Hospice agency contacts

Revised date
Purpose statement

This section gives contact information for medical institutions licensed by the State of Washington Department of Health (DOH) as hospice care centers and gives contact information for all hospice agencies with Medicaid contracts.

Hospice care center contacts

Hospice care center Mailing address Physical address Phone number Provider number
Evergreen Hospice and Home Health P O Box 11610
Tacoma WA 98411		 12822 124th Ave NE
Kirkland WA 98034		 1-425-899-1041 3990231
Franciscan Hospice Care Center Dpt.1010 P O Box 34936
Seattle WA 98124		 1717 S. J St.
Tacoma WA 98405-4944		 1-253-627-4100 3990264
Hospice of Spokane P O Box 2215
Spokane WA 99210		 121 S. Arthur
Spokane WA 99202		 1-509-456-0438 3990165
Hospice Southwest - Ray Hickey House P O Box 1588
Vancouver WA 98668		 3400 Main St.
Vancouver WA 98663		 1-360-256-2000 3990157
Tri-Cities Chaplaincy 2108 W Entiat Ave
Kennewick WA 99336		 2108 W Entiat Ave
Kennewick WA 99336		 1-509-783-7416 3990124
Hospice of Kitsap County The Care Center
P O Box 3416
Silverdale WA 98383		 570 Lebo Boulevard
Bremerton WA		 1-360-698-4611 3990066

Note: The provider numbers listed below are no longer current. Find the correct provider number by going to the INST screen and Shift-F8.

All hospice agencies with a Medicaid contract

Number Provider name Mailing address City State ZIP code Physical address Physical city State ZIP code
3990025 Central WA Hospital Hospice P O Box 1887 Wenatchee WA 98807-1887 903 Red Apple Rd Wenatchee WA 98801-0000
3990033 Community Home Health and Hospice P O Box 2067 Longview WA 98632-8189 14508 NE 20th Ave Suite 201 Vancouver WA 98686-6435
3990041 Good Samaritan Hospice P O Box 1247 Puyallup WA 98371-0000 1317 East Main St Puyallup WA 98372-0000
3990058 Kaiser Permanente 201 16th Ave CMB-C140 Seattle WA 98112-5260 125 16th Ave CMB-C140 Seattle WA 98112-5211
3990066 Hospice of Kitsap County P O Box 3416 Silverdale WA 98383-3416 3100 Bucklin Hill Rd #201 Silverdale WA 98383-3416
3990074 Hospice of Snohomish County 2731 Wetmore Suite 500 Everett WA 98201-0000 2731 Wetmore Suite 500 Everett WA 98201-0000
3990090 Skagit Hospice Services LLC Dept 1081 P O Box 1376 Mount Vernon WA 98273-0000 1971 Highway 20 Sedro-Wooley WA 98284-0000
3990108 Yakima Regional Med and Heart Ctr 7 South 10th Avenue Yakima WA 98902-0000 7 South 10th Avenue Yakima WA 98902-0000
3990124 Tri-Cities Chaplaincy 2108 W Entiat Ave Kennewick WA 99336-3000 2108 W Entiat Ave Kennewick WA 99336-3000
3990132 Walla Walla Community Hospice P O Box 2026 Walla Walla WA 99362-0948 1067 E Isaacs Walla Walla WA 99362-0000
3990157 Hospice Southwest P O Box 1588 Vancouver WA 98668-1600 3400 Main St Vancouver WA 98663-1600
3990165 Hospice of Spokane P O Box 2215 Spokane WA 99210-2215 121 S Arthur St Spokane WA 99202-0000
3990173 Providence Hospice of Seattle P O Box 389672 Seattle WA 98138-9672 425 Pontius Ave N STE 300 Seattle WA 98109-5312
3990181 Hospice of Palouse 700 S Main St Moscow ID 83843-3056 700 S Main St Moscow ID 83843-3056
3990199 Multicare Hospice of Tacoma P O Box 5200 Tacoma WA 98415-0200 315 S ML King Jr Way Tacoma WA 98415-0000
3990207 Harbors Home Health Services 201 7th St Hoquiam WA 98550-2506 201 7th St Hoquiam WA 98550-2506
3990215 Swedish Home Health and Hospice 5701 6th Ave So STE 404 Seattle WA 98108-2522 5701 6th Ave So STE 404 Seattle WA 98108-2522
3990231 Evergreen Hospice and Home Health P O Box 11610 Tacoma WA 98411-6610 12822 124th Lane NE MS #9 Kirkland WA 98034-0000
3990256 Kaiser Permanente Hospice P O Box 4000-95 Portland OR 97208-0000 500 NE Multnomah STE 100 Portland OR 97232-2099
3990264 Franciscan Hospice Dept 1010 P O Box 34936 Seattle WA 98124-1936 1717 S J Street Tacoma WA 98405-4944
3990280 Highline Home Health and Hospice 12844 Military Rd S Seattle WA 98168-0000 2801 S 128th Tacoma WA 98168-0000
3990298 Central Basin Home Health and Hospice 311 W 3rd Ave Moses Lake WA 98837-1905 311 W 3rd Ave Moses Lake WA 98837-1905
3990314 Home Care of Kittitas Valley 401 E Mountain View Ave Ellensburg WA 98926-5803 401 E Mountain View Ave Ellensburg WA 98926-5803
3990322 Lower Valley Hospice 3920 Outlook Rd Sunnyside WA 98944-0000 3920 Outlook Rd Sunnyside WA 98944-0000
3990330 Hospice of the Gorge P O Box 36 Hood River OR 97031-0049 814 13th St Hood River OR 97031-0000
3990355 Providence Sound Homecare P O Box 5008 Lacey WA 98509-0000 P O Box 5008 Lacey WA 98509-0000
3990371 Yakima Valley Memorial Hospital 1019 S 40th Ave Yakima WA 98908-0000 1019 S 40th Ave Yakima WA 98908-0000
3990470 Tri-State Hospital Hospice 1100 Highland Ave Clarkston WA 99403-0000 1100 Highland Ave Clarkston WA 99403-0000
3990496 Horizon Hospice 123 W Cascade Way STE #E Spokane WA 99208-6070 123 W Cascade Way STE #E Spokane WA 99208-6070
3990512 Northwest Healthcare Alliance I P O Box 94316 Seattle WA 98124-6616 1821 Cooks Hill Rd STE 200 Centralia WA 98531-0000
3990652 Okanogan Regional Hospice 800 Jasmine St STE 2 Omak WA 98841-9501 800 South Jasmine STE 2 Omak WA 98841-0000
3990744 Whatcom Hospice P O Box 1238 Bellingham WA 98227-1238 800 E Chestnut St #C-1 Bellingham WA 98225-5241
3990835 Hospice of Jefferson County 834 Sheridan St Port Townsend WA 98368-2443 834 Sheridan St Port Townsend WA 98368-2443
3990884 Odyssey of Cincinnati 4350 Glendale-Milford #110 Blue Ash Hamilton OH 45242-0000 4350 Glendale-Milford #110 Blue Ash Hamilton OH 45242-0000
3990934 Avera Mckennan Hospital P O Box 9191 Minneapolis MN 57105-1016 800 E 21st St Sioux Falls SD 57105-1016
3990967 Bonner Community Hospice P O Box 1448 Sandpoint ID 83864-0877 520 N Third Sandpoint ID 83864-0877
3991031 Family Home Care and Hospice Corp 9922 E Montgomery #3 Spokane Valley WA 99206-0000 9922 E Montgomery #3 Spokane Valley WA 99206-0000

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Long-term services and supports authorized under Apple Health

Revised date
Purpose statement

This section describes long-term services and supports (LTSS) authorized under institutional and noninstitutional Apple Health Medicaid programs.

WAC 182-513-1200 Long-term services and supports authorized under Washington Apple Health programs

WAC 182-513-1200 Long-term services and supports authorized under Washington Apple Health programs

Effective February 20, 2017

  1. Long-term services and supports (LTSS) programs available to people eligible for noninstitutional Washington apple health coverage who meet the functional requirements.
    1. Noninstitutional apple health coverage in an alternate living facility (ALF) under WAC 182-513-1205.
    2. Community first choice (CFC) under WAC 182-513-1210.
    3. Medicaid personal care (MPC) under WAC 182-513-1225.
    4. For people who do not meet institutional status under WAC 182-513-1320, skilled nursing or rehabilitation is available under the CN, medically needy (MN) or alternative benefits plan (ABP) scope of care if enrolled into a managed care plan.
  2. Non-HCB waiver LTSS programs that use institutional rules under WAC 182-513-1315 and 182-513-1380 or HCB waiver rules under chapter 182-515 WAC, depending on the person's living arrangement:
    1. Program of all-inclusive care for the elderly (PACE) under WAC 182-513-1230.
    2. Roads to community living (RCL) under WAC 182-513-1235.
    3. Hospice under WAC 182-513-1240.

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

Noninstitutional services are authorized for people who are eligible for a categorically needy (CN) or alternate benefit plan (ABP). These services are:

  1. Medicaid Personal Care (MPC)
  2. Community First Choice (CFC)
  3. Hospice. Hospice services can also be authorized under the medically needy (MN) program.

Noninstitutional medical programs include MAGI-based N-track programs through the Health Benefit Exchange and the non-MAGI medicaid programs such as SSI related, foster care, and breast and cervical cancer.

