Spousal impoverishment protections for the MAC and TSOA programs

Revised date
Purpose statement

This section describes the how spousal impoverishment protections apply to a married person who applies for MAC or TSOA.

WAC 182-513-1660 Medicaid Alternative Care (MAC) and Tailored Supports for Older Adults (TSOA) - Spousal Impoverishment

WAC 182-513-1660 Medicaid alternative care (MAC) and tailored supports for older adults (TSOA)—Spousal impoverishment.

Effective February 25, 2023

  1. The medicaid agency or the agency's designee determines financial eligibility for medicaid alternative care (MAC) or tailored supports for older adults (TSOA) using spousal impoverishment protections under this section, when an applicant or recipient:
    1. Is married to, or marries a person not in a medical institution; and
    2. Is ineligible for a noninstitutional categorically needy (CN) SSI-related program or the TSOA program due to:
      1. Spousal deeming rules under WAC 182-512-0920 for MAC;
      2. Exceeding the resource limit in WAC 182-512-0010 for MAC, or the limit under WAC 182-513-1640 for TSOA; or
      3. Both (b)(i) and (ii) of this subsection.
  2. When a resource test applies, the agency or the agency's designee determines countable resources using the SSI-related resource rules under chapter 182-512 WAC, except pension funds owned by the spousal impoverishment protections community (SIPC) spouse are not excluded as described under WAC 182-512-0550:
    1. Resource standards:
      1. For MAC, the resource standard is $2,000; or
      2. For TSOA, the resource standard is $53,100.
    2. Before determining countable resources used to establish eligibility for the applicant, the agency or the agency's designee allocates the state spousal resource standard to the SIPC spouse.
    3. The resources of the SIPC spouse are unavailable to the spousal impoverishment protections institutionalized (SIPI) spouse the month after eligibility for MAC or TSOA services is established.
  3. The SIPI spouse has until the end of the month of the first regularly scheduled eligibility review to transfer countable resources in excess of $2,000 (for MAC) or $53,100 (for TSOA) to the SIPC spouse.
  4. Income eligibility:
    1. For MAC:
      1. The agency or the agency's designee determines countable income using the SSI-related income rules under chapter 182-512 WAC, but uses only the applicant or recipient's income;
      2. If the applicant's or recipient's countable income is at or below the SSI categorically needy income level (CNIL), the applicant or recipient is considered a SIPI spouse and is income eligible for noninstitutional CN coverage and MAC services;
    2. For TSOA, see WAC 182-513-1635.
  5. Once a person no longer receives MAC services, eligibility is redetermined without using spousal impoverishment protections under WAC 182-504-0125.
  6. If the applicant's separate countable income is above the standards described in subsection (4) of this section, the applicant is not income eligible for MAC or TSOA services.
  7. The spousal impoverishment protections described in this section are time-limited for MAC clients and expire on September 30, 2027.
  8. Standards described in this chapter are located 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

Under Section 1924 of the Social Security Act, married people who receive coverage under an 1115 waiver demonstration project are considered to be an institutionalized spouse for the purposes of applying spousal impoverishment protections.  Spousal impoverishment protections do therefore apply to both MAC and TSOA clients if the spouse of the MAC/TSOA applicant doesn't reside in an institution.

For married TSOA applicants: the spousal impoverishment protections community (SIPC) spouse is allowed to have resources of $55,547 (effective 7/1/17) before any resources are counted towards the applicant’s $53,100 limit. The $53,100 standard does not change, however the state spousal resource standard ($55,547) may adjust every odd year in July. 

Combined resources must be at or below the state resource standard for a married couple plus $53,100 ($108,647 as 7/1/2017) for initial eligibility. Once eligibility is determined, the spouse receiving services has one year to transfer resources in their name over $53,100 to his or her spouse.

For TSOA income determinations, the name on check rule applies in that only the income of the TSOA applicant is counted, and not that of the community spouse.  For TSOA, the community income rule (add both spouses income together and divide by two) isn’t permitted.

For married MAC applicants: for the most part MAC applicants will already be eligible for CN or ABP Medicaid.  However, in the following circumstances a second review of the person’s income and resources is required:

  • A married MAC applicant is not eligible for SSI-related CN Medicaid (for example, the person is active on S95 medically needy coverage, or pending spenddown on S99 due to the deemed income of their spouse.
  • SSI-related Medicaid is denied due to the couple being over the $3000 resource limit.

If the MAC applicant’s separate income is below the SSI-related CNIL and the couples joint resources are below the combined standard of $2000 for the applicant plus $55,547 for the community spouse, the applicant is eligible for SSI-related CN coverage (S02) as a spousal impoverishment protections institutional (SIPI) spouse. 

A person who is approved for SSI-related CN coverage as a SIPI spouse receives a 12 month certification regardless of whether they receive ongoing MAC services throughout the certification period. 

Note: For working clients who are potentially eligible for HWD, the same spousal impoverishment income protections apply.

Under current statute the spousal impoverishment protections are time-limited for MAC applicants and will end on December 31, 2018. This does not affect spousal impoverishment protections for TSOA applicants.

Worker Responsibilities

Use an ACES workaround to approve S02 or S08 coverage for SIPI MAC recipients, by coding the community spouse as a nonmember in the assistance unit. Code all resources over the $2000 resource limit on the spouse’s resource screens. Manually generate a notice to notify the applicant of the requirement to transfer all resources in excess of $2000 to their spouse prior to the first eligibility review.

Text to include with the letter: “We will review your case in (last day of review month). The amount of resources in your name must be $2,000 or less by the end of the review month. You can transfer any resources over $2,000 to your spouse. We will need proof of these transfers. See WAC 182-513-1660 for more information.”

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Tailored supports for older adults (TSOA) presumptive eligibility

Revised date
Purpose statement

This section describes how the presumptive eligibility process works.

WAC 182-513-1620 Tailored Supports for Older Adults (TSOA) - Presumptive Eligibility

WAC 182-513-1620 Tailored Supports for Older Adults (TSOA) - Presumptive Eligibility (PE).

Effective May 29, 2021

  1. A person may be determined presumptively eligible for tailored supports for older adults (TSOA) services upon completion of a prescreening interview.
  2. The prescreening interview may be conducted by either:
    1. The area agency on aging (AAA); or
    2. By a home and community services intake case manager or social worker.
  3. To receive services under presumptive eligibility (PE), the person must meet:
    1. Nursing facility level of care under WAC 388-106-0355;
    2. TSOA income limits under WAC 182-513-1635; and
    3. TSOA resource limits under WAC 182-513-1640.
  4. The presumptive period begins on the date the determination is made and:
    1. Ends on the last day of the month following the month of the presumptive eligibility (PE) determination if a full TSOA application is not completed and submitted by that date; or
    2. Continues through the date the final TSOA eligibility determination is made if a full TSOA application is submitted before the last day of the month following the month of the PE determination.
  5. If the person applies and is not determined financially eligible for TSOA, there is no overpayment or liability on the part of the applicant for services received during the PE period.
  6. The medicaid agency or the agency's designee sends written notice as described in WAC 182-518-0010 when PE for TSOA is approved or denied.
  7. A person may receive services under presumptive eligibility only once within a twenty-four-month period.
  8. If the department of social and health services establishes a waitlist for TSOA services under WAC 388-106-1975, PE does not apply.

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

People who are interested in applying for TSOA or MAC may do so by contacting their local AAA or HCS office. A person may be found presumptively eligible and services may be approved for eligible people pending completion of the application process.

Both TSOA and MAC have a presumptive eligibility component that allows services to be authorized based on a quick prescreening of financial and functional eligibility criteria. The goals of both programs are to get services in place quickly to support the person and caregivers taking care of them. If the person is found presumptively eligible (PE) they can receive services for a period of up to about 60 days while the financial application is being processed and while DSHS confirms that the person meets the functional criteria for the programs.

As long as a financial application has been filed the PE period continues until the application is completed. 

If an application isn’t filed, the PE period will end at the end of the month after the month in which services were first authorized.

For example:

Mary is a caregiver to her father Joe. She talks with the local AAA office about getting some help with a bath bench for Joe. She asks about some possible training on how to safely lift him out of his bed in the morning and from his chair at night. Joe is found presumptively eligible for services under TSOA on 8/10 and is authorized to receive a bath bench.  Mary is scheduled for a local caregiver training class. Mary and Joe have until 9/30 to file an HCA 18-008 Application for TSOA if they wish to continue to receive services. If they don’t apply by that date, the TSOA services ends on 09/30.

