Contact hospice program eligibility

Revised date

Program Administration - HCS and DDA LTC Specialty Unit

Home and Community Services (HCS) determines eligibility for hospice when clients are receiving services authorized by HCS.

HCS services include Medicaid Personal Care (MPC), Community First Choice (CFC), or HCS Home and Community Based (HCB) Waiver services authorized by the HCS social service specialist.

HCS determines eligibility for hospice when one spouse is receiving services from HCS and the other spouse is in need of hospice.

HCS does not retain nursing facility cases once a nursing facility client has made an election of hospice. Upon receipt of the notice of election in a nursing facility (NF), the HCS office makes a program change to the hospice program and transfers the case to the DDA LTC Specialty Unit. (CSO 017).

Example: Client is admitted to a nursing facility. Client elects hospice in the facility. Once a client has elected hospice, the nursing home service with HCS ends. The case changes from a L02 nursing home to a L32 hospice case by the HCS financial worker. The case is then transferred to the Hospice LTC Specialty Unit to be maintained by the hospice financial worker. The client is still residing in the nursing facility, but the funding is through the hospice program.

The hospice program is currently specialized within the DDA LTC Specialty Unit. The unit determines eligibility for the hospice program for clients who elect hospice services either at home, an alternative living facility, hospice care center, or nursing facility. If a client who is currently active on medicaid in an NF, the HCS office that maintains the case will update the hospice election and transfer the case to CSO 017 for ongoing maintenance.

The unit does not determine eligibility for clients who are currently receiving HCS HCB waiver services, CFC, or MPC. If a client who is currently receiving MPC or CFC services authorized by HCS, the HCS office that maintains the case will update the hospice election and transfer the case to CSO 017 for ongoing maintenance. If a client who is currently receiving HCS waiver services in home, the HCS office that maintains the case will update the hospice election and continue maintaining the case.

Contact information for Hospice within the DDA LTC Specialty Unit

DDA LTC Specialty Unit/Hospice Phone:

855-873-0642

Mail items for the DDA LTC Specialty Unit to:

PO Box 45826
Olympia WA 98504-5826

Fax items (not hospice election notices) for the DDA LTC Specialty Unit to:

855-635-8305

Fax hospice election notices:

360-725-1965

All hospice notifications statewide are faxed to the Health Care Authority's (HCA) MEDS unit where they are scanned into Barcode document management systems (DMS). A copy is sent to the HCA notification unit to update the client information in the claims payment system and a copy is also sent to the DDA LTC Specialty Unit or HCS office of record for review.

Note: Hospice agencies must send notices within 5 working days of election. If the Agency receives a hospice election notice later than 5 days of election for a client, the service authorization is not backdated. The HCS or DDA financial worker must contact Lori Rolley at HCS HQ, as HCA will need to adjust the provider payment.

Hospice Applications

Applications received requesting hospice only may be routed via DMS to the CSO 017 @ HSP for processing.

Applications for hospice received in the CSO that include requests for cash and food assistance are processed by the local CSO office. Set a same day tickle to CSO 017 @HSP for application. The DDA LTC Specialty Unit will process the request for hospice medicaid coverage, if a hospice election is received.

Applications received where the client has requested hospice services are only handled by the DDA LTC Specialty Unit when there is an HCA 13-746 Hospice notification form in the client's record showing a current hospice election. If the client has indicated hospice on the application but no HCA 13-746 is in the client record, the DDA LTC Specialty Unit will contact the client, authorized representative or hospice agency to confirm whether the client has elected hospice or not, prior to denying the application for the hospice program or transferring the application to another office if other Medicaid or LTC services are requested.

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Long-term care partnership frequently asked questions

Revised date

What is the Washington State Long-Term Care Partnership Program

The Washington State Long-Term Care Partnership Program, administered by the Washington State Health Care Authority (HCA) and Washington State Office of Insurance Commissioner (OIC), provides an alternative to spending down or transferring assets by forming a partnership between Medicaid and private long-term care insurers.

What is long-term care?

Long-term care includes a wide range of services provided to people who need continued help with Activities of Daily Living, (ADL) such as: bathing, dressing, eating, using the toilet, transferring from a bed to a chair.

Where is it provided?

Long-term care can be provided in a variety of places, including a person's home, an assisted living facility (boarding home), adult family home, or a nursing home. You can search for a facility in your area.

What is the risk of needing long-term care?

Everyone is potentially at risk. A 2005 study found that 69 percent of people turning 65 years of age will need some form of long-term care before they die. Among those turning 65 years of age, 52 percent will need long-term care for at least one year before they die and 20 percent will need five years of care or more. For more information see Long Term Care Medicare.

What is the cost of long-term care?

The average private pay rate for a private room in a Washington State nursing home in 2011 is $246 per day or $89,790 per year. The amount may vary based on facility and level of care.

Home or residential care (adult family home or assisting living facility) can be just as expensive, depending on the frequency and services required.

Doesn't Medicare cover the cost of long-term care?

Many assume Medicare will pay for their long-term care expenses. Medicare covers only a small portion of the country's long-term care costs. Medicare will pay for care in a nursing home only when certain conditions are met, and even then, you are only fully covered for 20 days. In certain situations, some people may qualify for partial payment up to 100 days.

What does Medicare cover when it comes to long-term care?

Medicare, a federal program providing health insurance for individuals 65 and older or individuals with disabilities, has specific rules that apply for payment of nursing home care. Medicare requires a 3-day hospital stay prior to transferring to a nursing home. Services received in a nursing home must relate to the illness or injury that caused the hospitalization. Medicare coverage for nursing home care ends once an individual's needs change from skilled care to custodial care.

What is Medicaid and Title XIX?