Institutional services is also called long-term care (LTC). These services are authorized for people living in a medical institution 30 days or more. Home and Community based (HCB) Waivers are considered an institutional medical program. SSI-related institutional programs are subject to a 5 year look back for transfer penalties. There are 3 parts to the eligibility for institutional medical programs:

  1. Initial eligibility for the Medicaid
  2. Functional eligibility for the service
  3. Post-eligibility treatment of income to determine the client responsibility toward the cost of care. This payment is also called participation.

Institutional rules can be used to access LTSS if a person is not eligible for CN using noninstitutional rules. Whenever institutional rules are needed to determine eligibility, the person is subject to the post-eligibility treatment of income to determine the client responsibility toward the cost of care. These services do not have a 5 year look back for transfer penalties like institutional or HCB Waiver programs. These services are:

  1. Program of all-inclusive care for the elderly (PACE)
  2. Roads to Community Living (RCL)
  3. CFC
  4. Hospice.

People residing in a medical institution 30 days or more, with the exception of MAGI-based programs have eligibility determined under WAC 182-513-1315 and WAC 182-513-1380. MAGI-based programs cover nursing facility services as a claim and no program change is done even if residing in a NF 30 days or more.

Home and Community based (HCB) waivers are considered an institutional program. Eligibility is determined under Chapter 182-515 WAC.

Community First Choice (CFC) or Medicaid Personal Care (MPC) can be authorized by HCS or DDA for people who are functionally eligibility and receive a CN or ABP Apple Health program. The eligibility for CN and ABP are based on the following program rules:

  1. Modified adjusted gross income (MAGI) based eligibility through the Health Benefit Exchange (HBE) with the exception of alien emergent medical under N21 and N25. The remaining MAGI programs are under the N track. Notification of services under the N track programs is done through the social service authorization in Provider One.
  2. CN under a Classic (non-MAGI) Apple Health program:
    1. SSI-related noninstitutional programs:
      1. SSI (S01)
      2. SSI related CN (S02)
      3. SSI related CN Health Care for Workers with Disabilities (HWD)(S08
      4. SSI related CN in an Alternate Living Facility (ALF) (G03)
    2. Foster Care (D01, D02)
    3. Breast and Cervical Cancer (S30)

Consult the medical program chart desk tool located in the financial program SharePoint for a complete list of medical coverage groups (MCG) and the type of LTSS service that can be authorized for each MCG.

For MPC, the eligibility is based on any noninstitutional CN or ABP Apple Health program.

For CFC, the eligibility is based on any Apple Health CN or ABP program including eligibility for a HCB Waiver. If eligible person receives both CFC and HCB Waiver, the eligibility rules under Chapter 182-515 WAC apply including the 5 year look back for transfer penalties and post-eligibility treatment of income.

For people receiving CFC only, the 5 year look back for transfer penalties do not apply.

People living in the community, receiving PACE, RCL or Hospice, may have eligibility determined using HCB Waiver rules under Chapter 182-515 WAC. Even though HCB Waiver rules can be used for eligibility, these programs are not HCB Waivers and are not subject to the 5 year look back for transfer penalties. People receiving PACE, RCL or Hospice are considered to have institutional status under WAC 182-513-1320. People receiving PACE or Hospice in a nursing facility have eligibility based on WAC 182-513-1315 and WAC 182-513-1380.

All LTSS services are subject to excess home equity provisions under WAC 182-513-1350.

Worker Responsibilities

Use the following sections to determine eligibility depending on the service authorized and the setting:

  1. Overview- LTSS- Who does what. This section has the program responsibility chart
  2. Applications for LTSS
  3. Eligibility requirements
  4. Home and Community-based (HCB) Waivers. For people needing HCB Waiver rules to access LTSS
  5. Medicaid Personal Care (MPC)
  6. Community First Choice (CFC)
  7. Determining eligibility for noninstitutional coverage in an alternate living facility (G03), (Private pay ALF G95, G99). Includes BHO placements in ALF.
  8. Hospice index
  9. PACE
  10. Roads to Community Living (RCL)
  11. Modified Adjusted Gross Income (MAGI) based institutional. (K track). This program is used when a person is under age 65, not on medicare, and not eligible for a MAGI program through the HBE. The person must reside in a medical institution 30 days or more before this program can be considered.

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Patient access and affordability programs

Revised date
Purpose statement

Patient access and affordability programs assist individuals with their prescription drug costs when their prescriptions are not covered by Washington Apple Health or Medicare. In addition to prescription assistance some companies also provide assistance with coverage, medical management, and/or financial assistance.

The following resources may assist with health care affordability issues. These resources are not endorsed by HCA and are just a sample of what is available on the internet.

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Resource eligibility index

Revised date
Purpose statement

This section describes how the department looks at an individual's resources (also called assets) when determining eligibility for long-term care programs

Resources

Available Resources

This section describes resource eligibility for institutional Washington Apple Health programs, including home and community based (HCB) waiver programs. The section includes information on how to handle excess resources, vehicles, patient trust accounts at facilities, treatment of the home and the resource calculation of a married couple.

Annuities

Annuity Life Expectancy Tables

Excess Home Equity

This section explains the requirements relating to the amount of equity an individual may have in the home and still qualify for long-term care services.

Estate Recovery

Explains who is subject to Estate Recovery and includes the ALTSA Estate Recovery handout and Legal Services bulletin

Hardship Waivers for long-term care (LTC) services

This section includes information on when the department can look at a hardship waiver, how to request a hardship waiver and what to do if your request is denied. Hardship waivers can be considered any time the department denies a long-term care application due to transfer of assets or due to an individual having excess equity in their home.

How life estates affect eligibility

This section describes how Life Estates affect long term care eligibility

Determining the value of life estates

This section is a chart used to determine the value of a life estate

Long-term Care Partnership

Long-term Care Partnership - Information for Consumers

Long-term Care - Partnership - Frequently Asked Questions

These sections provide information for field staff and consumers regarding the Washington State Long-term care partnership program.

Standards - Long-term care (LTC) Long-term Services and Supports (LTSS) income and resource standards

Chart of current income and resource standards

Lump sum incomes and Long-term Services and Supports (LTSS)

This section provides information on how the department treats the receipt of lump sums of income. Depending upon the source of the income and when it is reported, the lump sum may be treated either as a resource or income.

Allowable medical expenses. Chart of allowable and nonallowable expenses

This section provides information on the type of medical expenses that may be used to reduce the countable resources of an applicant with resources over the limit in the month of application for long-term care services.

Reverse mortgage, promissory notes and loans

This section provides information on how the department treats income received from reverse mortgages, promissory notes and loans and when income received from these sources would be counted towards an individual's resource limit.

Resource ownership and availability

Institutional and HCB Waiver resource eligibility starts with SSI related medical resources. Rules that are specific to long-term care are stated in WAC 182-513-1350

Transfer of an asset

This section describes the process used by the department to determine if an individual has made an impermissible transfer of an asset during the five year look-back period prior to an application for long-term care and describes penalties the department establishes.

Treatment of entrance fees for people residing in continuing care or life care communities

This section explains how to treat life care contracts signed by the client and the facility and/or organization. Treatment of entrance fees in a continuing care retirement community or life care community is considered a resource available to the client in certain conditions

Trusts - How Trusts Affect eligibility for medical programs

This section explains how to treat trusts for the purposes of medicaid eligibility.

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Institutional status

Revised date

WAC 182-513-1320 Determining institutional status for long-term care (LTC) services.

WAC 182-513-1320 Determining institutional status for long-term care (LTC) services.

Effective February 17, 2017

  1. To attain institutional status outside a medical institution, a person must be approved for and receive:
    1. Home and community based (HCB) waiver services under chapter 182-515 WAC;
    2. Roads to community living (RCL) services under WAC 182-513-1235;
    3. Program of all-inclusive care for the elderly (PACE) under WAC 182-513-1230;
    4. Hospice services under WAC 182-513-1240(3); or
    5. State-funded long-term care service under WAC 182-507-0125.
  2. To attain institutional status in a medical institution, a person must reside in a medical institution thirty consecutive days or more, or based on a department assessment, be likely to reside in a medical institution thirty consecutive days or more.
  3. Once a person meets institutional status, the person's status is not affected if the person:
    1. Transfers between medical facilities; or
    2. Changes between any of the following programs: HCB waiver, RCL, PACE, hospice or services in a medical institution.
  4. A person loses institutional status if the person is absent from a medical institution, or does not receive HCB waiver, RCL, PACE, or hospice services, for more than twenty-nine consecutive days.

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

The term "institutional status" refers to a minimum period of time a person requires LTC services. An individual attains institutional status when the need for inpatient services in a medical institution is 30 days or more.

A person attains institutional status when they:

  • Reside continuously in a medical institution for 30 consecutive days or longer; 
  • Are likely to remain in a medical institution for 30 consecutive days or longer; or
  • Receives a home and community based (HCB) waiver service through DDA or HCS.
  • Receives program of all-inclusive care for the elderly (PACE); or
  • Elects hospice services; or
  • Receives state-funded long-term care for noncitizens. 

A person loses institutional status when they:

  • Are absent from a medical institution for at least 30 consecutive days, or
  • Doesn't receive DDA or HCS HCB waiver services, PACE, hospice, or state-funded long term care for noncitizens for at least 30 days. 