Mary indicates she would also like respite services so she can get some shopping done for her family once a week.  She agrees to complete a TCARE Assessment and files the TSOA application form on 8/25.  Because Mary filed the application before the PE period ended, she can continue to receive services, including respite services, until a final decision is made on Joe’s application, even if the final decision takes longer than 09/30. 

If it is later determined that the person wasn’t eligible for services, there is no requirement to repay any of the services that were received during the PE period.  TSOA and MAC can’t be back-dated and won’t cover services provided before the date of the authorization. 

Worker Responsibilities

The PE process is determined and authorized by the AAA and HCS social services staff. Unlike Fast Track, financial staff don’t need to send a 07-104 communication to the authorizing case manager, approving PE.

For MAC: PE is only authorized for people who are currently eligible for CNP or ABP coverage, therefore the PE determination is only for the functional eligibility criteria. Staff should document the PE approval in the person’s case. If NFLOC is approved and MAC services are authorized, HCS will need to transfer the medicaid case into their HCS office to manage. 

For TSOA:  The PE determination may be for both functional and financial eligibility criteria. In most cases, the TSOA applicant will not be eligible for medicaid so the HCS financial worker doesn’t need to do anything at the time of the PE approval. Once a TSOA application is received and a case is screened into ACES, the worker should document that PE was authorized and send the case manager a 07-104 communication notifying them that the application was filed so that the PE authorization period can be extended until the application is processed. There is no requirement to open T02 coverage in months prior to the application month to cover the PE period. 

Once the TSOA application is approved or denied, send another 07-104 communication to the case manager to notify them of the final decision.

Note:  If the PE determination is made by AAA staff, the worker must select the correct AAA location in Barcode in order to send the 07-104 form to AAA staff responsible for the Medicaid Transformation Project, and not to AAA Medicaid Case Management staff.

Related Links

Tailored supports for older adults (TSOA) - applications, rights, and responsibilities

Tailored supports for older adults (TSOA)

 

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Hospice applications - clients eligible for categorically needy (CN) coverage

Revised date
Purpose statement

Clients who elect hospice in the community who are otherwise eligible for CN or ABP program are financially eligible to receive hospice services at home.

If a client is in a nursing facility or hospice care center:

  • For the Aged/Blind/Disabled group, use the hospice institutional rules if in the institution 30 days or more.
  • For a MAGI coverage group, the client remains on the MAGI program. 

Hospice applications - eligibility for CN coverage

An 18-005 application is used for clients to apply for non-MAGI hospice coverage in a nursing facility, hospital, or hospice care center. The same application is used for noninstitutional aged, blind, or disabled coverage.

The financial worker will process applications following non-MAGI rules. If a client elects hospice outside of a nursing facility, hospital, or hospice care center, the L32 program is not used if client is eligible for CN under a noninstitutional CN coverage group, such as S01 or S02.

Note: The N05 coverage group also provides hospice care for those who meet program requirements. An 18-001 application is submitted to WA Health Plan Finder for MAGI coverage. 

If a client elects hospice when residing in a medical facility/care center and is expected to remain there 30 days or more, the L31 coverage group is used for clients who receive SSI cash. For clients who do not receive SSI cash, but are SSI-related based on aged, blind, or disabled requirements, the L32 coverage group is used. This group uses the institutional rules and the 300% Federal Benefit Rate (FBR) income standard when determining eligibility for CN coverage.

The hospice election needs to be updated in ACES when the client is active on a noninstitutional CN program. Code the hospice provider number on the Institutional Care screen in ACES, under the Home and Community Based Services section, and indicate MA (Health Care Authority) as the approval source. ACES uses the provider number to issue copies of the award letter to the hospice agency and ensure that the provider also receives copies of any pending letters sent to the client. This helps them assist the client in gathering any missing verifications.

Follow necessary Equal Access (EA) procedures. This is formerly known as Necessary Supplemental Accommodation (NSA).

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Filing an application

Revised date
Purpose statement

To explain the rules and procedures on who can apply for Washington Apple Health (Medicaid) coverage, how to apply, and the minimum amount of information that must be provided to start the application process.

WAC 182-503-0010 Washington apple health -- Who may apply.

WAC 182-503-0010 Washington apple health -- Who may apply.

Effective January 16, 2020.

  1. You may apply for Washington apple health for yourself.
  2. You may apply for apple health for another person if you are:
    1. A legal guardian;
    2. An authorized representative (as described in WAC 182-503-0130);
    3. A parent or caretaker relative of a child age eighteen or younger;
    4. A tax filer applying for a tax dependent;
    5. A spouse; or
    6. A person applying for someone who is unable to apply on their own due to a medical condition and who is in need of long-term care services.
  3. If you reside in an institution of mental diseases (as defined in WAC 182-500-0050(1)) or a public institution (as defined in WAC 182-500-0050(4)), including a Washington state department of corrections facility, city, tribal, or county jail, or secure community transition facility or total confinement facility (as defined in RCW 71.09.020), you, your representative, or the facility may apply for you to get the apple health coverage for which you are determined eligible.
  4. You are automatically enrolled in apple health and do not need to submit an application if you are a:
    1. Supplemental security income (SSI) recipient;
    2. Person deemed to be an SSI recipient under 1619(b) of the SSA;
    3. Newborn as described in WAC 182-505-0210; or
    4. Child in foster care placement as described in WAC 182-505-0211.
  5. You are the primary applicant on an application if you complete and sign the application on behalf of your household.
  6. If you are an SSI recipient, then you, your authorized representative as defined in WAC 182-500-0010, or another person applying on your behalf as described in subsection (2) of this section, must turn in a signed application to apply for long-term care services as described in WAC 182-513-1315.

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

Medical applications of parents with joint custody of a minor dependent child

Only one household may receive health care coverage for a child, but for modified adjusted gross income (MAGI) coverage, the child may be listed on more than one application in more than one assistance unit (MAU). The household that cares for the child the majority of time receives coverage for that child and that coverage follows the child within the state. When two households have joint custody of a child, the child may obtain health care services while staying at either home in Washington.

Applications by others

Individuals may apply on behalf of an individual if they have one of the following relationships to the applicant:

  1. A legal guardian;
  2. An authorized representative;
  3. A parent or caretaker relative of a child less than nineteen years of age;
  4. A tax filer applying for a tax dependent less than nineteen years of age; or
  5. A spouse.

Note: While others can apply for benefits on behalf of individuals, HIPAA restrictions prevent us from discussing the individual's health information with the person making the application unless the representative has power of attorney for the individual or the individual has signed an Authorization for release of information.

Authorized representative

An authorized representative can be any adult who has sufficient knowledge of the individual's circumstances to act on the individual's behalf. In general, the individual chooses who will be their authorized representative. For more information, see Authorized representatives.

Authorized representatives are not authorized to apply on behalf of deceased individuals.

Applications while in a public institution

Prior to release from a public institution, individuals may apply for Apple Health coverage. See the Incarceration overview page for more information.

WAC 182-503-0005 Washington apple health -- How to apply.

WAC 182-503-0005 Washington apple health -- How to apply.

