Guardianship training

Revised date
Purpose statement

A training giving examples to Public Benefits Specialist staff of how guardianship fees and costs and attorney fees relating to guardianship orders are allowed for clients residing in a medical institution or receiving Home and Community Based Services (HCBS).

Note: The computations used for this training material reflect standards as of 7/1/2022.

See Program standard for income and resources for current information.

See PNA and ALTSA room and board amounts.

Allowing Guardianship Fees & Costs/Attorney fees

WAC 182-513-1530 states the maximum allowed deductions for guardian fees and associated costs.

We will allow the guardianship fees and expenses as long as those costs, plus the Personal Needs Allowance (PNA), plus the earnings deduction, and mandatory tax deduction does not exceed the Medically Needy Income Level (MNIL) if residing in a medical institution.

For HCBS waivers the combined PNA, earnings deduction, and guardianship fee cannot exceed the Special Income Level (SIL).

Guardianship fees are an allowable deduction for those in medical institutions and those on HCBS waiver services only. (L track programs).

Medical institutions are defined in WAC 182-500-0050

Clients in Medical Institutions

For participation, there is a limit to the deductions that can be allowed each month, in addition to the limits imposed by the Guardianship WACs. See WAC 182-513-1380

For a client in a medical institution, when added together the following deductions cannot exceed the MNIL:

  • PNA
  • Mandatory income tax
  • Wages of a recipient in an approved employment/rehab plan
  • Guardianship Fees and associated costs

Here are some examples of how this will look:

Example #1 - Medical Institution

A single client has $1500 in unearned income. No earned income. Client also has a deduction for mandatory income taxes from their pension of $50 per month. In addition, this client has a guardian, and we have a court order approving the monthly fee of $235 as well as $1,000 attorney’s fees for the initial guardianship.

Month 1 – client enters nursing facility on the 5th of the month from home. This is the first month of the guardianship court order.

Participation will look like this:

$1500 Income

- 841 PNA (month of admit) CNIL as of 1/1/2022

$ 659.00 Participation

But wait – what happened to the $50 income tax, the guardianship fees, and the attorney’s fees?

Well, we can’t allow them this month. Why? Because we cannot allow more than the MNIL for all of those deductions combined, and the PNA for the initial month is the MNIL. There isn’t any more of an allowance we can use.

Example #2 - Medical Institution

Month 2

The same client is in the nursing facility the entire month.

Participation would be:

$1500.00 Income

- 75.36 PNA

- 50.00 Mandatory income tax

- 235.00 Guardianship fee - Month 1

- 235.00 Guardianship fee - Month 2

- 245.64 Attorney’s fees you can allow ($754.36 remaining)

- $659.00 Participation

Notice that the combined total of PNA + mandatory income tax + the first two months of Guardianship Fees and allowed costs is $841.00. The remaining attorney’s fees will need to be allowed in future months. Always allow guardianship fees before allowing attorney’s fees.

Example #3 - Medical Institution

Month 3

The same client is in the nursing facility the entire month.

Participation would be:

$1500.00 Income

- 75.36 PNA

- 50.00 Mandatory income tax

- 235.00 Guardianship Fee – Month 3

- 480.64 Attorney’s fee you can allow ($273.72 remaining)

$659.00 Participation

Example #4 -Medical Institution

Month 4

The client is in the nursing facility the entire month.

Participation would be:

$1500.00 Income

- 75.36 PNA

- 50.00 Mandatory income tax

- 235.00 Guardianship Fee Month 4

-273.72 Attorney's fee you can allow (You have now allowed the full $1000 attorney's fees)

$ 865.92 Participation

Note: Of course, for new nursing facility clients with a Medicare premium as an allowable medical expense deduction, those expenses come after we allow for PNA, Mandatory Income Tax, Guardianship Fees & Attorney’s fees.

Now, on to COPES (HCBS Waiver)

The COPES waiver was written and approved by CMS differently.

WAC 388-515-1509 states:

The total of the following amounts cannot exceed the Medicaid SIL: The SIL is 300% of the Federal Benefit Rate (FBR).

  • PNA
  • Earned income deduction of the first sixty-five dollars plus one-half of the remaining earned income in subsection
  • Guardianship fees and administrative costs

What is room and board and what is an alternate living facility? How do we deduct guardianship fees if there is only room and board?

The definitions for Room and Board and Alternate Living Facility (ALF) can be found under WAC 182-513-1100

  • What makes an ALF so complicated?
    • 2 parts
      • Federal part of the computation is what the client pays towards their cost of personal care, otherwise known as participation.
      • State funded part of the computation is called room and board (R & B). This is considered the shelter and food portion of the cost. Think of R & B as the rent. It is the part that does NOT cover personal care.
        • The R & B amount is the FBR minus the residential COPES PNA 
        • When a deduction is taken from R & B, it is coming from state funds.
        • HCS requires an ETR process to deduct anything from R & B because it is coming out of state funds. However, R&B deductions for guardianship fees and costs are allowed per rule effective June 1, 2018. Although an exception-to-rule (ETR) is no longer required to allow the deduction, Public Benefits Specialist (PBS) staff must code as a “Room and Board Exception” in ACES to allow the R&B deduction. The maximum deductions allowed for fees and costs are either the amounts in WAC 182-513-1530, or the court order, whichever is less. Any exceptions to these amounts are subject to the eligibility ETR WAC 182-503-0090.

Example #1 - HCBS Waiver
Single individual receiving HCBS waiver services at home:  $2836 unearned income, $50 mandatory income taxes, $235 guardianship fees with $1000 initial attorney’s fees.
AT HOME:

$2836.00 Income

- 2523.00 PNA (as of 7/1/2022)

$ 313.00 Participation

Did you forget the Guardianship fees and $50 mandatory income taxes?

No. WAC 182-515-1509 states that the total of PNA, earned income deduction, and guardianship fees can't exceed the Special Income Level (SIL). Because the PNA, in this case, is the SIL, guardianship fees are not allowed as a deduction. Additionally, the waiver does not allow for a reduction for mandatory income taxes. A client who is on HCBS Waiver at home must use their PNA to cover this cost.

Note: Unlike nursing homes, however, Medicare and medical expenses are allowed after PNA but before guardianship fees and attorney’s fees. So, if this client had medical expenses, we would be able to reduce the remaining participation by that amount.

