General eligibility for long-term care

Revised date
Purpose statement

WAC 182-513-1315 is the index roadmap WAC for the general eligibility of institutional and home and community based (HCB) waiver Medicaid.

WAC 182-513-1315 General eligibility requirements for long-term care (LTC) programs.

WAC 182-513-1315 General eligibility requirements for long-term care (LTC) programs.

Effective February 20, 2017

This section lists the sections in this chapter that describe how the agency determines a person's eligibility for long-term care services. These sections are:

  1. WAC 182-513-1316 General eligibility requirements for long-term care (LTC) programs.
  2. WAC 182-513-1317 Income and resource criteria for an institutionalized person.
  3. WAC 182-513-1318 Income and resource criteria for home and community based (HCB) waiver programs and hospice.
  4. WAC 182-513-1319 State-funded programs for noncitizens who are not eligible for a federally funded program.

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 182-513-1316 General eligibility requirements for long-term care (LTC) programs.

WAC 182-513-1316 General eligibility requirements for long-term care (LTC) programs.

Effective February 20, 2017

  1. To be eligible for long-term care (LTC) services, a person must:
    1. Meet the general eligibility requirements for medical programs under WAC 182-503-0505, except:
      1. An adult age nineteen or older must meet citizenship and immigration status requirements under WAC 182-503-0535 (2)(a) or (b);
      2. A person under age nineteen must meet citizenship and immigration status requirements under WAC 182-503-0535 (2)(a), (b), (c), or (d); and
      3. If a person does not meet the requirements in (a)(i) or (ii) of this subsection, the person is not eligible for medicaid and must have eligibility determined under WAC 182-513-1319.
    2. Attain institutional status under WAC 182-513-1320;
    3. Meet the functional eligibility under:
      1. Chapter 388-106 WAC for a home and community services (HCS) home and community based (HCB) waiver or nursing facility coverage; or
      2. Chapter 388-828 WAC for developmental disabilities administration (DDA) HCB waiver or institutional services; and
    4. Meet either:
      1. SSI-related criteria under WAC 182-512-0050; or
      2. MAGI-based criteria under WAC 182-503-0510(2), if residing in a medical institution. A person who is eligible for MAGI-based coverage is not subject to the provisions under subsection (2) of this section.
  2. A supplemental security income (SSI) recipient or a person meeting SSI-related criteria who needs LTC services must also:
    1. Not have a penalty period of ineligibility due to the transfer of assets under WAC 182-513-1363;
    2. Not have equity interest in a primary residence greater than the home equity standard under WAC 182-513-1350; and
    3. Disclose to the agency or its designee any interest the applicant or spouse has in an annuity, which must meet annuity requirements under chapter 182-516 WAC.
  3. A person who receives SSI must submit a signed health care coverage application form attesting to the provisions under subsection (2) of this section. A signed and completed eligibility review for LTC benefits can be accepted for people receiving SSI who are applying for long-term care services.
  4. To be eligible for HCB waiver services, a person must also meet the program requirements under:
    1. WAC 182-515-1505 through 182-515-1509 for HCS HCB waivers; or
    2. WAC 182-515-1510 through 182-515-1514 for DDA HCB waivers.

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 182-513-1317 Income and resource criteria for an institutionalized person.

WAC 182-513-1317 Income and resource criteria for an institutionalized person.

