WAC 182-526-0300 Order of dismissal based on subject matter

WAC 182-526-0300 Order of dismissal based on subject matter

Effective March 16, 2017

  1. An order of dismissal issued based on lack of subject matter jurisdiction must be entered as an initial order subject to the requirements of WAC 182-526-0520.

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.

WAC 182-526-0284 Orders of default

WAC 182-526-0284 Orders of default.

Effective August 18, 2018

  1. An order of default may be entered when the appellant fails to attend a scheduled prehearing conference or hearing. The order of default will include a notice of inquiry as to whether the appellant wants to petition to reinstate the hearing.
  2. The appellant may file a petition to vacate an order of default under WAC 182-526-0290.
  3. An order of default becomes a final order by operation of law, disposing of the appellant's request for a hearing under RCW 34.05.440 if:
    1. The appellant does not file a petition to vacate within twenty-one calendar days of the order being served (mailed) on the parties under WAC 182-526-0290 (2) and (5)(b); or
    2. If the appellant fails to appear at a prehearing conference scheduled to address the petition to vacate under WAC 182-526-0290 (3) and (4)(a).
  4. The health care authority or managed care organization action stands after an order of default becomes a final order.
  5. The appellant may seek judicial review of a final order of default to the superior court under WAC 182-526-0640.

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.

WAC 182-526-0102 Coordinated appeals process with the Washington health benefits exchange

WAC 182-526-0102 Coordinated appeals process with the Washington health benefits exchange.

Effective March 16, 2017

  1. The health care authority (HCA) coordinates with the Washington state health benefits exchange (HBE) to ensure a seamless appeal process for determinations related to eligibility for Washington apple health when the modified adjusted gross income (MAGI) methodology is used as described in WAC 182-509-0305.
  2. An applicant, recipient, or an authorized representative of an applicant or recipient may request an apple health hearing:
    1. By telephone;
    2. By mail (which should be sent to Health Care Authority, P.O. Box 45504, Olympia, WA 98504-5504);
    3. In person;
    4. By facsimile transmission;
    5. By email; or
    6. By any other commonly available electronic means.
  3. When an applicant or recipient appeals an HBE determination of eligibility for health insurance premium tax credits (HIPTC) or cost-sharing reductions with HBE and also requests a hearing with HCA related to apple health eligibility, the ALJ will not require the applicant or recipient to submit information to the ALJ that the applicant or recipient previously submitted to HBE.
  4. If an applicant or recipient submits to HBE a request for a hearing related to apple health eligibility, the ALJ will accept the date HBE received the request for the hearing as the date filed for the purposes of timeliness standards and will treat it as a valid hearing request.
  5. If the applicant or recipient appeals only the determination related to apple health eligibility, subsection (3) of this section does not apply.

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.

WAC 182-526-0100 Expedited administrative hearings for urgent health care needs

WAC 182-526-0100 Expedited administrative hearings for urgent health care needs.

