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

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

Revised March 1, 2025

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

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

Medically needy LTC programs

Revised date

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

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

Effective February 20, 2017

  1. For the purposes of this section only, "remaining income" means all gross nonexcluded income remaining after the post-eligibility calculation under WAC 182-513-1380.
  2. General information. To be eligible for institutional services when living in a medical institution under the SSI-related medically needy (MN) program, a person must:
    1. Meet program requirements under WAC 182-513-1315;
    2. Have gross nonexcluded income in excess of the special income level (SIL) defined under WAC 182-513-1100; and
    3. Meet the financial requirements of subsection (3) or (4) of this section.
  3. Financial eligibility.
    1. The agency or its designee determines a person's resource eligibility, excess resources, and medical expense deductions using WAC 182-513-1350.
    2. The agency or its designee determines a person's countable income by:
      1. Excluding income under WAC 182-513-1340;
      2. Determining available income under WAC 182-513-1325 or 182-513-1330;
      3. Disregarding income under WAC 182-513-1345; and
      4. Deducting medical expenses that were not used to reduce excess resources under WAC 182-513-1350.
  4. Eligibility for agency payment to the facility for institutional services and the MN program.
    1. If a person's remaining income plus excess resources is less than, or equal to, the state-contracted daily rate times the number of days the person has resided in the facility, the person:
      1. Is eligible for agency payment to the facility for institutional services and the MN program; and
      2. Is approved for a twelve-month certification period.
    2. The person must pay income and excess resources towards the cost of care under WAC 182-513-1380.
  5. Eligibility for agency payment to the facility for institutional services and MN spenddown. If a person's remaining income is more than the state-contracted daily rate times the number of days the person has resided in the facility, but less than the private nursing facility rate for the same period, the person:
    1. Is eligible to receive institutional services at the state-contracted rate; and
      1. Is approved for a three-month or six-month base period;
      2. Pays income and excess resources towards the state-contracted cost of care under WAC 182-513-1380; and
    2. Is eligible for the MN program for the same three-month or six-month base period when the total of additional medical expenses incurred during the base period exceeds:
      1. The total remaining income for all months of the base period;
      2. Minus the total state-contracted rate for all months of the base period.
  6. If a person has excess resources and the person's remaining income is more than the state-contracted daily rate times the number of days the person has resided in the facility, the person is not eligible to receive institutional services and the MN program.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

Clarifying information

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

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

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

Worker Responsibilities

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

Please report broken links or content problems.

Non-Grant Medical Assistance (NGMA) examples

Revised date
Purpose statement

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

Example #1: Individual is resource eligible for SSI-related Medicaid, but income exceeds the Substantial Gainful Activity (SGA) test.

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

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

Example #2: Earned income gives an individual the choice between SSI-related Medicaid and HWD if program requirements are met.

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

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

Example #3: An individual on a DDA waiver with earnings over SGA.

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

Please report broken links or content problems.

Healthplanfinder letters

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

Auto generated

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

Status of active is returned for an individual for WAH

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

Auto generated

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

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

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

Auto generated

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

Auto generated

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

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

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

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

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

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

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

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

Auto generated

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

Please report broken links or content problems.

Hardship waivers for long-term care (LTC) services

Revised date
Purpose statement

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

WAC 182-513-1367 Hardship waivers.

WAC 182-513-1367 Hardship waivers.

Effective March 1, 2025

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

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

Agency Responsibilities

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

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

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

Worker Responsibilities

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

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

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

Please report broken links or content problems.

Excess home equity

Revised date
Purpose statement

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

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

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

Effective February 25, 2023

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

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

Clarifying Information

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

Definition of a home:

Federal SSI related Policy Manual

WAC 182-512-0350 SSI related medical

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

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

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

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

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

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

Excess home equity provision is a pass/fail provision

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

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

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

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

How is reverse mortgage line of credit treated?

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

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

Excess home equity and LTC Partnership Rules

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Please report broken links or content problems.

Civil rights and complaints

Revised date
Purpose statement

To describe the civil rights rules, accompanying responsibilities, and how to file a civil rights complaint.

WAC 182-503-0100 Washington apple health -- Rights and responsibilities.

WAC 182-503-0100 Washington apple health -- Rights and responsibilities.

Effective June 3, 2025.

For the purposes of this chapter, "we" refers to the agency or its designee and "you" refers to the applicant for, or recipient of, health care coverage.