Effective February 20, 2017

  1. This section provides an overview of the income and resource eligibility rules for a person who lives in an institutional setting.
  2. To determine income eligibility for an SSI-related long-term care (LTC) applicant under the categorically needy (CN) program, the agency or its designee:
    1. Determines available income under WAC 182-513-1325 and 182-513-1330;
    2. Excludes income under WAC 182-513-1340; and
    3. Compares remaining available income to the special income level (SIL) defined under WAC 182-513-1100. A person's available income must be equal to or less than the SIL to be eligible for CN coverage.
  3. To determine income eligibility for an SSI-related LTC client under the medically needy (MN) program, the agency or its designee follows the income standards and eligibility rules under WAC 182-513-1395.
  4. To be resource eligible under the SSI-related LTC CN or MN program, the person must:
    1. Meet the resource eligibility requirements under WAC 182-513-1350;
    2. Not have a penalty period of ineligibility due to a transfer of assets under WAC 182-513-1363;
    3. Disclose to the state any interest the person or the person's spouse has in an annuity, which must meet the annuity requirements under chapter 182-516 WAC.
  5. A resident of eastern or western state hospital is eligible for medicaid if the person:
    1. Has attained institutional status under WAC 182-513-1320; and
    2. Is under age twenty-one; or
    3. Applies for or receives inpatient psychiatric treatment in the month of the person's twenty-first birthday that will likely continue through the person's twenty-first birthday, and can receive coverage until:
      1. The facility discharges the person; or
      2. The end of the month in which the person turns age twenty-two, whichever occurs first; or(d) Is at least age sixty-five.
  6. To determine long-term care CN or MN income eligibility for a person eligible under a MAGI-based program, the agency or its designee follows the rules under chapter 182-514 WAC.
  7. There is no asset test for MAGI-based LTC programs under WAC 182-514-0245.
  8. The agency or its designee determines a person's total responsibility to pay toward the cost of care for LTC services as follows:
    1. For an SSI-related person residing in a medical institution, see WAC 182-513-1380;
    2. For an SSI-related person on a home and community based waiver, see chapter 182-515 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.

WAC 182-513-1318 Income and resource criteria for home and community based (HCB) waiver programs and hospice.

WAC 182-513-1318 Income and resource criteria for home and community based (HCB) waiver programs and hospice.

Effective February 20, 2017

  1. This section provides an overview of the income and resource eligibility rules for a person to be eligible for a categorically needy (CN) home and community based (HCB) waiver program under chapter 182-515 WAC or the hospice program under WAC 182-513-1240 and 182-513-1245.
  2. To determine income eligibility for an SSI-related long-term care (LTC) HCB waiver, the agency or its designee:
    1. Determines income available under WAC 182-513-1325 and 182-513-1330;
    2. Excludes income under WAC 182-513-1340;
    3. Compares remaining gross nonexcluded income to:
      1. The special income level (SIL) defined under WAC 182-513-1100; or
      2. For HCB service programs authorized by the aging and long-term supports administration (ALTSA), a higher standard is determined following the rules under WAC 182-515-1508 if a client's income is above the SIL but net income is below the medically needy income level (MNIL).
  3. A person who receives MAGI-based coverage is not eligible for HCB waiver services unless found eligible based on program rules in chapter 182-515 WAC.
  4. To be resource eligible under the HCB waiver program, the person must:
    1. Meet the resource eligibility requirements and standards under WAC 182-513-1350;
    2. Not be in a period of ineligibility due to a transfer of asset penalty under WAC 182-513-1363;
    3. Disclose to the state any interest the person or that person's spouse has in an annuity and meet the annuity requirements under chapter 182-516 WAC.
  5. The agency or its designee determines a person's responsibility to pay toward the cost of care for LTC services as follows:
    1. For people receiving HCS HCB waiver services, see WAC 182-515-1509;
    2. For people receiving DDA HCB waiver services, see WAC 182-515-1514.
  6. To be eligible for the CN hospice program, see WAC 182-513-1240.
  7. To be eligible for the MN hospice program in a medical institution, see WAC 182-513-1245.

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 182-513-1319 State-funded programs for noncitizens who are not eligible for a federally funded program.

WAC 182-513-1319 State-funded programs for noncitizens who are not eligible for a federally funded program.

Effective February 20, 2017

  1. This section describes the state-funded programs available to a person who does not meet the citizenship and immigration status criteria under WAC 182-513-1316 for federally funded coverage.
  2. If a person meets the eligibility and incapacity criteria of the medical care services (MCS) program under WAC 182-508-0005, the person may receive nursing facility care or state-funded residential services in an alternate living facility (ALF).
  3. Noncitizens age nineteen or older may be eligible for the state-funded long-term care services program under WAC 182-507-0125. A person must be preapproved by the aging and long-term support administration (ALTSA) for this program due to enrollment limits.
  4. Noncitizens under age nineteen who meet citizenship and immigration status under WAC 182-503-0535 (2)(e) are eligible for:
    1. Nursing facility services if the person meets nursing facility level of care; or
    2. State-funded personal care services if functionally eligible based on a department assessment under chapter 388-106 or 388-845 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.