Effective January 5, 2018

  1. Requesting an expedited hearing.
    1. An expedited hearing may be requested only in matters involving applicants or recipients.
    2. An applicant or recipient may request an expedited administrative hearing when the applicant or recipient believes there is an urgent health care need as defined in subsection (3) of this section.
    3. The applicant or recipient bears the burden of proof to establish an urgent health care need and must submit evidence or arrange for evidence to be submitted to the office of administrative hearings (OAH) with the expedited hearing request to support the need for an expedited hearing. Agency staff may help an applicant or recipient who asks for assistance in obtaining information that the agency has pursuant to WAC 182-503-0120.
    4. A recipient may be eligible for continued coverage according to WAC 182-504-0130.
  2. Exception to notice requirements. The notice requirements in this section prevail over notice requirements in WAC 182-526-0250.
  3. Standard for granting an expedited hearing request.
    1. For the purposes of this section, an urgent health care need means that waiting for an otherwise timely final order could jeopardize the applicant's or recipient's life, health or ability to attain, maintain, or regain maximum function.
    2. The administrative law judge (ALJ) grants a request for an expedited hearing only if the ALJ finds by a preponderance of the evidence submitted with the applicant's or recipient's expedited hearing request and the information listed below that the applicant or recipient has an urgent health care need.
    3. Information the ALJ may consider when determining whether the applicant or recipient has an urgent health care need and whether to subsequently grant or deny an expedited hearing request includes, but is not limited to:
      1. The documentation submitted with the expedited hearing request to show an urgent health care need;
      2. Whether the recipient is eligible for continued coverage of the benefits denied, reduced, or terminated by the agency or the agency's designee pending resolution of the appeal as an expedited hearing request may not be granted for individuals receiving continued coverage;
      3. The length of time between the applicant's or recipient's receipt of the agency's or the agency designee's adverse notice and the applicant's or recipient's request for an expedited hearing; and
      4. Whether the documentation submitted with the expedited hearing request shows that an appointment with a provider for a health care procedure or treatment to address the applicant's or recipient's stated urgent health care need:
        1. Is scheduled; or
        2. Cannot be scheduled due to a lack of coverage.
  4. Time frame and notice requirements for expedited hearing request determination. The ALJ must grant or deny the expedited hearing request and issue the determination within four business days of receipt of the request by OAH or as expeditiously as possible. OAH must immediately notify the parties orally and in writing of the ALJ's determination, unless the parties waive written notification. The oral and written notice must clearly state:
    1. Whether the expedited hearing request was approved or denied;
    2. That a hearing has been or will be scheduled; and
    3. The information listed in subsection (3)(c) of this section that the ALJ relied upon.
  5. Scheduling an expedited hearing. If the ALJ grants a request for an expedited hearing, OAH will schedule a hearing and provide notice as expeditiously as possible, allowing for a reasonable amount of notice and time for the parties to prepare for hearing. The notice rules in WAC 182-526-0250 do not apply.
  6. Denial of expedited hearing. If the ALJ denies an expedited hearing request, OAH will schedule the hearing based on standard scheduling practices and the notice rules in WAC 182-526-0250.
  7. Appeal right. There is no right to appeal an ALJ's determination to grant or deny an expedited hearing request.
  8. Expedited hearing initial order. If an expedited hearing request is granted and an expedited hearing is held, the ALJ must issue an initial order as expeditiously as possible.
  9. Expedited final order. Any party may request administrative review of the initial order with the health care authority board of appeals according to WAC 182-526-0560 through 182-526-0600. The board of appeals will issue a final order as expeditiously as possible.
  10. Delayed expedited hearing request determination or expedited hearing initial order. The ALJ has a duty to determine whether to grant or deny an expedited hearing request and, if granted, to issue an expedited hearing initial order as expeditiously as possible, except in unusual circumstances when:
    1. An ALJ is unable to reach a decision because the applicant or recipient requests a delay or does not take a required action; or
    2. There is an administrative or other emergency beyond OAH's or the agency's control.

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.

WAC 182-505-0300 Hospital Presumptive Eligibility

WAC 182-505-0300 Hospital Presumptive Eligibility

Effective 6/30/2017

  1. Purpose. The hospital presumptive eligibility (HPE) program provides temporary Washington apple health coverage to HPE-eligible persons who enroll through an HPE-qualified hospital.
  2. HPE-eligible persons. To be HPE-eligible:
    1. A person must:
      1. Be younger than age 65; and
      2. Meet the eligibility requirements for one or more of the following programs:
        1. Washington apple health for pregnant women (chapter 182-505 WAC);
        2. Washington apple health for kids (chapter 182-505 WAC);
        3. Washington apple health for foster care (chapter 182-505 WAC);
        4. Washington apple health for parents and caretaker relatives (chapter 182-505 WAC);
        5. Washington apple health for adults (chapter 182-505 WAC); or
        6. Family planning only services (chapter 182-532 WAC).
    2. A person must not:
      1. Be an apple health beneficiary;
      2. Be a supplemental security income beneficiary; or
      3. Have received HPE coverage within the preceding 24 months.
  3. HPE-qualified hospitals. To be HPE-qualified, a hospital must:
    1. Operate in Washington state;
    2. Submit a signed core provider agreement (CPA) to the agency;
    3. Submit a signed HPE agreement to the agency;
    4. Comply with the terms of the CPA and HPE agreements;
    5. Determine HPE eligibility using only those employees who have successfully completed the agency's HPE training;
    6. Agree to provide HPE-application assistance to anyone who requests it; and
    7. Agree to be listed on the agency's web site as an HPE-application assistance provider.
  4. Limitations.
    1. An HPE-qualified hospital must attempt to help the person complete a regular apple health application before filing an HPE application. If the person cannot indicate whether they expect to file a federal tax return or be claimed as a tax dependent, the HPE-qualified hospital may treat the person as a nonfiler under WAC 182-506-0010 (5)(c) for HPE purposes.
    2. HPE coverage begins on the earlier of:
      1. The day the HPE-qualified hospital determines the person is eligible; or
      2. The day the HPE-qualified hospital provides a covered medical service to the person, but only if the hospital determines the person is eligible and submits the decision to the agency no later than five calendar days after the date of service.
    3. HPE coverage ends on the earlier of:
      1. The last day of the month following the month in which HPE coverage began; or
      2. The day the agency determines the person is eligible for other apple health coverage.
    4. HPE coverage does not qualify a person for continuous eligibility under WAC 182-504-0015.
    5. If HPE coverage is based on pregnancy, the pregnant person is eligible for HPE coverage only once for that pregnancy.
    6. The HPE program covers only those services included in the programs listed in subsection (2)(e) of this section, except that pregnancy-related services are limited to ambulatory prenatal care.
    7. A child born to a person with HPE coverage is ineligible for apple health under WAC 182-505-0210(2). An HPE-qualified hospital must complete a separate HPE determination for the newborn child.

