Other programs

Revised date

Breast and Cervical Cancer Treatment Program (BCCTP) for Women (S30):

This federally-funded program provides health care coverage for women diagnosed with breast or cervical cancer or a related precancerous condition. Eligibility is determined by the Department of Health's (DOH) Breast, Cervical, and Colon Health Program (BCCHP). DOH is responsible for screening and eligibility, while HCA administers enrollment and provider payment. Coverage continues through the full course of treatment as certified by the BCCHP.

A woman is eligible if she meets all of the following criteria:

  • Screened for breast or cervical cancer under BCCHP
  • Requires treatment for either breast or cervical cancer or for a related precancerous condition
  • Is under age 65
  • Is not covered for another CN (Categorically Needy) Apple Health program
  • Has no insurance or has insurance that is not creditable coverage
  • Meets residency requirements
  • Meets social security number requirements
  • Meets citizenship or immigration status requirements
  • Meets income limits set by the BCCHP.

For further information, see the Department of Health website.

Foster Care/Adoption Support/Former Foster Care (D01, D02, D26):

This program provides CN coverage to children receiving foster care or adoption support services. This program also provides CN coverage to individuals up to age 26 who turn 18 or age out of foster care in Washington State.

Medical Care Services (A01):

This state-funded program provides limited health care coverage to adults meeting incapacity requirements who are not eligible for Apple Health programs with CN, MN or ABP scope of care and who meet the income and resource standards for this program. Individuals over age 65 who are qualified immigrants within their 5-year bar and nonqualified immigrants are eligible for MCS if they meet income and resource requirements.

Refugee (R02, R03):

The Refugee Medical Assistance program (RMA) provides CN coverage to refugees who are not eligible for Apple Health programs with CN or ABP scope of care and who meet the income and resource standards for this program. RMA is a 100% federally funded program for persons granted asylum in the U.S. as refugees or asylees. Individuals enrolled in RMA are covered from the date they entered the U.S.

Eligibility for refugees/asylees that have been in the United States for more than twelve months is determined the same as for U.S. citizens.

Immigrants from Iraq and Afghanistan who were granted Special Immigrant status under Section 101(a)(27) of the Immigration and Nationality Act (INA) are eligible for Medicaid and Refugee Medical Assistance (RMA) the same as refugees.

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WAC 388-79A-005 Maximum Amount of Guardianship Fees and Related Costs for a Long-term Care Medicaid Eligible Client.

WAC 388-79A-005 Maximum amount of guardianship fees and related costs for a long-term care medicaid eligible client.

Revised March 8, 2019

  1. As mandated by RCW 43.20B.460 and in accordance with RCW 11.92.180, the maximum amount of guardianship fees and related costs must not exceed the limits of this section when the person under guardianship is:
    1. A medicaid eligible client, residing in:
      1. A medical institution, as defined under WAC 182-500-0050;
      2. An alternate living facility (ALF), as defined under WAC 182-513-1100; or
      3. An at-home setting; and
    2. Required under chapter 182-513 WAC or chapter 182-515 WAC to participate towards the cost of long-term care.
  2. The maximum amount of guardianship fees and related costs must not exceed the limits of WAC 388-79A-010​ when:
    1. The most recent court order establishing or continuing a guardianship was entered before June 1, 2018; and
    2. The client under guardianship was receiving medicaid-funded long-term care before June 1, 2018.
  3. For all other clients not described under subsection (2) of this section, the maximum amount of guardianship fees and related costs must not exceed the limits under WAC 182-513-1530.

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 388-79A-001 Definitions.

WAC 388-79A-001 Definitions.

Revised June 1, 2018

The following definitions apply to this chapter:

  1. "Client" means a person who is eligible for and is receiving medicaid-funded long-term care.
  2. "Guardianship fees" or "fees" means necessary fees charged by a guardian for services rendered on behalf of a client.
  3. "Participate" or "participation" means the amount a client must pay each month toward the cost of long-term care services received each month. It is the amount remaining after the post-eligibility process under:
    1. WAC 182-513-1380 for a client residing in a medical institution, as defined under WAC 182-500-0050;
    2. WAC 182-515-1509 for a client receiving home and community services (HCS) waivered services in an alternate living facility (ALF), as defined under WAC 182-513-1100, or in an at-home setting; or
    3. WAC 182-515-1514 for a client receiving developmental disability administration (DDA) waivered services in an ALF, as defined under WAC 182-513-1100, or in an at-home setting.
  4. "Related costs" or "costs" means necessary costs paid by the guardian, including attorney fees.

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.

Behavioral health and recovery

Behavioral health is a term that covers the full range of mental and emotional well-being – from day-to-day challenges of life, to treating mental health and substance use disorders.

HCA integrates state-funded (Medicaid) services for substance use, mental health and problem gambling. We provide funding, training, and technical assistance to community-based providers for prevention, intervention, treatment, and recovery support services to people in need.

With our community, state, and national partners, we are committed to providing evidence-based, cost-effective services that support the health and well-being of individuals, families, and communities in Washington State.

Goals

Our goals are to prevent substance use disorders and support holistic, evidence-based, person-centered care that addresses both medical and behavioral health conditions.

