Care Delivery - managed care

Revised date
Purpose statement

To explain managed care and provide a link to the various services.

WAC 182-538-060 Managed care choice and assignment

WAC 182-538-060 Managed care choice and assignment.

Effective October 25, 2020

  1. The medicaid agency requires a client to enroll in integrated managed care (IMC) when that client:
    1. Is eligible for one of the Washington apple health programs for which enrollment is mandatory;
    2. Resides in an area where enrollment is mandatory; and
    3. Is not exempt from IMC enrollment and the agency has not ended the client's managed care enrollment, consistent with WAC 182-538-130.
  2. American Indian and Alaska native (AI/AN) clients and their descendants may choose one of the following:
    1. Enrollment with a managed care organization (MCO) available in their regional service area;
    2. Enrollment with a PCCM provider through a tribal clinic or urban Indian center available in their area; or
    3. The agency's fee-for-service system for physical health or behavioral health or both.
  3. To enroll with an MCO or PCCM provider, a client may:
    1. Enroll online via the Washington Healthplanfinder at https://www.wahealthplanfinder.org ;
    2. Call the agency's toll-free enrollment line at 800-562-3022; or
    3. Go to the ProviderOne client portal at https://www.waproviderone.org/client and follow the instructions.
  4. An enrollee in IMC must enroll with an MCO available in the regional service area where the enrollee resides.
  5. All family members will be enrolled with the same MCO, except family members of an enrollee placed in the patient review and coordination (PRC) program under WAC 182-501-0135 need not enroll in the same MCO as the family member placed in the PRC program.
  6. An enrollee may be placed into the PRC program by the MCO or the agency. An enrollee placed in the PRC program must follow the enrollment requirements of the program as stated in WAC 182-501-0135.
  7. When a client requests enrollment with an MCO or PCCM provider, the agency enrolls a client effective the earliest possible date given the requirements of the agency's enrollment system.
  8. The agency assigns a client who does not choose an MCO or PCCM provider as follows:
    1. If the client was enrolled with an MCO or PCCM provider within the previous six months, the client is reenrolled with the same MCO or PCCM provider;
    2. If (a) of this subsection does not apply and the client has a family member enrolled with an MCO, the client is enrolled with that MCO;
    3. The client is reenrolled within the previous six months with their prior MCO plan if:
      1. The agency identifies the prior MCO and the program is available; and
      2. The client does not have a family member enrolled with an agency-contracted MCO or PCCM provider.
    4. If the client has a break in eligibility of less than two months, the client will be automatically reenrolled with his or her previous MCO or PCCM provider and no notice will be sent; or
    5. If the client cannot be assigned according to (a), (b), (c), or (d) of this subsection, the agency:
      1. Assigns the client according to agency policy, or this rule, or both;
      2. Does not assign clients to any MCO that has a total statewide market share of forty percent or more of clients who are enrolled in apple health IMC. On a quarterly basis, the agency reviews enrollment data to determine each MCO's statewide market share in apple health IMC;
      3. Applies performance measures associated with increasing or reducing assignment consistent with this rule and agency policy or its contracts with MCOs.
    6. If the client cannot be assigned according to (a) or (b) of this subsection, the agency assigns the client as follows:
      1. If a client who is not AI/AN does not choose an MCO, the agency assigns the client to an MCO available in the area where the client resides. The MCO is responsible for primary care provider (PCP) choice and assignment.
      2. For clients who are newly eligible or who have had a break in eligibility of more than six months, the agency sends a written notice to each household of one or more clients who are assigned to an MCO. The assigned client has ten calendar days to contact the agency to change the MCO assignment before enrollment is effective. The notice includes:
        1. The agency's toll-free number;
        2. The toll-free number and name of the MCO to which each client has been assigned;
        3. The effective date of enrollment; and
        4. The date by which the client must respond in order to change the assignment.
  9. An MCO enrollee's selection of a PCP or assignment to a PCP occurs as follows:
    1. An MCO enrollee may choose:
      1. A PCP or clinic that is in the enrollee's MCO and accepting new enrollees; or
      2. A different PCP or clinic participating with the enrollee's MCO for different family members.
    2. The MCO assigns a PCP or clinic that meets the access standards set forth in the relevant managed care contract if the enrollee does not choose a PCP or clinic.
    3. An MCO enrollee may change PCPs or clinics in an MCO for any reason, with the change becoming effective no later than the beginning of the month following the enrollee's request.
    4. An MCO enrollee may file a grievance with the MCO if the MCO does not approve an enrollee's request to change PCPs or clinics.
    5. MCO enrollees required to participate in the agency's PRC program may be limited in their right to change PCPs (see WAC 182-501-0135).