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.

Trauma-informed approach

Imagine a world where we interact with every life we meet as if we knew their story of hardship and trial—and engaged with them from that knowledge. Welcome to trauma-informed approach (TIA). 

What is trauma-informed approach?

Dr. Isaiah Pickens, Ph.D., an expert on cultivating trauma-informed approaches, explains:

For more information

Learn how to implement a trauma-informed approach in your agency

In 2019, HCA awarded nearly 1.4 million dollars in grants to organizations across the state to build on the trauma-informed work already happening across the state, and to support interest that had been previously unfunded.

To hear more from providers that participated in this initiative and what they learned, watch our webinar on trauma-informed approaches.

Expand your trauma-informed footprint

Use the following list of self-evaluation tools to explore how you can increase trauma-informed approach across your agency.

Events

Online training

The following online courses on trauma-informed approach (TIA) are available in English and Spanish:

  • TIA overview for everyone
  • TIA for agency leaders
  • TIA for staff
  • TIA for supervisors

How do I sign up? 

You will use the Bridge app to sign up for training. You must have a Bridge account before you can register for a course. 

  1. Go to the TIA Washington Training Center.
  2. Scroll down the page to register for Bridge.
  3. Once you have created a Bridge account, log into Bridge to register for a training. 
  4. You will receive a welcome invitation from TIA Washington to access the courses.

Promissory notes and loans

Revised date
Purpose statement

Describe and clarify rules on how promissory notes and loans affect Medicaid eligibility.

WAC 182-516-0400 Promissory notes and loans.

WAC 182-516-0400 Promissory notes and loans.

Effective March 2, 2018

  1. General.
    1. In this section, note includes promissory note, loan or other obligation to pay.
    2. The medicaid agency or the agency's designee determines the value of outstanding principal and interest payments using amortization schedules, unless otherwise stated in this section.
  2. A note as a resource.
    1. A note is a resource. The value of the note is the fair market value (FMV).
    2. The FMV of a note is the outstanding principal of the note, unless convincing evidence to the contrary is provided to the agency or the agency's designee.
    3. If the note owner provides convincing evidence to the agency or the agency's designee of a legal bar to the sale of the note, the note's FMV is zero.
  3. A note as income.
    1. Interest on a note is unearned income.
    2. If the FMV of the note under subsection (2)(c) of this section is zero, the principal portion of recurring payments is unearned income.
    3. The agency or the agency's designee may budget the unearned income in equal monthly amounts at the request of the note owner, or at the agency's or the agency's designee's discretion. The budgeting period will be the note owner's certification period under chapter 182-504 WAC.
  4. A note as an asset transfer under WAC 182-513-1363.
    1. Subject to (b) of this subsection:
      1. The agency or the agency's designee evaluates the purchase of a note as an asset transfer if the purchase price of the note exceeds the FMV of the note;
      2. The value of the asset transfer is the difference between the purchase price of the note and the FMV of the note at the time of purchase; and
      3. The agency or the agency's designee determines the FMV of the note at the time of purchase using subsection (2) of this section, but can also determine the FMV of the note at a time after purchase if the agency or the agency's designee determines FMV of the note has changed since the time it was purchased.
    2. The assets used to purchase a note are an uncompensated asset transfer under WAC 182-513-1363, unless the note:
      1. Prohibits the cancellation of the balance of the note upon death of the note owner; and
      2. Is paid out, in equal periodic amounts with no deferral and no balloon payments, over a term not greater than the actuarial life expectancy of that note owner.
    3. The value of the uncompensated asset transfer under (b) of this subsection is the outstanding balance of the note due as of the date of the client's application for medical assistance for institutional or home and community-based waiver services.
    4. If the purchase of a note results in a period of ineligibili­ty under both (a) and (b) of this subsection, then the period of in­ eligibility under WAC 182-513-1363 will be the period that is longer.