Example #2 HCBS Waiver

If this was month 1 of eligibility, and the same client had allowance medical expenses, it would look like this:

$2836.00 Income

- 2523.00 PNA

- 180.00 Allowable medical expenses

$ 133.00 - Participation

Example #3 HCBS Waiver

Same client in an ALF – admit month:

$2836.00 Income

- 841.00 PNA/Room & Board ($75.36 + $765.64)

- 180.00 Allowable Medical Deduction

- 235.00 Guardianship Fees

- 530.64 Attorney’s Fees (Remainder is $469.36 to be allowed in the next month)

$ 1,049.36 - Participation

+ 765.64 Room & Board

$ 1815.00 Client’s Cost of Care

Just like at home, Medicare and medical expenses are allowed after PNA but before guardianship fees and attorney’s fees. They are allowed out of participation, not out of room and board. If you must reduce R & B, then you must have an approved ETR to do so. R & B consists of state funds and is considered the portion for shelter and food.

What about Guardianship fees for non-institutional Medicaid programs?

  • A court ordered guardianship fee is not an allowable deduction in non institutional Medicaid.
  • Guardianship fees are only allowed in institutional programs with the limitations indicated above.
  • For individuals on Medicaid Personal Care (MPC) residing in an ALF, an ETR referral can be made to the HCS Regional designee. Before considering an ETR, consult the social worker about the possibility of services through the HCBS Waiver if the client would have available participation that we could apply the guardianship fee deduction.
  • HCBS Waiver cannot be used for Adult Residential Centers (ARC), but can be used for Adult Family Homes (AFH).

Example #1 MPC client residing in an adult family home.

Gross income is $2436 SSA.

Court order for $235 guardianship fee received.

Rather than doing an ETR to consider a deduction from the R & B, this case should be switched to the HCBS Waiver if the client meets the functional criteria.

The $235.00 would be an allowable deduction from the HCBS Waiver.

HCS Social Services determines the client cost of care for MPC, but in this circumstance a discussion with the financial worker and social worker should occur about the possibility of HCBS Waiver services.

The HCBS Waiver is considered the priority program over MPC for:

  • Clients meeting functional criteria for HCBS waiver and
  • Have income over the CNIL and
  • Reside in an adult family home.

Example #2 MPC client residing in an ARC.

Gross income is $2436 SSA

Court order for $235 guardianship fee received.

HCBS Waiver services are not authorized in an ARC setting, only MPC. An ETR to consider a deduction from room and board should be considered by the HCS Social Worker.

Example #3 MPC client on S02 living at home.

Guardianship fees are not an allowable deduction for non institutional Medicaid programs. An MPC client at home does not participate in the cost of personal care nor is there R & B. In this example there is no deduction for the guardianship fee.

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DDA Residential Habilitation Centers (RHC)

Revised date
Purpose statement

This section describes the processes between the DDA RHCs, LTC specialty financial worker and Office of Financial Recovery (OFR).

Residential Habilitation Centers (RHC)

  • Residential Habilitation Centers (RHC)
    • Fircrest School
    • Lakeland Village
    • Rainier School
    • Klamath Cottage is not certified as an institutional setting
    • Yakima Valley School

The RHCs are federally certified as Intermediate Care Facilities for individuals with Intellectual Disabilities (ICF/ID), Nursing Facilities (NF) or a combination of both.

Chapter 71A.20 RCW Residential Habilitation Centers

Residential Habilitation Centers- charges payable in advance

Chapter 388-837 WAC Residential Habilitation Center (RHC) ICF/MR program

LTC Specialty Financial Worker-Eligibility

  • Determines eligibility requirements for institutional Medicaid described in WAC 182-513-1315.
  • Determines resource eligibility for institutional medical described in WAC 182-513-1350.
  • Determines excess resources in the month of application described in WAC 182-513-1350 and applies any excess resource toward the cost of care in the admittance month. For recipients, excess resources are countable resources which are available for resident's use when over the $2,000 resource limit and have not been exhausted by the first moment of the first day of the following month.
  • Determines income and post eligibility (participation determination) described in WAC 182-513-1380. The financial worker inputs the information to the ACES system and issues an award letter. The income and post eligibility section has information on guardianships.
  • Sends the award letter with a copy of the notice of financial responsibility (NFR) by certified mail return receipt requested (CMRRR) to the POA, payee/guardian, OFR and the resident's RHC facility.

DDA LTC and Specialty Programs Unit (LTCSPU) Financial - Changes

Reporting requirements

Effective date of changes

WAC 182-504-0120 (subsection 11) When institutional medical assistance participation changes, we calculate the new participation amount beginning with the month income or allowable expense changes.

Effect of changes on medical program eligibility

The financial worker has 10 days to act on changes reported. Issue the appropriate award letter if there is a participation change or change of benefit.

Excess Resources. The LTC financial worker reviews the individual's resources as of the first moment of the first day of the month. If the resources exceed the $2,000 resource limit but are below the state cost of care for the month, a new award letter to update the individual's responsibility toward the cost of care for that month. The resources are indicated on the appropriate screens in ACES for the month. Make sure the resource screens in ACES are updated for the ACES ongoing month to account for the application of excess resources being applied toward the cost of care.

Lump sums and long-term care The financial worker:

  • Determines the type/source of the lump sum payment.
  • If the lump sum is a retroactive SSDI/SSI payment, exclude the income as a resource for 9 months. Set a barcode tickler to review case and request resource verification in the 9th month.
  • If the payment is an unanticipated lump sum from another source, request a resource statement from the RHC and individual/guardian as of the first of the month following the receipt of the lump sum.
  • If the lump sum amount plus the individual's available income exceeds the monthly projected cost of care, send a notice of termination (giving 10 days advance notice) for LTC and medical benefits.
  • If the financial worker determines there is an overpayment and the individual no longer has the available funds to pay the adjustment, an overpayment needs to be established by the financial worker and sent to OFR.

Discharge from an RHC

  • The LTCSPU will determine the impact on participation when there is a change in the individual's living situation. If the individual is discharging to another institution. the LTCSPU will determine how to split the participation appropriately between the two facilities by coding ACES correctly in the month of change. If the individual discharges home or to a residential setting, the LTCSPU will issue an amended award letter adjusting the participation to the highest PNA allowed in that month.
  • The LTC PNA chart includes instruction regarding how a PNA is chosen when the individual changes from one setting or service to another.

