Overview: long-term services and supports program administration

What is an institutional Medicaid program and what are Long-Term Care Services?

The definition of institutional is described in Institutional status | Washington State Health Care Authority

Long-term Care (LTC) and Long-term Services and Supports (LTSS) are defined in:  Definitions: long-term services and supports | Washington State Health Care Authority

LTC Apple Health has initial eligibility for Medicaid and post-eligibility treatment of income (PETI) to determine if the client pays toward the cost of care. LTC is:

• Residing in a medical institution 30 days or more
• On Home and Community Based (HCB) waivers and programs using HCB waiver rules | Washington State Health Care Authority:
  • Hospice as a program
  • Program of all-inclusive care for the elderly (PACE) | Washington State Health Care Authority
  • Roads to Community Living | Washington State Health Care Authority
  • State-funded long-term care for noncitizens | Washington State Health Care Authority

The LTSS group includes all LTC programs indicated above and non-institutional programs and services:

• Medicaid Personal Care | Washington State Health Care Authority
• Community First Choice | Washington State Health Care Authority
• Tailored supports for older adults (TSOA) | Washington State Health Care Authority
• Medicaid Alternative Care (MAC) | Washington State Health Care Authority
• HCS state-funded residential program through the Medical Care Service (MCS) program | Washington State Health Care Authority

In ACES, the LTSS medical programs are:

• L01, L02, L95, L99, (nursing facility (NF), Residential Habilitation Centers (RHC) and Hospice Care Center (HCC)
• L21, and L22 DDA and HCS HCBS Waivers
• L04 and L24 state funded LTSS for non-citizens
• L31 and L32 PACE or Hospice as a program
• L41 and L42 RCL program. 
• L51 and L52 non-institutional Community First Choice (CFC) or Medicaid Personal Care (MPC).

LTSS services not under L track in ACES:

• T02, Tailored Supports for Older Adults (TSOA, does not include Medicaid Coverage)
• A01, A05, A24 Medical Care Services (MCS) based on ABD cash or HEN eligibility covers NF and HCS state funded residential.  
• S08, Apple health for Workers with Disabilities (HWD) on HCS or DDA services remain on the S08 program with the service coded.  Apple Health for Workers with Disabilities | Washington State Health Care Authority
• N track, Modified Adjusted Gross Income (MAGI) programs when authorized CFC, MPC, MAC, RCL due to categorically needy (CN) or Alternate Benefit Plan (ABP) scope of care (maintained by Health Care Authority (HCA).
• D track, Foster Care. Can authorize CFC, MPC or MAC but the medical is maintained by HCA.
• S30 Breast and Cervical Cancer program. Can authorize CFC, MPC or MAC but the medical is maintained by HCA.

Basic guidelines:

DSHS maintains SSI, SSI related and Medicare Savings Programs (MSP) programs for the aged, blind, and disabled per the DSHS and HCA operating agreement.  DSHS has 3 entities determining eligibility for this group:   

• Home and Community Services (HCS) determines eligibility and maintains cases for those on HCS services, this includes their spouse even if the spouse is not on services. In addition, authorizes basic food and WASHCAP for those on HCS services.
• Developmental Disability Administration (DDA) determines eligibility and maintains cases on DDA services.  In addition, DDA does:
  • HWD cases not on HCS or DDA services
  • Hospice as a program when institutional rules are needed.
• Community Service Division (CSD) maintains:
  •  All remaining SSI, SSI related, and Medicare Savings Program cases are not on HCS or DDA services.
  • All cash programs except for ABD cash when a client is on DDA or HCS services.  This is a shared case.
  • Food benefits for the household when the DDA client is a minor child.

Health Care Authority (HCA) maintains the remaining Apple Health programs that are not SSI, SSI related or Medicare Savings Programs.

If a client submits an application that requests a variety of services, including Nursing Facility (NF), ALF and hospice, but the client hasn’t elected hospice yet, HCS determines eligibility and keeps the case until a hospice election is received.

The Apple Health Expansion state-funded program effective 7/1/2024 does not include long-term services and supports authorized by HCS or DDA.   

What is an institutional medicaid program and what are long-term care services?

The term "institutional" medicaid means institutional medicaid rules are used in eligibility. This group has initial eligibility for the medicaid and post-eligibility that determines if the client pays toward the cost of care. These clients are either residing in a medical institution or on a HCB Waiver. Some programs may use the same rules as a HCB Waiver such as Hospice, PACE and RCL and may pay toward the cost of care.  

In ACES, the institutional medical programs are under the L01, L02, L95, L99, L21, and L22 (ABD) programs, L04 and L24 state-funded long term care, or K-track (Modified adjusted gross income, MAGI) for children and families. PACE and Hospice as a program is under the L31 and L32 program.  RCL is under the L41 and L42 program.  Under MAGI, clients can be on the Hospice or RCL program.  Institutional rules are only used if the client is not eligible for another CN or ABP program.  

Long-term care (LTC) programs provide services for the aged and disabled in need of institutional care. Some individuals who receive LTC services are able to continue living in their home or in an alternate living facility (ALF) on a Home and Community based (HCB) Waiver authorized by Home and Community Services (HCS) or the Development Disabilities Administration (DDA). LTSS programs that are not considered “institutional” programs are Medicaid Personal Care (MPC) and Community First Choice (CFC). 

Basic guidelines:

ABD medical programs are the aged, blind, disabled (ABD) or SSI-related medical programs. MAGI medical is done through the Health Plan Finder/Health Benefit Exchange. 

TANF/Refugee cash and related food benefits are always maintained by Community Services Division (CSD).

HCS and DDA LTC specialty financial workers do not maintain MAGI medical or TANF/Refugee cash assistance and the related food benefits.

HCS and DDA LTC specialty workers always maintain ABD medical programs for clients receiving HCS and DDA services.  They also maintain the ABD medical program for a spouse when the other spouse is on LTSS.  If the client on LTSS is an adult, the HCS or DDA financial worker maintains the WASHCAP or food benefits for the HH.

DDA LTC specialty workers do not maintain related food benefits when the only client on DDA services is a minor.

ACES is programmed for shared cases based on the program responsibility chart.

Financial workers will manually assign Hospice cases and Health Care for Workers with Disabilities (HWD) cases that are not on HCS services to the DDA Long Term Care (LTC) Specialty Unit (017).

If a client submits an application that requests a variety of services, including NF, ALF and hospice, but the client hasn’t elected hospice yet, then HCS determines eligibility and keeps the case until a hospice election is received.

Find more information in the Long-term Services and Supports chart.