Clarifying Information

Noninstitutional services are authorized for people who are eligible for a categorically needy (CN) or alternate benefit plan (ABP). These services are:

1. Medicaid Personal Care (MPC)
2. Community First Choice (CFC)
3. Hospice. Hospice services can also be authorized under the medically needy (MN) program.

Noninstitutional medical programs include MAGI-based N-track programs through the Health Benefit Exchange and the non-MAGI medicaid programs such as SSI related, foster care, and breast and cervical cancer.

Institutional services is also called long-term care (LTC). These services are authorized for people living in a medical institution 30 days or more. Home and Community based (HCB) Waivers are considered an institutional medical program. SSI-related institutional programs are subject to a 5 year look back for transfer penalties. There are 3 parts to the eligibility for institutional medical programs:

1. Initial eligibility for the Medicaid
2. Functional eligibility for the service
3. Post-eligibility treatment of income to determine the client responsibility toward the cost of care. This payment is also called participation.

Institutional rules can be used to access LTSS if a person is not eligible for CN using noninstitutional rules. Whenever institutional rules are needed to determine eligibility, the person is subject to the post-eligibility treatment of income to determine the client responsibility toward the cost of care. These services do not have a 5 year look back for transfer penalties like institutional or HCB Waiver programs. These services are:

1. Program of all-inclusive care for the elderly (PACE)
2. Roads to Community Living (RCL)
3. CFC
4. Hospice.

People residing in a medical institution 30 days or more, with the exception of MAGI-based programs have eligibility determined under WAC 182-513-1315 and WAC 182-513-1380. MAGI-based programs cover nursing facility services as a claim and no program change is done even if residing in a NF 30 days or more.

Home and Community based (HCB) waivers are considered an institutional program. Eligibility is determined under Chapter 182-515 WAC.

Community First Choice (CFC) or Medicaid Personal Care (MPC) can be authorized by HCS or DDA for people who are functionally eligibility and receive a CN or ABP Apple Health program. The eligibility for CN and ABP are based on the following program rules:

1. Modified adjusted gross income (MAGI) based eligibility through the Health Benefit Exchange (HBE) with the exception of alien emergent medical under N21 and N25. The remaining MAGI programs are under the N track. Notification of services under the N track programs is done through the social service authorization in Provider One.
2. CN under a Classic (non-MAGI) Apple Health program:
   1. SSI-related noninstitutional programs:
      1. SSI (S01)
      2. SSI related CN (S02)
      3. SSI related CN Health Care for Workers with Disabilities (HWD)(S08
      4. SSI related CN in an Alternate Living Facility (ALF) (G03)
   2. Foster Care (D01, D02)
   3. Breast and Cervical Cancer (S30)

Consult the medical program chart desk tool located in the financial program SharePoint for a complete list of medical coverage groups (MCG) and the type of LTSS service that can be authorized for each MCG.

For MPC, the eligibility is based on any noninstitutional CN or ABP Apple Health program.

For CFC, the eligibility is based on any Apple Health CN or ABP program including eligibility for a HCB Waiver. If eligible person receives both CFC and HCB Waiver, the eligibility rules under Chapter 182-515 WAC apply including the 5 year look back for transfer penalties and post-eligibility treatment of income.

For people receiving CFC only, the 5 year look back for transfer penalties do not apply.

People living in the community, receiving PACE, RCL or Hospice, may have eligibility determined using HCB Waiver rules under Chapter 182-515 WAC. Even though HCB Waiver rules can be used for eligibility, these programs are not HCB Waivers and are not subject to the 5 year look back for transfer penalties. People receiving PACE, RCL or Hospice are considered to have institutional status under WAC 182-513-1320. People receiving PACE or Hospice in a nursing facility have eligibility based on WAC 182-513-1315 and WAC 182-513-1380.

All LTSS services are subject to excess home equity provisions under WAC 182-513-1350.