Hospice eligibility (with institutional Medicaid rules)

Revised date

Eligibility for the L32 Hospice program utilizing institutional rules

The L32 hospice program should be used for a client who receives hospice services and who resides in a medical institution (nursing facility, hospice care center). ACES will trickle to an L95 or L99 medically needy (MN) program if the gross income is over the medicaid special income level (SIL) when the client is in a medical institution.

For some clients who do not reside in medical institutions, it could be to their benefit to follow institutional rules when determining eligibility for hospice services. Institutional rules allow the spend-down of excess resources towards the cost of care, a higher resource standard for married couples, a higher income allocation amount for a spouse and a higher income standard for a single person. Clients need to meet aged, blind, or disabled criteria to be eligible for the L32 hospice program. Examples of cases that should be considered for L32 coverage are listed below:

L32 is a categorically needy (CN) program and has advantages over a MN program.

  1. SSI related medically needy. A client should always be considered for a L32 program before authorizing benefits or services under MN for the following reasons:
    • Clients will not have to meet a spend-down amount prior to becoming eligible. They may have to pay toward the cost of care each month; participation is paid directly to the hospice provider).
    • Once the client is found eligible, medicaid is backdated to the first of the month and CN scope of care.
    • The CN income limit is the SIL which is higher than the CN income limit for noninstitutional medical.
    • For a single client at home, the personal needs allowance standard is higher (100% FPL), as opposed to the Medically Needy Income Limit (MNIL) used for noninstitutional medical.
    • A community spouse’s income is not counted when determining hospice participation. The personal needs allowance (PNA) is the MNIL when there is a community spouse.
    • A dependent’s income is not counted when determining hospice participation.
    • Higher income allocation to a community spouse and dependents when living with a community spouse.

  2. A single Apple Health for Workers with Disability (HWD) client with income below 100% of the FPL. They would not have to pay a premium for medical coverage and would have no participation.

  3. A minor child with a disability who is not eligible for a children’s health care program due to the income of their parents.

For clients receiving waiver services through Aging and Long-term Supports Administration (ALTSA), see additional instructions under Worker Responsibilities - ALTSA HCB Waiver Programs.

HCB Waiver rules for Home and Community Services (HCS) clients are described in WAC 182-515-1505.

HCB Waiver rules for Development Disabilities Administration (DDA) clients are described in WAC 182-515-1510.

A client can be on an HCB waiver program (L21, L22) with HCS or DDA and receive hospice services, if functionally and financially eligible. Both waiver and hospice services are coded on the Institutional Care screen under Services. The Waiver program is the priority program over Hospice. All participation is applied to the waiver program.

For a hospice client in a medical institution with income over the SIL, see WAC 182-513-1395 Determining eligibility for institutional services for people living in a medical institution under the SSI-related medically needy program. 

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Social Security number

Revised date
Purpose statement

To explain the Social Security number (SSN) requirements and instructions for obtaining SSNs for applicants and recipients for Apple Health.

WAC 182-503-0515 Washington apple health -- Social Security number requirements.

WAC 182-503-0515 Washington apple health -- Social Security number requirements.