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

General

When a person loans something of value (almost always cash), the promise to repay that loan is worth something. Generally, the value of the promise is the amount remaining to be paid on the loan.

The person who receives the loan and promises to repay is the grantor/payor of the promissory note. The grantee/payee of the loan is the person who owns the promissory note. Generally, the Medicaid client is the grantee/payee and the client owning the promissory note may have resource implications if resources are a part of Medicaid eligibility.

Example: Sam loans his daughter Erin $10,000. Erin creates and signs a promissory note to repay the $10,000 over 5 years. Erin is the grantor and Sam is the grantee. Sam no longer has the $10,000, but owns the note Erin created. After three years, Erin owes Sam $6,000. At this time, the value of Sam’s note is $6,000.

Sales contracts

Certain promissory notes exchanged for real property that was the client's (or spouse's) home are named "sales contracts" in WAC 182-512-0350. Before continuing here, review the promissory note to determine if it falls under any sales contract rules under WAC 182-512-0350 (3) through (10).

Resource

The assumed fair market value (FMV) of a note is the amount owing (the "principal"). If a note cannot be sold because of a legal barrier, the FMV is $0 (as opposed to being an excluded resource). However, under WAC 182-512-0250 (8), the value of a note (or any resource) is its FMV, less any encumbrances. Accept and consider evidence for the FMV of the note. Certain factors can value a note at less than the owed principal.

Examples: A few examples of where the FMV of a note may be less than the principal owed: The note is unsecured (the owner of the note does not have the ability to seize property to satisfy the note if the grantor defaults. The note bears no interest (a $10,000 note with $10,000 outstanding principal is worth much less than $10,000 if it is paid off over many years with no interest). No contract (there is no written agreement to pay, only an oral promise or an implied promise).

Income

When a note has a FMV greater than $0, the periodic payment consists of interest 

and principal (though sometimes it may only be principal if the note is interest free). Because the note is a resource, the principal portion of a periodic payment is a resource conversion, and not income (i.e., a portion of the note is turned into cash). The interest portion, if any, is unearned income.

If the FMV of a note is $0, the entire periodic payment is unearned income.

Asset transfer

There are two tests for an asset transfer related to notes.

  • First, as with any resource, if the assets used to purchase the note (i.e., in most circumstances, the money loaned) exceed the FMV of the note, there is uncompensated value. The date of the purchase of the note is the transfer date. Factors that affect the present FMV of the note also affect the FMV of the note when it was created.
  • Second, there are objective tests that, if failed, make the entire note uncompensated. The transfer date for these tests is the date of application for long-term care (LTC); and the uncompensated value is the outstanding principal on the date of application for long-term care (LTC).
    • The note must explicitly prohibit note cancellation upon the death of the note owner. Mere silence on the ability to cancel is not enough, the note must state it cannot be cancelled on death. A note can be amended to conform with this.
    • The note must be paid out, in equal periodic amounts with no deferral and no balloon payments, over a term not greater than the actuarial life expectancy of that note owner. A note payment schedule can be restructured to conform with this.

Example: Sara loaned her sister Jamie $30,000 one year ago. The note is unsecured and bears no interest. The note has equal payments, no deferral or balloon payments, is paid off within Sara's life expectancy and is not cancellable on death. Today the outstanding principal is $29,000. Sara has tried to sell the note, but many potential buyers feel the note isn't worth much. One buyer valued the note at $1,000 and another valued it at $2,000. A reasonable FMV would be $1,500. Because Sara gave Jamie $29,000 (originally $30,000, but $1,000 has been paid back) in exchange for a note worth $1,500, Sara has an uncompensated transfer of $27,500.

