Overview: long-term services and supports program administration chart

The program responsibility chart gives most examples of which administration does what program.

Program responsibility chart

Home & Community Based Services

Home and community-based services, provided under a medicaid waiver granted by the federal government, enable a client to live in a residential setting outside of a nursing or other medical facility or in their own home. Such services are referred to as waiver services or use HCB Waiver rules in eligibility. The HCB services currently provided include:

• Community Options Program Entry System (COPES) authorized by HCS
• New Freedom authorized by HCS
• Program for All-Inclusive Care to the Elderly (PACE) is not a Waiver, but uses waiver rules for eligibility if a client is not eligible for another CN or ABP program. Can be authorized by HCS.
• Roads to Community Living (RCL) Not a Waiver, but uses waiver rules for eligibility if a client is not eligible for another CN or ABP program. Can be authorized by HCS, DDA or BHA.
• Core authorized by DDA
• Basic Plus authorized by DDA.
• Community Protection authorized by DDA.
• Children's Intensive In-home Behavioral Support (CIIBS) authorized by DDA.

Individual Family Services (IFS) authorized by DDA.

HCB Waiver services cannot be authorized under a MAGI or N track program. Eligibility for the L22 program must be done through the DDA/HCS financial worker. An HCA 18-005 or Washington Connections application are needed to apply for HCB Waiver, Institutional Medicaid or ABD medical program.

1115 Medicaid Transformation Demonstration Project (currently funded through 2022)

• MAC (Medicaid Alternative Care) MAC services are person-centered LTSS provided to unpaid caregivers caring for a Medicaid eligible person who meets NFLOC.
• TSOA (Tailored Supports for Older Adults) TSOA services are person-centered LTSS to unpaid caregivers caring for a person who meets NFLOC, but is not active on medicaid.

Institutional Services

Some clients require institutional services that can be provided only in a medical facility. Institutional medicaid rules must be used for clients who live in a medical facility for 30 days or more.

Hospice Services

Some clients receive Hospice index services in addition to or instead of services in their home or a medical facility. Hospice provides palliative care for clients dealing with a terminal illness or end-of-life issues. Hospice services are described in more detail in the Hospice section of the manual and in Chapter 182-551 WAC. Hospice services can be authorized as a service under any CN or ABP program. Hospice program rules are only used if a client outside an institution is not eligible for a noninstitutional CN or ABP program. Institutional rules are used for Hospice clients residing in a medical institution 30 days or more.

Hospice agencies must send notices within 5 business days of election. If the agency receives a ‘late’ hospice election notice for a client in a SNF, do not backdate services. Please contact Lori Rolley at HCS HQ, as HCA will need to adjust the provider payment.

Institutional Status

All clients approved for DDA Home and Community Based (HCB) waivers or ​​HCS Home and Community based (HCB) waivers Waiver services, Hospice services or in a medical institution 30 days or more have attained institutional status and are considered to be institutionalized as described in Medicaid law and the regulations used to implement these programs. A key difference for an institutionalized person is that eligibility is determined using only that person's income, and not the income of their spouse or children. Institutional status is described under WAC 182-513-1320.

Community First Choice (CFC)

Home & Community Services (HCS) and Developmental Disabilities Administration (DDA) can authorize Community First Choice (CFC) for clients eligible to receive a noninstitutional CN Medicaid program and assessed to be eligible for CFC. This includes clients under the adult medicaid expansion group who receive coverage under the Alternative Benefit Plan (ABP) scope of care (N05).

Medicaid Personal Care (MPC)

Home & Community Services (HCS) and Developmental Disabilities Administration (DDA) can authorize Medicaid Personal Care (MPC) for clients eligible to receive a noninstitutional CN Medicaid program and assessed to be eligible for MPC. This includes clients under the adult medicaid expansion group who receive coverage under the Alternative Benefit Plan (ABP) scope of care (N05).

MPC clients are not considered institutionalized. The financial eligibility for MPC is eligibility for a "noninstitutional" CN Medicaid program.