  1. If you are applying for or receiving health care coverage, you have the right to:
    1. Have your rights and responsibilities explained to you and given in writing;
    2. Be treated politely and fairly without regard to your race, color, political beliefs, national origin, religion, age, gender (including gender identity and sex stereotyping), sexual orientation, disability, honorably discharged veteran or military status, or birthplace;
    3. Ask for health care coverage using any method listed under WAC 182-503-0005 (if you ask us for a receipt or confirmation, we will provide one to you);
    4. Get help completing your application if you ask for it;
    5. Have an application processed promptly and no later than the timelines described in WAC 182-503-0060;
    6. Have at least ten calendar days to give the agency or its designee information needed to determine eligibility and be given more time if asked for;
    7. Have personal information kept confidential; we may share information with other state and federal agencies for purposes of eligibility and enrollment in Washington apple health;
    8. Get written notice, in most cases, at least ten calendar days before the agency or its designee denies, terminates, or changes coverage;
    9. Ask for an appeal if you disagree with a decision we make. You can also ask a supervisor or administrator to review our decision or action without affecting your right to a fair hearing;
    10. Ask for and get interpreter or translator services at no cost and without delay;
    11. Ask for voter registration assistance;
    12. Refuse to speak to an investigator if we audit your case. You do not have to let an investigator into your home. You may ask the investigator to come back at another time. Such a request will not affect your eligibility for health care coverage;
    13. Get equal access services under WAC 182-503-0120 if you are eligible;
    14. Ask for support enforcement services through the division of child support; and
    15. Refuse to cooperate with us in identifying, using, or collecting third-party benefits (such as medical support) if you fear, and can verify, that your cooperating with us could result in serious physical or emotional harm to you, your children, or a child in your care. Verification may include one of the following:
      1. A statement you sign, outlining your fears and concerns;
      2. Civil or criminal court orders (such as domestic violence protection orders, restraining orders, and no-contact orders);
      3. Medical, police, or court reports; or
      4. Written statement from clergy, friends, relatives, neighbors, or co-workers.
  2. You are responsible to:
    1. Report changes in your household or family circumstances as required under WAC 182-504-0105 and 182-504-0110;
    2. Give us any information or proof needed to determine eligibility. If you have trouble getting proof, we help you get the proof or contact other persons or agencies for it;
    3. Assign the right to medical support as described in WAC 182-503-0540, unless you can submit verification (which may include one of the items listed in subsection (1)(o) of this section) that your cooperating with us could result in serious physical or emotional harm to you, your children, or a child in your care;
    4. Complete renewals when asked;
    5. Give medical providers information needed to bill us for health care services; and
    6. Cooperate with quality assurance or post enrollment review staff when asked.

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

Civil Rights Complaints Filed with the Health Care Authority:

The Investigations and Reasonable Accommodation Unit (IRAU) investigates complaints we receive on discrimination. Someone may file a complaint with the IRAU using one of the toll free numbers below or by sending the complaint to IRAU.

Investigations and Reasonable Accommodation Unit (IRAU)
1115 S. Washington, OB2 2nd Floor NE Wing
PO Box 45839
Olympia, WA 98504-5839

Toll Free 800-521-8060

Toll Free TDD 800-521-8061

Filing A Complaint with the Office of Civil Rights

If you believe that you or someone you care about has been discriminated against by the agency or one of its agents or contractors you may file a complaint with the Office for Civil Rights. You may file a complaint for yourself or for someone else. Access additional information on filing a complaint with the Office of Civil Rights.

Hearings/Judicial Review

If we receive a complaint that a future hearing or judicial review covers, we may tell the person that the hearing or review will resolve the issue.

Equal Access

See WAC 182-503-0120 for information related to Equal Access services.

Limited English Proficient (LEP)

See WAC 182-503-0110 for information related to Limited English Proficient (LEP) services.

Managed Care

See WAC 182-538-0110 for information related to Apple Health Managed Care contractors.

See WAC 388-877-0600 for information related to behavior health care services.

Worker Responsibilities

  1. Explain why we made the decision:
    If someone doesn't like a decision we made or action we took, explain why we took the action and the rules we used to make the decision.
  2. Tell people about their options:
    If someone disagrees with a decision, tell them the options they have to review our decision, including:
    1. How to make a complaint;
    2. Their right to talk to a supervisor; and
    3. Their right to ask for a fair hearing.
  3. Verbal complaints of discrimination:
    If someone verbally complains that they were discriminated against, write down the details of the complaint for them.
  4. When someone wants to make a complaint that he or she was discriminated against:
    1. Help them write down their complaint as needed; and
    2. Get the complaint to the person who supervises the client's worker right away.
  5. Civil rights complaints:
    1. Tell the person that they can file a discrimination complaint directly with the U.S. Department of Health and Human Services, or Regional Manager, Office of Civil Rights, U.S. Department of Health and Human Services, 2201 Sixth Ave. – M/S: RX-11, Seattle, WA 98121-1831 (voice phone 800-368-1019, fax 206-615-2297, TDD 800-537-7697).
    2. Help the person with the complaint as needed.
  6. Discrimination complaints log:
    HCA's MEDS unit must keep a discrimination complaints log. The log must record the following information:
    1. Date of complaint;
    2. Name, address, telephone number, and client ID of the person making the complaint;
    3. Type of complaint (race, color, sex, political beliefs, etc.);
    4. The names, titles, and business addresses of people who may know about the action or decision in the complaint;
    5. How we addressed the complaint and the date we did this; and
    6. A copy of the written response to the complaint.
  7. Mandatory Civil Rights Training:
    Every year, all staff must complete civil rights training. Completion of this training is monitored, and staff receive a reminder if the training is not completed timely.