Example: Same example as above, except the note is paid off beyond Sara's life expectancy. Sara applied for LTC today. The uncompensated value is $29,000.

If a note is a transfer under both tests (the FMV test and the objective test), then the uncompensated value is the greater of the two.

Worker Responsibilities

Review any notes that the client or their financially responsible AU member owns. Accept and consider evidence as to the FMV of the note. Document the FMV of the note and how you determined the FMV. Calculate and document any unearned income on a note. 

Related links

WAC 182-512-0350

WAC 182-513-1363

Please report broken links or content problems.

Trusts continued

Revised date
Purpose statement

Describe and clarify rules on how trusts affect Apple Health (Medicaid) eligibility.

WAC 182-516-0110 Self-settled trusts overview

WAC 182-516-0110 Self-settled trusts overview.

Effective March 2, 2018

  1. A trust containing the assets of a beneficiary's spouse may be a self-settled trust based on the date it was established. For specific rules regard­ ing this, see WAC 182-516-0130.
  2. To determine whether the assets of the self-settled trust should be counted as income, a resource, or an asset transfer, the medicaid agency or the agency's designee applies the following rules based on when the trust was established:
    1. For revocable self-settled trusts, see WAC 182-516-0115.
    2. For irrevocable self-settled trusts for a disabled client under age sixty-five established on or after August 11, 1993, see WAC 182-516-0120.
    3. For irrevocable pooled self-settled trusts for a disabled client established on or after August 11, 1993, see WAC 182-516-0125.
    4. For all other irrevocable self-settled trusts:
      1. Established on or after August 11, 1993, see WAC 182-516-0130.
      2. Established before August 11, 1993, see WAC 182-516-0135.

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

A trust’s establishment date is the date the first asset was placed into the trust, not the date the trust was signed.

Before using the self-settled trust rules ensure the trust you are evaluating is self-settled. Trusts established after July 31, 2003 are self-settled even when all assets in the trust were owned by the client’s spouse.

A trust is still self-settled even when the beneficiary/grantor had no control over the establishment of the trust with their assets.

Example: Settlement funds from a lawsuit directed into a trust by a court or a guardian establishing a trust for an incapacitated individual with the individual's assets are both self-settled trusts.

WAC 182-516-0115 Revocable self-settled trusts established on or after August 11, 1993

WAC 182-516-0115 Revocable self-settled trusts established on or after August 11, 1993.

Effective March 2, 2018

  1. This section applies to revocable trusts that are self-settled and established on or after August 11, 1993.
  2. This section does not apply to assets in a revocable trust established before August 11, 1993.
  3. A revocable trust is a self-settled trust if:
    1. The assets of the trust are at least partially from the bene­ficiary or the beneficiary's spouse;
    2. The trust is not established by will; and
    3. The trust was established by:
      1. The beneficiary or that beneficiary's spouse;
      2. A person, including a court or administrative body, with legal authority to act in place or on behalf of the beneficiary or that beneficiary's spouse; or
      3. A person, including a court or administrative body, acting at the direction or upon the request of the beneficiary or that beneficiary's spouse.
  4. The medicaid agency or the agency's designee treats assets in a revocable self-settled trust under this section as follows:
    1. Assets are subject to the resource exclusions under chapter 182-512 WAC; however, for an institutionalized individual, the resource exclusion for the home under WAC 182-512-0350 does not apply; and
    2. Assets not excluded under chapter 182-512 WAC are available resources.
  5. Payments from assets in the trust under this section to or for the benefit of the beneficiary are unearned income of the beneficiary.
  6. If unearned income under subsection (5) of this section was from an available resource under subsection (4) of this section, then the value of the available resource will be reduced by the amount of unearned income under subsection (5) of this section.
  7. Any payments from the revocable trust, other than payments under subsections (5) and (6) of this section, are uncompensated asset transfers.

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

Generally, a revocable trust can be treated just the same as if the client or spouse (or both) owns the assets directly. This is because they have a choice whether to reacquire the assets in the trust or not.

Resource Example: As of the first of the month, a client has personal property, a car for transportation, and $50,000 in cash in a trust. The countable resource value of the trust is $50,000 because the personal property and car are excluded resources.

