WAC 182-513-1320 Determining institutional status for long-term care (LTC) services.

Effective February 17, 2017

1. To attain institutional status outside a medical institution, a person must be approved for and receive:
   1. Home and community based (HCB) waiver services under chapter 182-515 WAC;
   2. Roads to community living (RCL) services under WAC 182-513-1235;
   3. Program of all-inclusive care for the elderly (PACE) under WAC 182-513-1230;
   4. Hospice services under WAC 182-513-1240(3); or
   5. State-funded long-term care service under WAC 182-507-0125.
2. To attain institutional status in a medical institution, a person must reside in a medical institution thirty consecutive days or more, or based on a department assessment, be likely to reside in a medical institution thirty consecutive days or more.
3. Once a person meets institutional status, the person's status is not affected if the person:
   1. Transfers between medical facilities; or
   2. Changes between any of the following programs: HCB waiver, RCL, PACE, hospice or services in a medical institution.
4. A person loses institutional status if the person is absent from a medical institution, or does not receive HCB waiver, RCL, PACE, or hospice services, for more than twenty-nine consecutive days.

WAC 182-513-1318 Income and resource criteria for home and community based (HCB) waiver programs and hospice.

Effective February 20, 2017

1. This section provides an overview of the income and resource eligibility rules for a person to be eligible for a categorically needy (CN) home and community based (HCB) waiver program under chapter 182-515 WAC or the hospice program under WAC 182-513-1240 and 182-513-1245.
2. To determine income eligibility for an SSI-related long-term care (LTC) HCB waiver, the agency or its designee:
   1. Determines income available under WAC 182-513-1325 and 182-513-1330;
   2. Excludes income under WAC 182-513-1340;
   3. Compares remaining gross nonexcluded income to:
      1. The special income level (SIL) defined under WAC 182-513-1100; or
      2. For HCB service programs authorized by the aging and long-term supports administration (ALTSA), a higher standard is determined following the rules under WAC 182-515-1508 if a client's income is above the SIL but net income is below the medically needy income level (MNIL).
3. A person who receives MAGI-based coverage is not eligible for HCB waiver services unless found eligible based on program rules in chapter 182-515 WAC.
4. To be resource eligible under the HCB waiver program, the person must:
   1. Meet the resource eligibility requirements and standards under WAC 182-513-1350;
   2. Not be in a period of ineligibility due to a transfer of asset penalty under WAC 182-513-1363;
   3. Disclose to the state any interest the person or that person's spouse has in an annuity and meet the annuity requirements under chapter 182-516 WAC.
5. The agency or its designee determines a person's responsibility to pay toward the cost of care for LTC services as follows:
   1. For people receiving HCS HCB waiver services, see WAC 182-515-1509;
   2. For people receiving DDA HCB waiver services, see WAC 182-515-1514.
6. To be eligible for the CN hospice program, see WAC 182-513-1240.
7. To be eligible for the MN hospice program in a medical institution, see WAC 182-513-1245.

WAC 182-513-1317 Income and resource criteria for an institutionalized person.

Effective February 20, 2017

1. This section provides an overview of the income and resource eligibility rules for a person who lives in an institutional setting.
2. To determine income eligibility for an SSI-related long-term care (LTC) applicant under the categorically needy (CN) program, the agency or its designee:
   1. Determines available income under WAC 182-513-1325 and 182-513-1330;
   2. Excludes income under WAC 182-513-1340; and
   3. Compares remaining available income to the special income level (SIL) defined under WAC 182-513-1100. A person's available income must be equal to or less than the SIL to be eligible for CN coverage.
3. To determine income eligibility for an SSI-related LTC client under the medically needy (MN) program, the agency or its designee follows the income standards and eligibility rules under WAC 182-513-1395.
4. To be resource eligible under the SSI-related LTC CN or MN program, the person must:
   1. Meet the resource eligibility requirements under WAC 182-513-1350;
   2. Not have a penalty period of ineligibility due to a transfer of assets under WAC 182-513-1363;
   3. Disclose to the state any interest the person or the person's spouse has in an annuity, which must meet the annuity requirements under chapter 182-516 WAC.
5. A resident of eastern or western state hospital is eligible for medicaid if the person:
   1. Has attained institutional status under WAC 182-513-1320; and
   2. Is under age twenty-one; or
   3. Applies for or receives inpatient psychiatric treatment in the month of the person's twenty-first birthday that will likely continue through the person's twenty-first birthday, and can receive coverage until:
      1. The facility discharges the person; or
      2. The end of the month in which the person turns age twenty-two, whichever occurs first; or(d) Is at least age sixty-five.
6. To determine long-term care CN or MN income eligibility for a person eligible under a MAGI-based program, the agency or its designee follows the rules under chapter 182-514 WAC.
7. There is no asset test for MAGI-based LTC programs under WAC 182-514-0245.
8. The agency or its designee determines a person's total responsibility to pay toward the cost of care for LTC services as follows:
   1. For an SSI-related person residing in a medical institution, see WAC 182-513-1380;
   2. For an SSI-related person on a home and community based waiver, see chapter 182-515 WAC.

