Presumptive eligibility for Home and Community Services (HCS)

Revised date
Purpose statement

This section describes the presumptive eligibility (PE) process used by Home and Community Services (HCS) Long-term Services and Supports (LTSS) described in WAC 182-182-1110, WAC 388-106-1810 and 388-106-1820.

WAC 182-513-1110 Presumptive eligibility (PE) - Long-term services and supports (LTSS) in a home setting authorized by home and community services (HCS).

WAC 182-513-1110 Presumptive eligibility (PE) - Long-term services and supports (LTSS) authorized by home and community services (HCS).

Effective January 6, 2024

  1. A person may be determined presumptively eligible for long-term services and supports (LTSS) in their own home, as defined in WAC 388-106-0010:
    1. Upon completion of a screening interview; and
    2. When authorized by home and community services (HCS).
  2. The screening interview described in subsection (3) of this section may be conducted by either:
    1. A HCS case manager or social worker;
    2. An area agency on aging (AAA) or their subcontractor; or 
    3. A state designated tribal entity.
  3. To be presumptively eligible (PE), the person must:
    1. Be determined to meet nursing facility level of care under WAC 388-106-0355 during the screening interview; and
    2. Attest to information that meets the:
      1. Income limits at or below the average monthly state nursing facility rate;
      2. Resource limits defined under WAC 182-513-1350;
      3. Social security requirement under WAC 182-503-0515;
      4. Residency requirement under WAC 182-503-0520; and 
  4. The agency or the agency's designee determines how much client responsibility must be paid to the provider for PE home and community-based services authorized by HCS when living at home as outlined in WAC 182-513-1215, 182-515-1507, and 182-515-1509.
  5. The client or the client's representative must submit an online application through Washington connection or an HCA 18-005 application for aged, blind, disabled/long-term care coverage to HCS within 10 calendar days of PE determination.
  6. The PE period begins on the date the screening interview is completed and:
    1. Ends on the last day of the month following the month of the PE determination if an LTSS application is not completed and submitted within 10 calendar days of PE determination; or
    2. Ends the last day of the month that the final eligibility determination is made if a LTSS application is submitted under subsection (5) of this section within 10 calendar days of PE determination.
  7. For application processing times, refer to WAC 182-503-0060.
  8. If the applicant is determined not financially eligible for LTSS under WAC 182-513-1315, there is no overpayment for services received during the PE period; however, client responsibility applies as described in WAC 182-513-1215, 182-515-1507, and 182-515-1509. 
  9. People who qualify for PE under this section receive categorically needy (CN) medical coverage under WAC 182-501-0060 through the PE period. CN medical coverage begins as described in WAC 182-503-0070 (1).
  10. When PE services described in WAC 388-106-1810 and 388-106-1820 are approved or denied, the agency or the agency's designee sends written notice as described in WAC 182-518-0010.
  11. A person may receive services under a PE period only once within a consecutive 24-month period.
  12. The applicant does not have a right to an administrative hearing on PE decisions under chapter 182-526 WAC.
  13. Institutional resource and income standards are found at https://www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply….
  14. This section does not apply to medical assistance programs described in WAC 182-507-0125 or 182-508-0005.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

Clarifying information

Under the 1115 Medicaid Transformation Project (MTP) waiver, Long-Term Services and Supports Presumptive Eligibility (LTSS PE) is a package of services that allows the state to waive certain Medicaid requirements and provides individuals an opportunity for expedited access to specific home and community-based services in their own home and Medicaid medical coverage, for a limited time, while full functional and financial eligibility are being determined..

LTSS PE will establish presumptive eligibility for individuals in need of long-term services and supports under Medicaid state plan and 1915(c) waiver authorities and Medicaid medical coverage when discharging from an acute or community psychiatric hospital stay or diverting from these facilities.

LTSS PE will be rolled out statewide in 3 phases:

  • Phase 1 starts December 4, 2023, and will span through early 2025. Phase 1 will be offered to applicants who will be or have discharged an acute care hospital or diverted from a community psychiatric hospital to their own home, in the last 30 days.
  • Phase 2 is anticipated to roll out statewide in spring / summer 2025 and expand LTSS PE services to applicants who choose to receive services in their own home.
  • Phase 3 is still under review by CMS. This phase is projected to expand to an alternative living facility setting. If approved, it may roll out statewide Fall 2025. A new chapter 30e has been added to the HCS Social Services long term care manual.

