Long-term services and supports (LTSS) manual

As of Wednesday, March 18, HCA’s lobby will be closed. In-person customer services for Apple Health and the PEBB and SEBB Programs will not be available. Learn more.

Working clients on long-term care services and supports

Revised Date: 
January 1, 2020

Purpose: This section explains how to choose the correct program when a client is working and needs long-term services and supports (LTSS). 

Consult the Apple Health for Workers with Disabilities (HWD) section for complete information.

Clients eligible for HWD can receive MPC, CFC or HCB Waiver depending on the authorization by the Home and Community Services (HCS) or the Developmental Disabilities Administration (DDA) social worker or case-manager.

All documents for LTSS 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 . Those eligible may receive either CFC or MPC
  • HWD is included as an eligibility group in the HCB Waivers authorized by HCS or DDA.
  • HWD clients receiving CFC, MPC or an HCB Waiver are on the medical coverage group S08.
  • The functional approval for HCB Waiver, CFC or MPC is made by the HCS or DDA social worker or case manager.

What makes HWD (S08) better than using HCB Waiver rules (L22)?

  • No asset test for HWD.
  • No income test for HWD (income is verified for the premium calculation). This change is effective 1/1/2020.
  • 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 room and board standard to their provider and the HWD premium to the Office of Financial Recovery (OFR).
  • Earned income can be over the Social Security substantial gainful activity (SGA) limit. SGA is waived for the HWD program. SGA is a factor in determining disability for all the other SSI related Medicaid including HCB Waivers.

When is a HCB Waiver better than HWD?

  • The client's income is low enough where there is no, or less, client responsibility than the HWD premium. 
  • The client is not interested in saving more in resources than the $2,000 amount allowed under the HCB Waiver.

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

  • Same application form.
  • SSI-related rules when determining eligibility.
  • A non-grant medical assistance (NGMA) disability decision is needed if there is no current disability determination. A disability decision is needed for HWD clients 65 and over if there is no disability date indicated on the BENDEX, SDX or in the case record. Disability is an eligibility factor for HWD even if the client is age 65 or older.
  • Categorically Needy (CN) scope of care.

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

  • No asset test.
  • No income standard - clients pay monthly premiums instead of a spenddown or client responsibility based on income.
  • Only designated HWD staff determine eligibility.
  • The client must be employed full or part-time (including self-employment) as described in WAC 182-511-1200 at initial application and in the month of renewal.
  • The substantial gainful activity (SGA) limit is not a factor for HWD. For all other SSI-related Medicaid programs, the SGA is an aspect of the disability criteria. Earnings can't equal or exceed the SGA amount. For HWD disability, this test does not apply. For an 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.
  • Resources accumulated in a separate account, designated by the client, that result from work activity during the client's enrollment in HWD are excluded per WAC 182-512-0550. If a client needs a redetermination to another program because they are no longer employed at renewal or are admitted into a nursing facility for 30 days or more, the accumulated resource is excluded. This account is coded as "Earnings Accumulated while Enrolled in HWD-Exempt MA (EH)" in ACES

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

Working Clients and HCB Waiver programs (L22)

  • ACES supports the 65 and 1/2 earned income disregard in post eligibility for CN Waivers. Do not code an additional earnings deduction on the Long Term Care Expense/Deduction page.
  • Expenses for self employment are based on actual costs per SSI related rule in Chapter 182-512 WAC.
  • Impairment related work expenses (IRWE) are not allowed as a deduction in both initial and post eligibility for HCB Waivers under the L22 program. 

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 Division of Vocational Rehabilitation (DVR), HCS or DDA case manager.
  • The client's personal needs allowance (PNA), mandatory taxes, department approved wage deductions and guardianship fee deductions cannot exceed the MNIL.

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

Clients with earnings in medical facilities must have their employment plan approved by HCS or DDA the social worker, case manager, or Division of Vocational Rehabilitation (DVR) in order to receive an allowance for the earnings. ACES is programed to do the calculation correctly as long as the earnings are coded as Rehabilitation Income (RH).

Clients receiving services through DDA in a RHC or ICF-ID 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 Public Benefits Specialist will need to request an approval as part of the care plan from the HCS SW in order to code as RH in ACES. 

HWD public benefit specialists (PBS)

HWD eligibility is done by specialists for both DDA and HCS. Current HWD specialists for the DDA LTC specialty team and HCS are found under clarifying information Apple Health for Workers with Disabilities

DDA LTC specialty unit HWD public benefit specialists:

  • 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. 