"Likely to remain" means there is a reasonable expectation the person will be in a medical institution for 30 consecutive days or longer. Once made, the determination holds even if the person doesn't actually remain institutionalized for 30 consecutive days. If an admission into a medical institution is expected to last under 30 days for an evaluation, brief rehabilitation based on current information, then institutional medicaid rules can't be used.

For nursing facilities, the HCS social service worker gives the financial worker by the 14-443 as to whether the person is projected to be in the facility 30 days or more along with a determination of nursing facility level of care (NFLOC).

For State Veteran's nursing facility, the Veteran's Affairs Registered Nurse (VARN) gives the best projection possible as to whether the person is going to remain in the facility 30 days or more along with a determination of NFLOC.

For State IMD Hospitals, IMD social service or nursing staff give the best projection possible as to whether the person is going to remain in the facility 30 days or more.

For DDA institutions, the DDA case manager gives the best projection possible as to whether the person is going to remain in the facility 30 days or more along with a ICF-ID level of care.

The combination of HCB Waiver services, Hospice, state funded LTC for noncitizens or admission into a medical institution, hospitalization, etc. counts toward the 30 day institutionalization if there is no break in service.

What is a Medical Institution?

Not every facility is considered a medical institution. Assisted living, Enhanced Adult Residential Centers (EARC), Adult Residential Centers (ARC), DDA group homes and Adult Family Homes are not considered a medical institution. Clients can be receiving institutional HCB Waiver services in these facilities.

WAC 182-500-0050 defines a medical institution.

Note: Hospice services can be received in a medical facility or in conjunction with waiver services. They are a group of services provided to an individual who is terminally ill. Hospice services do not constitute a waiver program but waiver rules can be used for hospice medicaid eligibility. If residing in a medical institution 30 days or more (nursing facility, hospital, hospice care center) institutional rules must be used See hospice.

Note: Medicaid Personal Care (MPC) and Community First Choice (CFC) are not considered "institutional" programs.
MPC and CFC-only eligibility is tied to noninstitutional categorically needy (CN) medicaid.

Worker Responsibilities

Obtain the determination of whether the person is likely to remain institutionalized for 30 consecutive days from the department-designated social service worker or case manager.

For nursing facility cases, the HCS social service worker notifies financial of the date of request for assessment, whether the person is projected to be in a nursing facility 30 days or more and if the person meets NFLOC.

For those people who meet both 30 day or more institutionalization and NFLOC, institutional Medicaid is considered.

For individual persons who don't meet the 30 day or more institutionalization, institutional Medicaid can't be considered. Eligibility for Medicaid is determined as if the person were in their own home. If the person is eligible for another Medical program, the admission into the medical institution is considered a short stay (29 days or less). See Short Stays.

For active Apple Health clients who lose institutional medicaid status due to discharge from a medical institution or no longer receiving a HCB Waiver service, redetermine eligibility under a noninstitutional medical program.

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Definitions: long-term services and supports

Revised date
Purpose statement

Additional medical definitions: The main medical definitions are found on the HCA main WAC index page. This includes a clarification on medical institutions and alternate living facilities. WAC 388-106-0045

WAC 182-513-1100 Definitions related to long-term services and supports (LTSS)

WAC 182-513-1100 Definitions related to long-term services and supports (LTSS)

Revised March 1, 2025

This section defines the meaning of certain terms used in chapters 182-513 and 182-515 WAC. Within these chapters, institutional, home and community-based services (HCB) waiver, program of all-inclusive care for the elderly (PACE), and hospice in a medical institution are referred to collectively as long-term care (LTC). Long-term services and supports (LTSS) is a broader definition which includes institutional, HCB waiver, and other services such as medicaid personal care (MPC), community first choice (CFC), PACE, and hospice in the community.

  • See chapter 182-516 WAC for definitions related to trusts, annuities, life estates, and promissory notes.
  • See chapter 388-106 WAC for long-term care services definitions.
  • See WAC 182-513-1405 for long-term care partnership definitions.
  • See chapter 182-500 WAC for additional definitions.

"Adequate consideration" means that the fair market value (FMV) of the property or services received, in exchange for transferred property, approximates the FMV of the property transferred.

"Administrative costs" or "costs" means necessary costs paid by the guardian or conservator including attorney fees.

"Aging and long-term support administration (ALTSA)" means the administration within the Washington state department of social and health services (DSHS).

"Alternate living facility (ALF)" is not an institution under WAC 182-500-0050; it is one of the following community residential facilities:

(a) Adult family home (AFH) licensed under chapter 70.128 RCW.

(b) Adult residential care facility (ARC) licensed under chapter 18.20 RCW.

(c) Assisted living facility (AL) licensed under chapter 18.20 RCW.

(d) Behavioral health adult residential treatment facility (RTF) licensed under chapter 246-337 WAC.

(e) Intensive behavioral health treatment facility (IBHTF) is an RTF licensed under chapter 246-337 WAC.

(f) Developmental disabilities administration (DDA) group home (GH) licensed as an adult family home under chapter 70.128 RCW or an assisted living facility under chapter 18.20 RCW.

(g) Enhanced adult residential care facility (EARC) licensed as an assisted living facility under chapter 18.20 RCW.

(h) Enhanced service facility (ESF) licensed under chapter 70.97 RCW.

(i) Facility for children and youth 20 years of age and younger where a state-operated living alternative program, as defined under chapter 71A.10 RCW, is operated.

(j) Group care facility for medically complex children licensed under chapter 74.15 RCW.

(k) Staffed residential facility licensed under chapter 74.15 RCW.

"Assets" means all income and resources of a person and of the person's spouse, including any income or resources which that person or that person's spouse would otherwise currently be entitled to but does not receive because of action:

(a) By that person or that person's spouse;

(b) By another person, including a court or administrative body, with legal authority to act in place of or on behalf of the person or the person's spouse; or

(c) By any other person, including any court or administrative body, acting at the direction or upon the request of the person or the person's spouse.

"Authorization date" means the date payment begins for long-term services and supports (LTSS) under WAC 388-106-0045.

"Clothing and personal incidentals (CPI)" means the cash payment (under WAC 388-478-0090, 388-478-0006, and 388-478-0033) issued by the department for clothing and personal items for people living in an ALF or medical institution.

"Community first choice (CFC)" means a medicaid state plan home and community based service developed under the authority of section 1915(k) of the Social Security Act under chapter 388-106 WAC.

"Community options program entry system (COPES)" means a medicaid home and community-based services (HCBS) waiver program developed under the authority of section 1915(c) of the Social Security Act under chapter 388-106 WAC.

"Community spouse (CS)" means the spouse of an institutionalized spouse.

"Community spouse resource allocation (CSRA)" means the resource amount that may be transferred without penalty from:

(a) The institutionalized spouse (IS) to the community spouse (CS); or

(b) The spousal impoverishment protections institutionalized (SIPI) spouse to the spousal impoverishment protections community (SIPC) spouse.

"Community spouse resource evaluation" means the calculation of the total value of the resources owned by a married couple on the first day of the first month of the institutionalized spouse's most recent continuous period of institutionalization.

"Comprehensive assessment reporting evaluation (CARE) assessment" means the evaluation process defined under chapter 388-106 WAC used by a department designated social services worker or a case manager to determine a person's need for long-term services and supports (LTSS).

"Conservator" has the same meaning given in RCW 11.130.010.

"Conservatorship" means the process outlined in chapter 11.130 RCW for appointing a conservator and a conservator's carrying out of any duties pursuant to an order entered under RCW 11.130.360 through 11.130.575.

"Conservatorship fees" or "fees" means necessary fees charged by a conservator for services rendered on behalf of a client.

"Continuing care contract" means a contract to provide a person, for the duration of that person's life or for a term in excess of one year, shelter along with nursing, medical, health-related, or personal care services, which is conditioned upon the transfer of property, the payment of an entrance fee to the provider of such services, or the payment of periodic charges for the care and services involved.

"Continuing care retirement community" means an entity which provides shelter and services under continuing care contracts with its members and which sponsors or includes a health care facility or a health service.

"Dependent" means a minor child, or one of the following who meets the definition of a tax dependent under WAC 182-500-0105: Adult child, parent, or sibling.

"Developmental disabilities administration (DDA)" means an administration within the Washington state department of social and health services (DSHS).

"Developmental disabilities administration (DDA) home and community-based services (HCBS) waiver" means a medicaid HCB waiver program developed under the authority of section 1915(c) of the Social Security Act under chapter 388-845 WAC authorized by DDA. There are five DDA HCB waivers:

(a) Basic Plus;

(b) Core;

(c) Community protection;

(d) Children's intensive in-home behavioral support (CIIBS); and

(e) Individual and family services (IFS).

"Equity" means the fair market value of real or personal property less any encumbrances (mortgages, liens, or judgments) on the property.

"Fair market value (FMV)" means the price an asset may reasonably be expected to sell for on the open market in an agreement, made by two parties freely and independently of each other, in pursuit of their own self-interest, without pressure or duress, and without some special relationship (arm's length transaction), at the time of transfer or assignment.

"Guardian" has the same meaning given in RCW 11.130.010.

"Guardianship" means the process outlined in chapter 11.130 RCW for appointing a guardian and a guardian's carrying out of any duties pursuant to an order entered under RCW 11.130.265 through 11.130.355.

"Guardianship fees" or "fees" means necessary fees charged by a guardian for services rendered on behalf of a client.