Clarifying information

Special income level (SIL):

  1. The agency compares a client’s nonexcluded income to the Special Income Level (SIL) under Standards LTSS to determine whether a client is eligible for LTC services under the CN program. Clients applying for HCB Waiver services authorized by Home and Community Services (HCS) can have income over the Medicaid SIL. (See WAC 182-515-1508).
  2. The SIL is equal to 300% of the annually adjusted SSI Federal Benefit Rate (FBR).
  3. The agency does not allow income disregards when determining initial eligibility for CN services. Income that is excluded by federal statute under WAC 182-513-1340 is not counted.

Income transfers:

  1. The agency considers any agreement between spouses to transfer or assign rights to future income to be invalid when determining a client’s income eligibility and participation in the cost of care.
  2. The agency considers such income available when comparing a client’s income to program Standards LTSS and includes it when determining the participation amount whether or not the client continues to receive it.
  3. The agency considers all of a client’s income to be available as described in WAC 182-513-1325 and WAC 182-513-1330, unless exceptional circumstances exist that include but are not limited to the following:
    1. When income is established as unavailable in an administrative hearing as described in chapter 182-526 WAC.
    2. When income that at one time belonged exclusively to an individual becomes property of the spouse in a community property state. An example of this is when a court divides a pension between spouses by use of a "qualified domestic relations order" (QDRO). Under a QDRO a court transfers a portion of the pension, which it considers a resource, and thereby transfers a portion of the income produced by the resource.
  4. The agency does not consider income generated by a transferred resource to be available. The income is a part of the resource, which is why the agency evaluates the transfer of such an asset as the transfer of a resource as described in WAC 182-513-1363.

LTC/private insurance:

Third party resources and LTC insurance

Institutionalized SSI clients:

If an SSI client is admitted to a medical facility for a temporary period, SSI payments may continue for the first three months after admission.

Inpatient mental health treatment in Eastern or Western State Hospital:

Persons who are at least 21 and less than 65 years old who live in Eastern or Western State Hospital are not eligible for medical assistance (if the person turns 21 in the facility while on medical assistance they can receive medical assistance until they discharge or turn 22, whichever comes first). Their medical needs are the responsibility of the hospital.

Parental responsibility:

  1. The financial responsibility of parents is limited to what they choose to contribute when their child is institutionalized under WAC 182-513-1320 including receiving HCB waiver services.
  2. Children who are eligible for Medicaid under institutional rules remain continuously eligible for Medicaid through the end of their one year certification upon discharge from the facility. See Health care for children WAC 182-505-0210 and 182-504-0125 for instructions.

Residency:

  1. See clarifying information on WAC 182-503-0520 for clients not residing in an institution and WAC 182-503-0525 for clients residing in an institution.
  2. If the client or their representative expresses the client’s intent to return to the home, it is excluded when determining resources, even if the home is located in another state.
  3. The expressed intent to return to a home that is in another state does not affect the client’s status as a Washington resident.

Nursing facility (NF) - limitations on billing:

  1. For recipients active on medical coverage the NF can't bill a client who applies for or receives institutional services for the days between admission and the date the facility first notified the department of the admission.  This requirement is under RCW 74.42-056. There is an exemption to this rule.  If the NF admission is on the weekend or a holiday, and the NF notified the department on the next business day, the authorization date will start with the date of admit. 
  2. For applicants, the agency will back date nursing facility payment authorization up to 3 months as long as the individual is otherwise eligible.
  3. Recipients of non-MAGI medical programs must have their eligibility redetermined using institutional rules if the client is in a medical institution 30 days or longer. Recipients of non-MAGI medical can have nursing facility paid as a short stay for less than 30-day admissions only.
  4. Recipients of MAGI medical do not need an award letter for the nursing facility to submit a claim.  Instructions are in the nursing facility billing guide.
  5. Nursing Home Services Prior Authorization is required under the State-funded long-term care for noncitizens.

