Long-term services and supports (LTSS) manual

Working clients on long-term care programs (Waiver, Residing in a medical institution, or MPC)

Revised Date: 
December 15, 2017

Purpose: This section explains how to choose the correct program when a client is working and needs long-term services and supports. This section gives additional information on the health care for workers with disability program (HWD). 

Consult the Apple Health for Workers with Disabilities for complete information on HWD.

Clients eligible for HWD can receive either MPC, CFC or HCB Waiver depending on what is authorized by the HCS or DDA social worker or case-manager.

All documents sent to the financial worker for HWD are sent to:

ALTSA PO Box 45826 Olympia WA 98504-5826 or FAX 1-855-635-8305

Working clients on HWD and receiving Long-Term Services and Supports (LTSS)

  • HWD provides categorically needy (CN) scope of care and may receive either CFC or MPC
  • HWD is included as an eligibility group in the HCB Waivers authorized by Home and Community Services (HCS) or Developmental Disabilities Administration (DDA). HWD clients receiving HCB Waivers are put on medical coverage group S08.
  • The decision for HCB Waiver, CFC or MPC is done by the HCS social worker/case manager or the DDA case-manager.
  • Due to spousal impoverishment provisions, spousal income is not used in the eligibility determination when the HWD client is receiving CFC or HCB Waiver.  Code the spouse as a nonmember (NM) in ACES as a workaround.
  • Spousal income is used in eligibility for S08 clients receiving MPC or no services following regular HWD rules.

When is HWD (S08) better than using HCB Waiver rules (L22)

  • No asset test for HWD.
  • May have gross income over the special income level (SIL).
  • No client responsibility (participation) for the cost of care. There is a monthly HWD premium. HWD clients in alternate living facilities (ALF) are responsible to pay the ALTSA room and board standard and the HWD premium.
  • Earned income can be over the social security substantial gainful activity (SGA). SGA is waived for the HWD program. SGA is a factor in determining disability for the other SSI related medicaid including HCB Waivers.
  • Impairment related work expenses (IRWE) are allowed as a deduction in HWD eligibility. This deduction is not allowed in HCB Waiver initial or post eligibility.
  • Blind Work Expenses are allowed as a deduction in HWD eligibility. This deduction is not allowed in HCB Waiver initial or post eligibility.

When is a HCB Waiver better than HWD?

  • The client's income is low enough where there is no participation and there is already -0- out-of-pocket cost under the HCB Waiver program.
  • The client is interested in saving more in resources than the $2,000 amount allowed under the L22 program.
  • Many individuals with a community spouse or dependents may be better off using the rules under the L22/Waiver program because of the benefit of the spousal allocation in post eligibility.

How is HWD similar to other SSI-related medical (CN)?

  • Same application form.
  • SSI related rules when determining eligibility.
  • Non-grant medical assistance (NGMA) disability decision is needed if no current disability determination.
  • Categorically Needy (CN) scope of care.

How is HWD different from other SSI-related medical (CN)?

  • No asset test.
  • Higher income standard - clients pay monthly premiums instead of meeting spenddown or participation liability.
  • Only designated HWD staff determine eligibility.
  • A disabled individual must be under age 65 to receive HWD.
  • The substantial gainful activity (SGA) is not a factor for HWD. For all other SSI related medicaid programs, the SGA is a factor regarding disability criteria, Earnings can't equal or exceed the SGA amount. For HWD disability, this test does not apply. For a under age 65 client earning over the SGA standard, HWD is the only SSI related program that should be considered if the client is not receiving a payment from SSA based on disability. Detailed information on the SGA is in the HWD section of the manual.

Note: HWD covers short stays (29 days or less) in nursing homes. HWD does not cover medical institutionalization (Nursing Facility or RHC) projected 30 days more. A redetermination under the L track program is needed for HWD clients residing in a NF or RHC 30 days or more.

Working Clients and HCB Waiver programs (L22)

  • ACES supports the 65 and 1/2 earned income exclusion in post eligibility for the CN Waivers. Do not code an additional earnings deduction on the LTCX screen
  • Expenses for self employment are based on actual costs per SSI related rule
  • Impairment related work expenses (IRWE) are not allowed as a deduction in both initial and post eligibility for HCB Waivers under the L22 program. IRWE deductions are allowed for HWD under the S08 program. Clients with IRWEs should have a comparison of HCB Waiver vs HWD rules.

Working clients in a Medical Institution

  • Working clients in a medical institution don't receive the 65 and 1/2 earned income disregard in initial or post eligibility.
  • WAC 182-513-1380 (4) allows a post eligibility deduction for:
    • Mandatory taxes out of wages.
    • Department-approved training or rehabilitative program designed to prepare the client for a less restrictive placement. When determining this deduction employment expenses are not deducted. The employment must be approved by DVR, HCS or DDA case manager.
  • The client personal needs allowance (PNA), mandatory taxes, department approved wage deduction and guardianship fee deduction cannot exceed the MNIL.
  • HWD does not cover nursing facility payment when an individual is institutionalized 30 days or more in a medical facility. See short stays for using HWD for nursing facility admissions under 30 days.

Coding Department Approved Training or Rehabilitative Program Earnings for individuals in Medical Institutions.

Individuals with earnings in medical facilities must have their employment approved by the social worker, case manager or DVR in order to receive an allowance for the earnings. ACES is programmed to do the calculation correctly as long as the earnings are coded as "RH" on the EARN screen.

RH - Department-Approved Training or Rehabilitative Program

Clients receiving services through DDA in a RHC or ICF-MR are approved automatically through their care plan with DDA.