WAC 182-513-1316 General eligibility requirements for long-term care (LTC) programs.

Effective February 20, 2017

1. To be eligible for long-term care (LTC) services, a person must:
   1. Meet the general eligibility requirements for medical programs under WAC 182-503-0505, except:
      1. An adult age nineteen or older must meet citizenship and immigration status requirements under WAC 182-503-0535 (2)(a) or (b);
      2. A person under age nineteen must meet citizenship and immigration status requirements under WAC 182-503-0535 (2)(a), (b), (c), or (d); and
      3. If a person does not meet the requirements in (a)(i) or (ii) of this subsection, the person is not eligible for medicaid and must have eligibility determined under WAC 182-513-1319.
   2. Attain institutional status under WAC 182-513-1320;
   3. Meet the functional eligibility under:
      1. Chapter 388-106 WAC for a home and community services (HCS) home and community based (HCB) waiver or nursing facility coverage; or
      2. Chapter 388-828 WAC for developmental disabilities administration (DDA) HCB waiver or institutional services; and
   4. Meet either:
      1. SSI-related criteria under WAC 182-512-0050; or
      2. MAGI-based criteria under WAC 182-503-0510(2), if residing in a medical institution. A person who is eligible for MAGI-based coverage is not subject to the provisions under subsection (2) of this section.
2. A supplemental security income (SSI) recipient or a person meeting SSI-related criteria who needs LTC services must also:
   1. Not have a penalty period of ineligibility due to the transfer of assets under WAC 182-513-1363;
   2. Not have equity interest in a primary residence greater than the home equity standard under WAC 182-513-1350; and
   3. Disclose to the agency or its designee any interest the applicant or spouse has in an annuity, which must meet annuity requirements under chapter 182-516 WAC.
3. A person who receives SSI must submit a signed health care coverage application form attesting to the provisions under subsection (2) of this section. A signed and completed eligibility review for LTC benefits can be accepted for people receiving SSI who are applying for long-term care services.
4. To be eligible for HCB waiver services, a person must also meet the program requirements under:
   1. WAC 182-515-1505 through 182-515-1509 for HCS HCB waivers; or
   2. WAC 182-515-1510 through 182-515-1514 for DDA HCB waivers.

WAC 182-513-1315 General eligibility requirements for long-term care (LTC) programs.

Effective February 20, 2017

This section lists the sections in this chapter that describe how the agency determines a person's eligibility for long-term care services. These sections are:

1. WAC 182-513-1316 General eligibility requirements for long-term care (LTC) programs.
2. WAC 182-513-1317 Income and resource criteria for an institutionalized person.
3. WAC 182-513-1318 Income and resource criteria for home and community based (HCB) waiver programs and hospice.
4. WAC 182-513-1319 State-funded programs for noncitizens who are not eligible for a federally funded program.

WAC 182-513-1245 Medically needy hospice in a medical institution.