Some of the ways our services are making a difference include:

  • Decreasing costs to the public for criminal justice, medical care, foster care and financial assistance;
  • Helping people achieve higher levels of education, find living-wage jobs, and access affordable and supported housing; and
  • Strengthening families so children have the care and support they need to reach their full potential.

Guidance documents

Date Document

April 2018

February 2018

April 2016

March 2016

February 2016
Pictogram of person with thought bubble

How do I…

WAC 182-513-1530 Maximum guardianship fee and related cost deductions allowed from a client's participation or room and board on or after June 1, 2018.

WAC 182-513-1530 Maximum guardianship fee and related cost de­ductions allowed from a client's participation or room and board on or after June 1, 2018.

Revised March 1, 2025

  1. General information.
    1. This section sets the maximum guardianship or conservatorship fee and related cost deductions when:
      1. A court order was entered on or after June 1, 2018; or
      2. The client under guardianship or conservatorship began receiving medicaid-fun­ded long-term services and supports on or after June 1, 2018.
    2. This section only applies to a client who is:
      1. Eligible for and receives institutional services under this chap­ter or home and community-based waiver services under chapter 182-515 WAC, and who is required to pay participation under WAC 182-513-1380, 182-515-1509, or 182-515-1514; or
      2. Eligible for long-term services and supports under this chapter or chapter 182-515 WAC, and who is required to pay only room and board.
    3. All requirements of this section remain in full force whether or not the agency appears at a guardianship or conservatorship proceeding.
    4. In this section, the agency does not delegate any authority in determining eligibility or post-eligibility for medicaid clients.
      1. Under the authority granted by chapter 11.130 RCW, the agency does not deduct more than the amounts allowed by this section from partici­pation or room and board.
      2. The eligibility rules under Title 182 WAC remain in full force and effect.
    5. The agency does not reduce a client's participation or room and board under this section for guardianship or conservatorship fees or related costs accumulated during any month that a client was not required to pay:
      1. Participation under WAC 182-513-1380, 182-515-1509, or 182-515-1514; or
      2. Room and board under this chapter or chapter 182-515 WAC.
    6. If the client has another fiduciary, payee, or other princi­pal-agency relationship and the agent is allowed compensation, any monthly guardianship or conservatorship fee approved under this section is reduced by the agent's compensation.
  2. Maximum guardianship fee and related cost deductions.
    1. The maximum guardianship or conservatorship fee and related cost deductions un­der this section include all guardianship or conservatorship services provided to the client, regardless of the number of guardians or conservators appointed to a client during a period of time, or whether the client has multiple guardians appointed at the same time.
    2. Maximum guardianship or conservatorship fees and related cost deductions are as follows:
      1. The total deduction for costs directly related to establish­ing a guardianship or conservatorship for a client cannot exceed $1,850;
      2. The total deduction for all guardianship and conservatorship-related costs cannot exceed $1,200 during any three-year period; and
      3. The amount of the monthly deduction for all guardianship and conservatorship fees cannot exceed $235 per month.
  3. For people under subsection (1)(b)(i) of this section – Par­ticipation deductions.
    1. After receiving the court order, the agency or its designee adjusts the client's current participation to reflect the deductions under WAC 182-513-1380, 182-515-1509, or 182-515-1514.
    2. The amounts of the participation deductions are the amounts under subsection (2) of this section, or the court order, whichever are less.
    3. For clients who pay room and board in addition to participa­tion, if the client's amount of participation is insufficient to allow for the amounts under subsection (2) of this section, then, regardless of any provision of this chapter or chapter 182-515 WAC, the client's room and board will be adjusted to allow the amounts under subsection (2) of this section.
  4. For people under subsection (1)(b)(ii) of this section - Room and board deductions.
    1. The agency adjusts the client's room and board after receiv­ing the court order, regardless of any provision of this chapter or chapter 182-515 WAC.
    2. The amounts of the room and board deductions are the amounts under subsection (2) of this section, or the court order, whichever are less.

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.

Medically needy LTC programs

Revised date

WAC 182-513-1395 Determining eligibility for institutional services for people living in a medical institution under the SSI-related medically needy program

WAC 182-513-1395 Determining eligibility for institutional services for people living in a medical institution under the SSI-related medically needy program.

Effective February 20, 2017

  1. For the purposes of this section only, "remaining income" means all gross nonexcluded income remaining after the post-eligibility calculation under WAC 182-513-1380.
  2. General information. To be eligible for institutional services when living in a medical institution under the SSI-related medically needy (MN) program, a person must:
    1. Meet program requirements under WAC 182-513-1315;
    2. Have gross nonexcluded income in excess of the special income level (SIL) defined under WAC 182-513-1100; and
    3. Meet the financial requirements of subsection (3) or (4) of this section.
  3. 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.
  4. Eligibility for agency payment to the facility for institutional services and the MN program.
    1. If a person's remaining income plus excess resources is less than, or equal to, the state-contracted daily rate times the number of days the person has resided in the facility, the person:
      1. Is eligible for agency payment to the facility for institutional services and the MN program; and
      2. Is approved for a twelve-month certification period.
    2. The person must pay income and excess resources towards the cost of care under WAC 182-513-1380.
  5. Eligibility for agency payment to the facility for institutional services and MN spenddown. If a person's remaining income is more than the state-contracted daily rate times the number of days the person has resided in the facility, but less than the private nursing facility rate for the same period, the person:
    1. Is eligible to receive institutional services at the state-contracted rate; and
      1. Is approved for a three-month or six-month base period;
      2. Pays income and excess resources towards the state-contracted cost of care under WAC 182-513-1380; and
    2. Is eligible for the MN program for the same three-month or six-month base period when the total of additional medical expenses incurred during the base period exceeds:
      1. The total remaining income for all months of the base period;
      2. Minus the total state-contracted rate for all months of the base period.
  6. If a person has excess resources and the person's remaining income is more than the state-contracted daily rate times the number of days the person has resided in the facility, the person is not eligible to receive institutional services and the MN 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.