Medicaid and Title XIX are the same program. It is a program administered by the Washington State Health Care Authority (HCA) to provide health care for low income individuals, families and children. Medicaid covers close to half of the nation's long-term care bill.
In addition, individuals must meet certain eligibility and income criteria before they receive benefits from Medicaid.

How does Medicaid asset protection work?

The most unique benefit of a Partnership policy is the Medicaid asset protection. The difference between a Partnership policy and a nonpartnership policy is the Medicaid asset protection.
This includes protection from Estate Recovery after your death.
This feature provides dollar for dollar assets protection: For every dollar that a Partnership policy pays out in benefits, a dollar of assets can be protected from the long-term care Medicaid resource limit and estate recovery.
When determining long-term care Medicaid eligibility, any assets you have up to the amount the Partnership policy has paid out in benefits will be disregarded.
For example, if your Partnership policy paid $200,000 in benefits, Washington State LTC Medicaid program would allow you to keep $200,000 in assets and still qualify for Medicaid assistance as long as you meet all other Medicaid eligibility requirements. The amount of assets you are able to protect under the Partnership is in addition to the $2,000 in assets everyone on LTC Medicaid is allowed to keep, including any assets your spouse may be allowed to retain.

Will Washington State Medicaid try to recover my protected assets after I die?

No. The estate recovery program will not recover the amount of assets disregarded for the purposes of Medicaid eligibility, less the amount of any disregarded assets that were transferred or disposed of prior to the individual's death.

The Department of Social and Health Services (DSHS) and Health Care Authority (HCA) administers the Estate Recovery Program, which files claims against the estates of deceased Medicaid recipients. This helps the Department recover the cost of Medicaid benefits it has provided to those recipients.

Learn more about the Estate Recovery Program.

Example: Your long-term care partnership program has paid out $200,000 in services. You have designated your home valued at $150,000 as protected plus $50,000 in a savings account. You have $2,000 in a checking account, which is allowed for Medicaid eligibility.

When you die, the Estate Recovery program will not recover the $200,000 assets you have designated as protected based on the amount the long-term care partnership has paid out. The protected assets will go to your heirs.

NOTE: If protected assets go to your heirs after you die, the protection is not passed on to that individual if they need to apply for Medicaid.

Example: When you die, your $150,000 home and $50,000 savings is designated by you to go to your son John. John is 65 years old and is now living in the home he received as an inheritance. John needs long-term care Medicaid and still has the $50,000 received through the inheritance plus $1800 in his checking account. In this example, John is over the $2,000 resource limit for Medicaid eligibility. The asset protection does not carry over to another individual that has received the asset including a spouse. The asset protection only applies to the individual with the LTC insurance.

Do I have to use up all my partnership policy before I can apply or become eligible for Washington State Medicaid?

If you have a long-term care partnership policy, you do not have to use up all the benefits of the policy before applying for Washington Medicaid.
You do have to meet all other eligibility requirements for long-term care Medicaid including income, resource requirements.

Who do I contact for more information on Washington State Medicaid?

More helpful information about long-term care Medicaid

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Determining eligibility for noninstitutional coverage in an Alternative Living Facility (G03 or L52 group C and D)

Revised date
Purpose statement

This program is used for SSI-related people receiving a long-term service and support (LTSS) such as Medicaid Personal Care (MPC)(G03) or Community First Choice (CFC) when countable income is over the CNIL, but under the Special Income Level (SIL) and state-contracted rate.

Starting 10/2015, CFC clients using these rules will be under medical coverage group L52.

This program is used for Regional Support Network (RSN) placements in alternate living facilities (ALF). (G03).

This program is used for SSI-related people paying privately in a state-contracted ALF under medically needy (CN) G95, G99.

Long-term services and supports authorized under Washington Apple Health overview.

WAC 182-513-1205 Determining eligibility for noninstitutional coverage in an alternate living facility

WAC 182-513-1205 Determining eligibility for noninstitutional coverage in an alternate living facility (ALF).

Effective February 8, 2020

  1. This section describes the eligibility determination for noninstitutional coverage for a client who lives in a agency-contracted alternate living facility (ALF) defined under WAC 182-513-1100.
  2. The eligibility criteria for noninstitutional Washington apple health (medicaid) coverage in an ALF follows SSI-related rules under WAC 182-512-0050 through 182-512-0960, with the exception of the higher income standard under subsection (3) of this section.
  3. A client is eligible for noninstitutional coverage under the categorically needy (CN) program if the client's monthly income after allowable exclusions under chapter 182-512 WAC:
    1. Does not exceed the special income level (SIL) defined under WAC 182-513-1100; and
    2. Is less than or equal to the client's assessed state rate at a agency-contracted facility. To determine the CN standard: ((y × 31) + $38.84), where "y" is the state daily rate. $38.84 is based on the cash payment standard for a client living in an ALF setting under WAC 388-478-0006.
  4. A client is eligible for noninstitutional coverage under the medically needy (MN) program if the client's monthly income after allowable exclusions under chapter 182-512 WAC is less than or equal to the client's private rate at a agency-contracted facility. To determine the MN standard: ((z × 31) + $38.84), where "z" is the facility's private daily rate. To determine MN spenddown liability, see chapter 182-519 WAC.
  5. For both CN and MN coverage, a client's countable resources cannot exceed the standard under WAC 182-512-0010.
  6. The agency or the agency's designee approves CN noninstitutional coverage for twelve months.
  7. The agency or the agency's designee approves MN noninstitutional coverage for a period of months described in WAC 182-504-0020 for an SSI-related client, provided the client satisfies any spenddown liability under chapter 182-519 WAC.
  8. Clients who receive medicaid personal care (MPC) or community first choice (CFC) pay all of their income to the ALF except a personal needs allowance under WAC 182-513-1105.
  9. A client may have to pay third-party resources as defined under WAC 182-513-1100 in addition to the payment under this subsection.