Income Example: Using the same trust above, the trustee buys a plane ticket for the client for $1,000 from the trust in February 2018. This withdraw is countable unearned income for February 2018, even if the client did not directly receive the cash. Because the $1,000 in income was withdrawn from the $50,000 in cash, resources for February 2018 would be reduced by $1,000.

Institutionalization Example: Same trust as above, but the client also has their home in the trust. If the client is applying for a noninstitutional Medicaid program (for example, S02 or L52), the home is an excluded resource. However, if the client is institutionalized in a nursing home and is applying for nursing home coverage, or the client is applying for a home and community-based (HCB) waiver, the home is not excluded and is an available resource.

 

WAC 182-516-0120 Irrevocable self-settled trusts for a disabled client under age sixty-five established on or after August 11, 1993.

WAC 182-516-0120 Irrevocable self-settled trusts for a disabled client under age sixty-five established on or after August 11, 1993.

Effective March 2, 2018

  1. This section governs how the agency or the agency's designee treats self-settled trusts, for a disabled client under age sixty-five established under 42 U.S.C. 1396p(d)(4)(a) on or after August 11, 1993, for medicaid eligibility purposes.
  2. A self-settled trust established on or after August 11, 1993, is not an available resource if:
    1. The beneficiary is under age sixty-five and disabled under WAC 182-512-0050 (1)(c) when the trust is established;
    2. The trust is irrevocable;
    3. The trust was established for the sole benefit of that bene­ficiary;
    4. The trust was established by the beneficiary's parent, the beneficiary's grandparent, the beneficiary's legal guardian, by a court, or on or after December 13, 2016, the beneficiary; and
    5. The trust says that the states that have spent medicaid funds for the beneficiary will receive all amounts remaining in the trust up to the amount of medicaid funds spent for the beneficiary.
      1. For trusts established from August 11, 1993, to July 31, 2003, the trust must pay the states when the beneficiary dies.
      2. For trusts established on or after August 1, 2003, the trust must pay the states when the beneficiary dies, the trust terminates, or the beneficiary's disability ends.
  3. The medicaid agency or the agency's designee does not apply a penalty period to a beneficiary for asset transfers into a trust, described under subsection (2) of this section, when the beneficiary is under age sixty-five as of the date of the transfer.
  4. Assets in trusts under subsection (2) of this section contin­ue to be unavailable resources, even after the beneficiary turns age sixty-five.
  5. Asset transfers to the trust from the beneficiary, after the beneficiary turns age sixty-five, may be subject to a transfer penalty under WAC 182-513-1363.
  6. If a trust does not meet the requirements under subsection (2) of this section, see WAC 182-516-0130.

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.

WAC 182-516-0125 Irrevocable pooled self-settled trusts for a disabled client established on or after August 11, 1993.

WAC 182-516-0125 Irrevocable pooled self-settled trusts for a disabled client established on or after August 11, 1993.

Effective March 2, 2018

  1. This section governs how the agency or the agency's designee treats pooled self-settled trusts, for a disabled client established under 42 U.S.C.1396p(d)(4)(c) on or after August 11, 1993, for medicaid eligibility purposes.
  2. A pooled self-settled trust established on or after August 11, 1993, is not an available resource if:
    1. The beneficiary is disabled under WAC 182-512-0050 (1)(c) when the trust is established;
    2. The trust is irrevocable;
    3. An account in the trust was established for the sole benefit of that beneficiary;
    4. An account in the trust was established by that beneficiary, the beneficiary's parent, grandparent, legal guardian, or by a court;
    5. The trust was established by and is managed by a nonprofit association;
    6. A separate account is maintained for each beneficiary of the trust, but, for the purposes of the investment and management of funds, the trust pools these accounts; and
    7. The trust says that:
      1. Upon the death of the beneficiary, or, for trust accounts es­tablished on or after August 1, 2003, when the trust account terminates or the beneficiary's disability ends, the funds will remain in the trust to benefit other disabled beneficiaries; or
      2. The states that have spent medicaid funds for the beneficia­ry will receive all amounts remaining in the trust account for that beneficiary up to the amount of medicaid funds spent for the beneficiary.
        1. For trust accounts established from August 11, 1993, to July 31, 2003, the trust must pay the states when the beneficiary dies.
        2. For trust accounts established on or after August 1, 2003, the trust must pay the states when the beneficiary dies, the trust terminates, or the beneficiary's disability ends.
  3. The medicaid agency or the agency's designee does not apply a penalty period to a beneficiary for asset transfers into a trust, described under subsection (2) of this section, when the beneficiary is under age sixty-five as of the date of the transfer.
  4. Assets in trusts under subsection (2) of this section continue to be unavailable resources, even after the beneficiary turns age sixty-five.
  5. Asset transfers to the trust from the beneficiary, after the beneficiary turns age sixty-five, may be subject to a transfer penalty under WAC 182-513-1363.
  6. If a trust does not meet the requirements under subsection (2) of this section, see WAC 182-516-0130.