Clarifying information

  1. Determination of eligibility for the categorically needy (CN) or medically needy (MN) programs – income only:
    1. Program policy requires the department to use only the amount of an individual's nonexcluded income when determining eligibility for institutional, waivered, or hospice services under the CN program and institutional or hospice services under the MN program.
    2. For services under the CN program, an individual's nonexcluded income cannot exceed the special income level (SIL). For services under the MN program, an individual's nonexcluded income exceeds the SIL, but cannot exceed the amount established in rule and described below. The SIL is 300% of the federal benefit rate (FBR). The current SIL is located on the Standards LTSS chart.
    3. When determining an individual's eligibility for LTC services in the initial or review month, the department allows an amount of excess resources if, when the excess resources are added together with nonexcluded income, the combined total amount does not exceed the program requirements described below.

      Note: Income standard: The income standard used to determine an individual's eligibility for CN or MN program services does not include any amount of the individual's resources. Institutional Medicaid Standards.

  2. Excess resources: Individuals who have resources in excess of the resource standard in the month of application, or in the month in which they are completing an eligibility review, can be approved for or continue to receive LTC services, if the following conditions are met:
    1. For institutional or hospice services provided under the medically needy (MN) program, the combined total of the individual's nonexcluded income and excess resources cannot exceed the private rate of the facility in which the individual receives the services plus the amount of recurring medical expenses. The department adds the excess resources when determining the individual's participation in the cost of care for that month. Medically needy (MN) with no spenddown for institutional or hospice services: When the individual's nonexcluded income exceeds the facility's department-contracted rate with the department and is less than the facility's private rate plus the amount of recurring medical expenses, the individual is locked into the department-contracted rate for facility care only. The department counts the individual's nonexcluded income in excess of the department-contracted rate plus excess resources when determining the individual's spenddown liability for noninstitutional medical. See Spenddown. The contracted rate is equal to that of the medical facility in which the individual lives, or the monthly rate based on a thirty-one day month for hospice services provided in a medical facility.
    2. The department cannot approve noninstitutional medical for the individual, until the individual incurs medical expenses that are at least equal to the amount of nonexcluded income in excess of the department-contracted rate in the base period plus any excess resources. The individual remains liable for all such medical expenses, the amount of which is referred to as the individual's spenddown amount. WAC 182-513-1350 describes what medical expenses we can allow to reduce spenddown for long term care. The medical expenses are incurred by the institutional individual.
  3. Medically needy (MN) with no spenddown for institutional or hospice services: When the individual's nonexcluded income exceeds the facility's department-contracted rate with the department and is less than the facility's private rate plus the amount of recurring medical expenses, the individual is locked into the department-contracted rate for facility care only.
    1. The department counts the individual's nonexcluded income in excess of the department-contracted rate plus excess resources when determining the individual's spenddown liability for noninstitutional medical. See Spenddown. The contracted rate is equal to that of the medical facility in which the individual lives, or the monthly rate based on a thirty-one day month for hospice services provided in a medical facility.
    2. The department cannot approve noninstitutional medical for the individual, until the individual incurs medical expenses that are at least equal to the amount of nonexcluded income in excess of the department-contracted rate in the base period plus any excess resources. The individual remains liable for all such medical expenses, the amount of which is referred to as the individual's spenddown amount.
    3. WAC 182-513-1350 (8)(d) describes what medical expenses we can allow to reduce spenddown for long term care. The medical expenses are incurred by the institutional individual.

Worker Responsibilities

  1. When determining whether an individual is CN or MN eligible, do not add any resource amount to the individual's nonexcluded income.
  2. Include any excess resource amount in the initial or review month when determining an individual's participation in the cost of care or spenddown liability for noninstitutional medical.
  3. Establish the amount of excess resources and nonexcluded income used to determine an individual's participation in the cost of care by subtracting medical expenses from excess resources in an amount equal to incurred medical expenses such as:
    1. Premiums, deductibles, and coinsurance/copayment charges for health insurance and Medicare premiums;
    2. Necessary medical care recognized under state law, but not covered under the state's Medicaid plan;
    3. Necessary medical care covered under the state's Medicaid plan incurred prior to Medicaid eligibility.
      1. As long as the incurred medical expenses:
        1. Are not subject to third-party payment or reimbursement;
        2. Have not been used to satisfy a previous spend down liability;
        3. Have not previously been used to reduce excess resources;
        4. Have not been used to reduce the individual's responsibility toward cost of care;
        5. Were not incurred during a transfer of asset penalty described in WAC 182-513-1363, and
        6. Are amounts for which the individual remains liable.
      2. Expenses not allowed to reduce excess resources or participation in personal care are:
        1. Unpaid expense(s) prior to Waiver eligibility to an adult family home (AFH) or boarding home is not a medical expense.
        2. Personal care cost in excess of approved hours determined by the CARE assessment described in 106 WAC is not a medical expense.
  4. For LTC services provided under the medically needy (MN) program when excess resources are added to nonexcluded income, the combined total is less than the:
    1. Private medical institution rate plus the amount of recurring medical expenses for institutional services; or
    2. Private hospice rate plus the amount of recurring medical expenses, for hospice services in a medical institution.
    3. For MN Waiver eligibility, incurred medical expenses must reduce resources within allowable resource limits for MN-Waiver eligibility. The cost of care for the waiver services cannot be allowed as a projected expense.
  5. Contact the medical facility or hospice provider to obtain necessary documentation or verification as appropriate, since the individual will generally be physically and/or mentally unable to provide the information. It is not necessary to interview the individual.
  6. Use the rules described in WAC 182-513-1395 (5) when approving institutional or hospice services under the MN program. See SPENDDOWN when approving noninstitutional medical.