Clients receiving services in a Nursing Facility must have an approval with the HCS Social Worker in order to receive an allowance for the earnings. The financial worker will need to request an approval as part of the care plan from the HCS SW. If the employment is not approved, the earnings are coded as EI in ACES.

HWD specialists

All HWD documents can be faxed to: 1-855-635-8305 or mailed to ALTSA PO Box 45826 Olympia WA 98504-5826. Include client name and client ID on the documents.

DDA LTC specialty unit:

  • HWD barcode assignments are forwarded to the DDA LTC Specialty Unit via DMS under @HWD/017
  • DDA LTC specialty unit HWD Phone: 1-800-871-9275
  • To request an active HWD case from DDA LTC specialty unit, set a same day barcode tickler to @HWD for HCS 17 requesting the transfer. Indicate the HCS office that is requesting the transfer.
  • The financial record is requested from the DDA LTC HWD specialty unit when HCS services are opened
  • An application for HWD and HCS services goes to the HCS HWD regional specialist.
  • An application for HWD and no HCS services goes to the DDA LTC HWD specialty unit. This includes HWD clients with no DDA or HCS services.
  • HWD lead for non-HCS cases is Connie Sadler

HCS HWD Specialists:

Region 1 - Pend Oreille, Grant, Adams, Lincoln, Okanogan, Ferry, Douglas, Whitman, Spokane, Klickitat, Yakima, Walla Walla, Franklin, Benton, Garfield, Columbia, Asotin, Kittitas.

Attn: Mary Aspen, Wenatchee HCS
Phone: 509-886-6140
Alt. Phone: 800-670-8874
Fax: 509-886-6221
TTY: 509-886-6223

Back up is Jacque Bruns, Omak HCS 509-846-8635

Region 2 South-King

Attn: Ruby Pham 206-341-7880
Holgate HCS, 206-341-7750 or 1-800-346-9257
TTY: 1-800-833-6384

Region 2 North-Snohomish, Whatcom, Skagit, Island

Attn: Hang Nguyen, Lynnwood HCS
425-977-6562 or 1-800-780-7089
TTY: 425-977-6534
Back up is Anita Singh 425-977-6539

Region 3 HCS, Pierce, Kitsap, Clallam, Jefferson, Thurston, Mason, Lewis, Cowlitz, Clark, Pacific, Grays Harbor, Skamania, Wahkiakum.

Attn: Roxanne LaRoy, Kelso HCS
360-501-2527 Toll-free: 1-800-605-7322 TTY: 360-577-7591

Back up is Terri Carl 360-664-9056

Worker Responsibilities for HWD receiving HCS or DDA services

  • See complete HWD program information.
  • A trial HWD premium can be done using trial eligibility on a pending or active S08 AU. Indicate a HWD start date on the pending AU to get a projected HWD premium, and then delete the HWD start date if you are not ready to process the case.
  • HWD receiving HCB Waiver services are subject to transfer of asset, annuity declaration and excess home equity provisions that are specific to institutional programs (L22). MPC or CFC services are not subject to the transfer of asset provisions. An HWD client with a transfer penalty can't get HCB Waiver services.
  • The medical coverage group S08 must be used for HWD clients in order for the premium bill to go out to the client from FSA. (HCB Waiver, CFC or MPC service information is indicated on the INST screen under the HCB service field).
  • The L22 program is not used in ACES for HWD, but a client can still get services under the HCB Waiver under the S08 program. The approval letter for the HCB services is issued by the social services case manager.
  • HWD specialists inform the client and the client case manager/social worker when a tickler is received from FSA regarding overdue premiums. It is important for the client and/or their representative to pay the HWD premium to FSA timely. There are penalties described in the HWD chapter when premium payments are overdue. This penalty could result in no HWD coverage for 4 months which could affect the client's eligibility for continued services. Follow NSA/equal access provisions to notify the case manager if client is behind in their premiums.
  • When a NGMA is needed for HWD, make sure the following language is added to the NGMA cover sheet to DDDS: Disability determination is needed for Health Care for Workers with Disabilities (HWD). SGA is waived for this program.
  • If an HWD client's job ends and HWD continues to be the preferable program, it is continued through the certification period as long as the premium continues to be paid unless the HCD client is on a HCB Waiver service and there would be no participation with that program. Always consider the program that is most beneficial for the client.
  • Premium adjustments based on income changes occurs on the first of the following month.
  • Any premium adjustments for historical months due to department error need to go through Lori Rolley ALTSA HQ or Stephen Kozak of HCA. The case will be reviewed and FSA notified of the premium adjustment needed.
  • Code the appropriate LTSS service and service start date on the INST screen based on the HCS 14-443 or the DDA 15-345
  • For person applying for HCS services who is employed and not eligible for HCB Waiver with or noninstitutional Medicaid in an ALF under WAC 182-513-1205:
    • Deny the application for LTC or noninstitutional medicaid; and
    • Transfer the case to the designated HCS HWD specialist
    • Include text that the case is being referred to the HWD specialist for a determination. Indicate the HWD specialist name and phone number
  • Code the nonapplying spouse as a nonmember IF the HWD applicant is eligible for HCB Waiver or CFC. Spousal impoverishment is used for clients eligible for HCB Waiver or CFC, coding the spouse as a non member is a workaround. ACES will not count the spousal income in the HWD eligibility. If the HWD client goes off HCB Waiver or CFC services, the spouse has to be coded as a nonapplying spouse.

Additional information for financial workers on HWD and LTSS, including desk aids can be found on the financial SharePoint under advanced training.