Worker Responsibilities for HWD receiving HCS or DDA services

  • See complete HWD program information.
  • A preliminary HWD premium can be determined 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 OFR. (HCB Waiver, CFC or MPC service information is indicated on the Institutional Care screen under the HCB service field).
  • HWD specialists inform the client and the client case manager/social worker when a tickler is received from OFR regarding overdue premiums. It is important for the client and/or their representative to pay the HWD premium to OFR 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 on their premiums.
  • When a Non-grant medical assistance (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. A NGMA is also needed for an HWD applicant that is 65 or older and there is no disability indicated on the BENDEX, SDX or established by a NGMA in the case record.
  • 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 HWD 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. per HWD rule, the change is effective the first of the following month. 
  • Premium adjustments based on income changes occurs on the first of the following month.
  • Code the appropriate LTSS service and service start date on the Institutional Care screen based on the HCS 14-443 or the DDA 15-345
  • For people applying for HCS services who are not 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

What should staff do if a client reports employment or wants to be employed? 

For HCS Staff: 

  • Notify the HWD PBS in your region if the client is not an SSI and may benefit from HWD. Clients on SSI report their wages to the Social Security Administration for the determination of Medicaid. If the client is on food benefits, wages must be reported to PBS staff.
  • Notify the Employment Specialist in your Region when a HCS client starts employment or wants to be employed:
  • Send or give the client information on the HWD program: HCA 22-333 Apple Health for Workers with Disabilities. 

Applicants: 

  • When a request is received, via an application for HWD, the Financial Applications Customer Service Specialist or the Public Benefit Specialist based on regional processes will make the initial contact and document the following in narrative:
    • Is the client physically working or not? This does not include collecting sick leave and other employment based benefits.
    • if speaking with the client, verbally request verification of earnings.
    • Forward the application to the appropriate regional HWD PBS.
  • The HWD PBS will review the application within 5-days of receipt. If discovered that it will be more beneficial for the applicant to receive HCBS Waiver services, the HWD PBS will communicate to the HCS PBS based on regional processes for assigning new applications and the PBS will process the HCBS Waiver application. The PBS will also communicate vice versa to the HWD Specialist. 

Recipients: 

  1. The current PBS will request verification of earnings byh sending the Employment Verification (Form No. 14-252). You can attach this form to an ACES letter.
  2. Send an email correspondence to your Regional HWD Specialist. Do not forward in DMS.
  3. The HWD Specialist will be responsible for closing and opening HWD cases, the HWD specialist will redetermine eligibility for the appropriate medical program.
  4. If there is any overpayment for HCBS Waiver or Basic Food (SNAP), the PBS for the assigned alphabet will process it.

DDA Public Benefit Specialist (PBS) staff:

Process for a client currently receiving DDA services who is working and their income and/or resources are over the current program limit(s); when a change is reported by the client, a CRM via 15-345, or the LTC PBS discovers the change: 

  1. The current medical program remains active to allow the client to provide verification or take corrective action to remain income and resource eligible.
  2. The LTC PBS will contact the client or authorized representative (AREP) and request additional information by phone and/or mailing a Request for Information letter (023-02) to include specified mandatory text based on the Long-Term Care & Specialty programs Unit's process and procedures.
    1. Income: The LTC PBS will review and verify the current and anticipated on-going income, and budgeting method; to include if the client's income has reduced, is temporary, or if the client plans to reduce their work hours. 
    2. Resource: The LTC PBS will review, and address excess resource; to include if the client plans to spenddown or convert to an excludable resource.
  3. After the LTC PBS reviews and verifies all changes they will determine if an HWD referral is required.

If the client's income and/or resources are, and will continue, to exceed the program limit, and if the client/AREP prefers to maintain their current income and/or resources with the understanding that they will have to pay a monthly premium for medical benefits: 

  • The LTC PBS will document in the narrative, set a communication (COMM) tickle to @HWD notifying the HWD Specialists of the request for HWD consideration, and notify the client via mail of the HWD referral;
  • Current medical program will remain active during the HWD referral process; 
  • Once HWD eligibility has been determined, the HWD specialist will terminate the current medical program. 

Process for a working client who has just been determined functionally eligible for DDA services and their income is over the CN limit or SIL:

  • The LTC PBS will start application process to include completing an interview, and requesting required verification that is needed to determine financial eligibility. One verification is received, and the LTC PBS determines an HWD referral is needed; the LTC PBS will document in the narrative, and notify the HWD specialists for HWD.

Only an HWD specialist will determine financial eligibility if a client is changing from HWD to another medcial program. 

Additional information for staff on HWD and LTSS, including desk aids can be found on the financial eligibility and policy (FEP) SharePoint under advanced training.