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Non-Grant Medical Assistance (NGMA) examples

Revised date
Purpose statement

To provide examples of the decision-making process for non-grant medical assistance (Apple Health).

Example: Individual is resource eligible for SSI-related Medicaid, but income exceeds the Substantial Gainful Activity (SGA) test.

Robert (53) is working and earns $1885 per month managing an apartment complex. He has no other income, and his resources are below $2000. After allowing the $20 income exclusion and the $65 plus one half earned income disregard, it appears Robert's net countable income of $900 would make him eligible under the S02 program (based on the Categorically Needy Income Level (CNIL)). However, since S02 medical does not waive the SGA test, and Robert has earned income over the current SGA limit, Robert is not considered 'disabled' under S02 program rules and is not eligible for this program.

Since Robert is working he could be eligible for the Apple Health for Workers with Disabilities (HWD) program. Since Robert has gross earned income over SGA, send his application to the HWD unit for processing who will review for a disability and request a NGMA if appropriate.

Example: Earned income gives an individual the choice between SSI-related Medicaid and HWD if program requirements are met.

Katie (45) receives L&I payments of $950 per month and she has a small self-employment business and earns approximately $100 per week. Her total gross income is $1350 per month. Also, she has recently become eligible for Medicare. If she were not eligible for Medicare, then she should first be screened for MAGI coverage under the new adult group (N05), using the Healthplanfinder.

Since Katie's earnings are below the current SGA limit, she is eligible for regular SSI-related Medicaid with a spenddown OR she can choose HWD coverage with a premium. Explain the options available to her. If she chooses HWD, the NGMA referral is initiated by the HWD worker.

Example: An individual on a DDA waiver with earnings over SGA.

Miranda (34) has been receiving state-funded employment supports through the Developmental Disabilities Administration (DDA) but has not had medical coverage. Miranda applies for Apple Health, because DDA wants to transition her to the Basic Waiver program. She is working and earns $1800 per month. Miranda has been working with a benefit analyst who has recommended that she apply for HWD. Although Miranda's income is below the Special Income Level for the Basic Waiver program, her earnings are over the SGA amount. Refer Miranda's application to the HWD unit to complete the NGMA referral and premium determination. Miranda is not eligible for SSI-related medical under the L22 coverage group because of the SGA test.

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Healthplanfinder letters

Revised date
HPF Number HPF Letter Name Description Freeform Text Requirement Triggering Action/Sent When
EE001*** Additional Verification Required (conditionally approved - or pending verification) Produce a correspondence to an individual who needs to provide additional verifications to finalize their eligibility status Yes - able to add free form text

Auto generated

Status of conditionally eligible is returned for an individual for HIPTC/QHP

Status of active is returned for an individual for WAH

  • But citizenship is not verified.
  • But lawful presence is not verified
EE0034*** Complete Your Application Reminder to complete application None - unable to add free form text

Auto generated

When an individual has started an application, but has not completed it
EE005 WAH Information Request Information request for individuals with outstanding verifications for WAH Yes - able to add free form text

When an individual designates their application as "partially submitted".

When a worker manually triggers EE005 through an individual's dashboard
EE008 WAH Renewal Correspondence for automatic renewal for WAH (Medicaid/CHIP) coverage None - unable to add free form text

Auto generated

When an individual is currently enrolled in WAH and their new eligibility determination at renewal indicates a status of "approved" for WAH for the subsequent coverage period.
EE009 WAH Renewal - Action Required Correspondence notifying an individual of action required to complete a WAH renewal 60 days ahead of the end of the eligibility period. None - unable to add free form text

Auto generated

When HBE calls the Eligibility Service (ES) engine 60 days before the end of a household's WAH eligibility period and receives a status indicating that all members of the household cannot be auto renewed.
EE010 WAH Denial Correspondence notifying an individual who is denied for WAH Yes - able to add free form text

When a worker forces "denial" on an individual's application with an eligibility status of "pending".

When an individual receives the EE005 Information Request for a partially submitted application and has not responded by the due date specified in the Information Request.
EE011 WAH Termination Correspondence notifying an individual who is being terminated for WAH coverage  

When a status of "termination" is returned for an individual or household who is currently part of WAH

When a worker forces termination of WAH through the Application Review screen.