"Home and community-based services (HCBS) waiver programs authorized by home and community services (HCS)" means medicaid HCBS waiver programs developed under the authority of Section 1915(c) of the Social Security Act under chapter 388-106 WAC authorized by HCS. There are three HCS HCBS waivers: Community options program entry system (COPES), new freedom consumer directed services (New Freedom), and residential support waiver (RSW).

"Home and community based services (HCBS)" means LTSS provided in the home or a residential setting to persons assessed by the department.

"Institutional services" means services paid for by Washington apple health, and provided:

(a) In a medical institution;

(b) Through an HCBS waiver; or

(c) Through programs based on HCBS waiver rules for post-eligibility treatment of income under chapter 182-515 WAC.

"Institutionalized individual" means a person who has attained institutional status under WAC 182-513-1320.

"Institutionalized spouse" means a person who, regardless of legal or physical separation:

(a) Has attained institutional status under WAC 182-513-1320; and

(b) Is legally married to a person who is not in a medical institution.

"Life care community" see continuing care community.

"Likely to reside" means the agency or its designee reasonably expects a person will remain in a medical institution for 30 consecutive days. Once made, the determination stands, even if the person does not actually remain in the facility for that length of time.

"Long-term care services" see "Institutional services."

"Long-term services and supports (LTSS)" includes institutional and noninstitutional services authorized by the department.

"Medicaid alternative care (MAC)" is a Washington apple health benefit authorized under Section 1115 of the Social Security Act. It enables the medicaid agency and the agency's designees to deliver an array of person-centered long-term services and supports (LTSS) to unpaid caregivers caring for a medicaid-eligible person who meets nursing facility level of care under WAC 388-106-0355 and 182-513-1605.

"Medicaid personal care (MPC)" means a medicaid state plan home and community based service under chapter 388-106 WAC.

"Most recent continuous period of institutionalization (MRCPI)" means the current period an institutionalized spouse has maintained uninterrupted institutional status when the request for a community spouse resource evaluation is made. Institutional status is determined under WAC 182-513-1320.

"Noninstitutional medicaid" means any apple health program not based on HCB waiver rules under chapter 182-515 WAC, or rules based on a person residing in an institution for 30 days or more under chapter 182-513 WAC.

"Nursing facility level of care (NFLOC)" is described in WAC 388-106-0355.

"Participation" means the amount a person must pay each month toward the cost of long-term care services received each month; it is the amount remaining after the post-eligibility process under WAC 182-513-1380, 182-515-1509, or 182-515-1514. Participation is not room and board.

"Penalty period" or "period of ineligibility" means the period of time during which a person is not eligible to receive services that are subject to transfer of asset penalties.

"Personal needs allowance (PNA)" means an amount set aside from a person's income that is intended for personal needs. The amount a person is allowed to keep as a PNA depends on whether the person lives in a medical institution, ALF, or at home.

"Presumptive eligibility (PE)" for long-term services and supports is described in WAC 182-513-1110.

"Program of all-inclusive care for the elderly (PACE)" provides long-term services and supports (LTSS), medical, mental health, and substance use disorder (SUD) treatment through a department-contracted managed care plan using a personalized plan of care for each enrollee.

"Roads to community living (RCL)" is a demonstration project authorized under Section 6071 of the Deficit Reduction Act of 2005 (P.L. 109-171) and extended through the Patient Protection and Affordable Care Act (P.L. 111-148).

"Room and board" means the amount a person must pay each month for food, shelter, and household maintenance requirements when that person resides in an ALF. Room and board is not participation.

"Short stay" means residing in a medical institution for a period of 29 days or fewer.

"Significant financial duress" means, but is not limited to, threatened loss of, or financial burden from, basic shelter, food, or medically necessary health care. It means that a member of a couple has established to the satisfaction of a hearing officer that the community spouse needs income above the level permitted by the community spouse maintenance standard to provide for medical, remedial, or other support needs of the community spouse to permit the community spouse to remain in the community.

"Special income level (SIL)" means the monthly income standard that is 300 percent of the supplemental security income (SSI) federal benefit rate.

"Spousal impoverishment protections" means the financial provisions within Section 1924 of the Social Security Act that protect income and assets of the community spouse through income and resource allocation. The allocation process is used to discourage the impoverishment of a spouse due to the other spouse's need for LTSS. This includes services provided in a medical institution, HCB waivers authorized under 1915(c) of the Social Security Act, and through September 30, 2027, services authorized under 1115 and 1915(k) of the Social Security Act.

"Spousal impoverishment protections community (SIPC) spouse" means the spouse of a SIPI spouse.

"Spousal impoverishment protections institutionalized (SIPI) spouse" means a legally married person who qualifies for the noninstitutional categorically needy (CN) Washington apple health SSI-related program only because of the spousal impoverishment protections under WAC 182-513-1220.

"State spousal resource standard" means the minimum CSRA standard for a CS or SIPC spouse.

"Tailored supports for older adults (TSOA)" is a federally funded program approved under Section 1115 of the Social Security Act. It enables the medicaid agency and the agency's designees to deliver person-centered long-term services and supports (LTSS).

"Third-party resource (TPR)" means funds paid to or on behalf of a person by a third party, where the purpose of the funds is for payment of activities of daily living, medical services, or personal care. The agency does not pay for these services if there is a third-party resource available.

"Transfer" means, in the context of long-term care eligibility, the changing of ownership or title of an asset, such as income, real property, or personal property, by one of the following: (a) An intentional act that changes ownership or title; or(b) A failure to act that results in a change of ownership or title.

"Uncompensated value" means the fair market value (FMV) of an asset on the date of transfer, minus the FMV of the consideration the person receives in exchange for the asset.

"Undue hardship" means a person is not able to meet shelter, food, clothing, or health needs. A person may apply for an undue hardship waiver based on criteria under WAC 182-513-1367.

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.

Please report broken links or content problems.

Eligibility requirements for LTSS

Revised date

Eligibility requirements specific to long-term care

Washington Apple Health (WAH) eligibility WACs Title 182 Health Care Authority (HCA)

WAH includes Modified Adjusted Gross Income (MAGI) programs AND institutional and SSI related Medicaid, also known as "Classic Medicaid".

Please report broken links or content problems.

DDA Home and Community Based (HCB) waivers

Revised date
Purpose statement

Determining Medicaid eligibility and client responsibility for cost of care for clients functionally eligible for a Developmental Disabilities Administration (DDA) Waiver program.

WAC 182-515-1510 Home and community based (HCB) waiver services authorized by the developmental disabilities administration (DDA).

WAC 182-515-1510 Home and community based (HCB) waiver services authorized by the developmental disabilities administration (DDA).

Effective February 20, 2017

This chapter describes the general and financial eligibility requirements for categorically needy (CN) home and community based (HCB) waivers authorized by the developmental disabilities administration (DDA). The definitions in WAC 182-513-1100 and chapter 182-500 WAC apply throughout this chapter.

  1. The DDA waiver programs are:
    1. Basic Plus;
    2. Core;
    3. Community protection;
    4. Children's intensive in-home behavioral support (CIIBS); and
    5. Individual and family services (IFS).
  2. WAC 182-515-1511 describes the general eligibility requirements for HCB waiver services authorized by DDA.
  3. WAC 182-515-1512 describes the financial requirements for eligibility for HCB waiver services authorized by DDA if a person is eligible for a noninstitutional SSI-related CN program.
  4. WAC 182-515-1513 describes the financial eligibility requirements for HCB waiver services authorized by DDA when a person is not eligible for an SSI-related noninstitutional CN program under WAC 182-515-1512.
  5. WAC 182-515-1514 describes the rules used to determine a person's responsibility in the cost of care and room and board for HCB waiver services authorized by DDA if the person is eligible under WAC 182-515-1512.

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 182-515-1511 Home and community based (HCB) waiver services authorized by the developmental disabilities administration (DDA) - General eligibility.

WAC 182-515-1511 Home and community based (HCB) waiver services authorized by the developmental disabilities administration (DDA) - General eligibility.

Effective February 25, 2023

  1. To be eligible for home and community based (HCB) waiver services authorized by the developmental disabilities administration (DDA), a person must:
    1. Meet specific program requirements under chapter 388-845 WAC;
    2. Be an eligible client of the DDA;
    3. Meet the disability criteria for the supplemental security income (SSI) program under WAC 182-512-0050;
    4. Need the level of care provided in an intermediate care facility for the intellectually disabled (ICF/ID);
    5. Have attained institutional status under WAC 182-513-1320;
    6. Be able to reside in the community and choose to do so as an alternative to living in an ICF/ID;
    7. Be assessed for HCB waiver services, be approved for a plan of care, and receive HCB waiver services under (a) of this subsection, and:
      1. Be able to live at home with HCB waiver services; or
      2. Live in a department-contracted facility with HCB waiver services, such as:
        1. A group home;
        2. A group training home;
        3. A child foster home, group home, or staffed residential facility;
        4. An adult family home (AFH); or
        5. An adult residential care (ARC) facility.
      3. Live in the person's own home with supported living services from a certified residential provider; or
      4. Live in the home of a contracted companion home provider.
  2. A person is not eligible for home and community based (HCB) waiver services if the person:
    1. Is subject to a penalty period of ineligibility for the transfer of an asset under WAC 182-513-1363; or
    2. Has a home with equity in excess of the requirements under WAC 182-513-1350.
  3. See WAC 182-513-1315 for rules used to determine countable resources, income, and eligibility standards for long-term care (LTC) services.
  4. Current income and resource standard charts are found at http://www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/program-standard-income-and-resources.