Please report broken links or content problems.

200 Series reason codes

Revised date
Purpose statement

200 Series Reason Code Protocols

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

On this page: 200-212 | 220-250 | 266-299

200-212

Reason code Reason code description WAC references - Classic Apple Health Free form text - Classic Apple Health WAC references - MAGI-based Apple Health Free form text - MAGI-based Apple Health

200

Noncitizen Medicaid Ineligibility (F-Track Only)

You do not meet the citizenship requirements to receive federal Medicaid. You can get federal Medicaid only after living in the U.S. with legal status for five years or by becoming a naturalized citizen. For information on becoming a naturalized citizen visit the web at USCIS website about Naturalization.

Healthplanfinder (HPF) - Noncitizen Medicaid - lawfully present but not met 5-year bar

You don't meet the citizenship requirements to receive Washington Apple Health. You are ineligible for Medicaid for 5 years from your date of entry to the U.S.

182-503-0505

Need to specify which persons in AU do not meet citizenship requirements.

182-503-0535

  

201

Living Arrangement - Medical Assistance

Due to your living arrangement, we do not consider you a member of the household.

N/A

Your living arrangement does not meet our requirements because (specify relevant requirement and how the individual's living situation does not meet that requirement).

(Note to users: This reason code is based on the valid value entered in the living arrangement field.

182-505-0210

182-505-0240

182-506-0015

182-507-0110

  

202

Citizenship / Alien Status

Immigrant requirements have not been met to receive these benefits.

HPF

You do not meet the citizenship or immigration status requirements for Washington Apple Health.

 

N/A

If client submitted verification of immigration status:

You do not meet the requirements because (specify relevant requirement and how client's immigration status does not meet that requirement).

If client didn't submit verification of status:

We can't determine if you meet our requirements because we do not have verification of your citizenship status.

182-503-0505

182-503-0535

182-505-0115

182-505-0210

182-505-0240

182-505-0250

182-508-0001

  

208

We don't have one of the following:

  • A valid Social Security number (SSN)
  • Proof of a recent application for an SSN

N/A

 

None required

182-505-0115

182-508-0001

182-503-0505

182-503-0515

 None required

209

Failed Refugee Requirement

Refugees and asylees must meet certain requirements to get benefits from this program. You do not meet the requirements. See WAC rule (Washington Administrative Code):

N/A

For refugees:

You entered the United States on 00/00/00. (Specify why this doesn't meet the requirements.)

or

For asylees:

You were granted asylee status on 00/00/00. (Specify why this doesn't meet the requirement.)

182-507-0130

182-507-0135

  

210

 

N/A

You do not meet the residency requirements because (specify client individual facts showing why an individual is not considered a WA resident).

182-503-0505

185-503-0520

182-503-0525

None required

212

HPF

No Relationship

You do not meet the relationship criteria to apply for Washington Apple Health coverage for this individual

    

388-454-0005

388-454-0010

None

Required

220-250

Reason code Reason code description WAC references - Classic Apple Health Free form text - Classic Apple Health WAC references - MAGI-based Apple Health Free form text - MAGI-based Apple Health

220

Failed Age Requirement - Medical

You do not meet the age requirement for this program. See WAC rule (Washington Administrative Code):

 

You must be __ to get benefits from this program.

182-508-0001

182-505-0210

182-505-0211

None required

225

Now Receiving SSI

When you get SSI (Supplemental Security Income) you also get medical benefits from DSHS. You will get a letter telling you about SSI Medical. If you have questions, please call 800-562-3022. See WAC rule (Washington Administrative Code):

HPF

When you get SSI (Supplemental Security Income) you are eligible for health care coverage under the SSI program. You will get a separate letter telling you about SSI Medical.

  

None Required

182-510-0005

None required

230

Verification

You did not give us the information we asked for. We can't figure out if you are eligible without it.

388-472-0005

388-490-0005

 

On 00/00/00, I asked you to provide the following items by 00/00/00: List of items

    

235

Review Not Complete

We did not get your review form. If we get it before the end of the month, we will reconsider our decision. If you have already sent it, let me know. See WAC rule (Washington Administrative Code):

HPF

You have not completed your renewal for Washington Apple Health.

388-434-0005

388-434-0010

388-492-0110

388-492-0100

388-492-0090

388-447-0070

None Required

182-504-0035

None required

244

Death

We were notified that someone passed away. Please accept our condolences for your loss.

HPF

We were notified that someone passed away. Please accept our condolences for your loss.

Washington Apple Health coverage has been closed for this person.

N/A

Specify the person who died.

182-503-0505

None required

245

No Eligible Household Members

No one in your household meets the requirements to get assistance. See WAC rule (Washington Administrative Code):

388-400-0070

388-408-0005

388-408-0015

388-408-0020

388-408-0025

388-408-0035

388-408-0060

388-408-0070

388-492-0030

If no other reason code or letter: No one is eligible because (specify the requirement if not met. If more than one specifies the one that applies to all members or the one that primarily prevented eligibility).