Death of an Individual

  • The LTCSPU will update the individual's death in the appropriate months in ACES and issue an adjusted participation notice for the month of death along with a condolence notice.
  • Social Security has a rule that the month the beneficiary dies the payment is supposed to be returned for that month. HQ staff has contacted SSA as this policy appears inconsistent. Some are allowed to keep their SSA check, and some are requested by SSA to return the check. The rule for participation adjustment is if the PBS receives verification from social security that the SSA check received in the month of death has been returned, the financial worker will adjust the participation to reflect -0- SSA received in the month and issue a new award letter.

DDA LTC and Specialty Unit Financial - Hearings

If a hearing is received by the LTCSPU forward it using Barcode AHCS Request (DSHS 05-013). This will forward the information to the DDA Financial  Administrative Hearing Specialist for processing.

An individual must receive continued assistance, if all of the conditions in chapter 182-526 WAC. Advance notice is not required for changes to participation.

Adequate notice is mailed less than ten days before the effective date.

Advance notice is not required to change an individual's participation toward the cost of care, since no reduction, suspension, or termination of services will result. A change in the participation is not considered an adverse action.

Note: Notify Ken Washington of OFR-Estate Recovery via a DMS tickler when a trust is imaged in the electronic case record. This includes all trusts including pooled trusts.

Set up the following DMS tickler:

Document type for tickler: TD (use for either a trust or annuity)

Subject: Trust (if a trust) or Annuity (if an annuity)

Site: 101

User: WAKE

Ready date: Default date is fine

Make sure the trust is indicated on the appropriate navigation tree under resources in ACES 3G. Add in the remarks behind the resource screen that OFR has been notified of the trust in the ECR.

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TSOA income and resources

Revised date
Purpose statement

This section explains the income and resource rules and standards that apply to the Tailored Supports for Older Adults (TSOA) program.

WAC 182-513-1635 Tailored Supports for Older Adults (TSOA) - Income Eligibility

WAC 182-513-1635 Tailored Supports for Older Adults (TSOA) — Income Eligibility.

Effective October 6, 2023

  1. To determine income eligibility for the tailored supports for older adults (TSOA) program, the medicaid agency or the agency's designee uses the following rules depending on whether the person is single or married.
  2. If the TSOA applicant is single:
    1. Determine available income under WAC 182-513-1325;
    2. Exclude income under WAC 182-513-1340; and
    3. Compare remaining gross nonexcluded income to 400 percent of the federal benefit rate (FBR) for the supplemental security income (SSI) cash grant program. To be eligible, a person's gross income must be equal to or less than 400 percent of the FBR.
  3. If the TSOA applicant is married:
    1. Determine available income under WAC 182-513-1330 with the exception of subsection (5) of that section;
    2. Exclude income under WAC 182-513-1340;
    3. Compare the applicant's remaining gross nonexcluded income to 400 percent of the FBR. To be eligible, a person's gross income must be equal to or less than 400 percent of the FBR.
  4. The FBR changes annually on January 1st.
  5. The current TSOA income standard is found on the Washington apple health income and resource standards chart, institutional standards section; see 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.

Note:

  • Community income rule does not apply to TSOA.
  • TSOA is a gross income test, so standard SSI-related deductions, such as the $20 disregard, work-related expenses, and the earned income deduction, are not deducted.

WAC 182-513-1640 Tailored Supports for Older Adults (TSOA) - Resource Eligibility

WAC 182-513-1640 Tailored supports for older adults (TSOA) — Resource eligibility.

Effective October 9, 2023

  1. The resource standard for a single applicant for tailored supports for older adults (TSOA) is six times the Washington state average monthly private nursing facility rate, as determined by the department of social and health services under chapter 74.46 RCW.
  2. The resource standard for a married couple is six times the Washington state average monthly private nursing facility rate, as determined by the department of social and health services under chapter 74.46 RCW, for the TSOA applicant plus the state spousal resource standard for the spousal impoverishment protections community (SIPC) spouse. The state spousal resource standard may change annually on July 1st.
  3. The medicaid agency or the agency's designee uses rules in WAC 182-513-1350 (1), (3) and (4) to determine general eligibility relating to resources, availability of resources, and which resources count.
  4. The TSOA recipient has one year from the date of initial eligibility of TSOA to transfer resources in excess of the TSOA standard to the SIPC spouse.
  5. The resource standard for TSOA changes annually on January 1st based on the current average private nursing facility rate, as determined by the department of social and health services under chapter 74.46 RCW.
  6. The current TSOA standards and the current average private nursing facility rate are found on the Washington apple health income and resource standards chart, institutional standards section; see 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

Note:   Excess home equity, transfer penalties, annuities LTC provision don’t apply. We do count the Community Spouse pension as a resource for TSOA just like COPES. TSOA and MAC are not considered ‘paid care’ for the purposes of transferring the home in 182-513-1363.

The $53,100 does not increase – it’s a set amount.

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Apple Health for parents and caretakers

Revised date

WAC 182-505-0240 Parents and caretaker relatives.

WAC 182-505-0240 Parents and caretaker relatives.

Effective July 1, 2017.

  1. A person is eligible for Washington apple health categorically needy (CN) coverage when the person:
    1. Is a parent or caretaker relative of a dependent child who meets the criteria described in WAC 182-503-0565(2);
    2. Meets citizenship and immigration status requirements described in WAC 182-503-0535;
    3. Meets general eligibility requirements described in WAC 182-503-0505; and
    4. Has countable income below the standard in WAC 182-505-0100 (2).
  2. To be eligible for coverage as a caretaker relative, a person must be related to a dependent child who meets the criteria described in WAC 182-503-0565(2).
  3. A person must cooperate with the state of Washington in the identification, use and collection of medical support from responsible third parties as described in WAC 182-503-0540.
  4. A person who does not cooperate with the requirements in subsection (3) of this section is not eligible for coverage.

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. Individuals who are over income for Apple Health for Parents/Caretakers (N01) may be eligible for Apple Health for Adults (N05) as described in WAC 182-505-0250.
  2. Individuals who are ineligible for Apple Health for Parents/Caretakers (N01) based on citizenship may be eligible for Alien Emergency Medical (N21) as described in WAC 182-507-0110.
  3. Individuals are eligible for Apple Health for Parents/Caretakers (N01) even if they are eligible for Medicare and/or age 65 or older.