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

There are two exceptions to the normal counting an irrevocable self-settled trust as an available resource. We refer to these trusts by shorthand citation to their statuses in the Social Security Act - a "d4A" trust or a "d4C" trust:

  • 42 U.S.C. 1396p(d)(4)(A) - a self-settled irrevocable trust for a disabled individual established before that individual is age 65.
  • 42 U.S.C. 1396p(d)(4)(C) - a self-settled irrevocable pooled trust for a disabled individual of any age.

These are the only two trusts that require some form of payback language in order to be excluded for Medicaid.

If a trust does not meet the requirements of WAC 182-516-0120 (d4A) or WAC 182-516-0125 (d4C), then rules under WAC 182-516-0130 apply.

WAC 182-516-0130 Irrevocable self-settled trusts established on or after August 11, 1993.

WAC 182-516-0130 Irrevocable self-settled trusts established on or after August 11, 1993.

Effective March 3, 2018

  1. This section governs irrevocable self-settled trusts established on or after August 11, 1993, that do not meet the rules under either WAC 182-516-0120 or 182-516-0125.
  2. A trust established on or after August 1, 2003, is a self-settled trust if:
    1. The assets of the trust are at least partially from the bene­ficiary or the beneficiary's spouse, or would have been owned by the beneficiary or the beneficiary's spouse unless diverted by the beneficiary, the beneficiary's spouse, the court, or someone acting on be­half of the beneficiary or the beneficiary's spouse;
    2. The trust is not established by will; and
    3. The trust was established by:
      1. The beneficiary or that beneficiary's spouse;
      2. A person, including a court or administrative body, with le­ gal authority to act in place or on behalf of the beneficiary or that beneficiary's spouse; or
      3. A person, including a court or administrative body, acting at the direction or upon the request of the beneficiary or that beneficiary's spouse.
  3. A trust established from August 11, 1993, to July 31, 2003, is a self-settled trust if:
    1. The assets of the trust are at least partially from the bene­ficiary, or would have been owned by the beneficiary unless diverted by the beneficiary, the court, or someone acting on behalf of the beneficiary;
    2. The trust is not established by will; and
    3. The trust was established by:
      1. The beneficiary;
      2. A person, including a court or administrative body, with le­gal authority to act in place or on behalf of the beneficiary; or
      3. A person, including a court or administrative body, acting at the direction or upon the request of the beneficiary.
  4. This section applies only to the assets contributed to a trust:
    1. Under subsection (2) of this section, by either the benefi­ciary or that beneficiary's spouse; or
    2. Under subsection (3) of this section, by the beneficiary.
  5. The medicaid agency or the agency's designee applies the rules of this section without regard to:
    1. The purpose for establishing a trust;
    2. Whether the trustees have or may exercise any discretion un­der the terms of the trust;
    3. Restrictions on when or whether distributions may be made from the trust; and
    4. Restrictions on the use of distributions from the trust.
  6. Treatment of payments or benefits from trusts established un­ der this section.
    1. Subject to subsection (7) of this section, if there are any circumstances under which payment or benefit from the trust could be made to or for the benefit of the beneficiary, the portion of the principal from which, or the income on the principal from which, payment to the beneficiary could be made is an available resource to the beneficiary, and the payment or benefit from that portion:
      1. Is unearned income when payment or benefit is to or for the benefit of the beneficiary; and
      2. Is an uncompensated asset transfer, if payment or benefit is for any other purpose.
    2. If there are no circumstances under which any payment or any benefit from the trust could be made to or for the benefit of the ben­eficiary, the part of the trust or income of that trust, from which payment or benefit cannot be made, is an uncompensated asset transfer.
  7. For the purposes of subsection (6)(a) of this section, "available resource" means a resource after the resource exclusions under chapter 182-512 WAC are applied; however, for an institutional­ized individual, the resource exclusion for the home under WAC 182-512-0350 does not apply.
  8. If unearned income under subsection (6)(a)(i) of this section was from an available resource under subsection (6)(a) of this section, then the value of the available resource will be reduced by the amount of unearned income under subsection (6)(a)(i) of this section.

