The values from each month are added together to determine the spenddown liability.
    3. Qualifying medical expenses used to meet the spenddown liability are described in WAC 182-519-0110, except that only costs for hospice services not included within the state-contracted daily rate are qualifying medical expenses.
  6. Eligibility for MN spenddown.
    1. If a person's countable income is more than the institution's private rate times the number of days the person has resided in the medical institution, the person is not eligible for agency payment to the facility for institutional hospice services and institutional MN spenddown; and
    2. The agency or its designee determines eligibility for MN spenddown under chapter 182-519 WAC.

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.

Hospice Agency Contacts

Hospice Agencies FAX the HCA 13-746 Hospice notification form to the HCA DMS HUB at: 360-725-1965

Hospice Agency Contacts
Address, phone numbers and provider numbers. This link lists the Hospice Care Centers. Hospice Care Centers are considered medical institutions.