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

Note: Information on managed care service areas including how to change plans can be found on the HCA Managed Care website.

182-538 Chapters

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Allowable practitioners

Revised date

The following are a list of allowable practitioners for Classic (non-MAGI) Medicaid.

  • ARNP Advanced Registered Nurse Practitioner
  • CRN Certified Registered Nurse
  • D.C. Chiropractor
  • D.D.S. Dentist, Denturist, Orthodontist, Periodontist
  • D.O. Osteopath
  • D.P.M. Podiatrist
  • Dental Hygienist
  • Electrotherapist
  • Hydro therapist
  • Inhalation/Respiratory Therapist
  • LPN Licensed Practical Nurse
  • M.D. Physician
  • Midwife
  • Naturopath
  • O.D. Optometrist
  • Occupational therapist
  • Optician
  • P.A. Physician Assistant
  • Pharmacist
  • Psychologist/Psychiatrist
  • Speech therapist
  • X-ray Technician

Allowable practitioners, with a documented referral from an M.D., D.O., D.D.S., or ARNP

  • Acupuncturist
  • Dietician

Practitioners not allowable

  • Herbalist
  • Homeopath
  • Holistic Healer
  • Hypnotist
  • Masseur or Manipulator
  • Psychic or Faith Healer
  • Sanipractor
  • Veterinarian
  • Practitioners not recognized under Washington State law

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Managed care and long-term care

Revised date
Purpose statement

The Washington Apple Health (AH) managed care organization (MCO) plan is responsible to pay for nursing facility (NF) days that are qualifying rehabilitative and skilled nursing services. Long-term care nursing facility services (sometimes called custodial care or long term care) is paid by Aging and Long Term Supports Administration (ALTSA) as a fee for service once AH MCO coverage days end. This section gives instructions for the Public Benefit Specialist (PBS) when a client enrolled into AH MCO admits into a NF.

Program of all-inclusive care for the elderly (PACE) information.

Note: The instructions below are intended for Home and Community Service (HCS) and Developmental Disability Administration (DDA) LTC specialty Public Benefit Specialists. This section includes information for HCS and DDA social workers and case managers.

HCS and DDA do not determine medicaid eligibility for clients on a MAGI based medical programs (N track in ACES). The eligibility is done through the Health Benefit Exchange (HBE).

The HCS and DDA financial worker determines eligibility for SSI-related Aged, Blind, Disabled medicaid which includes Community First Choice (CFC), Institutional, and Home and Community Based (HCB) Waiver medical programs.

Consult the Overview - Long-term and Supports chart.

What are rehabilitative services or skilled nursing services?

Rehabilitative services can last for a few days to several weeks as long as a physician determines a client is in need and is responding to rehabilitation.

During rehabilitation days and skilled nursing days in a NF when the client has AH managed care, the client does not pay participation toward the cost of care. The AH MCO plan is responsible to pay the NF for qualified skilled nursing and rehabilitation days. Clients that are near the Medicaid resource limit, may need to be monitored by the Public Benefit Specialist (PBS). This is the same process as a Medicare/Medicaid client receiving NF services under Medicare.

Once the MCO deems the stay is no longer medically necessary and not covered by the plan, the NF needs to notify the Public Benefit Specialist via the DSHS 15-031 notice of action and request a social service intake as ALTSA is responsible to determine NFLOC in order to authorize the payment for the services once AH MCO coverage ends and coverage as a long-term care service begin.

What are long-term care services in a NF?

Long-term care services in a NF are when an individual does not meet the criteria for skilled nursing or rehabilitation. Most long-term care assists people with support services, (Sometimes this is called custodial care). The correct term is long term care or institutional services.

The AH MCO contract does not cover custodial long-term care services in a nursing facility. Long-term care services in a NF are approved by Home and Community Services (HCS) for medicaid eligible clients that meet nursing facility level of care (NFLOC). Medicaid eligibility for individuals needing long-term care services over 29 days is described in WAC 182-513-1315.