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

This program is used for individuals who have countable income over the CNIL and living in a licensed, department contracted alternate living facility (ALF).

Non institutional Medicaid in an ALF has the same program rules as SSI related Medicaid, but with a higher income standard.

The ACES medical coverage group (MCG) is G03 for MPC, and G95, G99 for private pay clients.

Effective 10/2015 CFC clients under group C and D will be in MCG L52.

For SSI-related individuals who are eligible to receive CN coverage because they are on SSI (S01) or are SSI related with income at or below the CNIL (S02), the higher standard used for non institutional Medicaid in an ALF is not needed because they already meet CN eligibility. MPC clients in an ALF will remain on the S01 or S02 program.

The G03/G95/G99 medical coverage group is used for eligibility when an individual resides in an alternate living facility. The daily rate is what drives the eligibility. The difference in eligibility between the SSI related series (S02, S95, S99) and non institutional in an ALF (G03, G95, G99) is the income standard. The standard is the daily rate x 31 days plus the ABD cash standard of $38.84.

For individuals receiving Home & Community Services (HCS), Developmental Disabilities Administration (DDA), or Behavioral Health Organization/Mental health (BHO) services with income at or below the Medicaid Special Income Level (SIL) use the state daily rate authorized for that individual.

For private pay individuals in a state contracted/licensed facility, use the private daily rate the individual is billed by the facility.

1. Categorically Needy (CN-P) G03

To be eligible for CN benefits, an individual must have nonexcluded income at or below both the CN standard and the SIL and resources at or below the resource standard for SSI related individuals.
There are 2 tests for CN-P eligibility under the G03 program:

    1. Is the individual's gross income under the Medicaid SIL? And;
    2. Is the individual's countable income under the state contracted daily rate x 31 days plus $38.84?

If the answer to both (a) and (b) are yes, the individual is income eligible for CN G03. If one or both are answered no, the case will trickle to a medically needy program.

2. Medically Needy (G95/G99)

The income standard used to determine eligibility for these benefits under the medically needy (MN) program is based on the private facility rate based on a thirty-one day month plus $38.84.
If the income exceeds the MN standard, the excess is used to determine the individual's spenddown liability. Refer to Spenddown for procedures.

3. What is a department contracted/licensed alternate living facility?

Department contracted facility means a licensed facility such as an adult family home or assisted living facility that is contracted with DSHS to provide services such as Medicaid Personal Care (MPC) or Developmental Disability Administration (DDA) or Home & Community Services (HCS) Waiver services. It also applies to facilities that are contracted with the Behavioral Health Organization (BHO) to provide services. The BHO provides Mental Health services. If the facility does not accept an individual with the BHO, DDA or HCS services it is not considered a department contracted facility. A facility can be licensed, but not contracted with DSHS or Mental Health. Eligibility for individual's living in a licensed but not contracted facility is done as if the individual is in their own home.
Facility rates can vary from one facility to another. The facility rate must be updated in ACES at each eligibility review and documented as to how the rate was verified.

  • The state rate is used for CN eligibility.
  • The private rate is used for MN eligibility.
  • The state and private rate could be the same, or the private rate could be lower than the state rate based on providing an individual with personal care services.

Some facilities that hold a contract with the department also have private-pay beds. Individuals not eligible for Medicaid or state payment for the cost of care in a department-contracted facility pay the private rate established by the facility. These individuals may still be eligible for noninstitutional medical assistance using the rules for the G03 program.
To search for Adult family Home or Boarding Homes contracted with DSHS.
The list on the Adult family home/Boarding Home indicates if the facility is not contracted for Medicaid or mental health.
Examples 1 through 5 how to determine if the facility is contracted for the purposes of G03.

4. Room and Board, what does this mean?

Throughout the manual both terms, room and board and board and room are used to describe a living arrangement in which an individual purchases food, shelter, and household maintenance requirements from one vendor. There is also a term used by ALTSA called the room and board rate. This rate is based on the FBR minus the current PNA in an ALF used in the HCB Waiver program.
For individual's receiving medical through this program, the rate paid to the ALF is usually higher than the standard room and board rate used by ALTSA.
The rate individuals on G03/MPC pay the facility is their countable income after SSI related deductions and disregards minus $62.79 PNA. This rate for the purpose of the G03 program is called the individual's total responsibility. All other ALTSA individuals on MPC pay the standard room and board rate with the exception of G03 individuals.

Do not use G03/G95/G99 in the following situations:

  • CN SSI related Medicaid under S01 or S02.

    For SSI-related individuals who are eligible to receive CN coverage because they are on SSI (S01) or are SSI related with income at or below the CNIL (S02), the higher standard used for non institutional Medicaid in an ALF is not needed because they already meet CN-P eligibility. Special income disregards for SSI-related programs such as disabled adult child (DAC) and COLA/Pickle are found in the clarifying section under WAC 182-512-0880. Individual's receiving services authorized by DDA or HCS pay the ALTSA Room and Board amount.

  • Health Care for workers with disability (HWD)(S08)

    In most cases, individuals who are on Health Care for Workers with disabilities (HWD/S08) would be better off remaining on HWD if receiving services from HCS or DDA. HWD individuals on MPC would pay their HWD premium to financial service administration (FSA) and the ALTSA Room and Board amount to the ALF provider.

  • Individuals receiving HCB Waiver services with DDA or HCS.
    • Individuals authorized for an HCB Waiver program through DDA (described in WAC 182-515-1510) or HCS (described in WAC 182-515-1505 ) may be living in an ALF. If the individual is authorized services through a HCB Waiver program, the L22 medical coverage group is used. There are exceptions to this if the client is eligible for HWD or D01 and receiving HCB Waiver services. The L22 Waiver medical coverage group is an institutional program using post eligibility rules to determine how much the client pays toward their cost of care. The amount the client pays along with the standard room and board amount is called participation. There are allowable deductions that can be used in post eligibility under an HCB Waiver program, but not allowed as a deduction in the SSI related rules used for the noninstitutional SSI related in an ALF program. Some examples of these deductions allowed in the post eligibility process for the Waiver programs are guardianship fees, court ordered child support, health insurance premiums, incurred medical expenses and spousal allocation under the spousal impoverishment act.
  • The Hospice program uses institutional rules under the L22 program for individual's who would benefit in using institutional rules.