LTSS PE allows services to be authorized based on a brief screening of financial and/or functional eligibility criteria. The screening is completed by Home and Community Services (HCS) social service staff and in the near future, Area Agency on Aging (AAA) social service staff. The goal of LTSS PE is to provide individuals with expedited access to home and community-based services. Those under PE receive Apple Health categorically needy (CN) coverage while eligibility is being determined. Individuals already determined financially eligible for Medicaid state plan medical benefits will only require a functional PE determination. If the person is found PE, services can be received while financial and functional eligibility is being determined.

If a financial application has been filed, the PE period continues until the last day of the month that the final eligibility determination is made. When determined financially ineligible, the PBS sends a denial letter to the client and services will end the date the decision was made on the client's application.

If an application isn't filed within 10 calendar days of PE determination, the PE period stops at the end of the month following the month services were first authorized.

If the client is active on an S01, S02, or S08 program, the PE process and a new application is not required. If the client is in their review month, the renewal for the S02 and S08 follows regular renewal procedures. Follow regular change of circumstance procedures when changing the program to an L track when services are authorized by the HCS social worker/case manager.

If the client is active on a MAGI CN or Alternative Benefit Plan (ABP) program, the PE process is not needed if the client's needs are covered under CFC or MPC.

If the MAGI client needs HCBS Waiver services, the MAGI medical program will continue until an application for HCBS is received and eligibility for the L22 is determined.

For example:

Mary is currently hospitalized and would like to discharge to her own home. She will need access to caregiving services immediately upon discharge. Mary is found PE for LTSS services on March 1 and is discharging home with both a caregiver and Medicaid coverage in place. Mary has until March 11 to file an application for LTSS if she wishes to continue to receive Medicaid and caregiver services after the LTSS PE ends. If she doesn't apply by that date, the LTSS PE will end on April 30.

Mary filed the application by March 11 and will continue to receive services until a final eligibility decision is made on her application.

If it is later determined that Mary wasn't eligible for services, there is no requirement to repay any of the services that were received during the PE period. LTSS PE can't be backdated and won't cover services provided before the date of the authorization.

Worker responsibilities

The PE process is determined and authorized by HCS social services staff. The PE determination will be for both functional and financial eligibility criteria.

Social services will send a 14-443 authorizing LTSS PE. The Public Benefits Specialist (PBS) will immediately screen in and open a workaround S02. Indicate under HCBS "I" 1915(i) as a workaround. Set a tickler for 10 days to check for application. Once an LTSS application is received, the PBS will leave the S02 open while financial eligibility for the L-track is being determined. Once the LTSS application is approved or denied, send another 07-104 communication to social services to notify them of the final decision.

When the final L-track approval or denial is processed and the letter is sent, close the workaroundS02 with ACES reason code 599 and suppress the letter.

Once ACES supports this process, the ACES program will be a S32.

S02 workaround:

  • Screen S02 for the month PE starts.
  • Reduce the income to the MNIL using the MAGI redetermination workaround process, coding the difference as CI
    • If the client applies and/or is approved for food assistance, the amount the income is reduced by CI needs to be coded as unearned income type: Other Countable-Food Assistance (OF).
    • Code Disability / Incapacitated / Psychiatric with SSA or DDDS approval source if available. If no other disability approval source is available and form HCA 19-0054 is provided while DDDS is making determination code Attested Disability as the Approval Source, use the date PE was approved on 14-443 for the Approval Date and Established Date, and use the end of the month following the month PE was approved as the End Date.
    • Code Home and Community Based Services type 1915(i) as a placeholder and tracker for the PE AUs. Use the approval date for PE from the 14-443 for the Start Date and Payment Auth Date.
    • Narrate: Date 14-443 was received Start date for Presumptive Eligibility Screened S02 and workarounds used Approval of S02 with start date, deletion of S02 approval letter as SW mailed PE Approval Letter Any attempts made to contact client for Telephonic LTC Application If no Telephonic Signature, 10 day Tickle set to track receipt of LTC Application.
    • The Social Worker is responsible for providing the client with a Presumptive Eligibility Letter. The S02 Approval Letter will need to be deleted/suppressed same day.
    • Code AVS Authorized as Exception.
    • Code a shelter amount as $100 if not on food benefit as a workaround

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