Apple Health - ACES Letters - Reason Code Quick links

1. Select the Reason Code Series number to go to the list of codes in that series in the chart below

   100's   200's   300's   400's   500's

2. In the chart, select the specific reason code to go directly to the Reason Code Series page and the code you have selected.
   The Reason Codes Series pages will show the following elements for each reason code:
   1. Code Number
   2. Reason Code Title / Required Text
   3. WAC Reference
   4. Free Form Text

For ACES procedures regarding letters, visit the ACES Information Center in ACES online.

Hospice care

Hospice is a 24-hour intermittent program coordinated by a hospice interdisciplinary team for persons with a terminal illness and a prognosis of six months or less to live. The hospice program allows the terminally ill client to choose physical, pastoral/spiritual and psychosocial comfort, and palliative care rather than cure. Hospitalization is used only for acute symptom management.

Hospice care is initiated by the choice of the client, family or physician. The client’s physician must certify a client as appropriate for hospice care. Hospice can be ended at any time by the client or family (revocation) by the hospice agency (discharge) or by the death of the client (expired).

Hospice care may be provided in a client’s home, in a medical institution including a hospice care center, nursing facility, or in an alternate living facility.

For certain clients who are eligible for Categorically Needy (CN) coverage, hospice care is a service that is covered by their Provider One services card. Institutional Hospice rules may be used to provide CN coverage for these services, when it is to the advantage of clients. The L31 program is used if the client receives an SSI cash grant or L32 if the client is SSI-related and not otherwise eligible for CN.

 The L31/L32 hospice program is not a waiver program; however, rules that are similar to waiver program rules under WAC 182-515-1505 are used when countable income is under the Special Income Level (SIL). The special income level is 300% of the Federal Benefit Rate (FBR).

General eligibility for hospice programs 

WAC 182-551-1000 General eligibility for hospice programs

1. Definitions relating to hospice are in WAC 182-551-1010. A person must meet these general eligibility requirements:
   1. Verification of age and identity
   2. Citizenship or immigration status. Noncitizen children are eligible to receive hospice services if they are eligible under a children's medical program
   3. Residency
   4. Social Security number
   5. Assignment of medical support rights
2. Attains institutional status (WAC 182-513-1320). Institutional status is met when the HCA 13-746 hospice notification is received from the hospice agency with an election date indicated.

• Chapter 182-551 WAC describes the hospice program as a service

Alien Medical Program and hospice

Clients receiving Alien Emergency Medical Program (AEMP) must have prior authorization for hospice services from the HCA Hospice Program Manager.

Indicate on the referral the request is for hospice for an AEM client on either the cancer or dialysis program. The request must be submitted within 5 business days of the client's election of hospice services.

Prior authorization for hospice is not required for clients enrolled in the state-funded long-term care program; however, the standard 5-day notification still applies.

Requests for prior authorization should be addressed to:

Notification Unit
P.O. Box 45535
Olympia, WA 98504-5535
Telephone: 800-562-3022
FAX: 866-668-1214

Links to information on veterans benefits

United States Department of Veterans Affairs

HCS VA Improved Pension and UME calculator Under the VA income and TPL training section.

HCS Financial Training on VA improved Pension and how to use the VA calculator

Veterans Benefit Chart

Veterans administration contacts in Washington State

All regions, counties and offices not listed:

Send Veterans Referral forms (DSHS 14-162(X) and 14-162A(X) to:
WDVA - Alternate Care
MS 41150
PO Box 41150
Olympia, WA 98504-1150
1-800-562-2308

Dates for wartime service

Mexican Border Period - May 9, 1916 through April 5, 1917 for veterans who served in Mexico, on its borders or in adjacent waters.

World War I - April 6, 1917 through November 11, 1918; for veterans who served in Russia, April 6, 1917 through April 1, 1920; extended through July 1, 1921, for veterans who had at least one day of service between April 6, 1917 and November 11, 1918.

World War II - December 7, 1941 through December 31, 1946.

Korean Conflict - June 27, 1950 through January 31, 1955.

Vietnam Era - August 5, 1964 (February 28, 1961, for veterans who served "in country" before August 5, 1964) through May 7, 1975.

Gulf War - August 2, 1990 through a date to be set by law or Presidential Proclamation.

Washington State Department of Veterans Affairs service offices with DSHS CSO / HCS numbers and counties for each office's service delivery area.

HCA VA Benefit Enhancement Project Contacts:

Tim Dahlin

Department of VA Affairs tables

Special Monthly Compensation

Go to the Reason Code Link chart to link directly to a specific reason code or scroll through the list below.

For ACES Procedures go to ACES Letters in the ACES User Manual.