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 182-515-1512 Home and community based (HCB) waiver services authorized by the developmental disabilities administration (DDA)- Financial eligibility if a client is eligible for a noninstitutional SSI-related categorically needy (CN) program

WAC 182-515-1512 Home and community based (HCB) waiver services authorized by the developmental disabilities administration (DDA)- Financial eligibility if a client is eligible for a noninstitutional SSI-related categorically needy (CN) program.

Effective February 25, 2023

  1. A client is financially eligible for home and community based (HCB) waiver services authorized by the developmental disabilities administration (DDA) if:
    1. The client is receiving coverage under one of the following categorically needy (CN) medicaid programs:
      1. Supplemental security income (SSI) program under WAC 182-510-0001. This includes SSI clients under 1619(b) status; or
      2. Health care for workers with disabilities (HWD) under chapter 182-511 WAC; or
      3. SSI-related noninstitutional (CN) program under chapter 182-512 WAC; or
      4. The foster care program under WAC 182-505-0211 and the client meets disability requirements under WAC 182-512-0050.
    2. The client does not have a penalty period of ineligibility for the transfer of an asset as under WAC 182-513-1363; and
    3. The client does not own a home with equity in excess of the requirements under WAC 182-513-1350.
  2. A client eligible under this section does not pay toward the cost of care, but must pay room and board if living in an alternate living facility (ALF) under WAC 182-513-1100.
  3. A client eligible under this section who lives in a department-contracted ALF described under WAC 182-513-1100:
    1. Keeps a personal needs allowance (PNA) under WAC 182-513-1105; and
    2. Pays towards room and board up to the room and board standard under WAC 182-513-1105.
  4. A client who is eligible under the HWD program must pay the HWD premium under WAC 182-511-1250, in addition to room and board if residing in an ALF.
  5. Current resource, income, PNA and room and board standards are found at www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/program-standard-income-and-resources.

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 182-515-1513 Home and community based (HCB) waiver services authorized by the developmental disabilities administration (DDA)—Financial eligibility using SSI-related institutional rules.

WAC 182-515-1513 Home and community based (HCB) waiver services authorized by the developmental disabilities administration (DDA)—Financial eligibility using SSI-related institutional rules.

Effective February 25, 2023

  1. If a person is not eligible for a categorically needy (CN) program under WAC 182-515-1512, the agency determines eligibility for home and community based (HCB) waiver services authorized by the developmental disabilities administration (DDA) using institutional medicaid rules. This section explains how a person may qualify using institutional rules.
  2. A person must meet:
    1. General eligibility requirements under WAC 182-513-1315 and 182-515-1511;
    2. Resource requirements under WAC 182-513-1350; and
    3. Have available income at or below the special income level (SIL) defined under WAC 182-513-1100.
  3. The agency determines available income and income exclusions according to WAC 182-513-1325, 182-513-1330, and 182-513-1340.
  4. A person eligible under this section is responsible to pay income toward the cost of care and room and board, as described under WAC 182-515-1514.
  5. Current resource, income standards are found at www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/program-standard-income-and-resources.

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 182-515-1514 Home and community based (HCB) services authorized by the developmental disabilities administration (DDA)- Client financial responsibility.

WAC 182-515-1514 Home and community based (HCB) services authorized by the developmental disabilities administration (DDA)- Client financial responsibility

Effective March 1, 2025

  1. A client eligible for home and community based (HCB) waiver services authorized by the developmental disabilities administration (DDA) under WAC 182-515-1513 must pay toward the cost of care and room and board under this section.
    1. Post-eligibility treatment of income, participation, and participate are all terms that refer to a client's responsibility towards cost of care.
    2. Room and board is a term that refers to a client's responsibility toward food and shelter in an alternate living facility (ALF).
  2. The agency determines how much a client must pay toward the cost of care for home and community based (HCB) waiver services authorized by the DDA when the client is living at home, as follows:
    1. A single client who lives at home (as defined in WAC 388-106-0010) keeps a personal needs allowance (PNA) of up to the special income level (SIL) defined under WAC 182-513-1100.
    2. A single client who lives at home on the roads to community living program authorized by DDA keeps a PNA up to the SIL but must pay any remaining available income toward cost of care after allowable deductions described in subsection (4) of this section.
    3. A married client who lives with the client's spouse at home (as defined in WAC 388-106-0010) keeps a PNA of up to the SIL but must pay any remaining available income toward cost of care after allowable deductions under subsection (4) of this section.
    4. A married couple living at home where each client receives HCB waiver services, one authorized by DDA and the other authorized by home and community services (HCS) is allowed the following:
      1. The client authorized by DDA keeps a PNA of up to the SIL but must pay any remaining available income toward the client's cost of care after allowable deductions in subsection (4) of this section; and
      2. The client authorized by HCS pays toward the cost of care under WAC 182-515-1507 or 182-515-1509.
  3. The agency determines how much a client must pay toward the cost of care for HCB wavier services authorized by DDA and room and board when the client is living in a department-contracted ALF defined under WAC 182-513-1100. A client:
    1. Keeps a PNA under WAC 182-513-1105;
    2. Pays room and board up to the room and board standard under WAC 182-513-1105; and
    3. Pays the remainder of available income toward the cost of care after allowable deductions under subsection (4) of this section.
  4. If income remains after the PNA and room and board liability under subsection (2) or (3) of this section, the remaining available income must be paid toward the cost of care after it is reduced by allowable deductions in the following order:
    1. An earned income deduction of the first $65, plus one-half of the remaining earned income;
    2. Guardianship fees, conservatorship fees, and administrative costs including any attorney fees paid by the guardian or conservator only as allowed under chapter 388-79A WAC;
    3. Current or back child support garnished or withheld from the client's income according to a child support order in the month of the garnishment if it is for the current month. If the agency allows this as a deduction from income, the agency does not count it as the child's income when determining the family allocation amount in WAC 182-513-1385;
    4. A monthly maintenance-needs allowance for the community spouse under WAC 182-513-1385. If the community spouse is on long-term care services, the allocation is limited to an amount that brings the community spouse's income to the community spouse's PNA;
    5. A monthly maintenance-needs allowance for each dependent of the institutionalized client, or the client's spouse, as calculated under WAC 182-513-1385; and
    6. Incurred medical expenses which have not been used to reduce excess resources. Allowable medical expenses are under WAC 182-513-1350.
  5. The total of the following deductions cannot exceed the SIL defined under WAC 182-513-1100:
    1. The PNA described in subsection (2) or (3) of this section, including room and board;
    2. The earned income deduction in subsection (4)(a) of this section; and
    3. The guardianship fees, conservatorship fees, and administrative costs in subsection (4)(b) of this section.
  6. A client may have to pay third-party resources defined under WAC 182-513-1100 in addition to the room and board and participation.
  7. A client must pay the client's provider the sum of the room and board amount, the cost of care after all allowable deductions, and any third-party resources defined under WAC 182-513-1100.
  8. A client on HCB waiver services does not pay more than the state rate for cost of care.
  9. When a client lives in multiple living arrangements in a month, the agency allows the highest PNA available based on all the living arrangements and services the client has received in a month.
  10. Standards described in this section are found on www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/program-standard-income-and-resources.

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

DDA Waivers

  1. DDA Waivers are categorically needy (CN) waiver programs that provide clients described in WAC 182-515-1510 through 182-515-1514 with alternatives to placement in an Intermediate Care Facility for the Mentally Retarded (ICF/MR). These alternatives include remaining in their home or placement in an alternate living facility (ALF) approved by the Developmental Disabilities Administration (DDA). The goal of these programs is to provide a safe level of care with maximum independence.
  2. In addition to the income allocations described in WAC 182-515-1514 the case manager (CM) can request an exception to rule to reduce the client's participation in the cost of care when the client requires the services of a guardian.
  3. If the client lives in an alternate living facility (ALF), the DDA case manager determines the amount the client keeps for personal needs and the amount the client pays for room and board.
  4. The department determines financial eligibility for these services according to WAC 182-513-1315. A client must have non excluded income at or below the special income level (SIL), but can reduce excess resources in the initial or review months as described in WAC 182-513-1350.
  5. Guardianship fees can be deducted in the post eligibility (participation determination) process if approved by court order for DDA Waivers in an ALF. See guardianship fee for clarifying information and a training module regarding guardianships. Since in home DDA Waiver clients keep the Medicaid SIL as a PNA, there is no guardianship deduction available.
  6. DDA Waiver clients at home do not pay toward personal care costs as they keep up to the Medicaid SIL. (300% of the FBR). DDA Waiver clients can pay up to the ALTSA room and board standard if living in an alternative living facility (ALF) such as a DDA group home or adult family home.
  7. Clients who are eligible to receive Apple Health for Workers with Disabilities (HWD) can receive DDA Waiver services if approved by DDA. HWD/S08 is the priority program in ACES if the client is better off with HWD/S08 over the L22 program. See HWD for more instructions on HWD for DDA Waiver clients. HWD clients on a DDA Waiver pay a premium and have no participation toward personal care. These clients do pay the ALTSA room and board rate if living in a DDA group home or Adult Family Home (these are also called Alternate living facilities (ALF)) See Working clients and long-term care programs (Waiver, Residing in a medical institution, or MPC).

