WAC 182-513-1425 Not qualifying for LTC medicaid if an LTC partnership policy is in pay status.

Effective February 20, 2017

You are not eligible for long-term care (LTC) medicaid when the following applies:

1. The income you have available to pay toward your cost of care under WAC 182-513-1380, combined with the amount paid under the qualifying LTC partnership policy, exceeds the monthly private rate at the institution.
2. The income you have available to pay toward your cost of care on a home and community based (HCB) waiver under chapter 182-515 WAC, combined with the amount paid under the qualifying LTC partnership policy, exceeds the monthly private rate in a home or residential setting.
3. You fail to meet another applicable eligibility requirement for LTC medicaid.

WAC 182-513-1420 Eligibility for asset protection under a partnership policy.

Effective February 20, 2017

1. The LTC partnership policy must meet all the requirements in chapter 284-83 WAC. For existing LTC policies which are converted to a LTC partnership policy via an exchange or through the addition of a policy rider or endorsement, the conversion must take place on or after December 1, 2011 unless the policy is paying out benefits at the time the policy is exchanged.
2. You meet all applicable eligible requirements for LTC medicaid and:
   1. Your LTC partnership policy benefits have been exhausted and you are in need of LTC services.
   2. Your LTC partnership policy is not exhausted and is:
      1. Covering all costs in a medical institution and you are still in need for medicaid; or
      2. Covering a portion of the LTC costs under your LTC partnership policy but does not meet all of your LTC needs.
   3. At the time of your LTC partnership policy has paid out more benefits than you have designated as protected. In this situation your estate can designate additional assets to be excluded from the estate recovery process up to the dollar amount the LTC partnership policy has paid out.

WAC 182-513-1410 LTC partnership policy qualifications.

Effective February 20, 2017

A LTC partnership policy is a LTC policy that has been approved by the office of insurance commissioner as a LTC partnership policy described in chapter 284-83 WAC.

WAC 182-513-1405 Definitions.

Effective February 20, 2017

For purposes of WAC 182-513-1400 through 182-513-1455, the following terms have the meanings stated. See chapter 182-500 WAC and WAC 182-513-1100 for additional definitions.

"Issuer" means any entity that delivers, issues for delivery, or provides coverage to, a resident of Washington, any policy that claims to provide asset protection under the Washington long-term care partnership act, chapter 48.85 RCW. As used in this chapter, issuer specifically includes insurance companies, fraternal benefit societies, health care service contractors, and health maintenance organizations.

"Long-term care (LTC) insurance" means a policy under chapter 284-83 WAC.

"Protected assets" means assets that are designated as excluded or not taken into account upon determination of long-term care medicaid eligibility under WAC 182-513-1315. The protected or excluded amount is up to the dollar amount of benefits that have been paid for long-term care services by the qualifying long-term care partnership policy on the medicaid applicant's or client's behalf. The assets are also protected or excluded for the purposes of estate recovery under chapter 182-527 WAC, up to the amount of benefits paid by the qualifying policy for medical and long-term care services.

"Qualified long-term care insurance partnership" means an agreement between the Centers for Medicare and Medicaid Services (CMS), and the health care authority (HCA) which allows for the disregard of any assets or resources in an amount equal to the insurance benefit payments that are made to or on behalf of a person who is a beneficiary under a long-term care insurance policy that has been determined by the Washington state insurance commission to meet the requirements of section 1917 (b)(1)(c)(iii) of the act. These policies are described in chapter 284-83 WAC.

"Reciprocity Agreement" means an agreement between states approved under section 6021(b) of the Deficit Reduction Act of 2005, Public Law 109-171 (DRA) under which the states agree to provide the same asset protections for qualified partnership policies purchased by a person while residing in another state and that state has a reciprocity agreement with the state of Washington.

WAC 182-513-1400 Long-term care (LTC) partnership program (index).

Effective February 20, 2017

Under the long-term care (LTC) partnership program, people who purchase qualified long-term care partnership insurance policies can apply for long-term care medicaid under special rules for determining financial eligibility. These special rules generally allow the person to protect assets up to the insurance benefits received from a partnership policy so that such assets will not be taken into account in determining financial eligibility for long-term care medicaid and will not subsequently be subject to estate recovery for medicaid and long-term care services paid. The Washington long term care partnership program is effective on December 1, 2011.