NOTE: When HBE runs an eligibility determination for a household that has a 19-year-old, HBE will receive a status of "denied" with a reason code of "failure to renew". At that point, HBE business logic will determine whether the household has a 19-year-old and will add the appropriate tag next.

Forced termination reason code text is included in this correspondence.
EE013 General Correspondence Correspondence used by staff to provide custom information to individuals Yes - able to add free form text

When a worker clicks the "next" button on the free form text screen
EE015 Eligibility Results Correspondence for determination of WAH, APTC, QHP during the initial application, at change reporting or renewal period None - unable to add free form text

Auto generated

When an individual receives their eligibility determination as part of the initial application, change reporting or renewal process

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Hardship waivers for long-term care (LTC) services

Revised date
Purpose statement

The criteria and process for hardship waivers due to denial or termination of long-term care services because of a transfer of asset penalty, excess home equity, or trusts.

WAC 182-513-1367 Hardship waivers.

WAC 182-513-1367 Hardship waivers.

Effective March 1, 2025

  1. This section defines undue hardship for long-term services and supports (LTSS) and specifies the request, approval, denial, and other processes for hardship waivers.
  2. Undue hardship.
    1. Undue hardship exists when, without LTSS benefits, the client is unable to obtain:
      1. Medical care to the extent that health or life is endangered; or
      2. Food, clothing, shelter or other basic necessities of life.
    2. Undue hardship does not exist when:
      1. The denial or termination of LTSS inconveniences the client or restricts the client's lifestyle but does not seriously deprive the client of the items described under (a) of this subsection;
      2. The denial or termination of LTSS is because of a period of ineligibility under WAC 182-513-1363, and the asset was transferred by a person or entity handling the financial affairs of the client denied or terminated from LTSS, unless the department has found evidence of financial exploitation; or
      3. The client's situation meets undue hardship under (a) of this subsection because of restrictions placed in a trust by that client, either personally or through a spouse, guardian, conservator, court, or another person authorized to act on behalf of that client through a power of attorney document (attorney-in-fact).
  3. ​A hardship waiver may be requested when a client is denied or terminated from LTSS under the following scenarios:
    1. A period of ineligibility under WAC 182-513-1363 was established for a client, and that client, who transferred the assets, or on whose behalf the assets were transferred, either personally or through a spouse, guardian, conservator, or another person authorized to act on behalf of that client through a power of attorney document (attorney-in fact), has exhausted all reasonable means including legal remedies to recover the assets or the value of the transferred assets that caused the period of ineligibility;
    2. A client was denied or terminated from LTSS due to exceeding the home equity standard under WAC 182-513-1350, and the client cannot legally access the excess equity; or
    3. The client was denied or terminated from LTSS due to the application of rules regarding trusts under chapter 182-516 WAC, except that if the application of rules regarding trusts under chapter 182-516 WAC results in a period of ineligibility under WAC 182-513-1363, then (a) of this subsection applies instead of (c) of this subsection.
  4. Process to request a hardship waiver.
    1. A hardship waiver may be requested by:
      1. The client;
      2. The client's spouse;
      3. The client's authorized representative; or
      4. With the consent of the client, a representative of the medical institution in which the client resides.
    2. The hardship waiver request must:
      1. Be in writing;
      2. State the reason for requesting the hardship waiver;
      3. Be signed by the requestor and include the requestor's name, address, and telephone number. If the request is being made on behalf of a client, then that client's name, address, and telephone number must be included;
      4. Be made within 30 days of the date of denial or termination of LTSS; and
      5. Returned to the originating address on the denial or termination letter.
    3. If additional information is needed to determine whether or not to approve a hardship waiver, then, within 15 days of receipt of the request for the hardship waiver, the agency or the agency's designee sends the client a written notice requesting additional information under WAC 182-503-0050.
  5. Standards to approve a hardship waiver request.
    1. Period of ineligibility: If a client was denied or terminated from LTSS under WAC 182-513-1363 (the scenario described in subsection (3) (a) of this section) and undue hardship under subsection (2) of this section is found to exist, then the agency or the agency's designee approves a hardship waiver.
    2. Excess home equity: If a client was denied or terminated from LTSS under WAC 182-513-1350 (the scenario described in subsection (3) (b) of this section) and undue hardship under subsection (2) of this section is found to exist, then the agency or the agency's designee approves a hardship waiver.
    3. Trusts.
      1. The client's home is in a revocable trust: If a client was denied or terminated from LTSS under chapter 182-516 WAC (the scenario described in subsection (3) (c) of this section), then the agency or the agency's designee approves a hardship waiver for up to 90 days if the following conditions are met:
        1. The client is an institutionalized individual;
        2. The home would otherwise meet the exclusion criteria in WAC 182-512-0350 (1) (b), but it is in a revocable trust; and
        3. The client must submit in writing to the agency or the agency's designee that, in order to exclude the home under WAC 182-512-0350 (1) (b), the home will be retitled out of the revocable trust to the client, the client's spouse, or both, within 90 days.
      2. All other denials or terminations of LTSS due to trusts: If a client was denied or terminated from LTSS under subsection (3) (c) of this section, and undue hardship under subsection (2) of this section is found to exist, then the agency or the agency's designee approves a hardship waiver.
  6. If the hardship is approved:
    1. The agency or the agency's designee sends a notice within 15 days of receiving all information needed to approve the hardship waiver. The hardship waiver approval notice specifies a time period for which the undue hardship waiver is approved.
    2. Any changes in a client's situation that led to the approval of a hardship waiver must be reported to the agency or the agency's designee within 30 days of the change per WAC 182-504-0110.
    3. If the hardship waiver is approved under subsection (5) (c) (i) of this section, the client must provide verification by the 90th day after the hardship waiver approval that the home has been retitled out of the revocable trust to the client, the client's spouse, or both.
  7. If the hardship waiver is denied:
    1. The agency or the agency's designee sends a denial notice within 15 days of receiving the hardship waiver request or the request for additional information. The notice will state the reason why the hardship waiver was not approved.
    2. The denial notice has instructions on how to request an administrative hearing. The agency or the agency's designee must receive an administrative hearing request within 90 days of the date of the adverse action.
  8. The agency or the agency's designee may revoke approval of an undue hardship waiver if any of the following occur:
    1. A client, or the client's authorized representative, fails to provide timely information or resource verifications as it applies to the hardship waiver when requested by the agency or the agency's designee per WAC 182-503-0050 and 182-504-0105;
    2. The lien or legal impediment that restricted access to home equity in excess of the home equity limit is removed; or
    3. Circumstances for which the undue hardship was approved have changed.
  9. If there is a conflict between this section and chapter 182-526 WAC, this section prevails.