Individuals may apply for MAGI health care coverage using the following options:

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Scope of care Early and Periodic Screening, Diagnosis and Treatment (EPSDT)

Revised date
Purpose statement

To describe Early and Periodic Screening, Diagnosis and Treatment (EPSDT) that is available to individuals under 21 years of age who are eligible for Apple Health CN or MN coverage.

WAC 182-534-0100 EPSDT

WAC 182-534-0100  EPSDT

Effective August 24, 2014

  1. Persons who are eligible for medicaid are eligible for coverage through the early and periodic screening, diagnosis, and treatment (EPSDT) program up through the day before their twenty-first birthday.
  2. Access and services for EPSDT are governed by federal rules at 42 C.F.R., Part 441, Subpart B which were in effect as of January 1, 1998.
    1. The standard for coverage for EPSDT is that the services, treatment or other measures are:
      1. Medically necessary;
      2. Safe and effective; and
      3. Not experimental.
    2. EPSDT services are exempt from specific coverage or service limitations which are imposed on the rest of the CN and MN program. Examples of service limits which do not apply to the EPSDT program are the specific numerical limits in WAC 182-545-200.
    3. Services not otherwise covered under the medicaid program are available to children under EPSDT. The services, treatments and other measures which are available include but are not limited to:
      1. Nutritional counseling;
      2. Chiropractic care;
      3. Orthodontics; and
      4. Occupational therapy (not otherwise covered under the MN program).
    4. Prior authorization and referral requirements are imposed on medical service providers under EPSDT. Such requirements are designed as tools for determining that a service, treatment or other measure meets the standards in subsection (2)(a) of this section.
  3. Transportation requirements of 42 C.F.R. 441, Subpart B are met through a contract with transportation brokers throughout the state.

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

This program provides preventive and enhanced service coverage for anyone under 21 years of age who is eligible for Apple Health CN or MN coverage. Parents who are under 21 years of age and who are on CN or MN coverage are also eligible for EPSDT services. "Under 21" means through the day before their 21st birthday.

The significance of this program is that medically necessary services identified by medical service providers are covered even if the services are not otherwise covered services under the standard scope of care.

If you are an Apple Health client and/or a parent/caregiver of a child enrolled in Apple Health, visit the well-child checkups webpage or review the EPSDT well-child checkups for your child or teen brochure (HCA 19-0056).

If you are a provider or biller, please see the EPSDT billing guide for guidance on billing for these services.

Program overview

Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) is a federally mandated, comprehensive, and preventive health care benefit. The purpose of this program is to ensure children and adolescents age 20 and younger receive appropriate preventive, dental, mental health, developmental, and specialty services. Medically necessary treatment identified in the EPSDT well-child checkup is covered under the EPSDT benefit.

The following are descriptions of the components of the program:

Early: Assessing and monitoring a child's health and ongoing development early in life can help prevent, identify, and intervene, so potential diseases and disabilities can be addressed before they become more complex and are in their preliminary stages, when they are most effectively treated. This means as early as possible in a child's life in the case of a family already receiving medical benefits or as soon as a child's eligibility has been established.

Periodic: As children and adolescents grow, visits with their health care providers should occur at regular intervals to ensure continued healthy development and to monitor current or emerging needs. Section 1905 of the Social Security Act requires periodicity schedules sufficient to ensure that at least a minimum number of health examinations occur at critical points in a child’s life, and that medically necessary screenings are provided.

Screening: Providers use preventive services, including comprehensive interviews, medical examinations, and standardized tools, to identify children who require further diagnostic assessment or intervention for health and developmental issues. The five categories of screenings covered under this program are medical, vision, hearing, dental, and developmental. Screening services must be available both at established times and on an as-needed basis. When a screening indicates the need for further diagnostic assessment, a child and their family should be referred for diagnosis without delay.

Diagnosis: When there is an indication that a child or adolescent may have a health problem, a follow-up diagnostic assessment and additional evaluations must be provided. This includes recommendations and any necessary referrals to needed services when a diagnosis is determined.

Treatment: In response to an identified need, health care services needed to correct, ameliorate, or lessen health problems, including care coordination for chronic conditions, are offered and provided. Services provided to the child or adolescent must be considered medically necessary (see WAC 182-500-0070).

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Renewals

Revised date
Purpose statement

This section describes the WAC and policy of the renewal process for long-term services and supports (LTSS) and SSI-related medical programs. Consult the Eligibility A-Z (EA-Z) manual for the eligibility review process for cash and recertification process for food benefits.

Washington Apple Health renewals

WAC 182-504-0035

What forms are used for Washington Apple Health LTSS renewals?

Renewals for LTSS medical can be completed:

  • Online through Washington Connections. Go to "renew by benefits"; or
  • By submitting DSHS 14-416 Eligibility Review for Long-Term Services and Supports (used just for SSI-related Medicaid) ; or
  • By submitting DSHS 14-078 Eligibility Review (used for cash, food and SSI-related Medicaid reviews); or
  • By phone. Contact the HCS Public Benefit Specialist (PBS) at the local Home and Community Service (HCS) office (link has HCS phone numbers by county).

Eligibility review forms for LTSS should be sent to:

Department of Social and Health Services 
Attn: HCS
PO Box 45826
Olympia WA 98504-5826

Or FAXED to:

Department of Social and Health Services
Attn: HCS
FAX: 1-855-635-8305

Any document mailed or faxed to DSHS should always include a complete name and the DSHS client ID so the document is assigned to the correct case record.

First annual review when there is a Community Spouse

A phone review can be completed at the first annual review when there is a community spouse, however, it is important that verification of all resources in excess of the $2,000 resource limit are out of the institutional spouse's name and into the community spouse's name. To confirm, request asset verification system (AVS) verifications for both spouses. 

Make sure the resources are document on the community spouse's screen in ACES.

Worker responsibilities

At the renewal process, review eligibility elements below for LTSS. Document in remarks where changes have occurred or new information is provided.

  1. Resource eligibility.
    1. If the home or property is owned by the client, check to make sure the home or property is still in the client's name.
    2. Use the AVS process to verify resources for the recipient only (except at first annual review for a married couple).
    3. Verification of life insurance and burial plans are required at application, don't request verification at review unless a new policy is reported or if client has a whole life policy with countable cash surrender value that needs to be verified.
    4. Use prudent person to request verification of any questionable resources.
  2. Income eligibility
    1. Request verification of gross income at renewal only if a change is reported and there is no interface such as social security, veterans, or Washington State pension. Only request verification if the department does not have access to income verification.
  3. Post eligibility deductions
    1. Request verification of post eligibility deductions such as uncovered medically necessary expenses, guardianship fees, etc. if the client is reporting a change in the amount.
    2. Spousal and dependent deductions
      1. Request verification of spousal income and shelter costs only if the community spouse would receive a spousal allocation and changes are reported.
      2. Request verification of dependent income only if the dependent would receive an allocation and changes are reported. 
  4. If doing a phone renewal it's important to document all eligibility elements including who you conducted the phone interview with and their contact information. 

