Clarifying Information

What is the best way to apply for LTSS?

Applications for LTSS may be submitted using any of the following methods:

• Apply online at: www.WashingtonConnection.org if the client is age 65 or older, blind, disabled (ABD), or on Medicare.
• Apply online at www.wahealthplanfinder.org.
  • Applications for clients under age 65 or ineligible for Medicare should be submitted through this site and will have a real-time determination of Washington Apple Health medical coverage eligibility under the modified adjusted gross income (MAGI) methodology.
• Apply by completing the HCA 18-005 Washington Apple Health Application for Aged, Blind, Disabled/Long-Term Care coverage and mail or fax into HCS, or
• Apply by completing the HCA 18-008 Washington Apple Health for Tailored Supports for Older Adults (TSOA), which is a program that provides supports to caregivers, or
• Apply in-person at a local Home & Community Services office. To find an HCS office near you, use the DSHS Office Locator, or
• Call the HCS intake line in the area in which you reside to schedule an assessment. See "How to request an LTSS assessment" below.

Mailing or faxing documents to Home and Community Services (HCS)

Mail to:
Home and Community Services - LTSS
PO Box 45826
Olympia WA 98504-5826; or
FAX to: 1-855-635-8305

Always include the client's full name and the DSHS client id (if known) on any document mailed or faxed to DSHS.

How to request a LTSS assessment:

Call to request an assessment for home and community services (in-home care in a residential facility, nursing facility coverage) through the HCS central intake lines.

Region 1 HCS

If you reside in one of the following counties: Adams, Asotin, Chelan, Colombia, Douglas, Ferry, Franklin, Garfield, Grant, Kittitas, Klickitat, Lincoln, Okanogan, Pend Oreille, Spokane, Stevens, Walla Walla, Whitman, or Yakima 509-568-3767 or 866-323-9409, FAX 509-568-3772

Region 2 HCS

If you reside in one of the following counties: Island, King (ZIP codes 98011, 98019, 98072, 98077, 98133, 98177) San Juan, Skagit, Snohomish, or Whatcom and are interested in:

• In-home or residential services, call 800-780-7094 or 425-977-6579, FAX 425-339-4859
• Nursing home services, call 800-780-7094, FAX 206-373-6855

If you reside in King County in a ZIP code not listed above and are interested in:

• In-home or residential services, call 206-341-7750, FAX 206-373-6855
• Nursing home services, call 800-780-7094, FAX 206-373-6855

Region 3 HCS

If you reside in one of the following counties: Clallam, Clark, Cowlitz, Grays Harbor, Jefferson, Kitsap, Lewis, Mason, Pacific, Pierce, Skamania, Thurston, or Wahkiakum 800-786-3799, FAX 360-586-0499

What if the applicant for LTSS is already on Washington Apple Health?

1. A new application isn't required for clients active on ABD SSI-related Apple Health who need LTSS as long as the Public Benefit Specialist (PBS) is able to determine institutional eligibility using information in the current case record. Examples are the SSI or SSI-related programs or Apple Health for Workers with Disabilities (HWD). Use the original eligibility review date to open institutional coverage. Center for Medicare and Medicaid Services (CMS) requires an annual review at least once a year for categorically needy (CN) Medicaid.
2. Review excess home equity, annuity and transfer of resource provisions that are specific to institutional and home and community-based (HCB) waivers.
3. SSI recipients who need institutional services, or HCB waiver, must complete and sign an application, or the DSHS 14-416 Eligibility Review for Long Term Services and Supports and complete an interview. Don't hold up eligibility for long-term care awaiting a signed review. If an application, eligibility review, or LTSS review is in the electronic case record within the past year, a new review form isn't needed.
4. Ensure an Asset Verification System (AVS) Authorization is on file, and if not, follow these procedures.

LTSS applications for clients on MAGI-based Washington Apple Health

Clients active on MAGI except AEM N21 and N25), don't need to submit an additional application if they are functionally eligible for, and in need of the following:

• Nursing Facility (NF) services,
• Community First Choice (CFC),
• Medicaid Personal Care (MPC), or
• Medicaid Alternative Care (MAC)

If a client needs waiver services they must submit an application and may need a disability determination.

Clarifying Information

An interview with the applicant or authorized representative is required to determine eligibility for institutional, HCB waiver services, or TSOA services. The PBS may waive the interview requirement. If the client is unable to complete the interview due to a medical condition or because no one is available to assist the client.