Who is enrolled in a Washington Apple Health (AH) Managed Care Organization (MCO)?

All categorically needy (CN) and alternate benefit plan (ABP) medicaid clients are enrolled or may be enrolled into an AH MC plan. There are some exceptions such as:

  • Individuals on Medicare
  • Individuals with an approved HCA exemption requested by the client due to tribal status.

Note: A medical benefit covered under the AH MCO plan or the fee for service (FFS) medicaid program is a covered service. If an AH MCO client chooses to go outside the MCO network without MCO approval for a covered medical service, the client will be responsible to pay out-of-pocket. This cost is not allowed to reduce participation because it is medical care covered under the state's Medicaid plan. See WAC 182-513-1350 and Allowable medical expenses.

Note: All Apple Health medicaid clients including those on Medicare are enrolled in a behavioral health MCO for coverage of behavioral health services.

Nursing Home admissions under a Modified Adjusted Gross Income (MAGI) Medical group

The instructions for financial workers below are limited to individuals on SSI-related (Aged, Blind and Disabled) Medicaid programs.

Individuals active on a MAGI-based program determined by the Health Benefit Exchange (HBE) are eligible to receive nursing facility services as part of the state plan or alternate benefit plan (ABP). The only exception is the AEM MAGI programs called N21 and N25 in ACES. AEM does not cover NF care.

The AH MCO plan is responsible to pay for rehabilitation and skilled nursing in a NF. Once rehabilitation ends, the NF is paid by Provider One as a claim.

No NF award letter is issued for a client receiving N track MAGI based medical.

No participation is paid to the NF provider for MAGI based clients.

How does a client change a Washington Apple Health Managed Care plan?

A client can choose to change plans by contacting Health Care Authority (HCA) by the Provider One portal or calling 1-800-562-3022.

Any issues regarding coverage needs to be addressed directly to the plans. For a complete list of current plans, see Apple Health Managed Care Medical Programs

How do I check to see if a Medicaid client is currently on an Apple Health (AH) managed care MCO plan?

ACES online has current real time data from Provider One on managed care. ACES online does not show historical data on any changes that have occurred in AH MCO such as change in an AH MCO plan, exemption data, enrollment/discharge dates.

To see the current AH MCO status, go to ACES online and check the details tab. Scroll down to "Medical Information" section. Check to see if one of the AH MCO plans is indicated.

Nursing Facility providers check for AH MCO plans searching in the client benefit inquiry under managed care information. If the client is on AH MCO, it will show up under Plan/PCCM Name.

When are long-term care clients disenrolled from Washington Apple Health (AH) Managed Care Organization (MCO) plan?

Developmental Disabilities Administration (DDA) RHC clients are disenrolled from AH MCO once they are in the institution over 29 days. The AH MCO plan does not cover services in a DDA state institution.

Once the client is disenrolled from AH MCO, they are considered a "fee for service" (FFS) client.

Note: The AH MCO plans do not cover long term services and supports (LTSS) for clients living in the community or residential settings. These services are not included in the AH MCO contract and considered a "carve out". In home care or residential services are authorized by either Home and Community Services (HCS) or the Developmental Disabilities Administration (DDA). AH MCO clients receiving services authorized by DDA or HCS get their prescription drugs, durable medical equipment, physician services and other medical services through their AH MCO plan.

Public Benefit Specialist responsibilities

  • If the NF admission is a AH MCO client, do a barcode tickler for 30 days from the date of admission to check the status.
    Submit a 65-10 referral through barcode to social service for a NFLOC determination. Even though it is not required for AH MCO rehabilitation days, it is required to generate a NF award letter when doing a program change once a client is institutionalized 30 days or more.

Short Stays

  • Do not issue a short stay letter for an AH MCO client unless the NF has submitted a DSHS 15-031 indicating rehabilitation days or skilled nursing days through the AH MCO plan has ended with an end date.
  • If the admission is under 30 days, and rehabilitation days has ended, indicate the day after the rehabilitation end date as the authorization date on the STAY screen. Add text to the short stay letter AH MCO rehabilitation day ends on XX-XX-19XX (enter date).
  • A confirmation of NFLOC is required by the HCS SW before a short stay letter is issued.
  • Most short stay NF admissions are considered rehabilitation. If the entire short stay is under AH MCO rehabilitation or skilled nursing status, do not issue a short stay letter.
  • Indicate in the ACES narrative "AH MCO Rehab Admit" with the date.