Worker Responsibilities - Processing Late Reviews

ALTSA gives all clients the extra time and consideration they need during the renewal process. We assure clients, representatives, case managers and facility staff all are made aware of the required eligibility review (ER) and that benefits will end if one isn't completed.

When an ER isn't initiated in ACES by mid-month, deadline alert 214 is generated. The day after alert 214 appears ACES sends a termination letter to the client and to all representatives coded in ACES to receive letters. The termination letter doesn't include another ER form and isn't sent to facilities on the institutional care facility page.

Please note: Refer to the ACES production calendar for exact dates the 214 alerts are generated. 

To ensure we meet equal access (EA) service requirements for all clients:

  1. Initiate Washington Apple Health Medical reviews only when the following has occurred:
    1. Review is physically received in office; or
    2. Contact is made with the client, authorized representative, or guardian and
      1. You completed a phone interview. Document the phone review including who you talked to.
  2. When 214 alerts are generated for Washington Apple Health Medical:
    1. Review your 214 alerts,
    2. Contact the client, authorized representative (AREP), or guardian by the last day of the certification period. If contact is made:
      1. Initiate a phone renewal,
      2. Review all eligibility factors subject to change during the renewal process, 
      3. Add remarks on the applicable screens, and 
      4. Complete an asset verification system (AVS) search on known accounts.
    3. Send a Request for Information (0023-01) for questionable information where verification is needed or there is conflicting information. Don't ask clients to provide verification of items we're able to obtain through interfaces.
  3. ACES will continue to mail renewal notices for Washington Apple Health medical 45 days prior to the client's certification ends date. Completing the phone renewal is applicable when:
    1. Client, AREP, or guardian makes contact with your anytime during the month of review, or
    2. Client, AREP or guardian hasn't returned the eligibility review form and you initiate phone contact to complete the review. Please note: You don't need to wait until a 214 alert is generated to begin the phone renewal process.
  4. If unable to contact the client, AREP or guardian, reprint the termination letter. For Washington Apple Health medical, send the letter and an ER form with a business reply envelope to:
    1. The client.
    2. All authorized representatives, or
    3. The nursing facility representative (if applicable). 
  5. If you're unable to reach the client by the 5th of the month following the certification end date for Apple Health, make a final contact with the client, AREP, or guardian by phone.
    1. If contact is made, reinstate, initiate the phone renewal process and send the reinstatement letter. 
    2. If no contact is made by phone, mail an additional ER request to the client, and authorized representative.
    3. If the phone renewal is completed, send the recertification letter (27-04), provided services were in place during the time period the case was closed.​ NOTE: Clients have 30 days from the termination date to submit a completed renewal per WAC 182-504-0035. 
  6. For cash and basic food.

The policy described above is for medical programs. Some recipients of LTSS are receiving cash and/or food benefits. Eligibility review requirements for cash assistance and recertification processes for food assistance are described in the EA-Z manual below.

  1. Eligibility review requirements for cash assistance are described in WAC 388-434-0005.
  2. Recertification process for food assistance is described in WAC 388-434-0010.

Follow Equal Access policies when doing renewals

Equal Access for LTSS

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Lump sum income

Revised date
Purpose statement

How are lump sums counted for aged, blind, disabled (SSI-related) and long term care medicaid.

Note: This policy applies to SSI related Medicaid programs only and not Modified Adjusted Gross Income (MAGI) programs authorized by the Health Benefit Exchange (HBE)

Lump Sums LTSS

Lump Sums are money received in the form of a nonrecurring payment including, but not limited to: lottery, bingo, or gambling winnings, inheritance, income tax refunds, rebates, retroactive payments, and insurance settlements.

For long term care, we must use the SSI related WACs to determine their effect on eligibility:

  • The SSI related WAC specifically excludes SSI and RSDI retroactive payments as income in the month of receipt and as a resource for 9 months following the month of receipt.
    WAC 182-512-0700 SSI related medical-Income eligibility 
    WAC 182-512-0550 SSI related medical-All other excluded resources 
  • Unspent portion of non recurring lump sum is counted as a resource on the first of the month following its receipt. (With the exception of any RSDI or SSI retroactive payment indicated above).

Note: What is RSDI? RSDI is Retirement and Survivors Disability Insurance payments under Title II of the Social Security Act.

  • All other lump sums must be looked at based on whether the agency could anticipate their receipt, and therefore anticipate their effect on eligibility, as well as reporting requirements and advance notice requirements for recipients. This includes retroactive VA payments.
  • For recipients, in most cases we will not be able to anticipate the lump sum and therefore the lump sum will not count as income.
  • Due to reporting requirements and the need to provide advance notice, a lump sum may not affect eligibility until the month following the change of circumstance report. See Change of Circumstance reporting requirement.

As Income (WAC 182-513-1325, 182-513-1330, 182-512-0650):

  • Anticipated nonrecurring lump sum payments are treated as income in the month received. Any remainder is considered a resource in the following month. Retroactive SSI and RSDI payments are an exception. They are always excluded as income in the month of receipt. To be anticipated means that the client reported to us early that they were going to be receiving a lump sum or we learned about the upcoming payment from some other source. It also means that we learned about it early enough that it could affect eligibility.
  • For applicants, a lump sum is income in the month received if we knew about the lump sum at the time we were making our eligibility decision.
  • For recipients, a lump sum is income in the month received if we knew about it early enough we could allow for 10 days' advance notice if the lump sum would cause the benefits to be reduced or terminated. 
  • Income that has been anticipated in a different amount than was actually received is not an overpayment if the anticipated amount was reasonable. If the anticipated amount was based on false information or information known at the time to be incomplete, or if the agency made an error in calculation, there may be an overpayment.

Unanticipated nonrecurring lump sums can't be counted as income in the month received because SSI related and LTC medical programs must budget prospectively. We can only count income that can be anticipated. However, any amounts remaining the first of the month after the month of receipt will be a resource. Even though the remaining amounts become a resource, retroactive SSI and RSDI are excluded for up to 9 months following the month of receipt.