Active MN Medicaid individual entering a nursing facility

Active MN Medicaid clients who have met spenddown and are placed in a nursing home see clarifying information for the medically needy program.

Worker responsibilities

  1. See Filing an application.
  2. Follow rules for Washington Apple Health (WAH) Eligibility requirements:
    1. Chapter 182-503 WAC describes:
      1. How to Apply
      2. Who can apply
      3. Interview requirements
      4. Verification requirements
      5. Application processing times
      6. When coverage begins
      7. Application denials and withdrawals
      8. Exceptions to rule
      9. Rights and responsibilities
      10. Limited English proficient (LEP) services
      11. Equal Access Services
      12. General eligibility requirements
      13. Program Summary
      14. Social Security number requirements
      15. Residency requirements-Persons who are not residing in an institution
      16. Residency requirements for an institutionalized person
      17. Citizenship and alien status- Definitions
      18. Assignment of rights and cooperation
      19. Age requirements for medical programs based on modified adjusted gross income (MAGI)
    2. Chapter 182-504 WAC describes:
      1. Retroactive certification period
      2. Certification periods for categorically needy (CN) programs
      3. Certification periods for noninstitutional medically needy (MN) programs
      4. Medicare Savings Programs certification periods
      5. Renewals
      6. Changes that must be reported
      7. When to report changes
      8. Effective dates of changes
      9. Effect of reported changes
      10. Continued coverage pending an appeal
      11. Monthly income standards based on the federal poverty level (FPL)
  3. Follow rules in Chapter 182-506 WAC regarding assistance units
  4. Follow rules in Chapter 182-507 WAC for state funded LTC for noncitizens and AEM
  5. Follow rules in Chapter 182-508 WAC for Medicare Care Services (MCS) state funded medical
  6. Follow rules in Chapter 182-510 for SSI medical
  7. Follow rules in Chapter 182-511 for SSI related Health Care for Workers with Disabilities (HWD).
  8. Follow rules in Chapter 182-512 for SSI related medical
  9. For a nursing facility or state funded residential individual whose eligibility is established under the A01 program, waive the sequential evaluation process (SEP) for a client who is eligible to receive ADS services in a nursing facility or state funded residential, refer to the CSO disability specialist for a determination of ABD cash if potentially eligible for ABD cash. If not eligible for ABD cash, because of the duration requirement, open on A01 MCS that includes a referral for Housing Essential Needs (HEN).
  10. For a client with a potential long-term disability who is not eligible for ABD cash, submit a request to the Division of Disability Determination Services (DDDS).
  11. If a person is ineligible because of excess income or resources, or does not meet functional eligibility requirements, notify the client of the reasons why the application is denied. Determine eligibility for noninstitutional medical assistance as if the client were living at home.
  12. If notice is received that an individual no longer needs care provided in a medical facility, redetermine eligibility for other medical programs. Continue CN Medicaid during the redetermination process.
  13. If a client who is denied services for not meeting functional requirements requests an administrative hearing, notify the SW. The staff person who completed the assessment represents the agency at the hearing, unless someone else is designated for that responsibility.
  14. Clients who have insurance must complete 14-194 Medical Coverage Information form including LTC insurance. The Coordination of Benefits (COB) unit at HCA will receive the 14-194 Medical Coverage Information form. The COB unit enters information from the Medical Coverage Form into their system. The information is interfaced with ACES and the TPL screens are auto populated.
  15. Nursing facilities will be responsible for collecting payments from TPL carriers or obtaining a denial of benefits before the agency can pay the facilities. The agency will continue to assign participation, which the nursing facility may collect until the TPL party begins making payments. See Third party resources and LTC insurance.
  16. Admissions under 30 days into a medical facility is a Short stay.

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