This category also describes the rules and procedures used to determine a person's eligibility for noninstitutional medical assistance provided in an ALF. This is a SSI related noninstitutional program under WAC 182-513-1205. For behavioral health placements or MPC in an ALF, the ACES program is a G03.

Eligibility Determinations

The department must determine a person's eligibility for LTC services according to both functional and financial requirements. Both financial and functional eligibility must be established concurrently. Coordination between financial and social service/case management staff is required to process applications and provide services.

Functional Eligibility

A department-designated social service specialist establishes functional eligibility for nursing home placement or long-term services and supports in the community or residential setting.

The HCS SW must authorize all nursing facility admissions before a nursing home award letter can be issued. (See applications for nursing facility care on the bottom of this clarifying page). For active Medicaid clients with short stay admissions (under 30 days) see Short stays. The exception to this is an admission into a State Veteran's Nursing Facility where a Veteran's Affairs Registered Nurse (VARN) determines NFLOC for admissions into a State Veteran's Nursing Facility. A NFLOC determination is not needed when a client enters a NF and is active on a HCB Waiver under a L21 or L22.

• The HCS social service specialist Area Agency on Aging (AAA) case resource manager, DDA case manager (CRM) or the Veterans Affairs registered nurse (VARN) determines functional eligibility for HCB waivers and MPC based on the client's assessment which takes into account the client's place of residence and services that are appropriate for the plan of care.
• The client admits into Providence Children's Hospital in Portland Oregon. A letter is issued upon admission. No NFLOC is needed.

Financial Eligibility

Financial Staff determines financial eligibility by comparing the person's income, resources, and circumstances to program requirements

The amount of income and excess resources a client must contribute to the cost of care for services received is established in what is called the post-eligibility determination (participation).

Financial staff must also determine eligibility for noninstitutional medical assistance at the same time they determine eligibility for institutional, waiver, or hospice services.

When determining eligibility and the cost of care for LTC services, program policy requires an allocation of income and resources from the institutionalized spouse (the applicant for LTC services) to the community spouse.(The spouse of an LTC applicant who is not applying for or receiving LTC services). This is to allow the community spouse to keep some assets and income necessary to maintain their home without requiring that the couple spend down all their assets to the individual resource limit of $2000. The Medicare Catastrophic Care Act in 1988 began the spousal allocation process used to discourage the impoverishment of a spouse due to the need for LTC services by their husband or wife. That law and those that have extended and/or amended it are referred to as spousal impoverishment legislation. (Section 1924 of the Social Security Act).

The rules used to determine eligibility and participation costs for waiver services are similar to those for institutional services, but there are important differences. These differences, in addition to those related to hospice services, are described in 182-551 WAC

A client may be eligible for both health care coverage and institutional services, or be eligible for one but not the other.

Agency/Department Responsibilities

Aged, Blind or Disabled medicaid (ABD) or Modified Adjusted Gross Income medicaid (MAGI)?

ALTSA is responsible for managing all the long-term care programs offered in the State of Washington. LTC programs are managed by both Home and Community Services (HCS) staff and by financial staff in the DDA/LTC specialty unit. The breakup of duties is defined below;