As Resources (WAC 182-513-1350; 182-512-0300)

  • For most lump sums, the amount the person still has (unspent portion) on the first of the month following receipt is a resource, unless specifically excluded as a resource.
  • For applicants, the amount remaining following the month of receipt would be counted for resource eligibility.
  • For recipients, use reporting requirements and advance notice when determining the effect of the remaining lump sum on resource eligibility.

Example #1 Anticipated Retroactive Social Security:

Bill receives a letter March 1 from Social Security that he has been approved for Social Security Disability insurance (SSDI, a type of RSDI) and will be sent $15,000 retroactive SSDI on April 4. Bill expects to receive it in April.

Although he has 30 days to report the receipt of the lump sum and knows he will not receive the money until April, he is so excited he calls his financial worker on March 1 to tell of his Social Security approval.

Since we know about the payment early enough to affect eligibility, the $15,000 is an anticipated lump sum and can't be counted as income in April because it is an excluded income type.

Further, beginning May 1, any unspent portion is excluded as a resource for 9 months, or from May 1 through January 31. 

Because it is an excluded resource, Bill can transfer the lump sum monies within the 9 month exclusion period without causing a transfer penalty.

If Bill is married and has a community spouse, he can transfer any resource to his spouse without penalty.

Example #2 Unanticipated Retroactive Veteran's Administration (VA):

Bill is active on COPES and receives $15,000 retroactive VA Benefits on April 4. He reports the receipt of the funds on May 1. This report is timely. The $15,000 is considered an unanticipated lump sum and can't be counted as income in April. Beginning May 1, any unspent portion is a countable resource. However, because he reported the change timely, it does not affect May's eligibility. The agency must give advance notice to close the case effective 5/31. There is no overpayment for May.

We will determine whether Bill is resource eligible June 1.

If he is married and has a community spouse, he can transfer the money to his community spouse before June 1 and it will not affect his resource eligibility nor cause a transfer penalty.

If he is not married and spends the money before June 1, he will need to disclose how the money was spent so we can determine whether he was compensated. We will need to determine if any of it was transferred without adequate consideration causing a transfer penalty.

Example #3 Anticipated Retroactive VA:

Bill is active on COPES and receives a letter March 1 from Veterans Affairs that he has been approved for Veterans Benefits and will be sent $15,000 retroactive VA on April 4. He expects to receive it in April.

Although he needs to report the payment within 30 days of receipt (he has until May 3), he is so excited he calls his financial worker on March 1 to tell of his Veteran Benefit approval.

Because we know about the payment early enough to affect eligibility and retroactive VA benefits are not excluded, the $15,000 is an anticipated lump sum and is countable income for the month of April.

Further, any unspent portion is a countable resource beginning May 1.

If he is married and has a community spouse, he can transfer the money to his community spouse before May 1 and it will not cause a transfer penalty.

Example #4 Unanticipated Inheritance:

Mary is a COPES client and her aunt died and left Mary $50,000 cash in her will. Mary learned of the inheritance on July 10 at the reading of the will and knew it would be sent to her in September. Mary received the cash on September 15. She reported it to us within thirty days on October 10.

The $50,000 is an unanticipated lump sum and can't be counted as income in September. It does not matter that Mary knew she was getting it before she received it. She was not required to report it until she received it and then had 30 days to report the receipt of the lump sum. Beginning November 1, any unspent portion is potentially a countable resource.

We will determine whether Mary is resource eligible November 1.

If she is married and has a community spouse, she can transfer the money to her community spouse before November 1 and it will not affect her resource eligibility nor cause a transfer penalty.

If she is not married and spends the money before November 1, she will need to disclose how the money was spent so we can determine whether she was compensated. We will need to determine if any of it was transferred without adequate consideration causing a transfer penalty.

Example #5 Anticipated Inheritance:

Mary is a COPES client and her aunt died and left Mary $50,000 cash in her will. Mary learned of the inheritance on July 10 at the reading of the will and knew it would be sent to her September 8.

Mary was concerned about how the cash would affect her COPES services and called her financial worker on August 1 to find out. During the call she disclosed the money would be sent to her by the attorney on September 8.

Mary knew when the money would be received and informed the agency early enough that we could prospectively budget it for September. Send advance notice because the $50,000 is an anticipated lump sum and must be counted as income in the month of September. COPES services would close effective August 31 because her income is too high. Inform the case manager of the termination effective August 31 and there may be a potential the client would need to be reassessed for eligibility by October 1.

Beginning October 1, any unspent portion is potentially a countable resource.

If she is married and has a community spouse, she can transfer the money to her community spouse before October 1 and it will not cause a transfer penalty. However, we would need to redetermine the resource eligibility as a couple since there has been a 30 day break in eligibility of institutional services.

If she is not married and spends the money before October 1, she will need to disclose how the money was spent so we can determine whether she was compensated. We will need to determine if any of it was transferred without adequate consideration causing a transfer penalty.

Worker Responsibilities

When a lump sum affects resource eligibility, propose termination giving 10 day advance notice. On the termination notice indicate the following text:

Your resources are currently over the resource standard described in WAC 182-513-1350. If resources are at or below the resource standard by the first of the following month, provide verification of the value of resources as of the first. Provide this verification within 30 days. A reconsideration of the termination will be completed and if eligible your case will be reinstated. Keep in mind, transfer of asset rules described in WAC 182-513-1363 apply for long-term care services. If you are married a redetermination of the couple's resources are required when there is a break of at least 30 days of service per WAC 182-513-1350.

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Program options for the justice involved

Revised date

The Department of Corrections and city/county correctional agencies have a variety of confinement levels that the justice involved individual may be placed in. The following table is intended to help clarify how participation in a correctional program affects a person's eligibility for Medicaid.

Is the justice involved individual eligible for Medicaid?