The following rules govern long-term care eligibility under the long-term care partnership program:

1. WAC 182-513-1405 Definitions
2. WAC 182-513-1410 LTC Partnership policy qualifications.
3. WAC 182-513-1415 Assets that can't be protected under the LTC partnership provisions.
4. WAC 182-513-1420 Eligibility for asset protection under a partnership policy.
5. WAC 182-513-1425 Not qualifying for LTC medicaid if an LTC partnership policy is in pay status.
6. WAC 182-513-1430 Change of circumstances that must be reported when there is an LTC partnership policy paying a portion of my care.
7. WAC 182-513-1435 When Washington recognizes an LTC partnership policy purchased in another state.
8. WAC 182-513-1440 Determining how many assets can be protected.
9. WAC 182-513-1445 Designating a protected asset and required proof.
10. WAC 182-513-1450 How the transfer of assets affects LTC partnership and medicaid eligibility.
11. WAC 182-513-1455 Protected assets under an LTC partnership policy after death.

WAC 182-513-1397 Treatment of entrance fees for people residing in a continuing care retirement community or a life care community.

Effective February 17, 2017

1. A person's entrance fee in a continuing care retirement community or life care community is an available resource to the person, to the extent that:
   1. The person has the ability to use the entrance fee, or the contract provides that the entrance fee may be used, to pay for care should other resources or income of the person be insufficient to pay for care;
   2. The person is eligible for a refund of any remaining entrance fee when the person dies or when the person terminates the continuing care retirement community or life care community contract and leaves the community; and
   3. The entrance fee does not confer an ownership interest in the continuing care retirement community or life care community.
2. Nothing in subsection (1) of this section prevents the agency or its designee from evaluating contracts with facilities not described in subsection (1) of this section.

WAC 182-513-1396 People living in a fraternal, religious, or benevolent nursing facility.

Effective February 20, 2017

1. The agency or its designee determines apple health coverage under noninstitutional rules for a person who meets all other eligibility requirements and lives in a licensed, but nonmedicaid-contracted facility operated by a fraternal, religious, or benevolent organization.
2. Nothing in subsection (1) of this section prevents the agency or its designee from evaluating contracts with facilities not described in subsection (1) of this section.

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.

WAC 182-513-1385 Determining the community spouse monthly maintenance needs allowance and dependent allowance in post-eligibility treatment of income for long-term care (LTC) programs.

Effective February 25, 2023

1. This section describes how to calculate the monthly maintenance needs allowance (MMNA) in post-eligibility treatment of income for long-term care (LTC) programs for a community spouse or dependent of the institutionalized individual.
2. The community spouse MMNA 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, unless a greater amount is calculated under subsection (5) of this section. The MMNA standards may change each January and July based on the consumer price index.
3. The community spouse MMNA is allowed only to the extent that the institutionalized spouse's income is made available to the community spouse, and is calculated as follows:
   1. The minimum MMNA as calculated in subsection (4)(a) of this section plus excess shelter expenses as calculated in subsection (4)(b) of this section;
      1. The total under (a) of this subsection cannot be less than the minimum MMNA; and
      2. If the total under subsection (4)(a) of this section exceeds the maximum MMNA, the maximum MMNA is the result under subsection (4)(a) of this section; and(b) The total under subsection (4)(a) of this section is reduced by the community spouse's gross income. The result is the MMNA.
4. The minimum MMNA and excess shelter expense values are calculated as follows:
   1. The minimum MMNA is 150 percent of the two-person federal poverty level (FPL); and
   2. If excess shelter expenses are less than zero, the result is zero. Excess shelter expenses are calculated as follows:
      1. Add:
         1. Mortgage or rent, which includes space rent for mobile homes;
         2. Real property taxes;
         3. Homeowner's insurance;
         4. Required maintenance fees for a condominium, cooperative, or homeowner's association that are recorded in a covenant; and
         5. The food assistance standard utility allowance (SUA) under WAC 388-450-0195 minus the cost of any utilities that are included in (b)(i)(D) of this subsection.
      2. Subtract the standard shelter allocation from the total in (b)(i) of this subsection. The standard shelter allocation is 30 percent of 150 percent of the two-person FPL. The result is the value of excess shelter expenses.
5. The amount allocated to the community spouse may be greater than the amount determined in subsection (3) of this section, but only if:
   1. A court order has been entered against the institutionalized spouse approving a higher MMNA for the support of the community spouse; or
   2. A final order has been entered after an administrative hearing has been held under chapter 182-526 WAC ruling the institutionalized spouse or the community spouse established the community spouse needs income, above the level otherwise provided by the MMNA, due to exceptional circumstances causing significant financial duress.
6. If a final order establishes that the conditions identified in subsection (5)(b) of this section have been met, then an amount of allocated resources under subsection (3) of this section will be substituted by an amount adequate to provide such an MMNA.
7. The agency or its designee determines the dependent allowance for dependents of the institutionalized individual or the institutionalized individual's spouse. The amount the agency allows depends on whether the dependent resides with the community spouse.
   1. For each dependent who resides with the community spouse:
      1. Subtract the dependent's income from 150 percent of the two-person FPL;
      2. Divide the amount determined in (a)(i) of this subsection by three;
      3. The result is the dependent allowance for that dependent.
   2. For each dependent who does not reside with the community spouse:
      1. The agency determines the effective MNIL standard based on the number of dependent family members in the home;
      2. Subtracts each dependent's separate income;
      3. The result is the dependent allowance for the dependents.
   3. Child support received from a noncustodial parent is the child's income.