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.

Agency Responsibilities

Hardship waiver requests are time sensitive, it is essential a determination is staffed by financial and social service staff authorizing long-term care services.

Refer a Hardship Waiver request to the designee appointed by the HCS Regional Administrator. Set an alert to check the status within 10 days.

Effective 11/22/2012 a new provision has been added to WAC 182-513-1367 to allow a hardship waiver for transfers that occur between state-registered domestic partners as described in chapter 26.60 RCW or transfers between same-sex couples who were married in states and the District of Columbia where same-sex marriages are legal and the transfer would not have caused a period of ineligibility if made between an opposite sex married couple under WAC 182-513-1363.

Worker Responsibilities

Once a request for a Hardship Waiver is received, refer to the HCS Regional Office immediately and set an alert for a response. Contact your Regional program manager to identify the individual that receives the hardship waiver request in your HCS region.

Each HCS region is responsible to appoint a designee from social services and financial to staff hardship waiver request and maintain time frames.

If it appears there has been financial exploitation, refer case to Adult Protective Services in addition to a referral for Hardship Waiver request. Make sure both APS and the Regional Designee are aware of each referral to facilitate coordination.

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Excess home equity

Revised date
Purpose statement

Section 6014 of the Deficit Reduction Act (DRA) of 2005 included a new provision which is a limitation on the payment of LTC services (Medicaid services in a medical institution or a Home and Community Based Waiver). The DRA states "this applies to individuals who are determined eligible for Medicaid with respect to nursing facility or other long-term care services." Effective 7/7/2022, Washington changed the rule from the minimum home equity limit to the maximum home equity limit allowed under federal rule.

WAC 182-513-1350 Defining the resource standard and determining resource eligibility for SSI-related long-term care (LTC) services.

WAC 182-513-1350 Defining the resource standard and determining resource eligibility for SSI-related long-term care (LTC) services.