1. DDA/LTC Specialty Unit financial service specialist (FSS) staff determine financial eligibility for the following long-term care (LTC) client:
   • Developmental Disabilities administration (DDA) clients receiving LTC services in a DDA medical institution, ​DDA Home and Community Based (HCB) waivers or Medicaid Personal Care (MPC) residential services paid for by DDA and authorized under a ABD medical assistance unit. (Unless the DDA client is married and spouse is on HCS services, see HCS responsibility below).
   • DDA LTC medical institutions are:
   • Residential Habilitation Centers (RHC)
   • Intermediate Care Facilities for individuals with the Intellectual Disabilities (ICF/IID)
   • Mental health clients receiving residential services paid for by Mental Health / Behavioral Health Organization (MH/BHO) in an ARTF. Client not eligible for a MAGI, S01 or S02 and G03 rules need to be used for eligibility.
   • Hospice program rules are needed for eligibility because the client is not on a CN, MN or ABP program living outside a medical institution, unless the client is receiving an HCS HCB waiver service in home.
   • Hospice program rules because a client is in a Nursing facility or Hospice Care Center 30 days or more and client is not eligible under MAGI.
   • Hospice services are paid by Health Care Authority (HCA).
   • NF admits for clients who receive DDA services. If discharge date is unknown or anticipated to be longer than six months, the case will be transferred to HCS for ongoing maintenance. HCS will complete exit maintenance at discharge, including updating HCB services authorized by DDA, prior to transferring back to DDA.
   • Health Care for Workers with Disabilities (HWD) unless on HCS services.
   • Basic food eligibility when associated with a DDA LTC case unless the DDA recipient is a minor child.
   • Medicare Savings Program eligibility when associated with a DDA LTC case.
2. Home and community services (HCS) FSS staff determine financial eligibility for LTC clients who receive the following services from HCS:
   • Nursing facility (NF) care;
     • NF applications and maintenance for nursing facility (NF) care under the L track program.
     • Active ABD medical clients when NF care is 30 days or longer.
     • Active WASHCAP (CSO 130) when NF care is under 30 days and a NF short stay award letter is needed.
   • HCS services either in home or in an alternate living facility. This includes:
     • COPES
     • Community First Choice
     • New Freedom
     • Residential Support Waiver (RSW)
     • PACE Managed Care LTSS
     • Roads to Community Living (RCL)
     • Medicaid Personal Care (MPC)
     • Medicaid Alternative Care (MAC)
     • Tailored Supports for Older Adults (TSOA)
   • Food stamp eligibility (associated with LTC services) when the non-LTC clients in the household do not receive TANF cash.
   • ABD cash for clients receiving services authorized by HCS and eligible for HEN/MCS. ABD cash requires a 9 month disability duration determination by CSD for clients under age 65.
   • Medical Care Services (MCS) for clients receiving services authorized by HCS if there is no TANF cash
   • Married couple, one client is on HCS services ( ABD medical MAC/MPC or CFC or HCS Waiver or nursing home) the other spouse is on active DDA services. (ABD medical MAC/MPC or CFC or DDA Waiver).
   • Married couple, one client is on HCS services (MAC/MPC or CFC or HCS Waiver or nursing home). The other spouse is not on institutional medical, but is applying for an ABD medical program HCS is responsible for the application and maintenance of the community spouse's application for ABD medical.
   • The HCS SW is responsible to gather the information needed to submit a disability determination (NGMA) packet and referral if needed for the community spouse ABD medical application even if the institutional spouse is receiving COPES and is being case managed by the Area Agency on Aging

Health Care Authority

3. The Health Care Authority staff are responsible for managing the following cases:

• MAGI based institutional (K01, K03, K95, K99)
• Foster Care and Adoption Support cases (D01/D02/D26)
• Breast and Cervical Cancer cases (S30)
• Take Charge Family Planning (P06)
• MAGI-based Alien Emergency medical cases (N21-/N25) (updating the case with the medical consultant approval-initial eligibility is done through the Health Benefit Exchange)
• Pregnant Teens program (not in ACES)

When an LTC client is active on a case managed by HCA, special handling of the case may be necessary. Here are some examples of when additional coordination activities are required:

• An client that is approved for DDA waiver or COPES waiver services who is active on a foster care or adoption support program through the 076 ​Foster Care Relative Placement Adoption Support Juvenile Rehabilitation Unaccompanied Minor Program. (Active D01/D02/D26) is not managed by ALTSA staff. The client will remain on the 'D' track program.
  • For HCS services email Lori Rolley HCS HQ to coordinate with HCA-Foster Care Unit. Include client name and client ID.
  • For DDA services, DDA financial workers will coordinate with the 076 Foster Care and Adoption Support (FCAS) Unit for client’s 18 and older, with support from DDA Unit Manager Marcie Birdsall if applicable.
  • D02/D26 Foster Care cases remain with 076 until they age out, usually at age 26.
• Client is active on S30 breast and cervical cancer case. Clients on this program are eligible for CFC or MPC services if found functionally eligible. Active S30 cases will remain with the MEDS unit. S30 clients are not eligible for waiver services or nursing home coverage 30 days or longer. The clients will need to submit an applications for LTC services to HCS. These cases will need to be coordinated between MEDS and HCS offices. Contact Kim Moore 360-725-1469
• Client is active on N25 AEM medical in a hospital setting requiring discharge to a nursing home. A slot is approved for the state-funded nursing facility program by ALTSA HQ. Staff will need to contact the HCA MEDS unit to update the AEM approval coding on the ALAS screen to reflect the institutional placement