 182-503-0505  

248

HPF

Head of Household Not Eligible

The person listed as the primary applicant on your Washington Apple Health coverage is no longer eligible.

 

 

 182-503-0010  

249

Healthplanfinder

You already received health care coverage from another state this month. You can't get health care coverage from Washington and another state in the same month.

    

182-503-0505

182-505-0210

182-505-0115

182-505-0240

182-503-0520

182-503-0525

None required

250

Not Aged, Blind or Disabled - Medical

You cannot get medical benefits under this program because you do not meet the rules set by the Social Security Administration (SSA). The rules say you must be age 65 or older, blind, or disabled. See WAC rule (Washington Administrative Code):

  

None required

182-508-0001

 None required

266-299

Reason code Reason code description WAC references - Classic Apple Health Free form text - Classic Apple Health WAC references - MAGI-based Apple Health Free form text - MAGI-based Apple Health

266

Noncooperation With TPL

We did not get your form about other coverage for your medical bills. You cannot get medical benefits from DSHS until we have the information. Your children can still get medical assistance. See WAC rule (Washington Administrative Code):

  

None required

182-503-0540

None required

275

No Longer Receiving SSI

You no longer get SSI (Supplemental Security Income).

 

182-510-0005

182-510-0001

None required

 

  

276

DSHS doesn't define your medical condition as an emergency.

 

HPF

No Medical Emergency for AEM

Your medical condition does not meet the emergency medical requirements for Washington Apple Health Alien Emergency Medical coverage.

182-507-0115

182-507-0110

182-507-0120

 

None required

    

279

QMB Start Date - Administrative Use Only

None

None required

    

280

Not Entitled to Medicare Part A

DSHS cannot pay for your Medicare Part B premium because you are not eligible for Medicare Part A. If you have questions about your Medicare coverage, call your Social Security Office. See WAC rule (Washington Administrative Code):

182-517-0300

None required

    

281

Waiver Not Approved

You need an approved plan of care before we can help pay for your care provider. See WAC rule (Washington Administrative Code):

182-515-1505

182-515-1510

182-515-1506

182-515-1511

    

We do not have a plan of care for your type of home or community based (HCB) program).

284

Failed To Meet Spenddown Requirement

You didn't give us enough medical bills to meet your spenddown. You can reapply for medical at any time. See WAC rule (Washington Administrative Code):

182-519-0100

    

None required

288

Ineligible ESLMB Already Receiving MA

You are not eligible for the Qualified Individual (QI-1) Program because you are receiving Medicaid Benefits. You are eligible for the State-funded Buy-In Program. We will pay for your Medicare Part A premiums, if you have any, as well as your Part B premiums, coinsurance, and deductibles. See WAC rule (Washington Administrative Code):

182-517-0300

    

None required

295

Dependent Has Creditable Medical Coverage (CHIP)

Your child/children have other medical coverage. See WAC rule (Washington Administrative Code):

HPF

Your child/children have other creditable medical coverage.

N/A

   182-505-0215

None required

298

AU Stopped Employer Sponsored Health Care Coverage (CHIP)

You stopped your employer sponsored health care coverage for your child/children. If you had a reason for stopping the coverage, contact us at Customer Service Support so we can determine if you meet the Good Cause reason for stopping the coverage.

N/A

   182-505-0215

None required

299

Premiums Not Paid (CHIP)

You are losing CHIP coverage because you have not paid the premiums for 4 months or more. To keep CHIP, your past due premium must be paid before the ending date listed above. Mail your payment to the Office of Financial Recovery, PO Box 3951, Olympia, WA 98503. See WAC rule (Washington Administrative Code):

N/A

   182-505-0215

None required

Please report broken links or content problems.

Roads to Community Living

Revised date
Purpose statement

To explain a long-term services and supports (LTSS) program called Roads to Community Living (RCL). RCL is for individuals who have been in a medical institution and may be able to live in the community if the additional services offered under RCL are provided. These services are provided either when the individual is in a medical institution or after they have been discharged.

WAC 182-513-1235 Roads to Community Living (RCL)

WAC 182-513-1235 Roads to Community Living (RCL).