1619B and "Deemed SSI eligible" clients

SSI deemed eligible clients (countable income is under the SSI standard after DAC, Pickle/COLA exclusion and SSI closed due to the receipt of DAC, COLA) do not pay toward the cost of personal care. They DO pay room and board if residing in an adult family home, boarding home or DDA group home. These facilities are also referred to as alternate living facilities or ALFs. ALFs are not medical institutions.

1619(b) clients are considered the same as an "SSI client". SSI payments have stopped due to earnings. SDX indicates continue Medicaid on SDX 1 in the Med Elig field. 1619(b) clients do not pay toward the cost of personal care. (also called participation). They DO pay room and board in an ALF.

"Deemed SSI clients" and 1619(b) status clients can have gross income over the Medicaid SIL (300% of the FBR) and still be eligible for the Waiver. 1619(b) is described in WAC 182-508-0001 (2).

Deemed SSI eligible clients. What does that mean?

Clients who have countable income under the SSI standard after allowing the exclusion for Disabled Adult Child (DAC), Pickle/COLA, Widow/Widowers and their SSI was closed because of the receipt of the DAC/COLA/Widow(er) income. These exclusions are described in the Overview chapter. Clients continue to receive CN Medicaid as long as they meet resource criteria. Not every client receiving DAC income is eligible for this exclusion. These are the requirements:

  • Lost cash payment of SSI after 7/1/88 due to receipt of DAC benefits from SSA or a COLA to those benefits.
  • Disability onset date prior to age 22

Deemed SSI eligible clients do not pay Waiver service participation, they do pay room and board if living in an adult family home, DDA group home or boarding home (ALFs).

If countable income is over the SSI standard after the exclusion then all income is counted in post eligibility in determining service participation for DDA Waiver clients living in an ALF. This includes DAC income.

Individuals who qualify for the DAC exclusion and countable income after the exclusion is under the SSI standard are referred to as "Protected DAC" cases.

Instructions are found in WAC 182-512-0880 Special income disregards for SSI-related medical programs.

In other words, an individual who would be eligible for CN-P/S02 in ACES

A client who would otherwise qualify for S02/CN SSI related medicaid because their countable income is at or below the SSI standard does not participate towards personal care under the Waiver program. (but they are responsible to pay room and board when living in an ALF).

These clients do need to meet the same criteria for long-term care services as other Waiver clients and may be subject to Asset transfers or excess home equity described in WAC 182-513-1350

The room and board amount ALTSA uses is based on the FBR minus the current HCS CN Waiver personal needs allowance (PNA) for individuals residing in an ALF.

See Standards - Long-term care (LTC) Long Term Services and Supports (LTSS) and PNA amounts.

1619(b) status, what does it mean?

SSI clients whose earnings put them over the SSI cash benefit standard but Social Security continues their SSI eligibility. They are considered an SSI recipient and continue to send in reviews to Social Security. The SDX indicates continued Medicaid when a client is 1619(b). 1619(b) clients don’t pay toward the cost of personal care because they are considered to be an SSI client. Follow the same instructions as SSI clients on a waiver for 1619(b) clients. Code SI on UNER to prevent an eligibility review from being generated for the L22. Clients would pay the ALTSA room and board amount if residing in an ALF. Clients can have GROSS income over the SIL and continue to receive a DDA Waiver as long as Social Security maintains their 1619(b) status.

How is this different if the client enters a Medical Institution?

Individuals entering a Medical institution and are "institutionalized" 30 days or more do participate toward the cost of care. This includes "deemed SSI eligible" clients. Institutional rules do apply once a client has entered a Medical institution. (WAC 182-513-1380) This means most of these individuals would participate in a medical institution. This is called the post eligibility process.

Worker Responsibilities

  1. Follow procedures in General eligibility for Long-Term Care to establish financial eligibility.
  2. This section from the main long-term care index links to the following eligibility requirements for DDA Waivers:
    1. Transfer of assets
    2. Available resources
    3. How annuities affect eligibility
    4. Aged-Blind-Disabled requirements
    5. Gross income cannot exceed the Special Income Level (SIL) which is 300% of the FPL.
    6. Available Income
    7. Excluded Income
    8. Overview - Long Term Services and Supports chart for responsibilities and program administration (Who does what program).
    9. AREP Screens for long-term care cases Required for some DDA programs).
  3. Consider a client who is approved for DDA Waivers by DDA as having attained Institutional status.
  4. The DDA case manager sends a DSHS 15-345 CSO/DDA Communication from barcode to inform the financial worker of DDA Waiver eligibility and the start date of services, type of service, change of service, if in an alternate living facility (ALF) such as an adult family home or DDA group home, the state daily rate of the facility, address of facility placement and other changes described in the instructions of the DSHS 15-345 form in barcode.
  5. Eligibility for the L21 or L22 DDA Waiver is a 2 prong eligibility program. The individual must meet both the financial and functional eligibility for the program. If DDA waiver services are closed by DDA, DDA must inform the financial worker via the DSHS 15-345 in barcode. Financial would then need to consider eligibility for other medical programs.
  6. The L21/L22 program code is used for the DDA Waivers. There are exceptions:
    1. Eligibility for Health Care for Workers with Disabilities (HWD), use the S08/HWD program. Refer to the HWD specialist.
    2. DDA Foster Care Program
    3. Because of systems issues such as a SSI deemed eligible client with gross income over the SIL. Use a S02 program.
  7. For a DDA client with earnings, see Working clients on long-term services and supports This link includes information on the Health Care for Workers with Disability program.
  8. Out-of-pocket medical expenses can be allowed as a deduction in post eligibility (another term for this is determining the client total responsibility toward the cost of care, or participation). See Allowable medical expenses.
  9. Court ordered guardianship fees used as a deduction in long term care are described in the Guardianship section.
  10. Information on DDA community based waivers are in WAC 388-845
  11. Follow necessary supplemental accommodation services (NSA). The DDA case manager will inform the DDA financial worker of any additional NSA services indicated in the CARE plan with a accommodation to access or maintaining services.

ACES Instructions

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

DDA Information

Developmental Disabilities Administration (DDA) (Internet site)

Information on DDA Waiver programs.182-512-0150 182-512-0050

Please report broken links or content problems.

LTC change of circumstance

Revised date

WAC 182-504-0105 Washington apple health -- Changes that must be reported.

WAC 182-504-0105 Washington apple health -- Changes that must be reported.

Effective August 29, 2014.

  1. You must report changes in your household and family circumstances to us (the agency or its designee) timely according to WAC 182-504-0110.
  2. We tell you what you are required to report at the time you are approved for WAH coverage. We also will tell you if the reporting requirements change.
  3. You must report the following:
    1. Change in residential address;
    2. Change in mailing address;
    3. Change in marital status;
    4. When family members or dependents move in or out of the residence;
    5. Pregnancy;
    6. Incarceration;
    7. Change in institutional status;
    8. Change in health insurance coverage including medicare eligibility; and
    9. Change in immigration or citizenship status.
  4. If you are eligible for a WAH long-term care program described in chapter 182-513 or 182-515 WAC, you must also report changes to the following:
    1. Income;
    2. Resources;
    3. Medical expenses; and
    4. Spouse or dependent changes in income or shelter cost when expenses are allowed for either.
  5. If you get WAH parent or caretaker (as described in WAC 182-505-0240) or WAH modified adjusted gross income (MAGI)-based adult coverage (as described in WAC 182-505-0250), you must also report changes to the following:
    1. When total income increases or total deductions decrease by one hundred fifty dollars or more a month and the change will continue for at least two months;
    2. Your federal income tax filing status that you expect to use when you file your taxes for the current tax filing year (such as changing from "married filing separately" to "married filing jointly"); and
    3. The tax dependents you expect to claim when you file your federal income tax return for the current tax filing year.
  6. If you get WAH based on age, blindness, or disability (SSI-related medical), then you must also report changes to the following:
    1. Income; and
    2. Resources. 

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 182-504-0110 Washington apple health -- When to report changes.

WAC 182-504-0110 Washington apple health -- When to report changes.

Effective August 29, 2014.

  1. All changes you report to us (the agency or its designee), as required by WAC 182-504-0105, are used to decide if you can receive or keep receiving Washington apple health (WAH) coverage.
  2. You must report changes during your certification period within thirty days of when the change happened.
  3. You must report all changes during application, renewal, or redetermination of your WAH eligibility, regardless of when the change happened.
  4. For a change in income, the date a change happened is the first date you received income based on the change. For example, the date you receive your first paycheck for a new job or the date you got a paycheck with a wage increase is the date the change happened.
  5. If you do not report a change or you report a change late, we will decide if you can receive or keep receiving WAH coverage based on the date the change was required to be reported.
  6. If you do not report a change or you report a change late, and if it affects the amount you must pay toward your cost of care as described in WAC 182-513-1380 or chapter 182-515 WAC, you may become liable for overpayments we make on your behalf and you may need to pay more to your care provider.
  7. If you do not report a change or you report a change late, it may result in us overpaying you and you having to pay us back for the health care costs we overpaid. See chapter 182-520 WAC.

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 182-504-0120 Washington apple health -- Effective dates of changes.

WAC 182-504-0120 Washington apple health -- Effective dates of changes.