See Short stay information for NF admissions not under AH MCO

30 days or more admissions

  • Once a classic aged, blind, disabled (ABD) AH MCO client is in a NF 30 days or more, make the necessary changes in the ACES system.
  • The authorization date on the INST for a recipient is normally the first date DSHS was notified of the admission. If the PBS has information from the NF via DSHS 15-031 NOA that the rehabilitation days have ended, indicate the day after the rehab end date as the authorization date on the INST screen.
  • ACES will issue an award letter even though the client may still be receiving rehabilitative services under the AH MCO . Indicate in the text of the award letter "Washington Apple Health Managed Care Rehabilitation Admission".
  • During rehabilitation days paid by the AH MCO, the client does not participate toward the cost of care. If the client is close to the resource limit, monitor the resources with the same process used as Medicare days in the NF.
  • Indicate in the ACES narrative "AH Managed Care rehab admit" and the date, if the NF reports AH MCO rehabilitation ends, indicate AH MCO rehab end date.

Example: Short Stay #1

S02/SSI related client, not on Medicare admits to a NF on 11/5/2016. 15-031 NOA from NF indicates the 11/5/2016 admission under AH MCO rehabilitation. A 2nd NOA from the NF indicates a discharge date of 11/20/2016 back home. In this example, a short stay letter is not needed. A NFLOC determination from the HCS SW is not needed. The NF admission is covered by the AH MCO. Added CFC to note.

Example: Short Stay #2

S02/SSI related client, on Medicare admits to a NF on 11/5/2016. 15-031 NOA from NF indicates the 11/5/2016 admission date. A 2nd NOA from the NF indicates a discharge date of 11/20/2016 back home. In this example, the client is not on AH MCO because the client is on medicare. A short stay award letter is needed in order for the NF to bill. Send a 65-10 referral for NFLOC. Once NFLOC is received, indicate the admission and discharge on the STAY screen in ACES in order to generate a short stay letter.

Example: Short Stay #3.

S02/SSI related client not on Medicare admits to a NF on 11/5/2016. 15-031 NOA from NF indicates 11/5/2016 admission under AH MCO rehabilitation. A 2nd NOA from the NF indicates rehabilitation days end on 11/20/2016. The FW sends a 65-10 to the HCS SW for a NFLOC determination. Set a barcode tickler to check the status on 12/4/2016. 3rd NOA from NF received indicating client discharged home on 12/1/2016. 14-443 received by the FW from the SW indicating NFLOC and discharged home on 12/1/2016 on MPC services. FW uses the short stay screen to issue the NF A/L. The payment authorization date on the STAY screen is 11/21/2016 (the day after the AH MCO rehabilitation days end). Update the INST with MPC service information.

Example: 30 day or more admission #1

S02/SSI related client not on Medicare admits to a NF on 11/5/2016. 15-031 NOA from NF indicates 11/5/2016 admission under AH MCO rehabilitation. A 2nd NOA from the NF indicates rehabilitation days end on 12/1/2016. The FW sends a 65-10 to the HCS SW for a NFLOC determination. Set a barcode tickler to check the status on 12/15/2016. 14-443 received by the FW from the SW indicating NFLOC and no discharge plan. FW does a program change from S02 to L02. The payment authorization date on the INST screen is 12/2/2016 (the day after the AH MCO rehabilitation days end). Once the program change is completed, the NF award letter is generated.

Example: 30 day or more admission #2

S02/SSI related client not on Medicare admits to a NF on 11/5/2016. 15-031 NOA from NF indicates 11/5/2016 admission under AH MCO rehabilitation. Set a barcode tickler for 12/5/2016 to check the status. 14-443 sent by SW to FW indicating NFLOC, will be in NF 30 days or more and client is still considered under rehabilitation status. The FW will need to do a program change from S02 to L02 as over 30 days. The FW does not know when AH MCO rehabilitation days end, so indicate the first date it was known the client was admitted into the NF. Once the program change is completed, the NF award letter is generated.