For an individual electing Hospice and paying private to an ALF, do use the G95 program as a priority if eligible. If not eligible under G95 rules, consider the L32 program for Hospice elections. Hospice description.

  • Individuals residing in a noncontracted alternate living facility. (Private Facilities)

    Some facilities are totally private and do not contract with the department to provide services. Determine eligibility for individuals in non contracted facilities as if they are in their own home. Do not use the amount the individual pays to the private non contracted facility as a medical expense. Alternate living facilities such as private assisted living, private adult family homes are not medical institutions, therefore the amount the individual pays to the facility is not considered a medical expense. The standard used for residents of private non contracted facilities is the MNIL standard.

  • Individuals receiving medicaid under a MAGI program.

Examples of noncontracted and private facilities or home settings:

  1. Residents of veteran's homes who received domiciliary or assisted living care are not eligible for Medicaid. The Department of Veterans Affairs is responsible for meeting the needs of the domiciliary or assisted living residents.
  2. Private boarding home, continuing care retirement center (CCRC), private assisted living facilities, supported living, and state operated living alternative (SOLA). Determine eligibility as if they are in their own home. (S02/S95/S99).
  • Examples 6 through 12 on choosing the correct medical coverage group based on the individual's circumstances.

Agency Responsibilities

Financial staff determines financial eligibility for financial and medical assistance programs.
For individuals receiving services from the BHO, HCS or DDA, the assigned case-manager/social service specialist indicates the state daily rate on the financial/social service communication form. If MPC or CFC is authorized, the assigned case-manager/social service specialist indicates the service, the date service was authorized along with the daily rate and type of facility. (For Internal staff)
HCS social service specialists use the DSHS 14-443 Financial/Social Service communication form. This form is automated through the barcode system.
DDA case managers use the DSHS 15-345 CSO/DDA Communication. This form is automated through the barcode system.
BHO case managers use the DSHS 13-348 BHO/CS0 communication form.

Worker Responsibilities

  1. See WAC 182-513-1200 Long-term services and supports authorized under Washington Apple Health.
  2. See SSI related Medical Income and SSI related Resources to determine income and resource eligibility.
  3. When an individual is placed in a facility on a HCS or DDA Waiver service, use Chapter 182-515 WAC to determine eligibility. Screen in a L22 for these programs.
  4. When an individual is otherwise eligible for a SSI related CN program (S01 or S02) the S01/S02 program is a priority program. If an MPC S02 individual residing in a contracted ALF has an increase in income that causes the S02 to trickle to a S95, do a redetermination under the G03 program. Starting 10/2015 all CFC SSI-related clients using rules of this program will be under MCG L52.
  5. HWD is a priority program for individuals on MPC or CFC when it is beneficial to the individual. Individuals on HWD pay the HWD premium plus the ALTSA room and board standard.
  6. If the individual's nonexcluded gross income is above the SIL and/or the department-contracted rate plus the PNA/CPI standard use the private facility rate plus the PNA/CPI standard. Cases that trickle to MN are not eligible for MPC or CFC. Consider eligibility for a HCB Waiver.
  7. To determine the individual's spenddown liability for noninstitutional medical assistance under the MN program, use the individual's nonexcluded income in excess of the private rate plus the PNA to determine the individual's spenddown liability. Do not use the amount charged by the ALF to reduce the spenddown amount, however the individual may use other incurred medical expenses to meet spenddown. (ALFs are not medical institutions).
  8. The agency will consider income and resources separately as of the first day of the month following the month of separation when spouses stop living together because of placement into a boarding home or adult family home when:
    1. Only one spouse enters the facility;
    2. Both spouses enter the same facility but have separate rooms; or
    3. Both spouses enter separate facilities.
  9. The agency will consider income and resources jointly when spouses are placed in a boarding home or adult family home and share a room. See WAC 182-512-0960.
  10. Indicate the type of services in ACES under HCBS/MPC services under the institutional care tab in ACES 3G with the service start date indicated by the social worker and the agency authorizing the service (DDA or HCS).
  11. Services authorized by DDA, HCS are tied to eligibility for CN Medicaid. If medicaid closes, the service authorized by the social service specialist/case manager must close too. Individuals must be eligible for a non institutional CN medicaid program in order to receive MPC or CFC.
    1. HCS social service specialists use the DSHS 14-443 Financial/Social Service communication form. This form is automated in barcode.
    2. DDA case managers use the DSHS 15-345 CSO/DDA Communication form. This form is automated in barcode.
    3. BHO case managers use the DSHS 13-348 BHO/CS0 communication form.
  12. The assigned case manager/social service specialist indicates what services are authorized with the start date, the state daily rate, the current address and any other pertinent information needed to process the case such as if a payee or power of attorney is involved in the case. The assigned case manager/social service specialist determines the functional eligibility for the service; the financial worker is responsible to determine the financial eligibility for Medicaid. Changes need to be communicated back and forth between the financial worker and assigned case manager/social service specialist.
  13. If G03 eligibility trickles to a G95 or G99 because the income is excess of the SIL or the state daily rate and the individual is receiving MPC services, notify the agency approving the MPC service that the individual is no longer eligible to receive MPC because of excess income.
  14. For people paying privately in a state-contracted ALF, contact the facility for the private rate.
  15. For more information search the DSHS Adult Family Home Locator or Assisted Living Facility Locator for Professionals and Providers.