Effective February 25, 2023

  1. General information.
    1. This section describes how the agency or the agency's designee defines the resource standard and countable or excluded resources when determining a person's eligibility for SSI-related long-term care (LTC) services.
    2. "Resource standard" means the maximum amount of resources a person can have and still be resource eligible for program benefits.
    3. For a person not SSI-related, the agency applies program specific resource rules to determine eligibility.
  2. Resource standards.
    1. The resource standard for the following people is $2000:
      1. A single person; or
      2. An institutionalized spouse.
    2. The resource standard for a legally married couple is $3000, unless subsection (3)(b)(ii) of this section applies.
    3. The resource standard for a person with a qualified long-term care partnership policy under WAC 182-513-1400 may be higher based on the dollar amount paid out by a partnership policy.
    4. Determining the amount of resources that can be allocated to the community spouse when determining resource eligibility is under WAC 182-513-1355.
  3. Availability of resources.
    1. General. The agency or the agency's designee applies the following rules when determining available resources for LTC services:
      1. WAC 182-512-0300 SSI-related medical—Resources eligibility;
      2. WAC 182-512-0250 SSI-related medical—Ownership and availability of resources; and
      3. WAC 182-512-0260 SSI-related medical—How to count a sponsor's resources.
    2. Married couples.
      1. When both spouses apply for LTC services, the resources of both spouses are available to each other through the month in which the spouses stopped living together.
      2. When both spouses are institutionalized, the agency or the agency's designee determines the eligibility of each spouse as a single person the month following the month of separation.
      3. If the agency or the agency's designee has already established eligibility and authorized services for one spouse, and the community spouse needs LTC services in the same month, but after eligibility has been established and services authorized for the institutionalized spouse, then the agency applies the standard under subsection (2)(a) of this section to each spouse. If doing this would make one of the spouses ineligible, then the agency applies subsection (2)(b) of this section for the couple.
      4. The resources of the community spouse are unavailable to the institutionalized spouse the month after eligibility for LTC services is established, unless (v) or (vi) of this subsection applies.
      5. When a single institutionalized individual marries, the agency or the agency's designee redetermines eligibility applying the resource and income rules for a legally married couple.
      6. A redetermination of the couple's resources under this section is required if:
        1. The institutionalized spouse has a break of at least 30 consecutive days in a period of institutional status;
        2. The institutionalized spouse's countable resources exceed the standard under subsection (2)(a) of this section, and WAC 182-513-1355 (2)(b) applies; or
        3. The institutionalized spouse does not transfer the amount, under WAC 182-513-1355 (3) or (5), to the community spouse by either:
          1. The end of the month of the first regularly scheduled eligibility review; or
          2. A reasonable amount of time necessary to obtain a court order for the support of the community spouse.
  4. Countable resources.
    1. The agency or the agency's designee determines countable resources using the following sections:
      1. WAC 182-512-0200 SSI-related medical—Definition of resources.
      2. WAC 182-512-0250 SSI-related medical—Ownership and availability of resources.
      3. WAC 182-512-0260 SSI-related medical—How to count a sponsor's resources.
      4. WAC 182-512-0300 SSI-related medical—Resources eligibility.
      5. WAC 182-512-0350 SSI-related medical—Property and contracts excluded as resources;
      6. WAC 182-512-0400 SSI-related medical—Vehicles excluded as resources;
      7. WAC 182-512-0450 SSI-related medical—Life insurance excluded as a resource; and
      8. WAC 182-512-0500 SSI-related medical—Burial funds, contracts and spaces excluded as resources.
      9. Chapter 182-516 WAC, Trusts, annuities, life estates, and promissory notes—Effect on medical programs.
    2. The agency or the agency's designee determines excluded resources based on federal law and WAC 182-512-0550, except:
      1. For institutional and HCB waiver programs, pension funds owned by a nonapplying spouse are counted toward the resource standard.
      2. For long-term services and supports (LTSS), based on the need for either nursing facility level of care or intermediate care facility for the intellectually disabled level of care, one home is excluded only if it meets the home equity limits of subsection (8) of this section. See WAC 182-512-0350 (1)(b).
    3. The agency or the agency's designee adds together the countable resources of both spouses if subsections (3)(b)(i) and (iv) apply, but not if subsection (3)(b)(ii) or (iii) apply. For a person with a community spouse, see WAC 182-513-1355.
  5. Excess resources.
    1. For LTC programs, a person may reduce excess resources by deducting incurred medical expenses under subsection (6) of this section;
    2. The amount of excess resources is limited to the following amounts:
      1. For LTC services provided under the categorically needy (CN) program:
        1. In a medical institution, excess resources and available income must be under the state medicaid rate based on the number of days the person spent in the medical institution in the month.
        2. For HCB waiver eligibility, incurred medical expenses must reduce resources within allowable resource standards. The cost of care for the HCB waiver services cannot be allowed as a projected expense.
      2. For LTC services provided under the medically needy (MN) program, see:
        1. WAC 182-513-1395 for LTC programs; and
        2. WAC 182-513-1245 for hospice.
    3. Excess resources not otherwise applied to medical expenses will be applied to the projected cost of care for services in a medical institution under WAC 182-513-1380.
  6. Allowable medical expenses.
    1. The following incurred medical expenses may be used to reduce excess resources:
      1. Premiums, deductibles, coinsurance, or copayment charges for health insurance and medicare;
      2. Medically necessary care defined under WAC 182-500-0070, but not covered under the state's medicaid plan. Information regarding covered services is under chapter 182-501 WAC;
      3. Medically necessary care defined under WAC 182-500-0070 incurred prior to medicaid eligibility. Expenses for nursing facility care are reduced at the state rate for the specific facility that provided the services.
    2. To be allowed, the medical expense must:
      1. Have been incurred no more than three months before the month of the medicaid application;
      2. Not be subject to third-party payment or reimbursement;
      3. Not have been used to satisfy a previous spenddown liability;
      4. Not have been previously used to reduce excess resources;
      5. Not have been used to reduce participation;
      6. Not have been incurred during a transfer of asset penalty under WAC 182-513-1363; and
      7. Be an amount for which the person remains liable.
  7. ​Nonallowable expenses. The following expenses are not allowed to reduce excess resources:
    1. Unpaid adult family home (AFH) or assisted living facility expenses incurred prior to medicaid eligibility;
    2. Personal care cost in excess of approved hours determined by the CARE assessment under chapter 388-106 WAC; and
    3. Expenses excluded by federal law.
  8. Excess home equity.
    1. A person with an equity interest in a primary residence in excess of the home equity limit is ineligible for long-term services and supports (LTSS) that are based on the need for either nursing facility level of care or intermediate care facility for the intellectually disabled level of care, unless one of the following persons lawfully resides in the home:
      1. That person's spouse; or
      2. That person's dependent child under age 21, blind child, or disabled child.
    2. The home equity provision applies to all applications for LTSS received on or after May 1, 2006.
    3. The excess home equity limit is the federal maximum allowed. On January 1st of each year, this standard may change by the percentage in the consumer price index for all consumers (CPI-U). The current maximum home equity limit is posted by the Centers for Medicare and Medicaid Services. (See subsection (9) of this section for institutional resource standards.)
    4. A person who is denied or terminated LTC services due to excess home equity may apply for an undue hardship waiver under WAC 182-513-1367.
  9. Institutional resource standards are found at www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/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.