Correctional type Medicaid eligibility -
Inpatient coverage only*		 Medicaid eligibility -
Full coverage
Electronic Home Monitoring (EHD/EHM)
The justice involved individual resides in their home and is monitored electronically. The justice involved individual does not occupy a jail or prison bed while in this program.		   X
Day jail / Day reporting
The justice involved individual reports at various assigned times throughout a 24-hour period OR are placed on supervised work or community betterment programs during regular work hours. In either situation, the justice involved individual does not occupy a jail or prison bed while in the program.		   X
Pretrial supervision / Probation
Pretrial supervision staff monitor the justice involved individual who is released from custody by the court pending the outcome of their trial and they do not occupy a jail or prison bed		   X
District Court probation
District Court probation officers monitor the justice involved individual who is convicted of or are pending trial for misdemeanor charges. The justice involved individual does not occupy a jail or prison bed.		   X
DOC community supervision
Community Corrections Officers monitor the justice involved individual who is convicted of felony charges. The justice involved individual does not occupy a jail or prison bed.		   X
Drug Court
A court-ordered program in which the justice involved individual with drug-related charges voluntarily chooses to participate in chemical dependency treatment. The individual may have their charges dismissed if they successfully complete the program. The individual does not occupy a jail or prison bed.		   X
Furloughs
Individuals are sometimes furloughed by a city/county jail for various reasons. When medically furloughed the individual is typically not reported out of the facility so the suspension coding does not change in ProviderOne. To be eligible for a Medicaid payment the individual must receive inpatient hospitalization services lasting 24 hours or more and not return to the jail in the same day. Same-day furloughs for services are typically the responsibility of the jail or a payer other than Medicaid.		 Depends  
**Work Release in city/county facilities
Justice involved individuals who are housed in a work release facility, jail, or corrections facility and are authorized to leave the facility for purposes of employment, education, court-ordered treatment or employment search. The justice involved individual does occupy a corrections bed while in this program. Most county work release programs operate under this model. For a complete list of approved city/county work release facilities, please refer to the list provided below this table. For DOC work release eligibility, please refer to Supervised Community Residential Facility/Halfway House / DOC Work Release.		 X  
Work crews / Community betterment
This program is offered to select justice involved individuals. The program includes working in the community on various public or nonprofit programs. The individual does occupy a corrections bed while in this program. There may be exceptions for those not occupying a corrections bed while in this program.		 X  

***Supervised Community Residential facility/Halfway House / DOC work release
The justice involved individual is housed in state or local corrections-related supervised community residential facility which allows for 'freedom of movement' to: 1) work outside the facility in employment opportunities available to individuals who are not under justice system supervision, 2) use community resources at will (libraries, grocery stores, recreation, etc.) and 3) seek health care treatment in the broader community to the same or similar extent as other Medicaid enrollees. The residential facility may be public or privately operated. These facilities may have “house rules” where for example residents may be required to report during certain times and sign in and out. Similarly, they may be restricted from traveling to or frequenting locations associated with criminal activity. The majority of state operated (DOC) work release programs use this model. Please refer to the list of approved work release facilities.

   X

Residential Reentry Centers (RCC) – Federal corrections facility
A justice involved individual housed in a RCC does not have freedom of movement and is only authorized to leave the RCC through sign-out procedures for approved activities, such as seeking employment, working, counseling, visiting, or recreational purposes. During the approved activity, the inmate's location and movements are constantly monitored and RCC staff may visit or call them at any time.

 No coverage - these are federal facilities and the cost of medical care is the responsibility of the Federal Government. No coverage - these are federal facilities and the cost of medical care is the responsibility of the Federal Government.

Voluntary and temporary residence in a public institution
This includes justice involved individuals who are residing in a public institution or detention center for a temporary period of time voluntarily after their case has been adjudicated and arrangements are being made for their transfer to a community residence. The justice involved individual must be free to leave and is voluntarily residing there pending other appropriate arrangements based on their needs.

   X

Residents in a Mental Health Facility or IMD
Individuals (justice involved and general public) who are between the ages of 22 and 64 and are a patient of an Institution for Mental Diseases (IMD) where there are over sixteen beds (e.g. Western State) for more than 15 days in a given month.

 X  

*Inpatient hospital events; must be admitted for 24 hours or more

**List of City/County Jail work release facilities that are approved living situations are Seattle/King County, Whatcom, and Thurston County.

***List of DOC work release facilities that are approved living situations are: Ahtanum View - Yakima County, Bellingham - Whatcom County, Bishop House - King County, Brownstone - Spokane County, Clark County - Clark County, Eleanor Chase House - Spokane County, Helen B Ratcliff - King County, Longview - Cowlitz County, Olympia - Thurston County, Peninsula - Kitsap County, Progress House - Pierce County, Reynolds - King County, Tri-Cities - Benton County. The only DOC facilities that are unapproved are: Lincoln and Rap Houses in Pierce County.

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Continued coverage pending an appeal

Revised date
Purpose statement

To explain how to receive continued when an administrative appeal is pending and how continued coverage works.

WAC 182-504-0130 Washington apple health -- Continued coverage pending an appeal.

WAC 182-504-0130 Washington apple health -- Continued coverage pending an appeal.

Effective December 1, 2016

  1. Continued coverage is when you continue to receive Washington apple health benefits while appealing a medicaid agency adverse action to terminate, suspend, or reduce your:
    1. Medicaid eligibility; or
    2. Authorization for a covered service.
  2. To qualify for continued coverage, you must request a hearing on the adverse action no later than:
    1. The tenth day after we (the medicaid agency or its designee) sent a notice of the action to you; or
    2. The last day of the month before the action takes effect.
  3. If your last day to request a hearing and still qualify for continued coverage falls on a Saturday, Sunday, or a designated holiday under WAC 357-31-005, you have until 5:00 p.m. on the next business day to request the hearing.
  4. Continued coverage ends when:
    1. You state in writing you no longer wish to receive continued coverage;
    2. You withdraw the appeal;
    3. You default and an order of dismissal is entered;
    4. An administrative law judge or a review judge issues an adverse ruling or written decision:
      1. Terminating your continued coverage; or
      2. Ruling you do not qualify for benefits.
  5. You cannot receive continued coverage if the adverse action was solely to a change in statute, federal regulation, or administrative rule, unless there is a question about whether you are in the class of people affected by the change.
  6. If you are receiving medically needy coverage, you cannot receive continued coverage past the end of the certification period described in WAC 182-504-0020.
  7. If you are receiving coverage under an alien medical program, you cannot receive continued coverage past the end of the certification period described in chapter 182-507 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

