State-funded long-term care for noncitizens
Note: Effective 11/1/2009 there is no nursing home coverage under the AEM program. The legislature gave limited funding for a state funded long-term care program to cover services that were being authorized under AEM prior to 11/1/2009.
Effective 5/14/2011, the legislature directed ADS-HCS to move individuals to a residential setting if appropriate. The WAC has been changed to allow for either nursing facility or residential setting under this program.
WAC 182-507-0125 describes the state-funded long-term care program.
New admissions into nursing facilities, residential or home settings under the state-funded long-term care program must be preapproved by Sandy Spiegelberg, Home & Community Services Headquarters. This program has limited 45 slots for coverage based on legislative funding.
Always consider the possibility of Aged Blind Disabled (ABD) cash/HEN which includes Medical Care Services (MCS)
Other programs should always be considered before considering the 45 slot state-funded long-term care program.
Many legally admitted noncitizens who are in a five year medicaid bar or other eligible non-federally qualified status can be considered for the ABD cash/HEN program. MCS should be considered for legally admitted noncitizens who do not qualify for federal medicaid.
State funded medical care services (MCS) program is described in WAC 182-508-0005.
ABD cash is described in WAC 388-400-0060.
For nursing facility coverage under MCS the individual must meet income and resource criteria and be assessed as nursing facility level of care (NFLOC) by an HCS social worker.
An active A01/A05 (MCS) does not require a preapproval by HCS HQ prior to nursing facility admission.
Long-term care services under State Funds for noncitizens
Aging and Long Term Supports Administration (ALTSA) has a limited amount of state funding available for noncitizens who have been denied or terminated from AEM coverage and are in need of long-term care services outside of a hospital. These noncitizens are not eligible for the ABD cash or MCS program
An L04 is used in ACES for nursing facility cases. ACES program L24 is used for LTC services preapproved by HCS HQ in a residential or home setting.
ALTSA/HCS headquarters must track each case using the state funds to pay for long-term care services under this program.
For state funded nursing home denials and terminations contact Sandy Spiegelberg, Financial at ADS-HCS headquarters via e mail.
The following must be reported to Sandy Spiegelberg RoberSK@dshs.wa.gov:
- New admits. Include the date and facility.
- Discharges. Include the date and circumstances.
- Any closures. Include the date and circumstances.
- If a state funded client's medical condition causes rehospitalization, HCS must follow AEM procedures by referring the case to the Health Care Authority (HCA) for consideration of federal coverage under the AEM program.
- Notify Sandy Spiegelberg of this referral and if AEM approval from HCA is received for the hospitalization.
Note: HCS staff contact HCS HQ policy staff for assistance when a L24 or L04 client ends up in the hospital do not refer the case back to CSD for the determination of AEM/S07.
Specialty Hospital Unit for AEM coverage
Most admissions into the state-funded long-term care program start out in a hospital. These applications are completed by a specialty hospital unit at the CSO for a determination of AEM.
The HBE determines the eligibility for individuals receiving Health Care Coverage under the Modified Adjusted Gross Income (MAGI) method.
This unit refers to HCA medical consultant for possible AEM coverage in the hospital.
Contact Nhan Thai, Supervisor of the AEM CSD Hospital Unit for coordination with CSD.
Prior to admission into a NF, a prior approval by ADS-HCS is needed. Even if there is an approval of AEM in the hospital, AEM does not cover NF admissions.
Once an AEM Hospital case has been approved a NF slot by ADS-HCS HQ, HCS financial staff will transfer the case into HCS for maintenance and tracking.
A client receiving services under the state funded long-term care program may have a health event that would require hospitalization. The federal AEM program must be considered for any hospitalization. HCS financial staff must refer the case to the HCA medical consultant so a AEM determination can be made. Contact HCS program policy staff Lori Rolley for assistance in referring to the medical consultant as Health Care Authority is in the process of updating manual instructions for this process.
Notify Sandy Spiegelberg, ADS-HCS Headquarters of any hospitalization so a slot can be held for a discharge to a nursing facility or residential setting.
Example #1: Joe Smith is approved through 10/31/2009 under the federal AEM program. The federal AEM program for nursing home ended on 10/31/2009. Effective 11/1/2009, this client was grandfathered into the state-funded nursing facility program as Mr. Smith is still in need of nursing home care. The medical coverage group in ACES is an L04.
Example #2: Jane Smith has been in a hospital for six months. All options for alternative settings have been explored by the hospital. She must either remain in the hospital indefinitely or be placed in a nursing home.
She is assessed by the HCS social worker and meets NFLOC. The HCS office handling the assessment contacts HCS headquarters for an available slot under the state-funded long-term care program. Once headquarters approves a slot and the client is financially and resource eligible, an L04 is opened in ACES. The nursing home will be able to admit Jane and bill under the state-funded nursing facility program.
Jayna is over 65 and has been hospitalized and is in need of nursing home care due to a stroke. She has been assessed by the HCS SW and meets NFLOC.
Jayna can be opened on ABD cash and state funded MCS medical. There is no need to refer for the state-funded funded nursing home program. MCS covers nursing facility coverage.
MCS placements do not need a preapproval by HCS HQ. See managed care section for instructions on the MCS program and nursing facility admissions.
If this individual is a candidate for SSI, submit a packet to the SSI facilitator.
Example #4: John Doe has been hospitalized and is in need of LTC. Mr. Doe's needs can be met in an adult family home setting. Mr. Doe is financially eligible for the L24 program and there has been a preapproval from HCS HQ. Any new admissions into the state-funded long-term care program must be served in a residential setting unless the person's needs cannot be met except in a nursing facility.
L04 is used for state funded long-term care nursing facility admissions.
L24 is used for state funded residential admissions and in-home services. Eligibility for residential settings and in home care is the same as the COPES program. The determination of room and board and participation would follow the calculation described in WAC 182-515-1509.
Notify Sandy Spiegelberg RoberSK@dshs.wa.gov 360-725-2576, HCS HQ of any admission, discharge, closure, or hospitalization under this program.