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Reason code quick links

Revised date
Purpose statement

Series Reason Code Protocols

Apple Health - ACES Letters - Reason Code Quick links

  1. Select the Reason Code Series number to go to the list of codes in that series in the chart below

    100's   200's   300's   400's   500's

  2. In the chart, select the specific reason code to go directly to the Reason Code Series page and the code you have selected.
    The Reason Codes Series pages will show the following elements for each reason code:
    1. Code Number
    2. Reason Code Title / Required Text
    3. WAC Reference
    4. Free Form Text

For ACES procedures regarding letters, visit the ACES Information Center in ACES online.

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Income requirements index

Revised date
Purpose statement

Long-term care income requirements - index.

Clarifying information

There is two (2) parts to eligibility in LTC.

  • Initial eligibility (Eligibility for Medicaid)
  • Post eligibility treatment of income (Determination of how much an individual must participate toward the cost of care)

There are differences in income that is counted in initial eligibility for Medicaid, and what deductions are allowed from income in the post eligibility treatment of income calculation.

Institutional and HCB Waiver LTC follows SSI-related income methodology.

Income specific to Long-term care:

SSI-related income:

Post eligibility treatment of income:

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Denials

Revised date
Purpose statement

To explain what the agency considers when denying an application.

WAC 182-503-0080 Washington apple health -- Application denials and withdrawals.

WAC 182-503-0080 Washington apple health -- Application denials and withdrawals.

Effective November 3, 2019. 

  1. We follow the rules about notices and letters in chapter 182-518 WAC. We follow the rules about timelines in WAC 182-503-0060.
  2. We deny your application for apple health coverage when:
    1. You tell us either orally or in writing to withdraw your request for coverage; or
    2. Based on all information we have received from you and other sources within the time frames stated in WAC 182-503-0060, including any extra time given at your request or to accommodate a disability or limited-English proficiency:
      1. We are unable to determine that you are eligible; or
      2. We determine that you are not eligible.
    3. You are subject to asset verification and do not provide authorization as described in WAC 182-503-0055.
  3. We send you a written notice explaining why we denied your application (per chapter 182-518 WAC).
  4. We reconsider our decision to deny your apple health coverage without a new application from you when:
    1. We receive the information that we need to decide if you are eligible within thirty days of the date on the denial notice;
    2. You give us authorization to verify your assets as described in WAC 182-503-0055 within thirty days of the date on the denial notice;
    3. You request a hearing within ninety days of the date on the denial letter and an administrative law judge (ALJ) or HCA review judge decides our denial was wrong (per chapter 182-526 WAC).
  5. If you disagree with our decision, you can ask for a hearing. If we denied your application because we do not have enough information, the ALJ will consider the information we already have and any more information you give us. The ALJ does not consider the previous absence of information or failure to respond in determining if you are eligible. 

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.

Worker responsibilities

If the applicant provides only part of the information we need per the timelines in WAC 182-503-0060, take the following actions:

  1. Review the case to see if we can determine eligibility for each program based on what we have received; and
  2. Send the person one of the following letters advising of our reconsideration decision for each program:
    1. An approval letter if we can determine that the person is eligible;
    2. A denial letter if we determine the person is not eligible for the original reason or for a different reason.

Note: When partial information is submitted during a reconsideration period, do not pend for additional information. If the applicant is not eligible based on the information provided, the original denial still stands.

Example: We request verification of income and residency due by 5/15/19. This is not provided, and we send a denial letter on 5/20/19. Applicant then provides the residency and income verification on 5/30/19. This is within 30 days of the denial, and is sufficient to determine eligibility. We approve coverage from the appropriate date.

Example: Same as above, but the applicant provides only the income verification. This information shows the person to be over the program’s income standard. We send a new denial letter to the person advising of the change in denial reason.

Example: Same as above, but the applicant provides only the residency verification. We cannot determine eligibility without the income information. We send a letter to the person advising that we received the partial information, but the denial from 5/20/19 stands as we still do not have the income verification we require.

ACES procedures

For ACES processing details, visit the ACES Information Center in ACES online.

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Home and Community Based (HCB) waivers and programs using HCB waiver rules

Revised date
Purpose statement

This section gives a brief overview of the Home and Community Based (HCB) Waivers authorized by Home and Community Services (HCS) or Developmental Disabilities Administration (DDA).

HCB Waivers is an institutional program under Section 1915(c) of the Social Security Act. HCB Waivers provide alternatives to placement in a medical institution. These alternatives include remaining in their own home or in an alternate living facility.

Note: Clients must be aged, blind, or disabled to receive HCS CN Waiver services and eligible under medical coverage group L21 for SSI recipients, L22 for SSI related recipients, S08 Health Care for Workers with Disabilities (HWD) or D01 Foster Care.

HCB Waivers authorized by HCS:

  • Community options program entry system (COPES)
  • New Freedom consumer directed services (New Freedom)
  • Residential Support Waiver (RSW)

Programs that use HCB Waiver financial eligibility rules but are not a HCB Waiver:

  • Roads to Community Living (RCL)
  • Program of all-inclusive care for the elderly (PACE)
  • Hospice as a program

HCB Waivers authorized by DDA:

Clarifying Information:

Clients needing the rules of a HCB Waiver in order to be eligible for a categorically needy (CN) program to access Community First Choice are subject to all the initial and post-eligibility rules in the HCB Waiver.

A Comprehensive Assessment, is the functional assessment (also called a CARE assessment) completed by HCS or DDA staff for all clients to determine initial or ongoing HCB Waiver eligibility. A client attains institutional status under WAC 182-513-1320 when he or she receives HCB Waiver services.