Asset verification, if not already authorized on the application by the client and financially responsible people (if applicable), may be authorized during the interview process.

Use Equal Access - Necessary Supplemental Accommodation (NSA) and long-term services and supports policies for LTSS applicants and recipients.

Worker Responsibilities

Document standard of promptness for all medical applications pending more than 45 days:

• Day one is the date the application was received.
• Update a good cause code when changing a program from an SSI-related assistance unit (AU) to an LTSS AU to prevent the case from being incorrectly reported as a new application.
• A good cause code must be used when finalizing any medical (AU) historically beyond 45 days.
• Cases without a delay reason code or updated with "No Good Cause (NG)" to the DSHS secretary.

Clarifying Information

There are two start dates for LTSS, the medicaid eligibility date and the LTSS start date:

1. Medicaid eligibility begins, the first day of the month the client is eligible for LTSS.
2. The LTSS authorization date, which is described in WAC 388-106-0045, WAC 388-106-0360 and RCW 74.42.056.
   1. If there is a transfer penalty as described in WAC 182-513-1363, the LTSS start date begins the day after the transfer penalty ends.
3. The LTSS start date is the date the client is both financially and functionally eligible. The authorization can't be backdated for HCB waiver, CFC, or MPC unless social services has fast-tracked services and the client is subsequently found financially eligible. Social services indicates the start date for HCB waiver on the DSHS 14-443 (communication from social services to HCS PBS), or the DSHS 15-345 (communication from DDA case manager to the DDA PBS).
4. For Hospice as a medicaid program, the hospice authorization date is based on the receipt of the 13-746 (HCA/medicaid Hospice notification). The hospice provider is required to submit this form within 5 business days of a hospice election on all active and pending Medicaid cases. If the 13-746 is not received timely, count back 5 business days from the date of receipt to determine the authorization date.
5. The LTSS authorization date can be backdated for nursing facility services up to 3 months prior to the date of application for a new applicant of Medicaid as long as the client is nursing facility level of care (NFLOC) and financially eligible.
6. The LTSS start date for nursing facility services on an active medicaid recipient is based on the first date the admission is reported to DSHS as long as the client meets all other eligibility factors. If the nursing facility admission is on a weekend or holiday, the authorization date is the date of admission as long as DSHS is notified by the next business day.

Clarifying information

If an applicant has withdrawn their request for medical benefits and then decides they want to pursue the application, we will redetermine eligibility for benefits without a new application as long as the client has notified the department within 30 days of the withdrawal. The PBS should review the original application to ensure there are no changes and proceed to determine eligibility.

Forms used in the application process

The application process begins and the application date is established when the request for benefits is received. These are the forms used in the application process for LTSS.

HCA forms, including translations are found on the HCA forms website.

DSHS forms, including translations are found on the DSHS forms website.

HCA 18-003 Rights and responsibilities (translations can be found at Health Care Authority (HCA) forms under 14-113)

HCA 18-005 Washington Apple Health application for aged, blind, disabled/long-term care coverage

HCA 18-008 Washington Apple Health application for tailored supports for older adults (TSOA)

DSHS 14-001 Application for cash or food assistance. This is used for any cash, food or medical care services (MCS) request as MCS is tied to ABD cash/HEN eligibility

HCA 14-194 Medical coverage information (used to report third party insurance coverage including LTC insurance)

DSHS 14-539 Revocable burial fund provision for SSI-related health care

DSHS 14-540 Irrevocable burial fund provision for SSI-related health care

DSHS 14-454 Estate recovery fact sheet. Repaying the state for medical and long-term services and supports

DSHS 14-501 Community resource declaration (used to evaluate resources (assets) for an applicant and their spouse based on date of institutionalization. WAC 182-513-1350)

DSHS 14-532 Authorized representative release of information.

DSHS 10-438 Long-term care partnership (LTCP) asset designation form (used to designate assets (resources) for those with a long-term care partnership insurance policy)

DSHS 14-012 Consent (release of information form) (used for all DSHS programs)

DSHS 27-189 Asset Verification Authorization

Note: The HCA 80-020 Authorization for Release of Information is for medical benefits under Health Care Authority and will be accepted as a release of information for all medical programs including LTSS programs. The DSHS consent form is preferred as it is used for all programs including medical, food and cash.

The long-term service and support application process - who makes the eligibility determinations

PBS determines financial eligibility by comparing the client's income, resources and circumstances to program criteria. The PBS also determines maximum client responsibility.