Effective June 4, 2023

  1. You may apply for Washington apple health at any time.
  2. For apple health programs for children, pregnant people, parents and caretaker relatives, and adults age 64 and under without medicare, (including people who have a disability or are blind), you may apply:
    1. Online via the Washington Healthplanfinder at www.wahealthplanfinder.org;
    2. By calling the Washington Healthplanfinder customer support center and completing an application by telephone;
    3. By completing the application for health care coverage (HCA 18-001P), and mailing or faxing to Washington Healthplanfinder; or 
    4. At a department of social and health services (DSHS) community services office (CSO).
  3. ​If you seek apple health coverage and are age 65 or older, have a disability, are blind, need assistance with medicare costs, or seek coverage of long-term services and supports, you may apply:
    1. Online via Washington Connection at www.WashingtonConnection.org;
    2. By completing the application for aged, blind, disabled/long-term care coverage (HCA 18-005) and mailing or faxing it to DSHS;
    3. By calling the DSHS customer service contact center and completing an application by telephone;
    4. In person at a local DSHS CSO or home and community services (HCS) office; or
    5. As specified in subsection (2) of this section, if you are a child, pregnant, a parent or caretaker relative, or an adult age 64 and under without medicare.
  4. You may receive help filing an application.
    1. For households containing people described in subsection (2) of this section:
      1. Call the Washington Healthplanfinder customer support center number listed on the application for health care coverage form (HCA 18-001P); or 
      2. Contact a navigator, health care authority volunteer assistor, or broker.
    2. For people described in subsection (3) of this section who are not applying with a household containing people described in subsection (2) of this section:
      1. Call or visit a local DSHS CSO or HCS office; or 
      2. Call the DSHS community services customer service contact center number listed on the medicaid application form. 
  5. To apply for tailored supports for older adults (TSOA), see WAC 182-513-1625.
  6. You must apply directly with the service provider for the following programs:
    1. The breast and cervical cancer treatment program under WAC 182-505-0120;
    2. The family planning only programs under chapter 182-532 WAC; and
    3. The kidney disease program under chapter 182-540 WAC.
  7. For the confidential pregnant minor program under WAC 182-505-0117 and for minors living independently, you must complete a separate application directly with us (the medicaid agency). More information on how to give us an application may be found at the agency's web site:  www.hca.wa.gov/free-or-low-cost-health-care (search for "teen").
  8. As the primary applicant or head of household, you may start an application for apple health by providing your:
    1. Full name;
    2. Date of birth; 
    3. Physical address, and mailing addresses (if different); and
    4. Signature.
  9. To complete an application for apple health, you must also give us all of the other information requested on the application.
  10. You may have an authorized representative apply on your behalf as described in WAC 182-503-0130.
  11. We help you with your application or renewal for apple health in a manner that is accessible to you. We provide equal access (EA) services as described in WAC 182-503-0120 if you:
    1. ​Ask for EA services, you apply for or receive long-term services and supports, or we determine that you would benefit from EA services; or
    2. Have limited-English proficiency as described in WAC 182-503-0110. 

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

Application forms

Application through Washington Healthplanfinder (18-001)

Application for aged, blind, disabled/long-term care coverage (18-005)

Program-specific application forms

Application for Medicare Savings Program (MSP)

Application for the Tailored Supports for Older Adults (TSOA) program

Application for pregnant teen health care coverage (under age 19)

K01 application process

Opportunity to apply

CSOs must make application forms readily available and provide a form to anyone requesting one. An individual cannot be refused an application form for any reason. For MAGI-based applications done via Washington Healthplanfinder, CSOs provide computers in their lobbies for applicants to apply for health care coverage in Washington Healthplanfinder. Additionally, CSOs may offer assistance in applying in Washington Healthplanfinder when an individual is also applying for SNAP (food assistance).

Starting an application

An individual has filed a partial application when a signed application is received with at least the name and date of birth of the head of household or primary applicant and the physical/mailing address. Once submitted, the individual will have at least 15 days to complete the application and submit verification, if needed.

Where to apply

MAGI-based coverage

Applying for Apple Health through Washington Healthplanfinder is best for individuals who are:

  1. Adults under age 65 who are ineligible for Medicare;
  2. Adults who are parents or caretaker relatives of minor children;
  3. Pregnant; or
  4. Under age 19.

Washington Healthplanfinder applications can be completed:

  1. Online at wahealthplanfinder.org;
  2. By phone with the Washington Healthplanfinder Customer Support Center at 1-855-WAFINDER (1-855-923-4633);
  3. Through a navigator;
  4. By submitting a paper Health Care Coverage application (18-001P) by fax to 1-855-867-4467; or
  5. By submitting a paper Health Care Coverage application (18-001P) by mail to:
    Washington Healthplanfinder
    PO Box 946
    ​Olympia, WA 98504

Navigators are available around the state. Navigators are a network of people, usually in clinics and hospitals, who can help individuals find and apply for coverage. The Washington Healthplanfinder Navigator Search can be found at Applications for long term services and supports (LTSS).

Individuals not eligible via Washington Healthplanfinder but who appear to qualify for non-MAGI coverage receive an application form by mail to apply for non-MAGI based coverage.

Non-MAGI-based Classic Apple Health coverage

DSHS processes applications for individuals who are age 65 or over, eligible for Medicare, are blind or disabled, need a disability determination, or are in need of long-term services and supports. DSHS has two areas that process applications: Economic Services Administration (ESA) and the Aging and Long-Term Support Administration (ALTSA).

DSHS Community Services Office (CSO)

DSHS CSOs process applications for individuals who are 65 or over, eligible for Medicare, are blind or disabled, or need a disability determination. Applications for non-MAGI Apple Health can be completed:

  1. Online at WashingtonConnection.org;
  2. By submitting a paper Application for aged, blind, disabled/long-term services and supports (18-005) by fax to 1-888-338-7410;
  3. By calling the DSHS Customer Service Contact Center at 1-877-501-2233 to complete an application over the telephone with a telephonic signature; or
  4. By submitting a paper Application for aged, blind, disabled/long-term services and supports (18-005) by mail to:
    DSHS
    Community Services Division – Customer Service Center
    PO Box 11699
    Tacoma, WA 98411-6699

Find a local CSO.

ALTSA Home and Community Services (HCS)

ALTSA’s HCS processes applications for individuals not eligible for MAGI-based coverage and who are in need of care in their own home, a community residential care facility (adult family home or assisted living facility) or nursing facility. More information on the HCS application process can be found in the Medicaid and Long-Term Care Services for Adults publication (22-619).

Individuals eligible under a categorically needy (CN) or alternative benefits plan (ABP) MAGI-based program can receive long-term services and supports (LTSS) if determined functionally eligible by an ALTSA social worker or case manager. A separate application is not needed for active MAGI based individuals for Medicaid personal care (MPC), Community First Choice (CFC) or nursing facility services. If LTSS is needed, contact the HCS intake for an assessment. The intake phone numbers for a social service assessment is located under applications for LTC: Applications for long term services and supports (LTSS)

Applications for services through HCS can be completed:

  1. Online at WashingtonConnection.org;
  2. By submitting a paper application for aged, blind, disabled/long-term care coverage (18-005) by fax to 1-855-635-8305; or
  3. By submitting a paper application for aged, blind, disabled/long-term care coverage (18-005) by mail to:
    DSHS
    Home and Community Services – Long Term Care Services
    PO Box 45826
    Olympia, WA 98504-5826

Find a local HCS office.

Pending applications

When an individual submits an application and more information is needed to determine eligibility, they will receive a letter in the mail (unless they are receiving electronic notices through Washington Healthplanfinder). This letter will tell them what information is needed, when to submit it, and how to submit it. See the General verification chapter for more information.

Example: Jenny, age 35, has a pending application for SNAP (Basic Food) and ABD cash. At her intake interview, she requests health care coverage. She reports she is not aged or blind, but may have a disability. The CSO worker offers assistance to apply in Washington Healthplanfinder, which Jenny accepts. The worker inputs the application data into Washington Healthplanfinder and Jenny is approved for Apple Health for Adults.

Example: Maria, age 66, has a pending application for SNAP (Basic Food). At her telephone intake interview, the worker lets her know she may be eligible for non-MAGI (Classic) Apple Health. She decides to apply for coverage as well. The worker can complete an interactive interview and follow procedures to capture a telephonic signature when appropriate.

Handling multiple applications from the same household (Classic Medicaid only)

  1. Additional applications received before we determine eligibility on the first application:
    1. Do not deny the additional application(s);
    2. Review the application(s) for impact on eligibility and whether the household is applying for any additional programs that were not selected on the first application;
    3. If the household is not applying for additional programs, document in the case that additional application(s) were received, the date(s) the additional application(s) were received, and that the agency is still considering eligibility under the original application date;
    4. If the household is applying for additional programs, treat the application as a new application for the additional programs only and continue to consider any requests for programs which are still pending under the original application date;
    5. Document in ACES to explain any additional information used to determine eligibility; and
    6. Do not extend the Timeliness period for the original application
      1. Note: If the additional application is received before we determine eligibility on the first application but a worker does not act on the additional application until after the first application has been approved or denied, follow procedures under (2) below.
  2. Additional applications received after we determine eligibility on the first application:
    1. If we denied the first application, treat this as an initial application.
      1. Exception: If we are still within the original 30 day reconsideration period under WAC 182-503-0080 and there has not been a change of circumstances that would warrant a new request for information, then do not treat this as an initial application. Instead, treat this as a reconsideration. See Denials.
    2. If we approved the first application, review the additional application(s) to determine if household circumstances have changed. Take appropriate actions on any changes reported.
    3. If neither (a) nor (b) applies, the additional application should be denied as a duplicate application as follows:
      1. Use reason code 587;
      2. Send out the required denial letter (if not system generated); and
      3. Add text to explain that the application is being denied because the person(s) on the application is already receiving the Apple Health coverage.