Nursing Facility Responsibilities

  • The NF is responsible to check the system to see if a Medicaid client is enrolled in an AH MCO plan prior to admission into the NF. WAC 182-501-0200 Third Party Resources and WAC 182-502-0100 General Conditions of payment describe that Medicaid fee for service is the payer of last resort.
  • The NF is responsible to get a preapproval and contract with the AH MCO before admitting an AH MCO client into the NF.
  • The NF will send a DSHS 15-031 to the DSHS Public Benefit Specialist and indicates if the admission is under an AH MCO.
  • The NF provider needs to consult the Apple Health NF billing guide for billing instructions.

Provider Billing Guides:

Other managed care information: MCS admissions into a nursing facility

Medical Care Services (MCS) program formally Disability Lifeline-Unemployable (DL-U) (formally GA-U). Instructions for managed care and MCS-State fund medical and nursing home admissions. A nursing home award letter and NFLOC determination will be needed for NF admissions under the MCS program as this group is not enrolled into managed care.

Other LTC insurance, Third party resources information

LTC Medicare, LTC insurance, Third Party Resources, LTC partnership and SHIBA information

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Equitable estoppel

Revised date

WAC 182-526-0495 Equitable estoppel.

WAC 182-526-0495 Equitable estoppel.

Effective March 16, 2017

  1. Equitable estoppel is a legal doctrine that may be used only as
    1. an affirmative defense to prevent the health care authority (HCA) from collecting an overpayment. Equitable estoppel may not be used to require HCA to continue to provide something or to require HCA to take action contrary to a statute.
  2. There are five elements of equitable estoppel. A party asserting the doctrine of equitable estoppel must prove all of the following five elements by clear and convincing evidence:
    1. HCA made a statement or took an action or failed to take an action, which is inconsistent with a later claim or position by HCA.
    2. The party reasonably relied on HCA's original statement, action or failure to act.
    3. The party will be injured to its detriment if HCA is allowed to contradict the original statement, action or failure to act.
    4. Equitable estoppel is needed to prevent a manifest injustice. Factors to be considered in determining whether a manifest injustice would occur include, but are not limited to, whether:
      1. The party cannot afford to repay the money to HCA;
      2. The party gave HCA timely and accurate information when required;
      3. The party did not know that HCA made a mistake;
      4. The party is free from fault; and
      5. The overpayment was caused solely by an HCA mistake.
    5. The exercise of government functions is not impaired.
  3. If the administrative law judge (ALJ) concludes that the party has proven all of the elements of equitable estoppel by clear and convincing evidence, HCA is estopped or prevented from taking action or enforcing a claim of overpayment against that party.

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

Two court cases (Chaplin v. Sugarman and Kramerevsky v. DSHS) established that an administrative law judge (ALJ) in Washington State may apply equitable estoppel in administrative hearings. Equitable estoppel is a legal principle which means that, in certain cases, the ALJ can order the agency to stop doing something because it is not fair to an individual.

The agency, in consultation with Legal Services, the Office of the Attorney General and the Office of Administrative Hearings, has developed a stipulation and agreed order of dismissal which can be used to take the place of a formal hearing and written decision by an ALJ.

An individual may raise the issue of equitable estoppel in any hearing.

The Stipulation and Agreed Order of Dismissal should be considered for cases which meet all of the following conditions:

  1. The sole issue for hearing is the fairness of the collection of an overpayment, and
  2. Neither party (appellant or agency) is disputing any fact affecting the outcome of the case. There is agreement about the amount and the facts of the overpayment; and
  3. The agency is satisfied that all elements of estoppel have been established by the appellant with "clear, cogent, and convincing" evidence. This means that the fact is proven by the evidence to be highly probable.

The purpose of the stipulation is to avoid unnecessary hearings on overpayments which would likely result in an equitable estoppel finding. A hearing is unnecessary only when the agency agrees that the appellant has established the case for equitable estoppel and the appellant agrees to the facts of the overpayment. If either party disputes any fact affecting the outcome of the case, a hearing should be held, and a formal decision made by the ALJ.

Worker responsibilities

Review each hearing request on an overpayment, to determine if equitable estoppel is a factor. If yes, apply the following guidelines to determine if the case is appropriate for use of the stipulation and agreed order.

Guidelines for Establishment of Equitable Estoppel:

Element #1:

An admission, statement, or act by the agency, which is inconsistent with a later claim. The agency made a statement, took action, or failed to act and later found that it was incorrect. The individual is informed after the fact that the error was made.