4. CSD financial staff are responsible for managing the following programs:

• TANF/SFA cash assistance
• ABD (Aged, blind disabled) cash assistance including those on a N track MAGI program through the Health Benefit Exchange and receiving MPC or NF services.
• PWA (Pregnant Women's Assistance)
• HEN (Housing & Essential Needs)
• RCA (Refugee Cash Assistance)
• Medical Care Services (MCS)
• Basic Food for non-LTC recipients unless the only household member receiving LTSS is a DDA child.
• WASHCAP for non-LTC recipients
• Childcare Assistance
• ABD non-LTC medical cases including, SSI-related (S02), medically needy/spenddown cases (S95/S99, Medicare Savings Program (S03, S04, S05, S06) and refugee medical (R03). This includes hospital applications with no plan of discharge.
• Medicare Savings Programs (MSP)

Health Benefit Exchange (HBE)

Effective 10/1/2013, children, parents and pregnant women must be converted over to health care coverage determined under the Modified Adjusted Gross Income (MAGI) methodology starting with the 11/2013 renewals. In January 2014, under the Medicaid expansion, single adults and parents with income at or below 138% FPL will also be eligible for health care coverage using MAGI methodologies. Eligibility for these coverage groups is determined by the Health Benefit Exchange through the Washington Healthplanfinder portal. The HBE is responsible for all 'N' Track programs as listed below, and determinations of eligibility for the Health Insurance Premium Tax Credit and Cost-Sharing reductions

• WAH for parents and caretaker relatives (N01)
• WAH transitional medical (N02)
• WAH Pregnancy coverage (N03)
• WAH MAGI-based adult coverage (N05)
• WAH Newborn coverage (N10)
• WAH Children's coverage (0 - 210%) - citizen and federally qualified noncitizens
• WAH Premium based children's coverage (210% - 312% FPL) - citizen and federally qualified noncitizens (N13)
• WAH Alien Emergency Medial for parents/caretaker relatives with income <= 53% FPL (N21)
• WAH Pregnancy coverage (noncitizens) (N23)
• WAH Alien Emergency Medical for single adults and parents/caretaker relatives with income <= 138% FPL (N25)
• WAH Children's coverage - noncitizen state-funded program (N31)
• WAH Premium based children's coverage - noncitizen state-funded program (N33)

ALTSA staff have limited ability to determine eligibility for cases managed through Washington Healthplanfinder limited to cases which require redetermination when an ABD medical case maintained by ALTSA closes. Contact your region designated staff if you have a case that needs redetermination through the Healthplanfinder. For all other changes and applications the person needs to be referred to the HBE call center (1-855-923-4633).

Shared Cases

A shared case is when cash, food and medical may be maintained by more than one agency or administration

• TANF and Refugee cash is always maintained by Community Service Division (CSD)
• HCB Waiver and institutional under the L track is always maintained by HCS or DDA Specialty Unit financial workers.

• Institutional under the K track is approved through the Health Care Authority (HCA), but maintained by DDA LTC Specialty Unit until upcoming ACES release.

• N track medical under MAGI is always maintained by the Health Benefit Exchange (HBE)
• Breast and Cervical Cancer and Foster Care medical is always maintained by the HCA.