Please note: Reuse AUs! When denying additional applications as described in (b)(iii) above, avoid creating a new AU if an old AU is available.

Name, address, and signature requirements

  1. Name and address
    If we receive an application without a name or address to contact the individual, we make any reasonable effort we can to contact the individual to find out who the individual is and where they can be reached. If contact cannot be made, no further action needs to be taken.
  2. Applications marked “homeless”
    If we receive a paper application that includes a name and signature, but is marked "homeless" and/or does not indicate a mailing address, make a reasonable attempt to locate an address or phone number for the individual. This can be done by searching the electronic case record, case narrative, ACES remarks, or past Washington Healthplanfinder applications to see if there’s a recent address reported. If no address is provided and no contact can be made, no further action needs to be taken.
  3. Signatures
    1. The individual/authorized representative must sign the application.
    2. A minor child may sign the application if there is no adult in the household.
    3. A mark is an acceptable signature if another person witnesses the making of the mark and signs the application.
    4. Online applications are considered signed electronically when transmitted.
    5. Telephonic signatures are accepted through Washington Healthplanfinder’s customer support center.
    6. See matrix below for signature requirements and date of application.

Application received

Online

In person, mailed, emailed, faxed, dropped off, scanned, or over the phone

Application signed?

Yes. Always signed when submitted

May or may not be signed. Does not need to be signed in order to be accepted. Must be signed, however, to be processed

Date of application

Date received or next business day if received after business hours

If signed, date received or next business day if received after business hours. If not signed, see "Action to Take".

Action to take

Only applicant needs to sign in two parent households

If not signed, or taken over the phone, have the individual sign or mail back for signature. The date we receive the signature is the date of application.

Note: When an interactive interview over the phone or in-person is used to complete an application for benefits, a signature must be obtained. This does not apply to applications completed by using the DSHS telephonic signature process.

Additional situations requiring an application or eligibility review
Signed application or eligibility review forms (which may be signed telephonically) are needed for:

  • When an individual is terminated from SSI and we must redetermine eligibility under a different program.
  • Adding someone new to an assistance unit who has either not previously applied, or whose previous DSHS coverage ended more than 30 days earlier.
  • Medically Needy (MN) coverage, and whenever establishing a new base period. If the application/review is completed by phone using the DSHS application telephonic signature process, the Interactive Interview Declaration (IID) must be printed out and sent to the individual for review.
  • When an individual applies for long-term services and supports (LTSS), such as COPES, nursing home care, or a DDA waiver, and is expected to receive the LTC service for longer than 30 days. This includes SSI recipients.

Other programs

Family Planning Only is a program that provides individuals coverage for family planning services.

Find more information on the Family Planning Only page.

Alien Emergency Medical (AEM) applications are processed by either HCA or DSHS. See the AEM presentation for more information.

Breast and Cervical Cancer Treatment Program (BCCTP) provides health care coverage for an individual diagnosed with breast or cervical cancer or a related precancerous condition. Find more information at the Department of Health’s BCCTP page.

The Apple Health Kidney Disease Program (KDP) is a state-funded program that helps low-income, eligible individuals with treatment costs for end-stage renal disease. Eligibility is determined by each contracted kidney center. More information can be found on the KDP page.

Pregnant minors under 19 who need confidential health care coverage can apply using the Application for Pregnant Teen (14-430) form. The form can be submitted by mail or fax to:

Medical Eligibility Determination Services (MEDS)

PO Box 45531
Olympia, WA 98504-5531
Fax 360-725-1898

Homeless teens applying on their own will need assistance with their Washington Healthplanfinder application. See the Homeless Teen Process form for more information.

WAC 182-503-0060 Washington apple health (WAH)-- Application processing times.

WAC 182-503-0060 Washington apple health -- Application processing times.

Effective August 8, 2021

  1. We process applications for Washington apple health medicaid within forty-five calendar days, with the following exceptions:
    1. If you are pregnant, we process your application within fifteen calendar days;
    2. If you are applying for a program that requires a disability decision, we process your application within sixty calendar days; or
    3. The modified adjusted gross income (MAGI)-based apple health application process using Washington Healthplanfinder may provide faster or real-time determination of eligibility for medicaid.
  2. For calculating time limits, "day one" is the day we get an application from you that includes at least the information described in WAC 182-503-0005(8). If you give us your paper application during business hours, "day one" is the day you give us your application. If you give us your paper application outside of business hours, "day one" is the next business day. If you experience technical difficulties while attempting to give us your application in Washington Healthplanfinder, "day one" is the day we are able to determine, based on the evidence available, that you first tried to submit an application that included at least the information described in WAC 182-503-0005(8).
  3. We determine eligibility as quickly as possible and respond promptly to applications and information received. We do not delay a decision by using the time limits in this section as a waiting period.
  4. If we need more information to decide if you can get apple health coverage, we will send you a letter within twenty calendar days of your initial application that:
    1. Follows the rules in chapter 182-518 WAC;
    2. States the additional information we need; and
    3. Allows at least ten calendar days to provide it. We will allow you more time if you ask for more time or need an accommodation due to disability or limited-English proficiency.
  5. Good cause for a delay in processing the application exists when we acted as promptly as possible but:
    1. The delay was the result of an emergency beyond our control;
    2. The delay was the result of needing more information or documents that could not be readily obtained;
    3. You did not give us the information within the time frame specified in subsection (1) of this section.
  6. Good cause for a delay in processing the application does NOT exist when:
    1. We caused the delay in processing by:
      1. Failing to ask you for information timely; or
      2. Failing to act promptly on requested information when you provided it timely; or
    2. We did not document the good cause reason before missing a time frame specified in subsection (1) of this section. 

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.

Worker responsibilities (Non-Classic Medicaid only)

Date stamping the application

  1. Date stamp the application, the same day we get the application, even if the application is sent to the wrong office; or
  2. The next business day if we received the application outside of normal business hours.

Shared case processing / transfers

CSO and Foster Care and Adoption Support (FCAS) may need to coordinate actions on shared cases involving foster and adopted children or foster alumni receiving D01, D02, or D26 medical programs. To contact the FCAS call 1-800-562-3022, extension 15480; or email at FCAS@hca.wa.gov.

CSO and MEDS staff must coordinate actions taken on shared cases. If the CSO needs a shared case transferred, email Medstransfer@hca.wa.gov. For MEDS, if there is a shared case, contact the CSO before making any change. If MEDS staff are unable to reach the CSO to take action on a shared case, they will contact the CSO supervisor of record for action.

How to contact MEDS:

By Mail:
MEDS
PO Box or Mail Stop 45531
Olympia, Washington 98504-5531

Phone: General Information: 800-562-3022

FAX: 855-867-4467

Email: Case transfers Medstransfer@hca.wa.gov

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ACES codes

Revised date
Purpose statement

This section provides additional clarification regarding ACES coding for medical expenses for spenddown.

ACES code Examples
PR
  • Medicare Part A, Part B, Part C, or Part D
    • Premiums
    • Copayments
    • Coinsurance charges that are not covered under the Qualified Medicare Beneficiary (QMB) Medicare Savings Program (MSP)
    • Deductibles

Premiums. Individuals typically pay premiums for Part B and Part D plans and sometimes for Part C plans. The charges are allowed towards spenddown as follows:

  • Allow premiums that the individual is or has been responsible to pay.
  • If S03, S05 or S06 is being approved to cover Part B premiums, allow the first two months premiums in the current base period.
  • Allow any premiums paid by the individual within the 3-month retroactive period if an MSP is not approved to cover this period. S05 or S06 can and should be approved for the retroactive period if requested – remember to notify the HCA Medicare Buy-In unit that you need retroactive coverage for Part B premiums.
  • Otherwise allow premiums as the expense is incurred.

Copayments. Individuals typically pay copayments for prescriptions under Part D, which vary depending on the drug and the Part D plan. These charges are allowed towards spenddown when the individual is responsible to pay for it. Medicaid only covers prescription drug costs for Medicare individuals if the drug is not covered by Medicare under the Part D plan but is covered by Medicaid.

Coinsurance. Individuals typically pay coinsurance charges under Parts A and B, which are generally 20% of the Medicare allowed charge. These charges are allowed towards spenddown unless the individual is also eligible for S03 coverage.