WAC 182-513-1380 Determining a client's financial participation in the cost of care for long-term care in a medical institution

Effective March 1, 2025

This rule describes how the agency or the agency's designee allocates income and excess resources when determining participation in the cost of care in a medical institution.

1. The agency or the agency's designee defines which income and resources must be used in this process under WAC 182-513-1315.
2. The agency or the agency's designee allocates nonexcluded income in the following order, and the combined total of (a), (b), (c), and (d) of this subsection cannot exceed the effective one-person medically needy income level (MNIL):
   1. A personal needs allowance (PNA) under WAC 182-513-1105.
   2. Mandatory federal, state, or local income taxes owed by the client.
   3. Wages for a client who:
      1. Is related to the supplemental security income (SSI) program under WAC 182-512-0050(1); and
      2. Receives the wages as part of an agency-approved or department-approved training or rehabilitative program designed to prepare the client for a less restrictive placement. When determining this deduction, employment expenses are not deducted.
   4. Guardianship fees, conservatorship fees, and administrative costs, including any attorney fees paid by the guardian or conservator, as allowed under chapter 388-79A WAC.
3. The agency or the agency's designee allocates nonexcluded income after deducting amounts under subsection (2) of this section in the following order:
   1. Current or back child support garnished or withheld from income according to a child support order in the month of the garnishment if it is:
      1. For the current month;
      2. For the time period covered by the PNA; and
      3. Not counted as the dependent member's income when determining the dependent allocation amount under WAC 182-513-1385.
   2. A monthly maintenance needs allowance for the community spouse as determined using the calculation under WAC 182-513-1385. If the community spouse is also receiving long-term care services, the allocation is limited to an amount that brings the community spouse's income up to the PNA.
   3. A dependent allowance for each dependent of the institutionalized client or the client's spouse, as determined using the calculation under WAC 182-513-1385.
   4. Medical expenses incurred by the institutionalized individual and not used to reduce excess resources. Allowable medical expenses and reducing excess resources are described in WAC 182-513-1350.
   5. Maintenance of the home of a single institutionalized client or institutionalized couple:
      1. Up to 100 percent of the one-person federal poverty level per month;
      2. Limited to a six-month period;
      3. When a physician has certified that the client or couple is likely to return to the home within the six-month period; and
      4. When social services staff documents the need for the income deduction.
4. A client may have to pay third-party resources as defined under WAC 182-513-1100 in addition to the participation.
5. A client is responsible to pay only up to the state rate for the cost of care. If long-term care insurance pays a portion of the state rate cost of care, a client pays only the difference up to the state rate cost of care.
6. When a client lives in multiple living arrangements in a month, the agency allows the highest PNA available based on all the living arrangements and services the client has in a month.
7. Standards under this section for long-term care are found at www.hca.wa.gov/health-care-services-supports/program-standard-income-and-resources.