Effective December 3, 2025

  1. Roads to community living (RCL) is a demonstration project authorized under Section 6071 of the Deficit Reduction Act of 2005 (P.L. 109-171) and extended through the Patient Protection and Affordable Care Act (P.L. 111-148).
  2. Program rules governing functional eligibility for RCL are described in WAC 388-106-0250 through 388-106-0265. RCL services are authorized by the department.
  3. A person must have a stay of at least 60 consecutive days in a qualified institutional setting such as a hospital, nursing home, or residential habilitation center, to be eligible for RCL. The 60-day count excludes days paid solely by medicare, must include at least one day of medicaid paid inpatient services immediately prior to discharge, and the person must be eligible to receive any categorically needy (CN), medically needy (MN), or alternate benefit plan (ABP) medicaid program on the day of discharge. In addition to meeting the 60-day criteria, a person who is being discharged from a state psychiatric hospital must be under age 22 or over age 64.
  4. Once a person is discharged to home or to a residential setting under RCL, the person remains continuously eligible for medical coverage for 365 days unless the person:
    1. Returns to an institution for thirty days or longer;
    2. Is incarcerated in a public jail or prison;
    3. No longer wants RCL services;
    4. Moves out-of-state; or
    5. Dies.
  5. Changes in income or resources during the continuous eligibility period do not affect eligibility for RCL services. Changes in income or deductions may affect the amount a person must pay toward the cost of care.
  6. A person approved for RCL is not subject to transfer of asset provisions under WAC 182-513-1363 during the continuous eligibility period, but transfer penalties may apply if the person needs HCB waiver or institutional services once the continuous eligibility period has ended.
  7. A person who is not otherwise eligible for a noninstitutional medical program must have eligibility determined using the same rules used to determine eligibility for HCB waivers. If HCB rules are used to establish eligibility, the person must pay participation toward the cost of RCL services. HCB waiver eligibility and cost of care calculations are under:
    1. WAC 182-515-1508 and 182-515-1509 for home and community services (HCS); and
    2. WAC 182-515-1513 and 182-515-1514 for development disabilities community services (DDCS).
  8. At the end of the continuous eligibility period, the agency or its designee redetermines a person's eligibility for other programs under WAC 182-504-0125.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

Clarifying Information.

WAC 182-513-1200 describes Long-term services and supports (LTSS).

What is RCL?

RCL is a demonstration project funded by the "Money Follows the Person" grant. The grant was received by Washington State from the federal Centers for Medicare and Medicaid Services (CMS). The purpose of the RCL demonstration project is to investigate what services and supports will successfully help people with complex, long-term care needs transition from institutional to community settings.

Who is eligible for the RCL project?

  • People of any age with a stay of at least 60 consecutive days or longer in a qualified medical institutional setting; or
  • Individuals in psychiatric hospitals with a stay of at least 60 consecutive days or longer who are under age 22 or over age 64. AND each of the following:
    • Receiving Medicaid-paid inpatient services immediately prior to discharge;
    • Interest in moving to a qualified community setting (home, apartment, licensed residential setting with 4 or less unrelated individuals at the time of placement);
    • On the day of discharge to begin the demonstration year, RCL participants must be functionally and financially eligible for, but are not required to receive, waiver or state plan services;
    • On the day of discharge, must be Medicaid eligible. If Medicaid is opened and it is subsequently discovered that the client was not eligible for Medicaid prior to the discharge from the institution, the Medicaid and RCL services may close. Examples of this are unreported resources or transfer of assets that would have caused a transfer penalty of ineligibility for long term care services, or it was determined the client is not a citizen.
  • How long are participants eligible for RCL services?
    • Participants are entitled to continued medical coverage through the end of the month of the 365 days following their discharge date. This is called continuous medical eligibility.
    • The clock on demonstration period services stops if a participant needs to be re-institutionalized for greater than 30 days. The social worker/case manager will inform the Public Benefit Specialist (PBS) of the new 365-day period if it has changed.
    • Participants are not to be reassessed for financial Medicaid eligibility until the end of their 365-day demonstration period.
    • In order to receive Medicaid beyond the 365 period, a participant must be determined eligible to receive medical by the PBS.

More about Medicaid eligibility during the demonstration period

RCL participants remain eligible for Medicaid during the demonstration period regardless of any changes in financial circumstances, including:

  • Acquisition of resources or income above program standards
  • Transfers of assets if this occurs after the discharge from the medical institution. If a transfer of asset is discovered that would have made a participant ineligible for Medicaid on the day of discharge, RCL and the Medicaid would be closed.

Financial eligibility will be reviewed at the end of the demonstration period. Clients must meet eligibility requirements for a medical/long-term care program at that time to continue to receive them after the 365-day period.

Worker Responsibilities

You will be notified by an HCS or DDA case manager that a client has been discharged from the medical facility to the RCL program.

HCS social workers use the DSHS 14-443 Financial/Social Service Communication via Barcode.

DDA case managers use the DSHS 15-345 CSO/DDA Communication via Barcode.

Change the Medicaid program

Most of the RCL clients will be receiving an institutional medical under L02. For most cases, you will change the ACES medical coverage group to RCL eligibility under L42 (L41 for an SSI recipient). The HCBS code for RCL is R.

RCL service lets you enter a future end date. This tells ACES to "push" the certification period to the end of the month of the RCL demonstration period. If the entered RCL Authorization end date is prior to the certification period end date, ACES will not "pull" the certification period back and the AU will eventually close for 281 - no waiver in the month of RCL ending.

The case manager/social worker will notify the PBS if there has been a change in the 365 days by submitting a 14-443 or 15-345 with a new ending date.

What if the client is on the Modified Adjusted Gross Income (MAGI) program in the medical facility?