For example: An individual is on spenddown without QMB. Dr. Jones bills an individual $425. The Medicare allowed amount is $370 for this charge. Medicare pays 80% or $296 towards the bill, and the individual is legally obligated to pay the remaining 20% coinsurance amount of $74. Dr. Jones is not allowed to bill the individual for the remaining $55 -- the difference between $425 and the $370 that Medicare allowed. $74 is what is applied towards spenddown. The Explanation of Benefits (EOB) will show the allowed charges and the amount the individual is responsible for.

Deductibles. Individuals pay a standard deductible under Parts A and B, which are listed on the Washington Apple Health Income and resource standards chart. This amount is also typically shown on the individual's EOB. Deductibles are allowed towards spenddown unless the individual is also eligible for S03 coverage.
CO
  • Private health insurance:
    • Copayments (not premiums)
    • Coinsurance charges
    • Deductibles

For example: An individual has Regence Health insurance. She pays $15 copayment for each doctor’s visit and has a $250 yearly deductible to meet before coverage begins. The $15 copayment would be coded “CO” in ACES. He brings you an insurance statement showing that he had a hospital visit in January and he is responsible for the first $250 of the bill. This would also be coded as “CO” in ACES.

Note: Do not code private health insurance premiums as "CO". Private health insurance premiums are coded on the MEDX screen, which reduces the total spenddown amount.
MU
  • Certain expenses, such as:
    • Transportation to medical appointments or to pick up prescriptions.
    • Items prescribed by an allowable provider but not covered by Medicaid, such as hearing aids.
    • Prior unpaid charges that were denied by HCA as an uncovered expense.
    • Prescribed vitamins, supplements, or over-the-counter medications, such as prenatal vitamins
    • Orthodontic or chiropractic treatments
    • Laser eye surgery

It is not necessary to code the expenses of a nonapplying spouse or other household members as "MU" in order for ACES to treat their expenses as "uncovered". Code expenses for nonmembers the same as if the nonmember were applying for coverage based upon the expense type.
HO
  • Inpatient or outpatient services provided in a hospital setting. This includes emergency room visits, physician charges for services provided in the hospital, lab fees, x-rays etc.

Note: Always code hospital expense with the date the individual first entered the hospital. When reviewing hospital statements, use the initial date of service and not the statement date.
MC
  • Any charges that are potentially payable by Medicaid, such as:
    • Doctor’s visits
    • Physical, speech or occupational therapy
    • Specialist appointments
    • Laboratory fees or X-rays
    • Mental health services, etc.

See Scope of Care for more information about services covered under the MN program. For questions regarding coverage for specific expenses, call the HCA Medical Assistance Customer Service Center at 1-800-562-3022.
RX
  • Prescription pharmacy expenses for non-Medicare-eligible individuals.

Note: When entering an RX expense, it is a required field to enter the name of the prescription drug.
Enter each prescription separately – do not lump prescription drugs into one expense even if paid for together.
Ensure the individual has provided a receipt showing payment and is not just providing a list of prescriptions they are waiting to fill.

DO NOT allow the following as prescription expenses:

  • A Medicare eligible individual CANNOT choose to self-pay for a Medicare covered drug and then use the expense toward meeting a spenddown.
  • A prescription drug that is not on the individual’s Medicare Part D plan’s formulary cannot be allowed towards spenddown unless the individual has requested an exception from their plan and has received a written denial.
  • Prescribed items that are not pharmaceuticals.

Please report broken links or content problems.

Free-form text for ACES letters

Revised date
Purpose statement

To describe the free-form text requirements for the Apple Health ACES Letters listed below.

Letter Letter Title Freeform Text Requirement

0004-05

General Denial - No Information

List items that you asked for that were not provided.

0020-01

MN Spenddown

When approved, the letter will list all bills used to meet spenddown or applied towards the spenddown.

In the first mandatory freeform text section:

  • List all the bills you did not use and why you didn't use them.

0070-05

ETR Denial

State why the ETR was denied.

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DSHS and HCA forms, WACs, rule-making, and useful LTC links

Revised date

HCA and DSHS forms

HCA and DSHS WACs and rulemaking links

Aging and long-term supports intake phone numbers and links

For more information on who does what LTSS program, see Overview- Long-term Services and Supports chart.

CSD/ESA contact numbers

Health Care Authority (HCA) links frequently used by LTSS staff

Health Care Authority (HCA) Health Care Coverage - Washington Apple Health (WAH) /information links

HCA - medical assistance coverage

HCA - medical assistance administrative hearing rules

Managed care, TPL and long-term care insurance information

HCA NF billing guides

HCA help desk and online services

HCA smarter track mailbox for internal ProviderOne manual updates

When to use mmishelp@hca.wa.gov: Situation: Client gets discharged from a NF and cannot get a prescription filled because of the coding. We need to email mmishelp@hca.wa.gov when needing a manual fix in the system. This includes when we correct an incorrect date of death in ACES. Once the case is closed in ACES, any fix must be manually sent over to HCA to match ACES data.

HCA Medicare buy-in issues:

  • Field staff use Barcode tickler 102@MBU
  • For clients, contact the Medicaid Customer Service Center 800-562-3022

Federal Medicaid, Medicare, Social Security and Railroad Retirement links used in LTC

Useful links used in LTC. Washington LawHelp, Ombudsman, RCS complaint line, SHIBA

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Who can apply for whom

Revised date
Purpose statement

To explain who can apply for Apple Health coverage and for whom.

WAC 182-503-0010 Washington apple health -- Who may apply.

WAC 182-503-0010 Washington apple health -- Who may apply.

Effective January 16, 2020.

  1. You may apply for Washington apple health for yourself.
  2. You may apply for apple health for another person if you are:
    1. A legal guardian;
    2. An authorized representative (as described in WAC 182-503-0130);
    3. A parent or caretaker relative of a child age eighteen or younger;
    4. A tax filer applying for a tax dependent;
    5. A spouse; or
    6. A person applying for someone who is unable to apply on their own due to a medical condition and who is in need of long-term care services.
  3. If you reside in an institution of mental diseases (as defined in WAC 182-500-0050(1)) or a public institution (as defined in WAC 182-500-0050(4)), including a Washington state department of corrections facility, city, tribal, or county jail, or secure community transition facility or total confinement facility (as defined in RCW 71.09.020), you, your representative, or the facility may apply for you to get the apple health coverage for which you are determined eligible.
  4. You are automatically enrolled in apple health and do not need to submit an application if you are a:
    1. Supplemental security income (SSI) recipient;
    2. Person deemed to be an SSI recipient under 1619(b) of the SSA;
    3. Newborn as described in WAC 182-505-0210; or
    4. Child in foster care placement as described in WAC 182-505-0211.
  5. You are the primary applicant on an application if you complete and sign the application on behalf of your household.
  6. If you are an SSI recipient, then you, your authorized representative as defined in WAC 182-500-0010, or another person applying on your behalf as described in subsection (2) of this section, must turn in a signed application to apply for long-term care services as described in WAC 182-513-1315.

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

Usually, individuals age 18 or younger apply for health coverage with their custodial parent(s) or guardian(s). But, they may be able to get health coverage on their own if they:

  • Live separately from their parents/guardians and are not claimed by them as a tax dependent;
  • Are homeless;
  • Are pregnant; or
  • Need birth control or sexually transmitted infection care.

If an individual age 18 or younger wishes to apply for Apple Health, he or she must call 855-WAFINDER (855-923-4633).

Who can apply when there is a custodial dispute of a dependent?

The primary custodial parent or guardian.

In cases where it is not clearly established who the custodial parent is, whether because the court orders establishes joint custody or there is no formal order, the custodial parent is the parent with whom the child spends the most nights.

If it is claimed the child spends an equal number of nights with each parent, but for purposes of establishing Apple Health eligibility for that dependent, the agency accepts the application for the custodial parent or guardian that applied first.

This action does not prevent the other custodial parent or guardian from including that dependent on their application and counted towards their medical assistance unit.

For more information on determining a person's medical assistance unit see Household composition.

Who can apply for a deceased individual?

  1. Their spouse;
  2. The parent or caretaker relative as described in WAC 182-500-0020;
  3. A relative, either through blood, marriage, or adoption;
  4. The Executor, Administrator, or Personal Representative of the deceased's estate;
  5. A court appointed guardian who was appointed after the applicant or recipient's death; or
  6. Anyone legally authorized by the courts or by state law to act on behalf of the deceased or his or her estate.

Who cannot apply for a deceased individual?