Overview

Medical expenses that are paid with public program funds (other than Medicaid) may be used to reduce a client's spenddown. They must be verified by the agency providing the services. HCA has negotiated individual agreements with the agencies identified below to recognize their programs as public programs for Medicaid purposes. This allows Medically Needy (MN) clients to use expenses paid on their behalf by the participating agency toward meeting their spenddown liability.

Public programs

The approved public programs in Washington are:

1. Lifelong AIDS Alliance (Evergreen Insurance Program)
2. Department of Health AIDS/HIV Early Intervention Program
3. Kidney Centers in various communities to administer the Kidney Disease Program (KDP)
4. Kitsap Mental Health Services
5. Indian Health Service
6. Behavioral Health Administrative Services Organizations

To qualify as a public program, the participating agencies must ensure that no federal funds are used to pay for these individual's expenses.

Public programs do not anticipate costs for medical expenses. They must submit verification to DSHS as medical expenses are incurred by the client and paid by the program. This verification may look different for each program depending upon the expenses that are being verified.

Expenses incurred by public programs prior to a Medicaid application

Public programs may pay spenddown expenses incurred by individuals during the three-month retroactive base period. Most public programs work with their clients to help them apply for Medicaid and to help cover the medical expenses while the Medicaid application is pending.

This enables clients to use expenses that are paid by the public program during the retroactive base period as qualifying expenses towards meeting spenddown liability in either the retroactive or current base period.

Indian Health Service

HCA has negotiated an agreement with the tribes to recognize tribal clinics as public programs. Tribal clinics may use Indian Health Service (IHS) funds to pay for medical expenses on behalf of their spenddown clients. The clinic must verify IHS is responsible for the cost of the medical expense before the expense can be applied toward spenddown.

Public programs - What do I need to do?

Accept verification of the expense amount submitted by the public program unless questionable. Allow the usual and customary charge from the provider toward the individual spenddown, even if the provider has reimbursement agreements with the public program that permit them to pay less for the service.

The Department of Health uses a form to verify prescription expenses paid on behalf of Early Intervention Program enrollees. Staff may use the expense listed, minus any third-party liability payments identified by the pharmacy, to reduce an individual's spenddown liability.

ACES no longer tracks public program expenses using the "PP" expense type. Staff need to enter the appropriate code based on the type of expense that has been paid by the public program and the date the expense was incurred.

Example: The HIV/AIDS Early Intervention program verifies it paid $150 in prescription expenses on April 3 and $30 transportation expenses to a medical appointment on April 7. Code the prescription expense as ‘RX’ (prescription expense) and code the transportation expense as ‘MU’ (not covered by Medicaid). ACES computes the effective date of eligibility based upon the combination of date of service and expense type entered.

Some public programs use their funding to purchase private health insurance on behalf of individuals. When a public program verifies payment of a health insurance premium on behalf of a spenddown individual, redetermine eligibility under the MN program using the expense as an income deduction and not a spenddown expense. Health Insurance premiums are coded on the MEDX screen in ACES and not entered as a spenddown expense in ACES online. Do not allow payments for Part C Medicare premiums on the MEDX screen.

In some cases, this results in clients becoming eligible for MN with no spenddown liability, and these cases are approved for 12 months. In other circumstances, the spenddown liability is simply reduced by the health insurance premium amount. Ensure a new letter is generated to let the client know what has changed.

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

All documents for LTSS are sent to:

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

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

• HWD provides categorically needy (CN) scope of care . Those eligible may receive either Community First Choice (CFC) or Medicaid Personal Care (MPC).
• HWD is included as an eligibility group in the Home and Community Based Services (HCBS) Waivers authorized by HCS or DDA.
• HWD clients receiving CFC, MPC or an HCBS Waiver remain on the medical coverage group S08.
• The functional approval for HCBS Waiver, CFC or MPC is made by the HCS or DDA social worker or case manager. The HCBS service is coded on the S08 in ACES.

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

• No asset test for HWD.
• No income test for HWD (income is verified for the premium calculation).
• May have gross income over the special income level (SIL).
• No client responsibility (participation) for the cost of care. There is a monthly HWD premium.
• HWD clients in alternate living facilities (ALF) are responsible to pay the room and board standard to their provider and the HWD premium to the Office of Financial Recovery (OFR).
• Earned income can be over the Social Security substantial gainful activity (SGA) limit. SGA is waived for the HWD program. SGA is a factor in determining disability for all the other SSI related Medicaid including HCB Waivers.

When is an HCBS Waiver program rules better than HWD?