Factors which may be used as evidence of element #1:

  1. The agency had all the information available to correctly determine eligibility.
  2. The individual received the coverage.
  3. The agency has assessed an overpayment.

Element #2:

An action by the individual on the faith of the agency's admission, statement, or act. The individual must have taken some action that was reasonable given the circumstances (i.e., utilized the COPES services).

Factors which may be used as evidence of element #2:

  • The individual's belief in the agency's action was reasonable.

Element #3:

An injury to the individual arising from permitting the agency to contradict or repudiate such admission, statement, or act. The individual experiences either a loss or a detrimental change in their position because the agency reverses a decision regarding eligibility. Depending on the specific circumstances of the case, the imposition of a debt that could not be anticipated or avoided by the individual may establish injury.

Factors which may be used as evidence of injury:

  1. Spent the money on items they would not have otherwise bought and which are not an available resource.
  2. Paid outstanding debts they would not otherwise have paid.
  3. Failed to use an available family or community resource due to the receipt of the benefits. Food Banks, help from relatives, the Salvation Army.

Element #4:

Equitable estoppel is necessary to prevent a manifest injustice. The overpayment is clearly unfair to the individual based on the way that it occurred and repayment would compromise the individual's ability to meet basic needs.

Factors which can be used as evidence of element #4:

  1. The individual cannot repay the overpayment without drawing on funds needed for basic requirements.
  2. It is clear that the individual acted in good faith by following the rules required to maintain eligibility.
    1. The individual reported income timely and accurately.
    2. The overpayment was solely due to agency error; and
    3. The individual has "clean hands", meaning they are without fault. The individual fulfilled all their responsibility to inform the agency of changes in their circumstances.

Element #5:

Applying equitable estoppel will not impair the exercise of governmental powers. Element #5 will be considered to be met unless there is an extraordinary circumstance. This element must be considered on a case-by-case basis. The cumulative effect of equitable estoppel applied to many cases is not permitted.

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Confidentiality information

Revised date
Purpose statement

To describe HCA's rules regarding confidential information and whom HCA discloses confidential information to.

Clarifying information

  1. The following information is considered confidential:
    1. Information contained in case records:
      1. Names, birth dates, marital status, employment status, personal history;
      2. Location, current address and telephone number;
      3. Types of services being received, amounts of benefits and fair hearing activity;
      4. Social Security numbers; and
      5. Medical or psychiatric information.
    2. Information about third parties:
      1. Information about the identity of individuals who have filed complaints; and
      2. The identity of individuals who have provided information under condition of remaining anonymous.
    3. Information available from other agencies:
      1. Employment or benefit information from the Employment Security Department;
      2. Information from the Social Security Administration; and
      3. Birth information from Vital Statistics.
  2. Confidential information except chemical dependency treatment information may be provided to a person who works directly with:
    1. Federal- or state-funded public assistance programs including the federal food stamp program when used for the administration of the programs;
    2. The child support program under Title IV-D of the Social Security Act when used for the administration of the child support program; or
    3. Local, state or federal law enforcement agencies. Information will be released to a local, state, or federal law enforcement agency only when the request:
      1. Identifies the person making the request including their authority to do so;
      2. Identifies the individual;
      3. Provides the Social Security number of the individual;
      4. States the request is an official duty or that finding and apprehending the individual is an official duty;
      5. Describes the violation being investigated; and
      6. Limits the requested information to the address of the individual.
  3. Release information to the U.S. Consulate (U.S. Department of State) only when the individual has provided a written release for the information requested.
  4. At the individual's request information provided by the individual or previously given to an individual may be disclosed to the individual or their representative.
  5. Information provided by third parties may be disclosed to the individual or the individual's representative when:
    1. A fair hearing has been requested on an issue related to the information; or
    2. The Public Disclosure Coordinator determines that:
      1. The release is necessary; and
      2. The information was provided with the understanding that it might be released.
  6. Information relating to the identity of third parties who have filed complaints regarding individuals (or other) and/or who have provided information on condition of anonymity must not be released unless required by a court order.
  7. Information may be released to individuals or agencies with valid releases of information signed and dated by the individual. A release of information is valid if it is:
    1. Signed by the individual, presented within any time frames mentioned on the release;
    2. Presented by the individual to whom the release is made out; and
    3. A request for information that can be legitimately released.
  8. Information other than chemical dependency treatment information may be disclosed to any administrative division of HCA when the purpose of the request for information is to administer the programs of HCA.
  9. Routine transfers of information are subject to the same criteria.
  10. Information may be disclosed to outside agencies only for purposes directly connected with the administration of HCA programs. Outside agencies who receive confidential information are bound by the same rules as HCA.
  11. The following information may be disclosed to medical providers:
    1. Proof that the individual is eligible for medical assistance;
    2. Dates of eligibility;
    3. The PIC code with the tie breaker;
    4. The program for which the individual is eligible; and
    5. Medicare eligibility status.
  12. The following information may not be disclosed to medical providers:
    1. Individual names and addresses;
    2. Medical services provided;
    3. Social and economic conditions or circumstances;
    4. Agency evaluation of personal information; and
    5. Medical data.
  13. Confidential information cannot be provided for:
    1. Commercial or political purposes
    2. Personal purposes by any employees of the department.