Worker Responsibilities

  1. Eligibility Determination Process
    1. Determine both financial need and functional need.
    2. Complete both eligibility determinations concurrently.
    3. Both financial and functional eligibility must be determined before you authorize HCB Waiver services.
    4. Eligibility rules for HCS HCB Waivers.
    5. Eligibility rules for DDA HCB Waivers.
  2. Staff Who Make Eligibility Determinations:
    1. The HCS social worker or DDA case manager determines the functional eligibility using CARE, and authorizes the long-term services and supports.
    2. The HCS social worker or DDA case manager notifies the financial worker of the start date of service, type of service, living arrangement, daily rate if in a ALF, address if placed in a facility and any other pertinent changes using the barcode 14-443 for HCS and the barcode 15-345 for DDA. The FSS determines the client’s financial eligibility for medical care and post eligibility (determination of participation) to the HCS Waiver program. The financial worker notifies the HCS social worker or the DDA case manager using the 07-104 formerly the 65-10 in barcode, that the client meets financial eligibility.
    3. The client authorized services must pay their responsibility toward the cost of care (service participation and room and board) to the provider or provider agency.

Note: A client can be authorized to receive Hospice services while on HCB Waiver services. The HCB program (usually COPES) is the priority program. Any participation is applied toward the HCB Waiver provider. For more information see Hospice index.
A client can be authorized to receive a HCB Waiver, Community First Choice and Hospice. The participation is applied toward the HCB Waiver and CFC provider before it is applied to the Hospice provider.

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Hospice overview

Revised date
Purpose statement

To provide an overview of the Hospice program and explain how to correctly determine eligibility for Hospice

Hospice care

Hospice is a 24-hour intermittent program coordinated by a hospice interdisciplinary team for persons with a terminal illness and a prognosis of six months or less to live. The hospice program allows the terminally ill client to choose physical, pastoral/spiritual and psychosocial comfort, and palliative care rather than cure. Hospitalization is used only for acute symptom management.

Hospice care is initiated by the choice of the client, family or physician. The client’s physician must certify a client as appropriate for hospice care. Hospice can be ended at any time by the client or family (revocation) by the hospice agency (discharge) or by the death of the client (expired).

Hospice care may be provided in a client’s home, in a medical institution including a hospice care center, nursing facility, or in an alternate living facility.

For certain clients who are eligible for Categorically Needy (CN) coverage, hospice care is a service that is covered by their Provider One services card. Institutional Hospice rules may be used to provide CN coverage for these services, when it is to the advantage of clients. The L31 program is used if the client receives an SSI cash grant or L32 if the client is SSI-related and not otherwise eligible for CN.

Note: The N05 coverage group also provides hospice care for those who meet program requirements. 

 The L31/L32 hospice program is not a waiver program; however, rules that are similar to waiver program rules under WAC 182-515-1505 are used when countable income is under the Special Income Level (SIL). The special income level is 300% of the Federal Benefit Rate (FBR).

General eligibility for hospice programs 

WAC 182-551-1000 General eligibility for hospice programs

  1. Definitions relating to hospice are in WAC 182-551-1010. A person must meet these general eligibility requirements:
    1. Verification of age and identity
    2. Citizenship or immigration status. Noncitizen children are eligible to receive hospice services if they are eligible under a children's medical program
    3. Residency
    4. Social Security number
    5. Assignment of medical support rights
  2. Attains institutional status (WAC 182-513-1320). Institutional status is met when the HCA 13-746 hospice notification is received from the hospice agency with an election date indicated.
  • Chapter 182-551 WAC describes the hospice program as a service

Alien Medical Program and hospice

Clients receiving Alien Emergency Medical Program (AEMP) must have prior authorization for hospice services from the HCA Hospice Program Manager.

Note: Hospice services may be considered for noncitizen clients who are eligible for Alien Medical cancer and dialysis programs. 

Indicate on the referral the request is for hospice for an AEM client on either the cancer or dialysis program. The request must be submitted within 5 business days of the client's election of hospice services.

Prior authorization for hospice is not required for clients enrolled in the state-funded long-term care program; however, the standard 5-day notification still applies.

Requests for prior authorization should be addressed to:

Notification Unit
P.O. Box 45535
Olympia, WA 98504-5535
Telephone: 800-562-3022
FAX: 866-668-1214

​Note: Refer to Alien Medical Programs (AMP) for clients not meeting citizenship requirements and needing Hospice services. Hospice Providers must get preapproval from HCA in order to bill services under alien medical programs.

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VA benefits chart and VA information appendix 4

Revised date
Purpose statement

This section provides information on Veteran's benefits. VA Benefit chart, VA contact information and information regarding VA benefits.

Clarifying Information

Veteran's Aid and Attendance ( A & A) and some Unusual Medical Expenses (UME) payments are considered excluded income for the purposes of SSI related Medical eligibility and Institutional Medical eligibility. This is described in WAC 182-512-0840. These payments act as reimbursement for services (usually long term care) received by eligible Veterans, and as such are a Third Party resource. VA A & A is counted in determining the total cost of care a client owes in post eligibility calculations for long term care services. (WAC references re Medicaid is payor of last resort and third party liability: WAC 182-503-0540, WAC 182-501-0100, WAC 182-501-0200, WAC 182-502-0100). Contact the Financial Eligibility Policy Unit at ALTSA headquarters.

For Veterans in medical institutions see WAC 182-513-1380 Determining a client's participation in the cost of care for long-term care services.

For Veterans on an HCS HCB Waiver program see WAC 182-515-1505.

WAC 182-513-1340 Determining excluded income for long-term care services describes benefits designated for the veteran's dependent, unusual medical expenses, aid and attendance allowance and household allowance. There is an exception when a client is residing in a state veterans nursing home with no dependents. VA benefits listed in WAC 182-513-1340 are excluded when determining initial eligibility, but counted when determining the participation in the cost of care.