Clarifying Information

WAC 182-513-1350 (8) is the rule for excess home equity. The current excess home equity standard is posted on the Washington Apple Health Income and Resource standard chart located in the Apple Health manual LTC medical standards.

Definition of a home:

Federal SSI related Policy Manual

WAC 182-512-0350 SSI related medical

The excess home equity is not an eligibility factor for noninstitutional Medicaid. It is a limitation on payment for long-term services and supports (LTSS). This includes Community First Choice (CFC), PACE, Home and Community Based Waiver Services (HCBS) and institutional Medicaid. A primary residence would not count as a resource under regular community Medicaid rules.

If there is a legal impediment it would still render the person ineligible for LTSS unless a hardship waiver is approved under WAC 182-513-1367.

Individuals with an equity interest in their home greater than the excess home equity limits are ineligible for nursing facility and other long-term care services (this includes Home and Community based Waivers).

This is a pass/fail provision. If an applicant or recipient has equity interest over the standard in the home, there is no eligibility for long term care services. Putting the home up for sale does not allow conditional eligibility when there is excess home equity. Deny an application based on reason code 410 excess home equity. The system will generate information regarding hardship waivers described in WAC 182-513-1367. For recipients, terminate the case following 10 day notice rules. Reason code 410 will generate information regarding excess home equity and hardship waivers.

The ACES system is programmed to do this for L track programs. The denial/termination reason code 410-Excess home equity. Unless the following criteria is met, excess home equity is based on:

  • On LTC services prior to 5/1/2006 with no break in service
  • A spouse, dependent minor or disabled adult child are living in the home
  • The home is essential for self-support
  • Hardship Waiver due to application of the rule has been approved

Excess home equity provision is a pass/fail provision

The excess home equity provision applies to the first determination of eligibility as well as at future redeterminations. The home equity provision does not apply to individuals who applied and were determined eligible before May 1, 2006 and have no break in LTC eligibility after May 1, 2006.

The amount of the individual's equity interest in the home should be based solely on the current market value of the home, minus any encumbrances such as mortgages or other loans that are secured by the home. If the overall equity interest in the home is shared by co-owners equity interest is determined according to POMS SI 0110.510. (fractional interest determination).

CMS guidance indicates that an allegation that home equity should not count because of a legal impediment to selling or transferring the home does not prevent a determination of the individual's equity interest. Such an allegation may be a legitimate reason for the state to consider waiving the application of the excess home equity requirement because of a hardship. (see Hardship Waiver).

The excess home value is not applied to the resource standard. It is a pass/fail provision.

How is reverse mortgage line of credit treated?

The most popular option to reduce equity interest is through a reverse mortgage. The equity value is reduced by deducting the debt from the current market value. The homeowner will have to receive the money for it to reduce equity.

Costs relating to obtaining the reverse mortgage can be included to reduce the home equity if the costs are paid out of the loan proceeds. (They become part of the outstanding debt). If the person pays out-of-pocket costs up front, they do not reduce the equity.

Excess home equity and LTC Partnership Rules

The home equity is not protected per se under the LTC Partnership rules. A person can take out a home equity loan converting equity into an otherwise countable resource and then the equity will be treated as any other resource will be treated.

Example #1
Applicant recently entered a nursing home. Equity in the home is $990,000. There is no spouse or dependents. Applicant intends to return home.

In this example, the application is denied due to excess home equity provisions.

Example #2
Applicant recently entered a nursing home. Equity in the home is $990,000. There is no spouse or dependents. Applicant's representative has put the home up for sale.

In this example, the application is denied due to excess home equity provisions. Putting the home up for sale does not negate this provision as it is a pass/fail test for LTC services. The applicant can look into the possibility of a reverse mortgage.

Example #3
Applicant recently entered a nursing home. Equity in the home is $990,000. The community spouse lives in the home.

In this example, the home is excluded. The excess home equity provision does not apply if the spouse (or dependents) are living in the home.

Example #4
Applicant recently entered a nursing home. Equity in the home is $800,000. In addition to the home, there is noncontiguous property worth $625,000 that is up for sale. There is no spouse or dependents. The applicant intends to return to the home.

The excess home equity provision only applies to the individual's home. In this example, the home equity value is under the standard. The individual intends to return home, so it is excluded from eligibility.

The 2nd piece of property is over the excess home provision, however was not the individual's primary home. The excess home provision does not apply to this 2nd piece of property. The property is listed for FMV, therefore we can look at conditional eligibility as the house is listed for sale.

Example #5
Applicant recently entered a nursing home. Equity in the home is $100.00 over the current home equity standard. The individual has no other resources.

The application is denied based on excess home equity. In this example we cannot apply the $2,000 that is over the standard toward the $2,000 resource standard. The home equity can exceed the standard by $1 and the case would need to be denied.

Example #6
Applicant recently entered a nursing home. Equity in the home is $900,000. In addition to the home, there is a contiguous property worth $150,000. There is no spouse or dependents. The applicant intends to return to the home.

In this example the home and the contiguous property all count towards the equity limit, so the applicant would be denied for excess home equity.

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