Effective February 20, 2017

1. General information.
   1. When living in a medical institution, a person may be eligible for medically needy coverage under the hospice program. A person must:
      1. Meet program requirements under WAC 182-513-1315;
      2. Have available income that exceeds the special income level (SIL), defined under WAC 182-513-1100, but is below the institution's monthly state-contracted rate;
      3. Meet the financial requirements of subsection (4) or (5) of this section; and
   2. Elect hospice services under chapter 182-551 WAC.
2. 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.
3. Determining the state-contracted daily rate in an institution, and the institutional medically needy income level (MNIL).
   1. The agency or its designee determines the state-contracted daily rate in an institution and the institutional MNIL based on the living arrangement, and whether the person is entitled to receive hospice services under medicare.
   2. When the person resides in a hospice care center:
      1. If entitled to medicare, the state-contracted daily rate is the state-contracted daily hospice care center rate. The institutional MNIL is calculated by multiplying the state-contracted daily rate by 30.42.
      2. If not entitled to medicare, the state-contracted daily rate is the state-contracted daily hospice care center rate, plus the state-contracted daily hospice rate. To calculate the institutional MNIL, multiply the state-contracted daily rate by 30.42.
   3. When the person resides in a nursing facility:
      1. If entitled to medicare, the state-contracted daily rate is ninety-five percent of the nursing facility's state-contracted daily rate. The institutional MNIL is calculated by multiplying the state-contracted daily rate by 30.42.
      2. If not entitled to medicare, the state-contracted daily rate is ninety-five percent of the nursing facility's state-contracted daily rate, plus the state-contracted daily hospice rate. The institutional MNIL is calculated by multiplying the state-contracted daily rate by 30.42.
4. Eligibility for agency payment to the facility for institutional hospice services and the MN program.
   1. If a person's countable income plus excess resources is less than or equal to the state-contracted daily rate under subsection (3) of this section times the number of days the person has resided in the medical institution, the person:
      1. Is eligible for agency payment to the facility for institutional hospice services;
      2. Is approved for MN coverage for a twelve-month certification period;
   2. Pays excess resources under WAC 182-513-1350; and
   3. Pays income towards the cost of care under WAC 182-513-1380.
5. Eligibility for institutional MN spenddown.
   1. If a person's countable income is more than the state-contracted daily rate times the number of days the person has resided in the medical institution, but less than the institution's private rate for the same period, the person:
      1. Is not eligible for agency payment to the facility for institutional hospice services; and
      2. Is eligible for the MN spenddown program for a three-month or six-month base period when qualifying medical expenses meet a person's spenddown liability.
   2. Spenddown liability is calculated by subtracting the institutional MNIL from the person's countable income for each month in the base period. The values from each month are added together to determine the spenddown liability.
   3. Qualifying medical expenses used to meet the spenddown liability are described in WAC 182-519-0110, except that only costs for hospice services not included within the state-contracted daily rate are qualifying medical expenses.
6. Eligibility for MN spenddown.
   1. If a person's countable income is more than the institution's private rate times the number of days the person has resided in the medical institution, the person is not eligible for agency payment to the facility for institutional hospice services and institutional MN spenddown; and
   2. The agency or its designee determines eligibility for MN spenddown under chapter 182-519 WAC.

WAC 182-513-1240 The hospice program

Effective February 25, 2023

1. General information.
   1. The hospice program provides palliative care to people who elect to receive hospice services and are certified as terminally ill by their physician.
   2. Program rules governing election of hospice services are under chapter 182-551 WAC.
   3. A person may revoke an election to receive hospice services at any time by signing a revocation statement.
   4. Transfer of asset rules under WAC 182-513-1363 do not apply to the hospice program in any setting, regardless of which apple health program the person is eligible to receive.
2. When hospice is a covered service.
   1. A person who receives coverage under a categorically needy (CN), medically needy (MN), or alternative benefits plan (ABP) program is eligible for hospice services as part of the program specific benefit package.
   2. A person who receives coverage under the alien emergency medical (AEM) program under WAC 182-507-0110 may be eligible for payment for hospice services if preapproved by the agency.
   3. A person who receives coverage under the medical care services (MCS) program is not eligible for coverage of hospice services.
3. When HCB waiver rules are used to determine eligibility for hospice.
   1. A person who is not otherwise eligible for a CN, MN, or ABP noninstitutional program who does not reside in a medical institution, may be eligible for CN coverage under the hospice program by using home and community based (HCB) waiver rules under WAC 182-515-1505 to determine financial eligibility.
   2. When HCB waiver rules are used, the following exceptions apply:
      1. A person on the hospice program may reside in a medical institution, including a hospice care center, 30 days or longer and remain eligible for hospice services; and
      2. A person residing at home on the hospice program who has available income over the special income limit (SIL), defined under WAC 182-513-1100, is not eligible for CN coverage. If available income is over the SIL, the agency or its designee determines eligibility for medically needy coverage under WAC 182-519-0100.
   3. When HCB waiver rules are used, a person may be required to pay income and third-party resources (TPR) as defined under WAC 182-513-1100 toward the cost of hospice services. The cost of care calculation is described under WAC 182-515-1509.
   4. When a person already receives HCB waiver services and elects hospice, the person must pay any required cost of care towards the HCB waiver service provider first.
4. Eligibility for hospice services in a medical institution:
   1. A person who elects to receive hospice services, resides in a medical institution for 30 days or longer, and has income:
      1. Equal to or less than the SIL is income eligible for CN coverage. Eligibility for institutional hospice is determined under WAC 182-513-1315; or
      2. Over the SIL may be eligible for MN coverage under WAC 182-513-1245.
   2. A person eligible for hospice services in a medical institution may have to pay toward the cost of nursing facility or hospice care center services. The cost of care calculation is under WAC 182-513-1380.
5. Changes in coverage. The agency or its designee redetermines a person's eligibility under WAC 182-504-0125 if the person:
   1. Revokes the election of hospice services and is eligible for coverage using HCB waiver rules only, described in subsection (3) of this section; or
   2. Loses CN, MN, or ABP eligibility.
6. Personal needs allowance and income and resource standards for hospice and home and community based (HCB) waiver programs 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.