WAC 182-512-0840 SSI related medical-Work-and agency-related income exclusions describe that VA A & A, Housebound allowance, and UME are excluded income for SSI related medical. If a client goes off long-term care services and continues to receive these VA benefits, they would be excluded when doing a redetermination under non institutional SSI related medical.

Veteran's residing in a State Veterans nursing home are allowed a higher personal needs allowance. (LTC standards).

Veterans that receive the $90 VA improved pension amount are allowed to keep the $90 plus their regular PNA when residing in a medical institution or residential setting. These must be coded as VZ in ACES. Add text to the letter indicating the individual is allowed to keep the $90 VA plus their regular PNA.

For detailed information on the VA benefits chart, the types of VA benefits and how to correctly code VA income in ACES, see the link at the top of this page titled HCS Financial Training Packet on VA benefits.

Protecting PNA with VA TPR Example

Worker Responsibilities-VA referral project (HCS applicants)

For long-term care applicants with HCS, an automated referral process is sent directly to the HCA Veterans project team from ALTSA

The VA referral project benefits:

  • Improved client service and access to VA benefit
  • Increased available income for ALTSA clients
  • Standardized and streamlined Veterans Benefit Referral process
  • Centralized documentation of Veterans Benefit Referrals and results

VA project process:

  • HCA VA Project team compiles new recipients through Bar Code and transmits to Washington Department of Veterans Affairs (WDVA) weekly
  • WDVA runs data through SHARE to determine clients potentially eligible for VA benefits
  • WDVA requests referrals for potentially eligible clients from the HCA VA Project team
  • HCA VA Project team sends Veterans Benefit Referrals for requested clients to WDVA
  • WDVA considers additional information and calls client or representative to make full assessment regarding eligibility for VA benefits. Some are ruled out.
  • If WDVA is unable to contact after 3 attempts in 3 weeks, returns 14-162a to Project Team as "unable to contact"
  • Contracted agency or WDVA visits client or representative to complete VA paperwork
  • Contracting agency or WDVA submits claim to VARO
  • WDVA sends 14-162a to Project Team to notify that VA claim has been filed
  • Project Team tracks claim application
  • Contracting agency notifies WDVA if client or representative is not cooperating
  • WDVA advises financial worker of noncooperation via DSHS 14-162a
  • Financial worker sends the client a letter with requirement to pursue possible VA benefits
  • Financial worker contacts HCA VA Project team for 2nd Veterans Benefit Referral after client or the client’s representative contacts and indicates intent to pursue benefits
  • Financial worker notifies HCA VA Project team if client is unable to pursue benefits and has no one to assist them
  • Financial worker receives VA claim determination results from either WDVA or PARIS
  • HCS financial worker will, in cases of noncooperation, advise clients of the requirements to do everything necessary to obtain income to which they are entitled.
  • Financial worker will notify HCA VA Project team if client is unable to pursue benefits and has no one to assist them
  • Veterans Affairs (VA) will adjudicate claims submitted in a customary timeframe
  • Follow instructions for those needing Necessary Supplemental Accommodation (NSA) and chapter 3 of the long-term care manual detailing NSA procedures for those receiving HCS services.

Links to information on veterans benefits

United States Department of Veterans Affairs

HCS VA Improved Pension and UME calculator Under the VA income and TPL training section.

HCS Financial Training on VA improved Pension and how to use the VA calculator

Veterans Benefit Chart

Veterans administration contacts in Washington State

Address County CSO# HCS#

Region 1

American Legion 4815 North Assembly, Bldg 6A Spokane, WA 99205-6197
509-434-7750

 Stevens 33 78
Pend Oreille 26 78
Lincoln 22 57
Spokane 32, 58, 59, 60 57
Adams 01 81
Whitman 38 57
Address County CSO# HCS#

Region 2 North

Veterans of Foreign Wars
Medical/Dental Building #415
2722 Colby Avenue
Everett, WA 98201
425-339-1973

 Skagit 29 63
Island 15 63
Snohomish 52, 68, 65, 31 89, 90,91, 92
Address County CSO# HCS#

Region 2 South

Veterans of Foreign Wars
Federal Bldg, VARO Room 1040
915 Second Avenue
Seattle, WA 98174
206-220-6191

 King 80, 40, 42, 74, 43, 55, 44, 46, 47, 45, 41 56
Address County CSO# HCS#

Region 3 North

Department of Veterans Affairs
262 Burwell Street
Bremerton, WA 98337
360-478-4565

 Kitsap 18 88

American Legion
VA Medical Center Bldg 16, Room 111
American Lake
Tacoma, WA 98493
253-583-1300

 Pierce 49, 48, 67, 51 17, 66
Address County CSO# HCS#

Region 3 South

Department of Veterans Affairs
262 Burwell Street
Bremerton, WA 98337
360-478-4565

Clallam

Jefferson

05, 64

16

93

93

Department of Veterans Affairs
1011 Plum St, Bldg 5, 2nd Floor
PO Box 41150
Olympia WA 98504-1150
1-800-562-2308
360-753-5586

Grays Harbor

Mason

Lewis

Thurston

14, 61

23

21

34

94

96

95

96

American Legion
1603 E. 4th Plain Blvd, Room 123
Vancouver WA 98661
360-690-0274

Pacific

Wahkiakum

Cowlitz

Skamania

Clark

25, 71

35

08

30

53, 06

97

97

97

98

98

All regions, counties and offices not listed:

Send Veterans Referral forms (DSHS 14-162(X) and 14-162A(X) to:
WDVA - Alternate Care
MS 41150
PO Box 41150
Olympia, WA 98504-1150
1-800-562-2308

Dates for wartime service

Mexican Border Period - May 9, 1916 through April 5, 1917 for veterans who served in Mexico, on its borders or in adjacent waters.

World War I - April 6, 1917 through November 11, 1918; for veterans who served in Russia, April 6, 1917 through April 1, 1920; extended through July 1, 1921, for veterans who had at least one day of service between April 6, 1917 and November 11, 1918.