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

General

By definition, a self-settled trust is established for the benefit of the grantor/beneficiary. When reviewing trusts under this rule, the agency essentially ignores any restrictions or requirements written into the trust. This includes disregarding:

  • The purpose for establishing a trust;
  • Whether the trustees have or may exercise any discretion under the terms of the trust;
  • Restrictions on when or whether distributions may be made from the trust; and
  • Restrictions on the use of distributions from the trust.

After disregarding the above, whether an irrevocable self-settled trust is a resource or not is whether the trust principle or income can be used for the beneficiary. It will be extremely rare, if possible at all, that a self-settled irrevocable trust cannot be used for the benefit of the beneficiary.

Can/Cannot Example 1: An irrevocable self-settled trust states the trust cannot be used for medical expenses for the beneficiary. We disregard this restriction, the trust can be used for the grantor/beneficiary.

Can/Cannot Example 2: An irrevocable self-settled trust gives the trustee complete discretion on when to use trust assets. The trustee states they will never use the trust assets. We disregard the trustee’s discretion, the trust can be used for the grantor/beneficiary.

Once it is determine whether a trust can be used for the beneficiary, we must evaluate the trust’s resources and income.

Resource Example: As of the first of the month, a client has personal property, a car for transportation, and $50,000 in cash in a trust. The countable resource value of the trust is $50,000 because the personal property and car are excluded resources.

Income Example: Using the same trust above, the trustee buys a plane ticket for the client for $1,000 from the trust in February 2018. This withdraw is countable unearned income for February 2018, even if the client did not directly receive the cash. Because the $1,000 in income was withdrawn from the $50,000 in cash, resources for February 2018 would be reduced by $1,000.

Institutionalization Example: Same trust as above, but the client also has their home in the trust. If the client is applying for a noninstitutional Medicaid program (for example, S02 or L52), the home is an excluded resource. However, if the client is institutionalized in a nursing home and is applying for nursing home coverage, or the client is applying for a home and community-based (HCB) waiver, the home is not excluded.

The August 1, 2003 Cutoff

From August 11, 1993, to July 31, 2003, the definition of a self-settled trust for a married individual was narrower than it is today. A trust was only self-settled if all or a portion of the assets in the trust were from the client. This means that if all assets in the trust were solely the spouse’s assets, and the client is the beneficiary, the trust would be third-party. However, we would still analyze whether the trust was a countable resource for the spouse (assuming the spouse could also receive some benefit from the trust). Further, we would need sufficient evidence that all assets in the trust were separate property of the spouse, and not community property.

As of August 1, 2003, it does not matter whose assets of the married couple is in the trust. If the trust is for the benefit of the client, and at least some assets in the trust were from the client or the client’s spouse, it is a self-settled trust.

Additional information about Trusts can be found on the Trusts page.

Please report broken links or content problems.

Overview: long-term services and supports program administration

Revised date
Purpose statement

To give an overview of program administration for Long-Term Services and Supports (LTSS) for individuals in medical institutions or receiving Home and Community Based services authorized by:

  • Developmental Disabilities Administration (DDA) or
  • Home and Community Services (HCS) or
  • Hospice as a program

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:

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

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.

Note:

Medical Program chart for HCS and DDA is located on the Financial Eligibility and Policy SharePoint under desk aids.

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. 

Medical Program - LTSS Chart

Please report broken links or content problems.

WAC 182-501-0175 Medical care provided in bordering cities.

WAC 182-501-0175 Medical care provided in bordering cities.

Effective July 1, 2011

  1. An eligible Washington state resident may receive medical care in a recognized out-of-state bordering city on the same basis as in-state care.
  2. The only recognized bordering cities are:
    1. Coeur d'Alene, Moscow, Sandpoint, Priest River, and Lewiston, Idaho; and
    2. Portland, The Dalles, Hermiston, Hood River, Rainier, Milton-Freewater, and Astoria, Oregon.

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.

Subscribe to