Worker responsibilities

  1. Disclosure to third parties: HCA must disclose to anyone making inquiry whether or not a named individual is currently receiving Apple Health coverage. HCA's response is limited to a "yes" or "no" answer. Further information is prohibited without a release from the individual.
  2. Disclosure to courts of law: Information can only be disclosed with a court order.
  3. Disclosure to government officials: Treat requests from government officials like any other third-party request. Refer the request to the HCA public disclosure coordinator.
  4. Special situations:
    1. Translators and contractors must be informed of the rules regarding confidentiality and are bound by those rules to the same degree as a department employee.
    2. See Civil Rights and Complaints for rules and procedures related to the rights and responsibilities of an individual receiving public assistance.
    3. See Equal Access for rules and procedures for equal access services.

Clarifying information

Disclosing information to parents with visitation rights or legal custody

Disclosure of the address of a child covered by Apple Health to a parent who is not in the child's household is governed by RCW 74.04.060, 26.23.120 and 74.12.

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Hospice and long-term services and supports (LTSS) programs

Revised date

LTSS programs (HCS and DDA HCB Waivers)

  • LTSS programs such as CFC, COPES, PACE, New Freedom and DDD Waiver programs take precedence over Hospice. ACES is coded under the primary HCB Waiver service and participation is applied toward the Waiver program first; the hospice service is added to the HCBS screen. It is important that services are coordinated between the Hospice provider and the DSHS agency providing services so there is no duplication of services.
  • For clients who elect hospice in a nursing facility, ACES is coded as hospice in a nursing facility on the institutional care screen under facilities and add the hospice service information in the HCBS screen. This will add the hospice indicator to the case; the case will trickle to a L31/L32.
  • Use the short stay screen for a hospice election in a NF when the client is already on Medicaid and the election and end of hospice service is under 30 days. 
  • Use the short stay screen for a hospice election when a client is active on a medicaid program and is admitted into a hospice care center or hospice NF admission 30 days or less.

Example: Active client on L02 in nursing home elects Hospice on 10/2/2017 and dies or revokes hospice on 10/15/2017. This case does not need to be changed in order to issue a hospice award letter. Use the short stay screen to issue a hospice award letter from 10/2/2017 to 10/15/2017.

Example: Active CFC client on L52 elects hospice.
The client remains in the ALF under the CFC program. The hospice agency will bill the medicaid agency with hospice as a service. The CFC program remains the priority program. The hospice service should be updated in ACES on the institutional care screen.

Example: Active L22 COPES client elects hospice; the client resides in their own home.

The hospice service should be updated in ACES on the institutional care screen along with the COPES service. The COPES Waiver is the priority program and participation would go to the COPES provider. 

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CMS guidance on Part D prescription drug expenses and spenddown

Revised date
Purpose statement

This is an overview of guidance given by CMS regarding Medicare D and spenddown expenses. The same guidance can be applied to reducing LTC participation by a Medicare D related expense.

  • When are prescription drugs for Medicare beneficiaries an allowable expense under spenddown?