Social service staff and case managers determine functional eligibility and what services to authorize based on a complete and comprehensive CARE assessment.

For HCS clients, both functional and financial eligibility are determined concurrently. Functional eligibility for DDA is determined prior to the submission of a financial application. LTSS can begin once a client is found financially and functionally eligible and an approved provider is in place.

What is the process for nursing facility care?

For ABD, SSI-related Washington Apple Health programs:

1. Department-designated social service staff:
   1. Assess the client's functional eligibility for institutional care.
   2. Screen all clients to determine potential for HCB services.
   3. Determine if the client is likely to attain institutional status and be likely to reside at the nursing facility for 30 days or longer WAC 182-513-1320), or notifies the facility when the client doesn't appear to meet the need for nursing facility care.
   4. Determine if a housing maintenance allowance (HMA) is appropriate (current rule states HMA is the amount of the Federal Poverty Level).
   5. Provide PBS staff with the following information:
      1. Date of NF admission,
      2. Whether the client meets nursing facility level of care (NFLOC),
      3. For medicaid recipients, the first date DSHS was notified of the admission by the nursing facility,
      4. If the client is likely to attain institutional status,
      5. Whether there is a housing maintenance allowance and the start date, if appropriate.
2. Public benefit specialist (PBS) staff:
   1. Refer the client to social services for a care assessment if the client contacts the PBS first and document the date the client first requested NF care.
   2. Determine the client's financial eligibility for LTSS and noninstitutional medical assistance including 3 months retroactive medical coverage if financially eligible.
   3. Authorize payment for NF care if the client is both functionally and financially eligible.
      1. For medicaid applicants, institutional services are approved based on the date the client is eligible up to 3 months prior to the date of application.
      2. For medicaid recipients, institutional services are approved based on the first date the admission is known to DSHS as long as the client meets all other eligibility factors. If the NF admission is on a weekend or holiday, the NF has until the first business day to report the admission.
3. Issue the NF award letter to the applicant/recipient and the nursing facility.

What is the process for in-home or residential waiver services?

This process applies to SSI-related programs only MAGI-based clients are not eligible for HCB waiver.

1. Department-designated social service staff:
   1. Assess the client's functional eligibility for in home or residential care.
   2. Provide the PBS staff with the following information:
      1. Service start date
      2. Type of service
      3. Residential facility name and address, including room number, if applicable.
2. Public Benefits Specialists:
   1. Refer the client to social service intake for a CARE assessment if the client contacts the PBS first and document the date the client first requested in-home or residential care.
   2. Give a projected client responsibility amount to the case worker using the LTSS referral 07-104. Clearly indicate this is a projection and the financial application is in process.
   3. Determine the client's financial eligibility for LTSS medicaid and/or noninstitutional medical assistance including a request for retro medical if needed.
   4. Authorize in ACES for in-home or residential HCB waiver if the client is both functionally and financially eligible.
   5. Issue the award letter to the applicant/recipient.

Note: Services can't be backdated prior to the date of the authorization until the date that financial eligibility is established.

Clients switching from private pay to medicaid are advised to apply for benefits 30 to 45 days before being resource eligible for the program. There is good information on the Washington LawHelp site that explains the timing of an LTSS application.

What are the best practice guidelines for fast track?

Fast Track is a social service process that allows the authorization of LTSS prior to a financial eligibility determination. The HCS case manager coordinates and consults with the PBS to see if Fast Track is appropriate.

The PBS should make a Fast Track recommendation based on the information, verifications and cross-matches available, and send this determination via 07-104 to social services.

Questions to consider when making a Fast Track recommendation:

1. What resources is the client reporting on the application or past applications?
2. Are transfers indicated?
3. Did you receive verification of resources with the application?
4. Have you received Accurint and/or AVS results and reviewed the assets reported?
5. Is the client single or married, and which resource standard is being used to make a recommendation?

Social services can’t begin Fast Track until a CARE assessment is completed. The determination of Fast Track is ultimately up to social services.

Clients receiving services during the Fast Track period won't receive a medical services card until financial eligibility is established. Services may be authorized using Fast Track for a maximum of 90 days.

Don’t open a case in ACES until you have everything needed to establish financial eligibility.

If the client isn't financially eligible, notify social services. Social services will state fund Fast Track services when the client isn't financially eligible during the fast track period. An overpayment isn't established.