  1. An Authorized Representative (AREP) who was designated while the applicant or recipient was living unless they are one of the following:
    • Their spouse;
    • The parent or caretaker relative as described in WAC 182-500-0020;
    • A relative, either through blood, marriage, or adoption;
    • The Executor, Administrator, or Personal Representative of the deceased's estate; or
    • Anyone legally authorized by the courts or by state law to act on the behalf of the deceased or his or her estate
  2. An individual or organization assigned guardianship or Power of attorney (POA) while the applicant or recipient was living.
    Guardianship and POA assigned while the individual is living ends after the applicant or recipient is deceased.

Note: This information does not apply to long-term care applications that were received prior to the applicant's death. ALTSA will continue to work with the applicant's designee to approve or deny the request.

Power of Attorney defined:

A "power of attorney" (POA) is a legal document giving one person the legal power to act on behalf of someone else. A POA can grant someone a wide range of powers or a narrow range; it depends on what is written in the POA. The only way to know what powers are granted by a POA is to read the POA itself. A POA ends if:

  • The applicant or recipient dies;
  • The applicant or recipient becomes incompetent;
  • The person who granted the power revokes the POA;
  • The person who is given power by a POA terminates the POA; or
  • A court invalidates the POA.

Durable Power of Attorney defined:

A durable power of attorney (DPOA) is a power of attorney that stays in effect even if the person who signed it becomes incompetent or incapacitated. A DPOA can grant someone a wide range of powers or a narrow range; it depends on what is written in the DPOA. The only way to know what powers are granted by a DPOA is to read the POA itself.

Note: A person who is already legally incompetent cannot create a valid DPOA.

A DPOA ends if:

  • The applicant or recipient dies
  • The person who granted the power revokes the DPOA;
  • The person who is given power by a DPOA terminates the POA.
  • The person who is given power by a DPOA cannot be found; or
  • A court invalidates the DPOA.

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Tailored supports for older adults (TSOA)

Revised date
Purpose statement

To describe the Tailored Supports for Older Adults (TSOA) program and the eligibility requirements for a person to become eligible.

WAC 182-513-1610 Tailored Supports for Older Adults (TSOA) - Overview

WAC 182-513-1610 Tailored supports for older adults (TSOA) — Overview.

Effective July 1, 2017

  1. The tailored supports for older adults (TSOA) program is a federally funded program approved under section 1115 of the So­cial Security Act. It enables the medicaid agency and the agency's designees to deliver person-centered long-term services and supports (LTSS) to a person who:
    1. Meets nursing facility level of care described in WAC 388-106-0355; and
    2. Meets the functional requirements under WAC 388-106-1900 through 388-106-1990.
  2. For the purposes of TSOA, the applicant is the person receiv­ing care even though services may be authorized to the person provid­ing care. TSOA does not provide Washington apple health 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.

WAC 182-513-1615 Tailored Supports for Older Adults (TSOA) - General Eligibility

WAC 182-513-1615 Tailored Supports for Older Adults (TSOA) - General Eligibility

Effective July 1, 2017

  1. The person receiving care must meet the financial eligibility criteria for tailored supports for older adults (TSOA).
  2. To be eligible for the TSOA program, the person receiving care must:
    1. Be age 55 or older;
    2. Be assessed as meeting nursing facility level of care under WAC 388-106-0355;
    3. Meet residency requirements under WAC 182-503-0520;
    4. Live at home and not in a residential or institutional setting;
    5. Have an eligible unpaid caregiver under WAC 388-106-1905, or meet the criteria under WAC 388-106-1910 if the person does not have an eligible unpaid caregiver;
    6. Meet citizenship or immigration status requirements under WAC 182-503-0535. To be eligible for TSOA, a person must be a:
      1. U.S. citizen under WAC 182-503-0535 (1)(c);
      2. U.S. national under WAC 182-503-0535 (1)(d);
      3. Qualifying American Indian born abroad under WAC 182-503-0535 (1)(f); or
      4. Qualified alien under WAC 182-503-0535 (1)(b) and have either met or is exempt from the five-year bar requirement for medicaid.
    7. Provide a valid Social Security number under WAC 182-503-0515;
    8. Have countable resources within specific program limits under WAC 182-513-1640; and
    9. Meet income requirements under WAC 182-513-1635.
  3. TSOA applicants who receive coverage under Washington apple health programs are not eligible for TSOA, unless they are enrolled in:
    1. Medically needy program under WAC 182-519-0100;
    2. Medicare savings programs under WAC 182-517-0300;
    3. Family planning program under WAC 182-505-0115;
    4. Family planning only programs under chapter 182-532 WAC; or
    5. The kidney disease program under chapter 182-540 WAC.
  4. A person who receives apple health coverage under a categorically needy (CN) or alternative benefit plan (ABP) program is not eligible for TSOA but may qualify for:
    1. Caregiver supports under medicaid alternative care (MAC) under WAC 182-513-1605; or
    2. Other long-term services and supports under chapter 182-513 or 182-515 WAC.
  5. The following rules do not apply to services provided under the TSOA benefit:
    1. Transfer of asset penalties under WAC 182-513-1363;
    2. Excess home equity under WAC 182-513-1350;
    3. Client financial responsibility under WAC 182-515-1509;
    4. Estate recovery under chapter 182-527 WAC;
    5. Disability requirements under WAC 182-512-0050;
    6. Requirement to do anything necessary to obtain income under WAC 182-512-0700(1); and
    7. Assignment of rights and cooperation under WAC 182-503-0540

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

TSOA is a program funded under the Medicaid Transformation Project Demonstration and provides services to support unpaid caregivers in Washington State, and provides a small personal care benefit to people who don’t have an unpaid family caregiver to help them. It creates a new eligibility category and benefit package for people age 55 or older who are “at risk” of needing long-term services and supports in the future who don’t currently meet Medicaid financial eligibility criteria.

TSOA doesn’t provide health care coverage and is targeted towards people who aren’t currently eligible for medicaid. However, TSOA may be used for people who are currently only eligible for a limited scope program such as the Medicare Savings Programs, or who are only eligible for medically needy coverage.

Eligibility for TSOA is determined by reviewing the income and resources of the person (and their spouse) who receives care. The person must also be functionally eligible under WAC 388-106-1910. However, the services authorized are for the benefit of the caregiver, not the care receiver.

For example:

Joe is 85 years old and has dementia. He is being cared for by his 60 year old daughter Mary. Mary calls to apply for TSOA because Joe has started wandering and she wants to get a personal emergency response system set up to monitor Joe. She is also concerned that she doesn’t know the best way to care for Joe as his dementia worsens.

Joe is screened and meets nursing facility level of care. He meets TSOA financial eligibility criteria. Mary is approved to get a PERS unit for Joe and she is also registered to attend a local class that provides dementia education for caregivers. She is also authorized to receive respite care so someone is able to care for Joe while she attends the class.

What are the financial eligibility criteria for TSOA?

The person who receives the care must be:

  • Age 55 or older and live in a home setting
  • A Washington State resident
  • Meet the citizenship and immigration eligibility for federally funded medicaid
  • Meet NFLOC
  • Provide a valid SSN or proof of application for an SSN
  • Meet income requirements under WAC 182-513-1635
  • Meet resource requirements under WAC 182-513-1640

A person may be authorized services under the TSOA program while also applying for medicaid. However, if the person is approved for medicaid, TSOA must be closed.

What LTSS financial rules don’t apply to TSOA services?

Certain provisions that apply to traditional long-term care services don’t apply to people who are eligible for TSOA. These include:

Recovery and TEFRA liens (Chapter 182-527 WAC)

Estate Recovery doesn’t apply to services paid by the TSOA program. Likewise the state can’t establish a TEFRA lien for the cost of services provided under this program.

Worker Responsibilities

The AAA worker will notify financial staff using the 14-443 communication form when a person has been approved for TSOA services. The form will include the date services are authorized which will be used to open the T02 coverage group in ACES.

HCS financial staff are responsible for ongoing case maintenance on TSOA clients, which includes processing food assistance requests if applicable.

Related links

Tailored supports for older adults (TSOA) - applications, rights, and responsibilities

Tailored supports for older adults (TSOA) presumptive eligibility

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Patient review and coordination

Revised date
Purpose statement

To explain the Patient Review and Coordination (PRC) program, which is intended to protect the health and safety of individuals, assure continuity of medical care, and prevent duplication of services.

WAC 182-501-0135 Patient review and coordination (PRC).

WAC 182-501-0135 Patient review and coordination (PRC).