For the purposes of Medicaid spenddown, incurred Part D pharmacy costs are treated in the same manner as any other costs incurred for medical care. All usual rules for determination of an applicant’s liability, insurance coverage and spenddown eligibility is applicable. Costs paid in whole or in part by a State Pharmaceutical Assistance Program (SPAP), or other public program of the state or a political subdivision of the state, which involves no federal funds may be counted as an incurred medical expense to establish eligibility for a Medicaid spenddown.

Note

If a State’s Medicaid program provides coverage of any of these costs, they are not allowable under spenddown.

Enrollment in Part D is voluntary, therefore not all Medicare beneficiaries will be enrolled in a Medicare Part D plan (PDP) or a Medicare Advantage plan (MA-PD). For those enrolled in a PDP or MA-PD, not all drugs will be covered. Each plan may have a different combination of deductibles, copays and coverage gaps. To determine if drug costs incurred by Medicare beneficiaries are allowable under spenddown, apply the following rules:

  • If the Medicare beneficiary was not enrolled in a PDP or MA-PD on the date of service, allow the prescription drug cost.
  • If the Medicare beneficiary was enrolled in a PDP or MA-PD on the date of service, the plan must issue a periodic (at least monthly) statement to the beneficiary explaining all benefits paid and denied, and amounts attributed to cost sharing. If the drug charge is identified on this statement as a beneficiary liability, i.e. part of a deductible, copay, or coverage gap, allow the expense under spenddown.
  • When a plan denies coverage of a prescription the beneficiary has the right to request an exception for coverage of the drug. The beneficiary is notified in writing of the decision. If the drug charge appears on the statement as a denial, and no exception was requested, do not allow the charge.
  • If the drug charge appears on the statement as a denial, and an exception was requested and denied, allow the charge.

These procedures will help ensure that legitimate part D cost sharing expenses are allowed under spenddown, as well as expenditures for drugs not covered by the PDP or MA-PD. By relying on the statements and exception notices, eligibility workers will not need to be concerned with knowing the cost sharing rules for each plan, the plan formularies or nonformulary drugs covered under a transition plan or under the exception process. Applicants should be advised to retain their statements and other related documentation for consideration under spenddown.

Clarifying information

If the Medicare beneficiary is not enrolled in a Part D plan (PDP or MA-PD) on the date of service allow the prescription drug cost toward spenddown. It doesn't matter why the beneficiary is not enrolled. The reverse would also be true if a Medicare beneficiary is enrolled in a PDP or MA-PD on the date of service, we would not allow the prescription drug cost, whether self-paid or not, because the drug is covered drug under the beneficiaries' Medicare Part D plan.

Enrollment in Medicare Part D is voluntary. A Medicaid individual could tell Medicare that they are "affirmatively declining Medicare Part D coverage" but this would not make them eligible for Medicaid to cover their prescription expenses. We could, however, apply the costs they incur for prescription drugs towards a spenddown liability upon confirmation from SSA that the individual had affirmatively declined coverage.

Since Medicare is primary payer for drugs covered under Part D and not Medicaid, there is no prescription drug coverage available to full benefit dual eligible individuals, including those not enrolled in a Part D plan—for (1) Covered Part D drugs; or (2) any cost-sharing obligations under Part D relating to covered Part D drugs. This means that if a CN or MN Medicaid individual with Medicare chooses to "affirmatively decline" Medicare Part D coverage, Medicaid will still not pay for any prescription drug costs that would have been covered under Medicare Part D or any Part D cost-sharing.

Disenrollment from a current Part D plan will not prevent Medicare reenrollment in the same or a different plan. To prevent reenrollment individuals must get their Medicare records documented with their statement that they are "declining prescription coverage under the national Medicare Part D prescription drug program". 

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Spousal impoverishment protections for the MAC and TSOA programs

Revised date
Purpose statement

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

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

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

Effective February 25, 2023

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

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

Clarifying Information

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

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

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

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

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

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

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

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

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

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

Worker Responsibilities

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

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

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Tailored supports for older adults (TSOA) presumptive eligibility

Revised date
Purpose statement

This section describes how the presumptive eligibility process works.

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

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

Effective May 29, 2021

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

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

Clarifying Information

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

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

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

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

For example:

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

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

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

Worker Responsibilities

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

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

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

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

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

Related Links

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

Tailored supports for older adults (TSOA)

 

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

Revised date
Purpose statement

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

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

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

Hospice applications - eligibility for CN coverage

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

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

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

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

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

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

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