MAGI clients, with the exception of N21 and N25 are eligible for RCL services. DSHS PBS are unable to issue RCL letters or make any changes on a MAGI case as these cases are maintained by the Health Benefit Exchange/Health Care Authority (HCA).

Note:

The Expanded Apple Health program for non-citizens will be implemented on 7/1/24 using MAGI N20. This state program does not include LTSS therefore those on the N20 program can't receive RCL services.

What if the RCL client initially declines personal care services upon discharge?

The case manager/social worker will notify the PBS if the client has initially declined services upon discharge based on LTC chapter 29. PBS will add freeform text to the ACES award letter: If you choose to receive ongoing RCL services through your 365-day period, the amounts listed as total responsibility toward the cost of care will be your contribution to your provider. (Up to the cost of the actual services).

Example: RCL clients can start receiving services prior to the discharge from the medical institution. An example of this is a person who assists the client (called a Community Choice Guide) to find housing before they are discharged. Upon discharge, the client may choose not to have personal care services during the 365 days. The social worker/case manager will inform the PBS that the client is discharged under RCL and is declining ongoing services.

Provide continuous eligibility throughout the demonstration period

A change in financial circumstances that would ordinarily cause closure of the Medicaid assistance unit does not affect Medicaid eligibility for RCL clients. This only applies to Medicaid eligibility. The continuous eligibility guarantee does not apply to cash, food, state-funded medical or Medicare Savings programs.

If a change occurs during the demonstration period which may cause ineligibility at review, advise the client and the case manager that the change may affect eligibility after the demonstration period ends.

Are there any exceptions to continuous eligibility?

Yes. The only exceptions are:

  • Citizenship
  • Moving out of state
  • incarceration for 30 days or more
  • death
  • It is determined the client was not eligible for Medicaid on the day of discharge. An example of this is an unreported resource, a transfer of asset that occurred within the 5-year look-back, individual determined not to be a citizen or have a valid Social Security number.

What if there is mail return?

If mail is returned, see if a forwarding address is provided.

  • If one is provided, update the address. No further action is necessary.
  • If one is not provided, the PBS will attempt to call the client via the phone number or inquire with the case manager as to the current address.
  • If the PBS is still unable to determine where the client is, terminate the medical for loss of contact/whereabouts unknown. Advance notice is not necessary.
  • If the client provides an updated Washington address at any time during the original 365-day period, the assistance unit is reinstated from the month of termination through the end of the original 365-day certification period. A new application is not necessary.

Determine the client's cost of care

Depending on the client’s income amount, clients receiving RCL services may have to participate toward the cost of room and board and personal care in an alternate living facility (ALF) or for personal care costs in their own homes. Rules for determining the amount the client is responsible for are in WACs 182-515-1505 for HCS clients and 182-515-1510 for DDA clients.

What happens at the end of the 365-day period?

For non-SSI clients an eligibility review will be sent to the client and/or the client's representative for the annual review. After the 365-day period, a redetermination must be made. The client must meet income and resource eligibility under the HCS or DDA Waiver.

In addition to the financial eligibility, functional criteria for the HCS or DDA Waiver must be met. This must be confirmed by the current case manager.

Coordination with the agency case managing the service is important. If the client is no longer eligible under financial rules for another LTSS program or eligible for a non institutional CN Medicaid program, the PBS will need to notify the case manager to close services on day 366 or as soon as possible once the review is completed. During the redetermination period, keep the Medicaid open even if it goes beyond 365 days unless we know the client is not eligible for any other Medicaid program.

If the client is eligible for a non institutional categorically needy Medicaid program, Medicaid Personal Care (MPC) can be considered.

NOTE: During the 365-day period after discharge from the medical institution, Medicaid is continued. A reconsideration is done for Medicaid eligibility beyond the 365 day period.

The agency authorizing services will communicate to the PBS by the 365th day.

This communication should include what services, if any, will be authorized beyond the 365th day (either CFC or Waiver services).

For MPC, a client would need to be eligible for a non-institutional Medicaid program.

If services are not authorized by HCS or DDA, redetermine Medicaid eligibility using non-institutional Medicaid rules.

What happens if a client receiving RCL returns to a medical institution during the 365-day period?

If the RCL client returns to a medical institution for a short stay (under 30 days), treat the case like any other short stay. Keep the case active on the current Medicaid program active in the community and issue the medical facility an award letter using the short stay screen.

If the RCL client returns to a medical institution and the placement is projected for over 30 days, the case will need to be changed back to the institutional program (L01 for SSI, L02, L95 track for SSI related, K track for children).

  • Make sure the eligibility review is pulled back in ACES to reflect the month that is one year later than the last review was completed.
  • If it has been over a year since a review has been completed, do the program change and pull the eligibility review to the last review while a redetermination is being made.
    • Send a new eligibility review for completion.
    • Set a Barcode tickler to check the status.
    • Keep the Medicaid case open while doing a redetermination of eligibility.
  • Once a client is no longer in the RCL program, they must meet the income and resource eligibility for institutional medical.