World War II - December 7, 1941 through December 31, 1946.

Korean Conflict - June 27, 1950 through January 31, 1955.

Vietnam Era - August 5, 1964 (February 28, 1961, for veterans who served "in country" before August 5, 1964) through May 7, 1975.

Gulf War - August 2, 1990 through a date to be set by law or Presidential Proclamation.

Washington State Department of Veterans Affairs service offices with DSHS CSO / HCS numbers and counties for each office's service delivery area.

HCA VA Benefit Enhancement Project Contacts:

Tim Dahlin

Department of VA Affairs tables

Special Monthly Compensation

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100 Series reason codes

Revised date
Purpose statement

100 Series Reason Code Protocols

Go to the Reason Code Link chart to link directly to a specific reason code or scroll through the list below.

For ACES Procedures go to ACES Letters in the ACES User Manual.

Reason Code Reason Code Description WAC References - Classic Medicaid Free Form Text - Classic Medicaid WAC References - MAGI-Based Medicaid Free Form Text - MAGI-Based Medicaid

101

ABD Cash/HEN Referral Spouse Ineligible

You can't receive Aged, Blind, & Disabled (ABD) Cash or Housing and Essential Needs (HEN) Referral when your spouse receives Supplemental Security Income (SSI).

388-400-0060

388-400-0070

388-474-0010

None Required

    

102

WASHCAP Application Month Denied - For Administrative Use Only

None

None Required

    

103

WASHCAP Terminates - Individual Has Had Earned Income For More Than Three Months

You can't receive WASHCAP food assistance because you've been working more than 3 months.

388-492-0030

None Required

    

104

SSA Terminates WASHCAP Food Assistance

Social Security asked us to stop your food benefits See WAC rule (Washington Administrative Code)

388-492-0110

None Required

    

105

WASHCAP Terminates - Individual's Living Situation Has Changed

You can't receive Washington State Combined Application Project (WASHCAP) food benefits because your living arrangement changed.

388-492-0030

None Required

    

106

WASHCAP Terminates - Individual Getting $1.00 Or Less SSI Money

You stopped receiving SSI cash.

388-492-0030

None Required

    

107

WASHCAP Terminates - Individual Not Eligible For SSI Money Or Medical

SSA decided that you cannot get SSI. See WAC rule (Washington Administrative Code):

388-492-0030

None Required

    

109

Not SSP Eligible - Individual's SSI Terminated

You can't receive a state supplemental payment if you're not receiving a SSI payment

388-474-0012

None Required

    

111

Not SSP Eligible - SSI Eligibility Category Change

You can only receive a State Supplemental Payment (SSP) if you receive SSI and one of the following is true:

  • You live with your SSI ineligible spouse.
  • You are blind.
  • You are age 65 or older.

388-474-0012

None Required

    

112

Receiving Tribal TANF Benefits

We believe you are eligible for cash benefits from the tribe

388-400-0005

If you are an individual in a household which is eligible for a tribal TANF program, you cannot receive state and tribal TANF in the same month.

    

120

Failed to Provide Proof of Citizenship/Identity

You did not provide proof of citizenship for a member or members of your household. Proof of citizenship is required before a person can receive medical.

388-490-0005

Specify the persons who are ineligible due to lack of proof of citizenship

 182-503-0535 None Required
121

Ineligible Spouse of an SSI Recipient – Medical

Because your spouse receives SSI, you aren’t eligible for Community First Choice services. See WAC rule (Washington Administrative Code):

     182-512-0100 None Required

130

Not TFA Eligible – Not Recipient of BF in Prior Month

The people listed above will not get Transitional Food benefits with you because they did not get Basic Food benefits with you during the last month you got TANF. If you want to find out if you would get more food benefits by including others in your household, please apply for Basic Food. You can choose the program that gives you the most benefits, Basic Food or Transitional Food.

388-408-0035

388-489-0005

None Required

    

131

A Member of the Household is now receiving TANF

Someone who gets Transitional Food with you is approved for Temporary Assistance for Needy Families (TANF) or Tribal TANF. We will see if you can get Basic Food. You may need to turn in an eligibility review for us to see if you can get Basic Food.

388-489-0025

Specify the person who is receiving TANF or Tribal TANF.

    

141

Mid-Certification Review Not Returned

We did not get your change report form. If you get us what we need before the end of the month, we will reconsider our decision.

You must either:

  • Turn in the form; or
  • Call us to report your current circumstances.

388-418-0011

None Required

    

142

Incomplete Mid-Certification Review

We got your change report form. Some information is still missing. We sent you a letter telling you what you need to give to us. We did not get it.

388-418-0011

None Required

    
167

TSOA - Invalid Waiver

You need an approved plan before we can help you and your caregiver. See WAC rule (Washington Administrative Code):

     182-513-1610 None Required
168

TSOA – Client Active in a Different AU

You can’t receive services under this program when you are eligible for certain Medicaid programs.

     182-513-1615 None Required

187

Individual Already Received CN Medicaid In Another AU For This Benefit Month - For Administrative Use Only

None

None Required

 182-503-0510 None Required

188

Medical Review Not Completed

Your medical disability review was not completed in time. This is because: We did not get updated medical information; or We got your medical information but it is still being reviewed.

388-511-1105

Specify person who is being terminated.

    
190

Non-Federally Qualified Individual Becomes Federally Qualified

You are now eligible to receive health care coverage under a federally-funded program.

     182-503-0535 None Required
191

Federally Qualified Individual Changed to Non-Federally Qualified

You are no longer eligible to receive health care coverage

     182-503-0535 None Required
193

Alien Emergency Medical Requirement

You don't meet the requirements to receive Washington Apple Health Alien Emergency Medical coverage.

     182-507-0110 None Required

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