Effective August 29, 2014.

  1. We (the agency or its designee) determine the date a change affects your Washington apple health (WAH) coverage based on:
    1. The date you report the change to us;
    2. The date you give us the requested verification; and
    3. The type of WAH you or your family is receiving.
  2. When you report a change after you submit your application, but before your application is processed, the change is considered when processing your application.
  3. If another person, agency, or data source reports a change in circumstances, the information may be used in determining your eligibility. We will not rely on information received from a person, agency, or data source to terminate your WAH coverage without requesting additional information from you.
  4. A change in income affects your ongoing eligibility only if it is expected to continue beyond the month when the change is reported, and only if it is expected to last more than two months.
  5. A change that results in termination of your WAH coverage takes effect the first of the month following the advance notice period.
  6. The advance notice period:
    1. Begins on the day we send the letter about the change to you; and
    2. Is determined according to the rules in WAC 182-518-0025.
  7. A change that results in a decreased scope of care takes effect on the first of the month following the advance notice period. Examples of a decreased scope of care are:
    1. Termination of WAH categorically needy (CN) medical and approval for other WAH coverage with a lesser scope of care such as WAH medically needy (MN) medical;
    2. WAH-MN recipient with a change that increases the spenddown liability amount;
    3. WAH-MN recipient with no spenddown liability with a change that results in WAH-MN with a spenddown liability.
  8. A change that results in an increased scope of care takes effect on the first of the month following the date the change was reported, when you provide the required verification:
    1. Within ten days of the date we requested the verification; or
    2. By the end of the month of your change report, whichever is later.

      If you are a WAH-MN applicant with a spenddown liability that has not yet been met and you report a change that results in your becoming eligible for WAH-CN medical or WAH for adults, your change report will be treated as a new application for purposes of retroactive WAH coverage as described in WAC 182-504-0005.

  9. If you do not provide the required verification timely under subsection (8) of this section, we make the change effective the first of the month following the month in which you provide the verification. We may terminate your WAH coverage if you do not provide the required verification.
  10. When a law or regulation requires a change in WAH, the date specified by the law or regulation is the effective date of the change.
  11. When a change in income or allowable expenses is reported timely (within thirty days) and changes the amount you pay towards the cost of your care for institutional programs (residing in a medical institution), we calculate your new participation amount based on:
    1. Either actual income received in a month or allowable deductions incurred in a month, or both; or
    2. An estimate of your monthly or allowable expenses in a prospective period of six months or less, based on both actual income received in a preceding period of six months or less and income expected to be received during the prospective period. At the end of the prospective period or when any significant change occurs, we reconcile this estimate for the period with income received during the same period.
  12. When a change in income, or allowable expenses, changes the amount you pay towards the cost of your care for a home and community-based waiver or service, we calculate your new participation amount effective the first of the month following the date the change was reported, except that the new participation amount will be effective the month the change occurs if the change is the loss of an income source that you report within thirty days of the change.
  13. We use the following rules to determine the effective date of change for the health care for workers with disabilities (HWD) program:
    1. HWD coverage begins the month after coverage in another medical program ends and the premium amount has been approved by the eligible person; and
    2. If a change in income increases or decreases the monthly premium, the change is effective the first of the month after the change is reported. For more information on premium requirements for this program, see WAC 182-511-1250.

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 182-504-0125 Washington apple health -- Effect of reported changes.

WAC 182-504-0125 Washington apple health -- Effect of reported changes.

Effective October 1, 2017.

  1. If you report a change required under WAC 182-504-0105 during a certification period, you continue to be eligible for Washington apple health coverage until we decide if you can keep getting apple health coverage under your current apple health program or a different apple health program.
  2. If your apple health categorically needy (CN) coverage ends due to a reported change and you meet all the eligibility requirements for a different apple health CN program, we will approve your coverage under the new apple health CN program. If you are not eligible for coverage under any apple health CN program but you meet the eligibility requirements for either apple health alternative benefits plan (ABP) coverage or apple health medically needy (MN) coverage, we will approve your coverage under the program you are eligible for. If you are not eligible for coverage under any apple health CN program but you meet the eligibility requirements for both apple health ABP coverage and apple health MN coverage, we will approve the apple health ABP coverage unless you notify us that you prefer  apple health MN coverage.
  3. If your apple health coverage ends and you are not eligible for a different apple health program, we stop your apple health coverage after giving you advance and adequate notice unless the exception in subsection (4) of this section applies to you.
  4. If you claim to have a disability and that is the only basis for you to be potentially eligible for apple health coverage, then we refer you to the division of disability determination services (within the department of social and health services) for a disability determination. Pending the outcome of the disability determination, we also determine if you are eligible for apple health coverage under the SSI-related medical program described in chapter 182-512 WAC. If you have countable income in excess of the SSI-related categorically needy income level (CNIL), then we look to see if you can get coverage under apple health MN with spenddown as described in chapter 182-519 WAC pending the final outcome of the disability determination.
  5. If you are eligible for and receive coverage under the apple health parent and caretaker relative program described in WAC 182-505-0240, you may be eligible for the apple health medical extension program described in WAC 182-523-0100, if your coverage ends as a result of an increase in your earned income.
  6. Changes in income during a certification period do not affect eligibility for the following programs:
    1. Apple health for pregnant women;
    2. Apple health for children, except as specified in subsection (7) of this section;
    3. Apple health for SSI recipients;
    4. Apple health refugee program; and
    5. Apple health medical extension program.
  7. We redetermine eligibility for children receiving apple health for kids premium-based coverage described in WAC 182-505-0210 when the:
    1. Household's countable income decreases to a percentage of the federal poverty level (FPL) that would result in either a change in premium for apple health for kids with premiums or the children becoming eligible for apple health for kids (without premiums);
    2. Child becomes pregnant;
    3. Family size changes; or
    4. Child receives SSI.
  8. If you get SSI-related apple health CN coverage and report a change in work or earned income which results in a determination by the division of disability determination services that you no longer meet the definition of a disabled person as described in WAC 182-512-0050 due to work or earnings at the level of substantial gainful activity (SGA), we redetermine your eligibility for coverage under the health care for workers with disabilities (HWD) program. The HWD program is a premium-based program that waives the SGA work or earnings test, and you must approve the premium amount before we can authorize coverage under this program. For HWD program rules, see chapter 182-511 WAC.

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

When to report changes

  • Changes must be reported by the 30th day after the change.
  • For a change in income or post eligibility deductions, the date a change happened is the first date income based on the change was received.

Example: The date a new pension amount is received is the date the change happened.

Example: The date the client is notified of their liability after a primary insurance has paid on a claim is the first date a medical expense is known.

Changes and how it affects post eligibility treatment of income

Method 1, 2 and 3 is described in WAC 182-504-0120 (11) for institutional and (12) for HCB Waivers :

  1. When a change in income or allowable expenses is reported timely (within thirty days) and changes the amount you pay towards the cost of your care for institutional programs (residing in a medical institution), we calculate your new participation amount based on:
    1. Either actual income received in a month or allowable deductions incurred in a month, or both; or (Method 1)
    2. An estimate of your monthly or allowable expenses in a prospective period of six months or less, based on both actual income received in a preceding period of six months or less and income expected to be received during the prospective period. At the end of the prospective period or when any significant change occurs, we reconcile this estimate for the period with income received during the same period. (Method 2)
  2. When a change in income, or allowable expenses, changes the amount you pay towards the cost of your care for a home and community-based waiver or service, we calculate your new participation amount effective the first of the month following the date the change was reported, except that the new participation amount will be effective the month the change occurs if the change is the loss of an income source that you report within thirty days of the change. (Method 3)

For individuals residing in medical institutions federal rule requires clients to contribute to their cost of care, in the amount of:

  • Income received
  • Less allowable post eligibility deductions

Two methods are allowed to determine post eligibility participation for individuals residing in a medical institution

  1. Method 1 Total income received less allowable deductions in the month incurred.
  2. Method 2 Projecting income and deductions, not to exceed six (6) months. Income and deductions can be reconciled at the end of the six (6) months, earlier if a significant change occurs.
  • Method 1 is used for income and deductions that typically do not change much
  • Method 2 is used for clients that have frequent changes in income or post eligibility deductions. An example is an RHC DDA client with varying earned income.
  • Method 1 and 2 are used for institutional post eligibility, (residing in a medical institution).
  • Method 1 or Method 2 is the rule – there is no option for Method 3

Method 3 is used for HCB Waiver post eligibility.

  • When changes affect your HCB Waiver cost of care we calculate the new participation amount effective the first of the month following the date the change was reported, except that the new participation amount will be effective the month the change occurs if the change is the loss of an income source that you report within thirty days of the change.
  • Any change to an HCB Waiver client’s income or deductions that affect cost of care takes effect in the ongoing month in ACES.
    With the exception of loss of an income source or the lowering of income. The change takes effect the actual month of change. We will make these historical changes in ACES.
  • For HCB Waiver clients, Method 3 is the rule – there is no option to use Method 1 or Method 2
  • Medical expenses
  • Qualifying medical expenses incurred by the institutional client can be used to reduce participation (Institutional 182-513-1380)
  • Qualifying unpaid medical expenses can be used to reduce participation (182-515-1509 and 182-515-1514). For HCB Waiver clients, as long as a medical expense is still outstanding, a report of this expense will be timely, regardless of Chapter 182-504 WAC reporting requirements. The expense will be allowed (If requirements of 182-513-1350 are met.) This is because the client's expenses have not "changed" when an expense is unpaid.