It is possible that a client will be reenrolled in the RCL program again as part of discharge planning. If a client is placed back into the community under the RCL program, they are reenrolled in RCL for what remains of their 365 days. If the original 365-day end date has been changed, the social worker or case manager will notify the PBS.

Can clients who have previously completed their 365-day demonstration project reenroll in RCL? If so, how?

Yes, clients who are reinstitutionalized after their 365-day demonstration period is over may be reenrolled in RCL if the need is clearly stated and the new plan of care has been reviewed. The purpose of reenrollment planning is to ensure that a thorough look is taken at why the original plan did not result in long term successful community placement, and to outline how the new plan addresses the identified gaps.

If the client has been subsequently reinstitutionalized for at least 60 consecutive qualified days, he/she/they may be reenrolled in RCL for another 365-day demonstration period using the following process. All processes outlined above apply for the 2nd enrollment.

How can the PBS tell if it is an RCL case?

  • The client will be active on an L41 if SSI or an L42 if SSI-related.
  • The PBS will indicate in the narrative and remark behind the institutional screen the client was approved for Roads to Community Living (RCL).

Please report broken links or content problems.

Apple Health for Refugees

Revised date
Purpose statement

To describe the program rules for the Refugee Medical Program (RMA).

WAC 182-507-0130 Refugee medical assistance (RMA).

WAC 182-507-0130 Refugee medical assistance (RMA)

Effective September 6, 2025

  1. You are eligible for refugee medical assistance (RMA) if all the following conditions are met. You:
    1. Meet immigration status requirements of WAC 182-507-0135;
    2. Have countable resources below $2,000 on the date of application;
    3. Have countable income equal to or below 200 percent of the federal poverty level (FPL) on the date of application.  The following income is not considered when determining eligibility for RMA:
      1. Resettlement cash payments made by a resettlement agency;
      2. Income of a sponsor is not counted unless the sponsor is also part of your assistance unit; and 
      3. Income received after the date of application.
    4. Provide the name of the resettlement agency which helped bring you to the United States so that the department of social and health services (DSHS) can promptly notify the resettlement agency (or sponsor) about the medical application.
  2. If you receive refugee cash assistance (RCA) you are eligible for RMA if you have countable resources below $2,000 on the date of application and you are not otherwise eligible for another medicaid or a children's health care program as described in WAC 182-505-0210. You do not have to apply for or receive RCA in order to qualify for RMA.
  3. You are not eligible to receive RMA if you are:
    1. Already eligible for another medicaid or a children's health care program as described in WAC 182-505-0210;
    2. A full-time student in an institution of higher education unless the educational activity is part of a DSHS-approved individual responsibility plan (IRP); or
    3. A nonrefugee spouse of a refugee.
  4. If approved for RMA, the agency or its designee issue an approval letter in both English and your primary language. The agency or its designee also sends a notice every time there are any changes or actions taken which affect your eligibility for RMA.
  5. You may be eligible for RMA coverage of medical expenses incurred during the three months prior to the first day of the month of the application. Eligibility determination will be made according to medicaid rules.
  6. If you are a victim of human trafficking you must provide the following documentation and meet the eligibility requirements in subsections (1) and (2) of this section to be eligible for RMA:
    1. Adults, 18 years of age or older, must provide the original certification letter from the United States Department of Health and Human Services (DHHS). No other documentation is needed. The eligibility period will be determined based on the entry date on your certification letter;
    2. A child victim under the age of 18 does not need to be certified. DHHS issues a special letter for children. Children also have to meet income eligibility requirements;
    3. A family member of a certified victim of human trafficking must have a T-2, T-3, T-4, T-5 or T-6 visa (derivative T-Visas), and the family member must meet eligibility requirements in subsections (1) and (2) of this section.
  7. The entry date for an asylee is the date that asylum status is granted. For example, you entered the United States on December 1, 1999, as a tourist, then applied for asylum on April 1, 2000, interviewed with the asylum office on July 1, 2000, and were granted asylum on September 1, 2000. The date of entry is September 1, 2000, and that is the date used to establish eligibility for RMA.
  8. RMA certification period.
    1. (a) RMA ends on either:
      1. The last day of the eighth month from the month the person entered the United States if they entered the United States on or before September 30, 2021. For example, if they entered the United States on September 30, 2021, they are eligible through April 30, 2022;
      2. The last day of the 12th month from the month the person entered the United States if they entered the United States on or after October 1, 2021, through May 4, 2025. For example, if they entered the United States on October 25, 2021, they are eligible through September 30, 2022; or
      3. The last day of the fourth month from the month the person entered the United States if they entered the United States on or after May 5, 2025. For example, if they entered the United States on June 20, 2025, they are eligible through September 30, 2025.
    2. The number of months you may receive RMA benefits could change if the federal Office of Refugee Resettlement changes the eligibility period.
  9. If you are approved for RMA you are continuously eligible through the end of the initial RMA certification period, regardless of an increase in income.
  10. The agency, or its designee, determines eligibility for medicaid and other medical programs for your spouse when the spouse arrives in the United States. If the spouse is not eligible for medicaid due to your countable income, the spouse is still eligible for RMA under subsection (8) of this section.
  11. If you disagree with a decision or action taken on the case by the agency, or its designee, you have the right to request a review of the case action(s) or request an administrative hearing (see chapter 182-526 WAC). The request must be received by the agency, or its designee, within 90 days of the date of the decision or action.