Effective November 23, 2024

  1. Patient review and coordination (PRC) is a health and safety program that coordinates care and ensures clients enrolled in PRC use services appropriately and in accordance with agency rules and policies.
    1. PRC applies to medical assistance fee-for-service and managed care clients organization (MCO) enrollees.
    2. PRC is authorized under federal medicaid law by 42 U.S.C. 1396n (a)(2) and 42 CFR 431.54.
  2. Definitions. Definitions found in chapter 182-500 WAC and WAC 182-526-0010 apply to this section. The following definitions apply to this section:
    "Appropriate use" - Use of healthcare services that are safe and effective for a client's healthcare needs.
    "Assigned provider" - An agency-enrolled healthcare provider or one participating with an agency-contracted managed care organization (MCO) who agrees to be assigned as a primary provider and coordinator of services for an FFS client or MCO enrollee in the PRC program. Assigned providers can include a primary care provider (PCP), a pharmacy, a prescriber of controlled substances, and a hospital for nonemergency services.
    "At-risk" - A term used to describe one or more of the following:
    1. A client with a medical history of:
      1. Seeking and obtaining healthcare services at a frequency or amount that is not medically necessary;
      2. Potential life-threatening events or life-threatening conditions that required or may require medical intervention.
    2. Behaviors or practices that could jeopardize a client's medical treatment or health including, but not limited to:
      1. Indications of forging or altering prescriptions;
      2. Referrals from medical personnel, social services personnel, or MCO personnel about inappropriate behaviors or practices that place the client at risk;
      3. Noncompliance with medical or drug and alcohol treatment;
      4. Paying cash for medical services that result in a controlled substance prescription or paying cash for controlled substances;
      5. Arrests for diverting controlled substance prescriptions;
      6. Positive urine drug screen for illicit street drugs or nonprescribed controlled substances;
      7. Negative urine drug screen for prescribed controlled substances; or
      8. Unauthorized use of a client's services card for an unauthorized purpose.
        "Care management"- Services provided to MCO enrollees with multiple health, behavioral, and social needs to improve care coordination, client education, and client self-management skills.
        "Client" - See WAC 182-500-0020.
        "Conflicting" - Drugs or health care services that are incompatible or unsuitable for use together because of undesirable chemical or physiological effects.
        "Contraindicated" - A medical treatment, procedure, or medication that is inadvisable or not recommended or warranted.
        "Duplicative" - Applies to the use of the same or similar drugs and health care services without due medical justification. Example: A client receives health care services from two or more providers for the same or similar condition(s) in an overlapping time frame, or the client receives two or more similarly acting drugs in an overlapping time frame, which could result in a harmful drug interaction or an adverse reaction.
        "Emergency department information exchange (EDIE)" - An internet-delivered service that enables health care providers to better identify and treat high users of the emergency department and special needs patients. When patients enter the emergency room, EDIE can proactively alert health care providers through different venues such as fax, phone, email, or integration with a facility's current electronic medical records.
        "Emergency medical condition" - See WAC 182-500-0030.
        "Emergency services" - See 42 C.F.R. 438.114.
        "Fee-for-service" or "FFS" - See WAC 182-500-0035.
        "Just cause" - A legitimate reason to justify the action taken including but not limited to, protecting the health and safety of the client.
      9. "Managed care organization (MCO) enrollee" - A medical assistance client enrolled in, and receiving health care services from, an agency-contracted managed care organization (MCO).
        "Prescriber of controlled substances" - Any of the following health care professionals who, within their scope of professional practice, are licensed to prescribe and administer controlled substances (see chapter 69.50 RCW, Uniform Controlled Substance Act) for a legitimate medical purpose:
        (a) A physician under chapter 18.71 RCW;
        (b) A physician assistant under chapter 18.71A RCW;
        (c) An osteopathic physician under chapter 18.57 RCW;
        (d) An advanced registered nurse practitioner under chapter 18.79 RCW.
        "Primary care provider" or "PCP" - A person licensed or certified under Title 18 RCW including, but not limited to, a physician, an advanced registered nurse practitioner (ARNP), or a physician assistant (PA) who supervises, coordinates, and provides health care services to a client, initiates referrals for specialty and ancillary care, and maintains the client's continuity of care.
  3. Clients selected for PRC review. The agency or agency's designee selects a client for PRC review when either or both of the following occur:
    1. An agency or MCO claims utilization review report indicates the client has not used health care services appropriately; or
    2. Medical providers, social service agencies, or other concerned parties have provided direct referrals to the agency or MCO.
  4. Clients not selected for PRC review. Clients are not reviewed or placed into the PRC program when they :
    1. Are in foster care;
    2. Are covered under state-only funded programs;
    3. Do not have medicaid as the primary payor; or
    4. Are covered under the alien emergency medical (AEM) program according to WAC 182-507-0115.
  5. Prior authorization. When an FFS client is selected for PRC review the prior authorization process as defined in WAC 182-500-0085 may be required:
    1. Before or during a PRC review; or
    2. When the FFS client is currently in the PRC program.
  6. Review for placement in the PRC program. When the agency or MCO selects a client for PRC review, the agency or MCO staff, with clinical oversight, reviews either the client's medical history or billing history, or both, to determine if the client has used health care services at a frequency or amount that is not medically necessary (42 CFR 431.54(e)).
  7. Usage guidelines for PRC placement. Agency or MCO staff use the following usage guidelines to determine PRC placement. A client may be reviewed for placement in the PRC program when the review shows the usage is not medically necessary and either the client's medical history or billing history, or both, documents any of the following:
    1. Any two or more of the following conditions occurred in a period of 90 consecutive calendar days in the previous 12 months. The client:
      1. Received services from four or more different providers, including physicians, ARNPs, and PAs not located in the same clinic or practice;
      2. Had prescriptions filled by four or more different pharmacies;
      3. Received 10 or more prescriptions;
      4. Had prescriptions written by four or more different prescribers not located in the same clinic or practice;
      5. Received similar services in the same day not located in the same clinic or practice; or
      6. Had 10 or more office visits;
    2. Any one of the following occurred within a period of 90 consecutive calendar days in the previous 12 months. The client:
      1. Made two or more emergency department visits;
      2. Exhibits "at-risk" usage patterns;
      3. Made repeated and documented efforts to seek health care services that are not medically necessary; or
      4. Was counseled at least once by a health care provider, or an agency or MCO staff member with clinical oversight, about the appropriate use of health care services;
    3. The client received prescriptions for controlled substances from two or more different prescribers not located in the same clinic or practice in any one month within the 90-day review period; or .
    4. The client has either a medical history or billing history, or both, that demonstrates a pattern of the following at any time in the previous 12 months:
      1. Using health care services in a manner that is duplicative, excessive, or contraindicated;
      2. Seeking conflicting health care services, drugs, or supplies that are not within acceptable medical practice;
  8. PRC review results. As a result of the PRC review, the agency or MCO staff may take any of the following steps:
    1. Determine that no action is needed and close the client's file;
    2. Send the client and, if applicable, the client's authorized representative a one-time only written notice of concern with information on specific findings and notice of potential placement in the PRC program; or
    3. Determine that the usage guidelines for PRC placement establish that the client has used health care services at an amount or frequency that is not medically necessary, in which case one or more of the following actions take place:
      1. The MCO:
        1. Refers the MCO enrollee:
          1. For education on appropriate use of health care services; or
          2. To other support services or agencies; or
        2. Places the MCO enrollee into the PRC program for an initial placement period of no less than 24 months. For MCO enrollees younger than 18 years of age, the MCO must get agency approval before placing the MCO enrollee into the PRC program; or
      2. The agency places the FFS client into the PRC program for an initial placement period of no less than 24 months.
  9. Initial placement in the PRC program.
    1. When an FFS client is initially placed in the PRC program, the agency places the FFS client for no less than 24 months with a primary care provider (PCP) for care coordination and a pharmacy for all medication prescriptions and one or more of the following types of health care providers:
      1. Prescriber of all controlled substances if different than PCP;
      2. Hospital for nonemergency services unless referred by the assigned PCP or a specialist. An FFS client may receive covered emergency services from any hospital; or
      3. Another qualified provider type, as determined by agency program staff on a case-by-case basis; or
      4. Additional pharmacies on a case-by-case basis.
    2. Based on a medical necessity determination, the agency may make an exception to PRC rules when in the best interest of the client. See WAC 182-501-0165 and 182-501-0160.
    3. When an MCO enrollee is initially placed in the PRC program, the MCO restricts the MCO enrollee for no less than 24 months with a primary care provider (PCP) for care coordination and a primary pharmacy for all medication prescriptions and one or more of the following types of health care providers:
      1. Prescriber of controlled substances if different than PCP;
      2. Hospital for nonemergency services unless referred by the assigned PCP or a specialist. An MCO enrollee may receive covered emergency services from any hospital;
      3. Another qualified provider type, as determined by MCO program staff on a case-by-case basis; or
      4. Additional pharmacies on a case-by-case basis.
  10. MCO enrollees changing MCOs. MCO enrollees:
    1. Remain in the same MCO for no less than 12 months for initial placement and whenever the enrollee changes MCOs, unless:
      1. The MCO enrollee moves to a residence outside the MCO's service area and the MCO is not available in the new location;
      2. The MCO enrollee's assigned PCP no longer participates with the MCO and is available in another MCO, and the MCO enrollee wishes to remain with the current provider;
      3. The MCO enrollee is in a voluntary enrollment program or a voluntary enrollment county.
      4. The MCO enrollee is in the address confidentiality program (ACP), indicated by P.O. Box 257, Olympia, WA 98507; or
      5. The MCO enrollee is an American Indian/Alaska native.
    2. Placed in the PRC program must remain in the PRC program for no less than 24 months regardless of whether the MCO enrollee changes MCOs or becomes an FFS client.
  11. Notifying the client about placement in the PRC program. When the client is initially placed in the PRC program, the agency or the MCO sends the client and, if applicable, the client's authorized representative, a written notice that:
    1. Informs the client of the reason for the PRC program placement;
    2. Informs the client of the providers the client has been assigned to;
    3. Directs the client to respond to the agency or MCO to take the following actions if applicable:
      1. Change assigned providers, subject to agency or MCO approval;
      2. Submit additional health care information, justifying the client's use of health care services; or
      3. Request assistance, if needed, from agency or MCO program staff; and
    4. Informs the client of administrative hearing or appeal rights (see subsection (16) of this section).
  12. Selection and role of assigned provider. A client has a limited choice of providers.
    1. The following providers are not available:
      1. A provider who is being reviewed by the agency or licensing authority regarding quality of care;
      2. A provider who has been suspended or disqualified from participating as an agency-enrolled or MCO-contracted provider; or
      3. A provider whose business license is suspended or revoked by the licensing authority.
    2. For a client placed in the PRC program, the assigned:
      1. Provider(s) must be located in the client's local geographic area, in the client's selected MCO, and be reasonably accessible to the client.
        1. PCP supervises and coordinates health care services for the client, including continuity of care and referrals to specialists when necessary.
          (A) The PCP:
          (I) Provides the plan of care for clients that have documented use of the emergency department for a reason that is not deemed to be an emergency medical condition;
          (II) Files the plan of care with each emergency department that the client is using or with the emergency department information exchange;
          (III)Makes referrals to behavioral health treatment for clients who are using the emergency department for behavioral health treatment issues.
        2. (B) The assigned PCP must be one of the following:
          (I) A physician;
          (II) An advanced registered nurse practitioner (ARNP); or
          (III) A licensed physician assistant (PA)
          (iii) Prescriber of controlled substances prescribes all controlled substances for the client;
          (iv) Pharmacy fills all prescriptions for the client; and
          (v) Hospital provides all hospital nonemergency services.
    3. A client placed in the PRC program must remain with the assigned provider for 12 months after the assignments are made, unless:
      1. The client moves to a residence outside the provider's geographic area;
      2. The provider moves out of the client's local geographic area and is no longer reasonably accessible to the client;
      3. The provider refuses to continue to serve the client;
      4. The client did not select the provider. The client may request to change an assigned provider once within 30 calendar days of the assignment;
      5. The MCO enrollee's assigned PCP no longer participates with the MCO. In this case, the MCO enrollee may select a new provider from the list of available providers in the MCO network or follow the assigned provider to the new MCO; or
      6. The client is in the address confidentiality program (ACP), indicated by P.O. Box 257, Olympia, WA 98507.
    4. When an assigned prescribing provider no longer contracts with the agency or the MCO:
      1. All prescriptions from the provider are invalid 30 calendar days following the date the contract ends;
      2. The client must choose or be assigned another provider according to the requirements in this section.
  13. PRC placement.
    1. The initial PRC placement is no less than 24 consecutive months.
    2. The second period of PRC placement is no less than an additional 36 consecutive months.
    3. Each subsequent PRC placement is no less than 72 consecutive months.
  14. Agency or MCO review of a PRC placement period. The agency or MCO reviews a client's use of health care services before the end of each PRC placement period described in subsection (13) of this section using the guidelines in subsection (7) of this section.
    1. The agency or MCO assigns the next PRC placement if the usage guidelines for PRC placement in subsection (7) of this section apply to the client.
    2. When the agency or MCO assigns a subsequent PRC placement, the agency or MCO sends the client and, if applicable, the client's authorized representative, a written notice informing the client:
      1. Of the reason for the subsequent PRC program placement;
      2. Of the length of the subsequent PRC placement;
      3. That the current providers assigned to the client continue to be assigned to the client during the subsequent PRC placement;
      4. That all PRC program rules continue to apply;
      5. Of administrative hearing or appeal rights (see subsection (16) of this section); and
      6. Of the rules that support the decision.
    3. The agency or MCO may remove a client from PRC placement if the client:
      1. Successfully completes a treatment program that is provided by a substance use disorder (SUD) service provider certified by the agency under chapter 182-538D WAC;
      2. Submits documentation of completion of the approved treatment program to the agency; and
      3. Maintains appropriate use of health care services within the usage guidelines described in subsection (7) of this section for six consecutive months after the date the treatment ends; or
      4. Successfully stabilizes due to the usage of treatment medications including, but not limited to, Buprenorphine.
    4. The agency or MCO determines the appropriate placement for a client who has been placed back into the program.
    5. A client remains placed in the PRC program regardless of change in eligibility program type or change in address.
  15. Client financial responsibility. A client placed in the PRC program may be billed by a provider and held financially responsible for nonemergency health care services obtained from a nonpharmacy provider when the provider is not an assigned or appropriately referred provider as described in subsection (12) of this section. See WAC 182-502-0160.
  16. Right to administrative hearing or appeal.
    1. An FFS client who disagrees with an agency decision regarding placement or continued placement in the PRC program has the right to an administrative hearing regarding placement. An FFS client must request an administrative hearing from the agency within 90 days of the written notice of placement or continued placement to exercise this right.
    2. An MCO enrollee who disagrees with an MCO decision regarding placement or continued placement in the PRC program has a right to appeal this decision in the same manner as an adverse benefit determination under chapter 182-538 WAC.
    3. The agency conducts an administrative hearing according to chapter 182-526 WAC.
    4. A client who requests an administrative hearing or appeal within 10 calendar days from the date of the written notice of an initial PRC placement will not be placed in the PRC program until ordered by an administrative law judge (ALJ) or review judge.
    5. A client who requests an administrative hearing or appeal more than 10 calendar days from the date of the written notice of initial PRC placement will remain placed in the PRC program until a final administrative order is entered that orders the client's removal from the program.
    6. A client who requests an administrative hearing or appeal in all other cases and who has already been assigned providers will remain placed in the PRC program unless a final administrative order is entered that orders the client's removal from the program.
    7. An ALJ may rule the client be placed in the PRC program prior to the date the record is closed and before the date the initial order is issued based on a showing of just cause.

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. The agency may receive an administrative hearing request from the individual regarding assignment to PRC. Call HCA at 800-351-6827 or Office of Administrative Hearings at 800-583-8271 regarding PRC administrative hearing requests.
  2. The agency issues the notice to the individual when the individual is assigned to PRC when the medical review indicates the individual overuses medical services or uses medical services inappropriately or unnecessarily as determined by the agency's review of the individual:
    1. Medical records and other documents which indicate the individual's use of medical services meets the criteria in WAC 182-501-0135 (6); and
    2. Diagnoses, the history of services provided or other medical information supplied by the health care provider or managed care plan.
  3. When an individual has been enrolled in more than one managed care plan during the review period, the agency obtains and evaluates the individual's medical records and other documents from all agency-contracted managed care plan(s) in which the individual is or has been enrolled during the review period.
  4. When HCA designates a PCP, pharmacy, hospital or other providers for the individual, HCA inputs the assigned providers into the ProviderOne billing system. Providers have access to this information when they swipe the ProviderOne Services Card or through the benefit inquiry which identifies the individual as an individual in the patient review and coordination program.

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