  1. When Apple Health coverage is terminated, an individual can request an administrative appeal. This appeal must be requested by the end of the month their coverage is to be terminated in order to be considered timely and to receive continued coverage.
  2. When an individual requests an administrative hearing, the agency sends a notice that includes the approval or denial of continued coverage, the reason for denial of continued coverage (if applicable), and that the individual might be liable for up to two months of medical expenses (overpayments) if continued coverage is received and the agency’s termination is upheld.
  3. An individual is eligible for continued coverage if:
    1. An appeal is received by the agency, its designee (including the Health Benefits Exchange), or the Office of Administrative Hearings by 5:00PM on the last day of the month; or
    2. If the last day of the month falls on a weekend or holiday, the appeal is received by 5:00PM on the following business day; or
    3. An administrative law judge issues an order granting continued coverage.
  4. Continued coverage ends the last day of the month when:
    1. The individual fails to appear for his or her hearing.
    2. An administrative law judge issues an order upholding the agency’s decision;
    3. The individual withdraws their appeal.
    4. The individual declines continued coverage in writing; or
    5. An administrative law judge issues an order stopping continued coverage.
  5. If an individual fails to appear for the hearing or if an order is issued upholding the agency’s decision, the agency may seek reimbursement for the cost of the two months of continued coverage received. See WAC 182-520-0010 for more information.
  6. Continued coverage is not an option when a termination is caused by a change in rule. There is also not an option for continued coverage for medically needy coverage after the original certification period.

Worker responsibilities

Administrative hearing coordinator

  1. Review each hearing request to determine eligibility for continued benefits. An individual may have noted on the request that they do not want continued coverage.
  2. If an individual is eligible for continued coverage:
    • Reopen health care coverage.
    • Document in ACES why coverage was reopened;
    • Send a notice to the individual with the following text:

      You have requested an administrative hearing and will receive continued health care coverage unless you tell us you do not want it (WAC 182-504-0130).

      You may have to pay back the agency’s costs for the two months of continued coverage after you requested a hearing if the Administrative Law Judge (ALJ) agrees with our decision (WAC 182-520-0010).

      You will receive continued coverage through the end of the month an administrative hearing decision is sent to you unless:

      a) An ALJ or our presiding officer serves an order ending continued coverage; or

      b) You:

      1. Tell us in writing that you do not want continued health care coverage; or

      2. Withdraw your request for an administrative hearing in writing or during the hearing.

  3. If an individual is not eligible for continued coverage:
    1. Document in ACES why they are not eligible; and
    2. Send a notice to the individual with the following text:

      “You have requested an administrative hearing regarding your health care coverage. Your request has been sent to the Office of Administrative Hearings.

      You requested continued coverage pending the outcome of your appeal. You are not eligible because _______. See WAC 182-504-0130.

      If you disagree with the decision to deny continued coverage, you may contact the Office of Administrative Hearings at 360-407-2700 and request a prehearing conference. The prehearing conference will be with an Administrative Law Judge who will determine only if you are or are not eligible for continued coverage.”

  4. If the individual is on continued coverage for any long-term care, COPES or other services through ALTSA, notify the case manager of the reopening of coverage pending the appeal.

Example: Mohamed is on WAH for adults. He is terminated 6/30 for being over income. He submits a request for a hearing on 6/29. He is eligible for continued coverage.

Example: Gloria receives WAH for her children. Coverage ends 1/31. She submits a request for a hearing on 2/15. Deny continued coverage as the request was not timely.

Example: Giuseppe receives WAH for adults. Coverage ends Sunday, 12/31. He submits a request for a hearing on 1/2. He is eligible for continued coverage as the last day of the month falls on a weekend, the next day is a holiday, and the hearing request was received on the next business day.

Example: Jacques applies for WAH and is denied for not meeting the immigration criteria. He submits a timely appeal and wants continued coverage. He is not eligible because he was not a recipient of WAH at the time of the denial.

Example: Walter was on an active WAH MN spenddown for 9/14 to 11/30. He submits an appeal on 11/15 about having to meet a new spenddown as of 12/1. He asks for continued coverage. He is not eligible as continued coverage for MN programs does not extend past the certification period end date.

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Excluded income

Revised date

WAC 182-513-1345 Determining disregarded income for institutional or hospice services under the medically needy (MN) program.

WAC 182-513-1345 Determining disregarded income for institutional or hospice services under the medically needy (MN) program.

Effective February 20, 2017

This section describes income the agency or its designee disregards when determining a person's eligibility for institutional or hospice services under the medically needy (MN) program. Disregarded income is available when determining a person's participation in the cost of care.

  1. The agency or its designee disregards the following income amounts in the following order:
    1. Income that is not reasonably anticipated, or is received infrequently or irregularly, when such income does not exceed:
      1. Twenty dollars per month if unearned; or
      2. Ten dollars per month if earned.
    2. The first $20 per month of earned or unearned income, unless the sole source of income paid to a person is:
      1. Based on need; and
      2. Totally or partially funded by the federal government or a nongovernmental agency.
  2. For a person who is related to the supplemental security income (SSI) program under WAC 182-512-0050(1), the first $65 per month of earned income not excluded under WAC 182-513-1340, plus one-half of the remainder.
  3. Department of Veterans Affairs benefits designated for:
    1. The veteran's dependent when determining LTC eligibility for the veteran. The VA dependent allowance is considered countable income to the dependent unless it is paid due to unusual medical expenses (UME);
    2. Unusual medical expenses, aid and attendance allowance, special monthly compensation (SMC) and housebound allowance, with the exception under subsection (4) of this section.
  4. Benefits under subsection (3)(b) of this section for a person who receives long-term care services are excluded when determining eligibility, but are considered available as a third-party resource (TPR) defined under WAC 182-513-1100 when determining the amount the person contributes in the cost of care.

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

Income that is counted

Income that remains after exclusions and disregards provided by specific program rules must be counted when determining eligibility and participation in the cost of care for long-term care (LTC) services. This is "countable" income.

Income described in WAC 182-513-1340 is excluded when determining both initial eligibility and post eligibility (participation) in the cost of care. These exclusions apply to both the categorically needy (CN) and medically needy (MN) programs. Specific federal statutes provide that each type of income listed be excluded when determining a client's countable income.

Income described in WAC 182-513-1345 is disregarded when determining eligibility for MN programs. Disregarded income must be counted when determining eligibility for CN programs and when determining a client's participation in the cost of care.

Refer to WAC 182-515-1510 for income post eligibility deductions provided under DDA HCB Waivers.

Refer to WAC 182-515-1505 for income deductions post eligibility deductions provided under HCS HCB Waivers.

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