Basic Program Division:

• HCS maintains ABD medical cases when a HH member is receiving HCS services or an ABD medical client residing in a NF 30 days or more.
• HCS maintains TSOA clients. HCS maintains MAC clients when active ABD medicaid.
• DDA LTC specialty unit maintains ABD medical cases when a HH member is receiving DDA HCB Waiver services, ABD CN medical for MPC in DDA residential settings and DDA institutions. In addition this unit does:
  • All HWD cases with the exception of HWD clients on HCS services.
  • Hospice eligibility under the L track program if the client is not eligible for any other CN or ABP program.
  • BHO placements in Mental Health residential facilities (G03 programs), unless otherwise eligible for CN or ABP medicaid.
• L track hospitalization 30 days or more ONLY if the person is not eligible for another CN, MN or ABP medical program including S99. L track medical for hospitalization 30 days or more may need to be considered under L track because of higher resource allowances for a married couple.
• HCS or DDA maintain any Medicare Savings program associated with an LTC case under the 'L' track.

Hospital Admits from NF or active HCB waiver

For SNF clients:

• Update living arrangement and institutional setting after client has been in the hospital for 30 days; medical will trickle to an institutional program and the case will stay with HCS or DDA office.
• If client is still in hospital at 90 days, check with SW or CRM to see if there is a discharge plan. If not, redetermine coverage under appropriate program (MAGI or classic). Individual regions may choose to keep these cases or transfer them out to CSD.

For active HCB waiver:

• If a hospital admit is less than 30 days, update as a short stay.
• If client is still in hospital at 90 days, check with SW or case manager to see if there’s a discharge plan. If not, redetermine coverage under appropriate program (MAGI or classic). Individual regions may choose to keep these cases or transfer them out to CSD.

CSD Cases:

• ABD medical cases when no HH member is receiving DDA or HCS services including hospital applications under S track medical programs. The exception to this is HWD (S08), BHO placements in residential (G03), institutional children (K track) and Hospice where L track is needed for eligibility.
• Food benefits if a medical program under N track (MAGI) maintained by HBE even if there is MPC services authorized by HCS or DDA
• Medicare Savings Program
• TANF, SFA and Refugee cash assistance
• CSD has out-stationed workers at Eastern and Western State hospital that determine eligibility for clients:
  • Age 21 or under at discharge.
  • 65 or older
  • Clients needing ABD medical upon discharge

Example # 1

Parent is on L21 receiving HCS HCB Waiver services. The parent is also receiving TANF cash for 3 children. The children are receiving N track medical through the HBE. The entire household is on basic food.

The L21/HCB Waiver case will be maintained by the HCS financial worker;

The TANF cash and basic food will be maintained by the CSD financial worker; and

The children's medical will be maintained by the Health Benefit Exchange (HBE).

Example # 2

Parent A is on CFC L51 authorized by DDA.

Parent B is on CFC L52 authorized by HCS.

2 children are on MAGI medical through the HBE.

The L51 and L52 are maintained by HCS. If the family applies for food benefits, it goes through HCS.

Example #3

Parent A is on CFC L51 authorized by DDA.

Parent B is on CFC L52 authorized by HCS.

2 children are on MAGI medical through the HBE.

The 2 children are on TANF cash through CSD.

In this example, since there is TANF cash involved it is a shared case. HCS maintains the 2 ABD CFC L51 and L52 programs and CSD maintains the TANF cash and associated food.

Example #4

Child is on L22 DDA Waiver.

Parent is on L22 HCS Waiver.

The L22 waiver for a minor child is always maintained by the DDA LTC specialty unit. In this example it is a shared case between the DDA specialty unit and HCS. Food benefits would be maintained by HCS as the adult is the head of household.

Example #5

Child is on L22 DDA Waiver.

Parents are on MAGI/N track through the HBE.

Family is on food benefits.

In this example, the DDA LTC specialty unit maintains the L22/DDA Waiver, HBE maintains the MAGI and food benefits are done through CSD as the adults are not on LTSS through DDA.

Forms, WACs, Rule Making and useful LTC links

DSHS and HCA forms, WACs, Rule Making and Useful Links

Washington State Health Care Authority income and resource standards for Medicaid

HCA ​Program standard for income and resources