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

Effective May 30, 2021

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 sixty consecutive days in a qualified institutional setting such as a hospital, nursing home, or residential habilitation center, to be eligible for RCL. The sixty-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 sixty-day criteria, a person who is being discharged from a state psychiatric hospital must be under age twenty-two or over age sixty-four.
4. Once a person is discharged to home or to a residential setting under RCL, the person remains continuously eligible for medical coverage for three hundred sixty-five 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 administration (DDA) services.
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.

WAC 182-513-1230 Program of all-inclusive care for the elderly (PACE).

Effective February 20, 2017

1. The program of all-inclusive care for the elderly (PACE) provides long-term services and supports (LTSS), medical, mental health, and chemical dependency treatment through a department-contracted managed care plan using a personalized plan of care for each enrollee.
2. Program rules governing functional eligibility for PACE are listed under WAC 388-106-0700, 388-106-0705, 388-106-0710, and 388-106-0715.
3. A person is financially eligible for PACE if the person:
   1. Is age:
      1. Fifty-five or older and disabled under WAC 182-512-0050; or
      2. Sixty-five or older;
   2. Meets nursing facility level of care under WAC 388-106-0355;
   3. Lives in a designated PACE service area;
   4. Meets financial eligibility requirements under this section; and
   5. Agrees to receive services exclusively through the PACE provider and the PACE provider's network of contracted providers.
4. Although PACE is not a home and community based (HCB) waiver program, financial eligibility is determined using the HCB waiver rules under WAC 182-515-1505 when a person is living at home or in an alternate living facility (ALF), with the following exceptions:
   1. PACE enrollees are not subject to the transfer of asset rules under WAC 182-513-1363; and
   2. PACE enrollees may reside in a medical institution thirty days or longer and still remain eligible for PACE services. The eligibility rules for institutional coverage are under WAC 182-513-1315 and 182-513-1380.
5. A person may have to pay third-party resources as defined under WAC 182-513-1100 in addition to the room and board and participation.

WAC 182-513-1225 Medicaid Personal Care (MPC)

Effective February 25, 2023

1. Medicaid personal care (MPC) is a state-plan benefit available to a client who is determined:
   1. Functionally eligible for MPC services under WAC 388-106-0200 through 388-106-0235; and
   2. Financially eligible for a noninstitutional categorically needy (CN) or alternative benefits plan (ABP) Washington apple health (medicaid) program.
2. MPC services may be provided to a client residing at home, in a department-contracted adult family home (AFH), or in a licensed assisted living facility that is contracted with the department to provide adult residential care services.
3. A client who resides in an alternate living facility (ALF) listed in subsection (2) of this section:
   1. Keeps a personal needs allowance (PNA) under WAC 182-513-1105; and
   2. Pays room and board up to the room and board standard under WAC 182-513-1105, unless CN eligibility is determined using rules under WAC 182-513-1205.
4. A client who receives MPC services under the health care for workers with disabilities (HWD) program under chapter 182-511 WAC must pay the HWD premium in addition to room and board under WAC 182-513-1105, if residing in an ALF.
5. A client may have to pay third-party resources as defined under WAC 182-513-1100 in addition to room and board.
6. Current PNA and room and board 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.