For additional information on Method 1, Method 2 and Method 3, go to the financial SharePoint site. Financial training under the policy and program changes. HCB Waiver - Method 3

For additional information on allowable medical expenses and post eligibility treatment of income, see allowable medical expenses.

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Guardianship training

Revised date
Purpose statement

A training giving examples to Public Benefits Specialist staff of how guardianship fees and costs and attorney fees relating to guardianship orders are allowed for clients residing in a medical institution or receiving Home and Community Based Services (HCBS).

Note: The computations used for this training material reflect standards as of 7/1/2022.

See Program standard for income and resources for current information.

See PNA and ALTSA room and board amounts.

Allowing Guardianship Fees & Costs/Attorney fees

WAC 182-513-1530 states the maximum allowed deductions for guardian fees and associated costs.

We will allow the guardianship fees and expenses as long as those costs, plus the Personal Needs Allowance (PNA), plus the earnings deduction, and mandatory tax deduction does not exceed the Medically Needy Income Level (MNIL) if residing in a medical institution.

For HCBS waivers the combined PNA, earnings deduction, and guardianship fee cannot exceed the Special Income Level (SIL).

Guardianship fees are an allowable deduction for those in medical institutions and those on HCBS waiver services only. (L track programs).

Medical institutions are defined in WAC 182-500-0050

Clients in Medical Institutions

For participation, there is a limit to the deductions that can be allowed each month, in addition to the limits imposed by the Guardianship WACs. See WAC 182-513-1380

For a client in a medical institution, when added together the following deductions cannot exceed the MNIL:

  • PNA
  • Mandatory income tax
  • Wages of a recipient in an approved employment/rehab plan
  • Guardianship Fees and associated costs

Here are some examples of how this will look:

Example #1 - Medical Institution

A single client has $1500 in unearned income. No earned income. Client also has a deduction for mandatory income taxes from their pension of $50 per month. In addition, this client has a guardian, and we have a court order approving the monthly fee of $235 as well as $1,000 attorney’s fees for the initial guardianship.

Month 1 – client enters nursing facility on the 5th of the month from home. This is the first month of the guardianship court order.

Participation will look like this:

$1500 Income

- 841 PNA (month of admit) CNIL as of 1/1/2022

$ 659.00 Participation

But wait – what happened to the $50 income tax, the guardianship fees, and the attorney’s fees?

Well, we can’t allow them this month. Why? Because we cannot allow more than the MNIL for all of those deductions combined, and the PNA for the initial month is the MNIL. There isn’t any more of an allowance we can use.

Example #2 - Medical Institution

Month 2

The same client is in the nursing facility the entire month.

Participation would be:

$1500.00 Income

- 75.36 PNA

- 50.00 Mandatory income tax

- 235.00 Guardianship fee - Month 1

- 235.00 Guardianship fee - Month 2

- 245.64 Attorney’s fees you can allow ($754.36 remaining)

- $659.00 Participation

Notice that the combined total of PNA + mandatory income tax + the first two months of Guardianship Fees and allowed costs is $841.00. The remaining attorney’s fees will need to be allowed in future months. Always allow guardianship fees before allowing attorney’s fees.

Example #3 - Medical Institution

Month 3

The same client is in the nursing facility the entire month.

Participation would be:

$1500.00 Income

- 75.36 PNA

- 50.00 Mandatory income tax

- 235.00 Guardianship Fee – Month 3

- 480.64 Attorney’s fee you can allow ($273.72 remaining)

$659.00 Participation

Example #4 -Medical Institution

Month 4

The client is in the nursing facility the entire month.

Participation would be:

$1500.00 Income

- 75.36 PNA

- 50.00 Mandatory income tax

- 235.00 Guardianship Fee Month 4

-273.72 Attorney's fee you can allow (You have now allowed the full $1000 attorney's fees)

$ 865.92 Participation

Note: Of course, for new nursing facility clients with a Medicare premium as an allowable medical expense deduction, those expenses come after we allow for PNA, Mandatory Income Tax, Guardianship Fees & Attorney’s fees.

Now, on to COPES (HCBS Waiver)

The COPES waiver was written and approved by CMS differently.

WAC 388-515-1509 states:

The total of the following amounts cannot exceed the Medicaid SIL: The SIL is 300% of the Federal Benefit Rate (FBR).

  • PNA
  • Earned income deduction of the first sixty-five dollars plus one-half of the remaining earned income in subsection
  • Guardianship fees and administrative costs

What is room and board and what is an alternate living facility? How do we deduct guardianship fees if there is only room and board?

The definitions for Room and Board and Alternate Living Facility (ALF) can be found under WAC 182-513-1100

  • What makes an ALF so complicated?
    • 2 parts
      • Federal part of the computation is what the client pays towards their cost of personal care, otherwise known as participation.
      • State funded part of the computation is called room and board (R & B). This is considered the shelter and food portion of the cost. Think of R & B as the rent. It is the part that does NOT cover personal care.
        • The R & B amount is the FBR minus the residential COPES PNA 
        • When a deduction is taken from R & B, it is coming from state funds.
        • HCS requires an ETR process to deduct anything from R & B because it is coming out of state funds. However, R&B deductions for guardianship fees and costs are allowed per rule effective June 1, 2018. Although an exception-to-rule (ETR) is no longer required to allow the deduction, Public Benefits Specialist (PBS) staff must code as a “Room and Board Exception” in ACES to allow the R&B deduction. The maximum deductions allowed for fees and costs are either the amounts in WAC 182-513-1530, or the court order, whichever is less. Any exceptions to these amounts are subject to the eligibility ETR WAC 182-503-0090.

Example #1 - HCBS Waiver
Single individual receiving HCBS waiver services at home:  $2836 unearned income, $50 mandatory income taxes, $235 guardianship fees with $1000 initial attorney’s fees.
AT HOME:

$2836.00 Income

- 2523.00 PNA (as of 7/1/2022)

$ 313.00 Participation

Did you forget the Guardianship fees and $50 mandatory income taxes?

No. WAC 182-515-1509 states that the total of PNA, earned income deduction, and guardianship fees can't exceed the Special Income Level (SIL). Because the PNA, in this case, is the SIL, guardianship fees are not allowed as a deduction. Additionally, the waiver does not allow for a reduction for mandatory income taxes. A client who is on HCBS Waiver at home must use their PNA to cover this cost.

Note: Unlike nursing homes, however, Medicare and medical expenses are allowed after PNA but before guardianship fees and attorney’s fees. So, if this client had medical expenses, we would be able to reduce the remaining participation by that amount.

Example #2 HCBS Waiver

If this was month 1 of eligibility, and the same client had allowance medical expenses, it would look like this:

$2836.00 Income

- 2523.00 PNA

- 180.00 Allowable medical expenses

$ 133.00 - Participation

Example #3 HCBS Waiver

Same client in an ALF – admit month:

$2836.00 Income

- 841.00 PNA/Room & Board ($75.36 + $765.64)

- 180.00 Allowable Medical Deduction

- 235.00 Guardianship Fees

- 530.64 Attorney’s Fees (Remainder is $469.36 to be allowed in the next month)

$ 1,049.36 - Participation

+ 765.64 Room & Board

$ 1815.00 Client’s Cost of Care

Just like at home, Medicare and medical expenses are allowed after PNA but before guardianship fees and attorney’s fees. They are allowed out of participation, not out of room and board. If you must reduce R & B, then you must have an approved ETR to do so. R & B consists of state funds and is considered the portion for shelter and food.

What about Guardianship fees for non-institutional Medicaid programs?

  • A court ordered guardianship fee is not an allowable deduction in non institutional Medicaid.
  • Guardianship fees are only allowed in institutional programs with the limitations indicated above.
  • For individuals on Medicaid Personal Care (MPC) residing in an ALF, an ETR referral can be made to the HCS Regional designee. Before considering an ETR, consult the social worker about the possibility of services through the HCBS Waiver if the client would have available participation that we could apply the guardianship fee deduction.
  • HCBS Waiver cannot be used for Adult Residential Centers (ARC), but can be used for Adult Family Homes (AFH).

Example #1 MPC client residing in an adult family home.

Gross income is $2436 SSA.

Court order for $235 guardianship fee received.

Rather than doing an ETR to consider a deduction from the R & B, this case should be switched to the HCBS Waiver if the client meets the functional criteria.

The $235.00 would be an allowable deduction from the HCBS Waiver.

HCS Social Services determines the client cost of care for MPC, but in this circumstance a discussion with the financial worker and social worker should occur about the possibility of HCBS Waiver services.

The HCBS Waiver is considered the priority program over MPC for:

  • Clients meeting functional criteria for HCBS waiver and
  • Have income over the CNIL and
  • Reside in an adult family home.

Example #2 MPC client residing in an ARC.

Gross income is $2436 SSA

Court order for $235 guardianship fee received.

HCBS Waiver services are not authorized in an ARC setting, only MPC. An ETR to consider a deduction from room and board should be considered by the HCS Social Worker.

Example #3 MPC client on S02 living at home.

Guardianship fees are not an allowable deduction for non institutional Medicaid programs. An MPC client at home does not participate in the cost of personal care nor is there R & B. In this example there is no deduction for the guardianship fee.

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