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 182-507-0135 Immigration status requirement for refugee medical assistance (RMA).

WAC 182-507-0135 Immigration status requirement for refugee medical assistance (RMA).

Effective November 24, 2024

  1. An individual is eligible for refugee medical assistance (RMA) if the individual provides documentation issued by the United States Citizenship and Immigration Services (USCIS) to show that the individual is:
    1. Admitted as a refugee under section 207 of the Immigration and Nationalities Act (INA);
    2. Paroled into the United States as a refugee or asylee under section 212 (d)(5) of the INA;
    3. Granted conditional entry under section 203 (a)(7) of the INA;
    4. Granted asylum under section 208 of the INA;
    5. Admitted as an Amerasian immigrant from Vietnam through the orderly departure program, under section 584 of the Foreign Operations Appropriations Act, incorporated in the FY88 continuing resolution P.L. 100-212;
    6. A Cuban-Haitian entrant who was admitted as a public interest parolee under section 212 (d)(5) of the INA;
    7. Certified as a victim of human trafficking by the federal Office of Refugee Resettlement (ORR);
    8. An eligible family member of a victim of human trafficking certified by ORR who has a T-2, T-3, T-4, or T-5 visa; 
    9. Admitted as special immigrant from Iraq or Afghanistan under one of the following:
      1. Special immigrant status under section 101 (a) (27) of the INA;
      2. Special immigrant conditional permanent resident; or 
      3. Parole under section 602 (b) (1) of the Afghan Allies Protection Act of 2009 or section 1059 (a) of the National Defense Authorization Act of 2006;
    10. An Afghan granted humanitarian parole between July 31, 2021, and September 30, 2023, their spouse or child, or a parent or guardian of an unaccompanied minor who is granted parole after September 30, 2022 under section 2502 of the Extending Government Funding and Delivering Emergency Assistance Act of 2021; or
    11.  A citizen or national of Ukraine (or a person who last habitually resided in Ukraine) who, under section 401 of the Additional Ukrainian Supplemental Appropriations Act, 2022 (AUSAA) and the Ukraine Security Supplemental Appropriations Act, 2024 (USSAA), is evaluated as a qualified alien when:
      1. Granted parole into the United States between February 24, 2022, and September 30, 2024; or
      2. Granted parole into the United States after September 30, 2024, and is:
        1. The spouse or child of a person described in (k)(i) of this subsection; or
        2. The parent, legal guardian or primary caregiver of a person described in (k)(i) of this subsection who is determined to be an unaccompanied child under section 462 (g) (2) of the Homeland Security Act of 2002 or section 412 (d) (2) (B) of the Immigration and Nationality Act. 
  2. A permanent resident alien meets the immigration status requirements for RCA and RMA if the individual was previously in one of the statuses described 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.

Clarifying information

  • Refugees and other humanitarian immigrants as described in WAC 182-507-0135 may be eligible for RMA if they are not eligible for Apple Health (Medicaid).
  • RMA eligibility is established based on an applicant's income and resources on the date of the application, rather than averaging income over the application processing period.
    • Income received after the date of application for RMA is not considered when determining eligibility for RMA.
  • A student enrolled in an institution of higher education and carrying a full-time academic workload is considered a full-time student. A full-time student is eligible for RMA only if educational activity is a part of their WorkFirst personal employment plan.

For an overview of citizenship and immigration status eligibility rules, see the Citizenship and Immigration Status Guide.

Worker responsibilities

Applicants under age 65

For applicants as described in WAC 182-507-0135 who are under age 65, HCA determines eligibility for modified adjusted gross income (MAGI)-based Apple Health programs first.

  • Applications for medical assistance should be submitted through Healthplanfinder. If you experience an issue when submitting the application, complete a paper application and email it to HCA WAHRMA apps​ and include:
    • Primary applicant name
    • Healthplanfinder app ID
    • Managed care organization (MCO) plan selection (optional)
    • Error code (if any)

If an applicant is not eligible for MAGI-based Apple Health or they become ineligible during the certification period, HCA will determine eligibility for refugee medical assistance.

Applicants over age 65

DSHS determines eligibility for medical assistance for clients over age 65 who are refugees or have other eligible immigration statuses.

For applicants age 65 or older, with blindness or disability, as described in WAC 182-507-0135, complete applications:

  • In person at a local DSHS CSO.
  • Online at Washington Connection.
  • Faxed to CSD at 1-888-338-7410.
  • Mailed to DSHS - CSD Customer Service Center, PO Box 11699, Tacoma WA 98411-6699.

View a list of refugee resettlement agencies in Washington State.

Please report broken links or content problems.

Subscribe to