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

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

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

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

• No resource test.
• No income standard - clients pay monthly premiums instead of a spenddown or client participation responsibility based on income.
• Only designated HWD staff determine eligibility.
• The client must be employed full or part-time (including self-employment) as described in WAC 182-511-1200 at initial application and in the month of renewal.
• The substantial gainful activity (SGA) limit is not a factor for HWD. For all other SSI-related Medicaid programs, the SGA is an aspect of the disability criteria. Earnings can't equal or exceed the SGA amount. For HWD disability, this test does not apply. For an under age 65 client earning over the SGA standard, HWD is the only SSI-related program that should be considered if the client is not receiving a payment from SSA based on disability.
• Resources accumulated in a separate account, designated by the client, that result from work activity during the client's enrollment in HWD are excluded per WAC 182-512-0550. If a client needs a redetermination to another program because they are no longer employed at renewal or are admitted into a nursing facility for 30 days or more, the accumulated resource is excluded. This account is coded as "Earnings Accumulated while Enrolled in HWD-Exempt MA (EH)" in ACES

Working Clients and HCBS Waiver programs (L22)

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

Working clients in a Medical Institution

• Working clients in a medical institution don't receive the 65 and 1/2 earned income disregard in initial or post eligibility.
• WAC 182-513-1380 (4) allows a post eligibility deduction for:
  • Mandatory taxes out of wages.
  • Department-approved training or rehabilitative program designed to prepare the client for a less restrictive placement. When determining this deduction employment expenses are not deducted. The employment must be approved by Division of Vocational Rehabilitation (DVR), HCS or DDA case manager.
• The client's personal needs allowance (PNA), mandatory taxes, department approved wage deductions and guardianship fee deductions cannot exceed the MNIL.

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

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

Clients receiving services through DDA in an RHC, or ICF-ID are approved automatically through their care plan with DDA.

Clients receiving services in a Nursing Facility must have an approval with the HCS Social Worker to receive an allowance for the earnings. The Public Benefits Specialist will need to request an approval as part of the care plan from the HCS SW to code as RH in ACES.

HWD public benefit specialists (PBS)

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

DDA LTC specialty unit HWD public benefit specialists:

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

Worker Responsibilities for HWD receiving HCS or DDA services

• A preliminary HWD premium can be determined using trial eligibility on a pending or active S08 AU. Indicate a HWD start date on the pending AU to get a projected HWD premium, and then delete the HWD start date if you are not ready to process the case.
• HWD receiving HCBS Waiver services are subject to transfer of asset, annuity declaration and excess home equity provisions that are specific to institutional programs (L22). MPC or CFC services are not subject to the transfer of asset provisions. An HWD client with a transfer penalty can't get HCBS Waiver services.
• The medical coverage group S08 must be used for HWD clients for the premium bill to go out to the client from OFR. (HCBS Waiver, CFC or MPC service information is indicated on the Institutional Care screen under the HCBS service field).
• HWD specialists inform the client and the client case manager/social worker when a tickler is received from OFR regarding overdue premiums. It is important for the client and/or their representative to pay the HWD premium to OFR timely. There are penalties described in the HWD chapter when premium payments are overdue. This penalty could result in no HWD coverage for 4 months which could affect the client's eligibility for continued services. Follow NSA/equal access provisions to notify the case manager if client is behind on their premiums.
• When a Non-grant medical assistance (NGMA) is needed for HWD, make sure the following language is added to the NGMA cover sheet to DDDS: Disability determination is needed for Health Care for Workers with Disabilities (HWD). SGA is waived for this program. A NGMA is also needed for an HWD applicant that is 65 or older and there is no disability indicated on the BENDEX, SDX or established by a NGMA in the case record.
• If an HWD client's job ends and HWD continues to be the preferable program, it is continued through the certification period if the premium continues to be paid unless the HWD client is on an HCBS Waiver service and there would be no participation with that program. Always consider the program that is most beneficial for the client. per HWD rule, the change is effective the first of the following month.
• Premium adjustments based on income changes occurs on the first of the following month.
• Code the appropriate LTSS service and service start date on the Institutional Care screen based on the HCS 14-443 or the DDA 15-345
• For people applying for HCS services who are employed follow management bulletin H19-071 Apple Health for Workers with Disabilities for detailed instructions on referring a case to the regional HCS HWD specialist.

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

For HCS Staff:

• Notify the HWD PBS in your region if the client is not an SSI and may benefit from HWD. Clients on SSI report their wages to the Social Security Administration for the determination of Medicaid. If the client is on food benefits, wages must be reported to PBS staff.
• Notify the Employment Specialist in your Region when a HCS client starts employment or wants to be employed:
  • R1 Jim Bischoff, Support Employment Specialist 360-870-4511, James.Bischoff@dshs.wa.gov.
  • R2 Ruby Pham, Support Employment Specialist 564-200-2264, Ruby.Pham@dshs.wa.gov
  • R3 Laura DeVol, Support Employment Specialist 360-870-4918, Laura.Devol1@dshs.wa.gov.
• Send or give the client information on the HWD program: HCA 22-333 Apple Health for Workers with Disabilities.

Applicants:

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

Recipients:

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

DDA Public Benefit Specialist (PBS) staff:

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

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

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

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

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

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

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