Effective February 7, 2025

  1. To be eligible for Washington apple health (medicaid), or tailored supports for older adults (TSOA) described in WAC 182-513-1610, you (the applicant or recipient) must provide your valid Social Security number (SSN) or proof of application for an SSN to the medicaid agency or the agency's designee, except as provided in subsections (2) and (6) of this section.
  2. An SSN is not required if you are:
    1. Not eligible to receive an SSN or may only be issued or may only be issued an SSN for a valid nonwork reason described in 20 C.F.R. 422.104;
    2. A household member who is not applying for apple health coverage, unless verification of that household member's resources is required to determine the eligibility of the client;
    3. Refusing to obtain an SSN for well-established religious objections as defined in 42 C.F.R. 435.910 (h) (3); or
    4. Not able to obtain or provide an SSN because you are a victim of domestic violence.
  3. If you are receiving coverage because you meet an exception under either subsection (2) (c) or (d) of this section, we (the agency) will confirm with you at your apple health renewal, consistent with WAC 182-503-0050, that you still meet the exception.
  4. If we ask for confirmation that you continue to meet an exception in subsection (2) of this section and you do not respond in accordance with subsection (3) of this section, or if you no longer meet an exception and do not provide your SSN, we will terminate your apple health coverage according to WAC 182-518-0025.
  5. If you are not able to provide your SSN, either because you do not know it or it has not been issued, you must provide:
    1. Proof from the Social Security Administration (SSA) that you turned in an application for an SSN; and
    2. The SSN when you receive it.
      1. Your apple health coverage will not be delayed, denied, or terminated while waiting for SSA to send you your SSN. If you need help applying for an SSN, assistance will be provided to you.
      2. We will ask you every ninety days if your SSN has been issued.
  6. An SSN is not required for the following apple health programs:
    1. Refugee medical assistance program described in WAC 182-507-0120, and 182-507-0125;
    2. Alien medical programs described in WAC 182-507-0115, 182-507-0120, and 182-507-0125;
    3. Newborn medical program described in WAC 182-505-0210 (2)(a);
    4. Foster care program for a child age eighteen and younger as described in WAC 182-505-0211(1); or
    5. Medical programs for children and pregnant women who do not meet citizenship or immigration status described in WAC 182-503-0535 (2)(e)(ii) and (iii); or
    6. Family planning only program described in WAC 182-532-510 if you do not meet citizenship or immigration status for Washington apple health or you have made an informed choice to apply for family planning services only; or
    7. Washington apple health expansion program described in chapter 182-525 WAC.
  7. If you are required to provide an SSN under this section, and you do not meet an exception under subsection (2) of this section, failure to provide an SSN may result in:
    1. Denial of your application or termination of your coverage because we cannot determine your household's eligibility; or
    2. Inability to apply the community spouse resource allocation (CSRA) or monthly maintenance needs allowance (MMNA) for a client of long-term services and supports (LTSS).

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

  1. A valid Social Security number (SSN) or proof that an individual has submitted an application for a SSN is required for all Apple Health programs except for the programs listed in subsection 6 of WAC 182-503-0515.
  2. If an individual is otherwise eligible for Apple Health, coverage is approved and time allowed to provide their SSN, proof an SSN was applied for, or proof they meet a good cause exception.
  3. Household members who are not applying for coverage are not required to provide their SSN. However, for long-term services and supports, a community spouse needs to provide an SSN for DSHS to use the community spouse resource allocation (CSRA) or monthly maintenance needs allowance (MMNA).
  4. An individual who refuses to apply for or provide an SSN due to religious beliefs must provide verification from a church elder or other officiant showing the individual is a member and that providing or applying for an SSN is against the church doctrine. Personal, cultural, or political beliefs do not qualify as a religious objection to providing or applying for an SSN.
  5. If a current and valid SSN is not available and the individual needs to pay an agency for a copy of his or her birth certificate, the agency must help the individual obtain the birth certificate and pay for any applicable fees. The individual receives Apple Health during this time if otherwise eligible.
  6. ACES and Healthplanfinder automatically submit every SSN to the SSA for validation.
  7. Individuals who are required to provide an SSN, but refuse to do so without good cause are not eligible for Apple Health.
  8. Some clients come from cultures where they only have one name. Their Social Security card may show only one name or may have “NFN” or “NLN” to signify no first/last name. Often the only way to get ACES and Healthplanfinder to verify the SSN is to update the first or last name to NFN or NLN.

Worker responsibilities

  1. Document all actions taken to comply with SSN requirements for Apple Health programs.
  2. For applications in ACES, see the SSN chapter in the ACES manual.
    1. Verification
      1. If SOLQ shows that the SSN does not belong to the individual or otherwise does not validate, send a request for verification of the SSN.
      2. If the individual sends verification, update the SSN and try to revalidate through SOLQ. If SOLQ does not validate the SSN, deny or close coverage.
      3. If the individual does not send verification or otherwise refuses to cooperate, close coverage.
    2. If the applicant does not provide an SSN that is required, but is otherwise eligible for Apple Health:
      1. Approve the application and send ACES Letter 023-08 (SSN Referral) to refer the applicant to Social Security Administration District Office (SSADO) for:
        1. Application for a SSN;
        2. Application for a replacement card; or
        3. Determination of a previously issued number.
      2. If the individual sends verification, update the SSN and try to validate through SOLQ. If SOLQ does not validate the SSN, check that the name in ACES matches the name on the Social Security card.
        1. If the name matches and still does not validate, request an explanation from the client. Close coverage if the client does not respond.
      3. If the individual does not send verification or otherwise refuses to cooperate, close coverage.
  3. For applications in Healthplanfinder (note Healthplanfinder automatically tries to validate every SSN):
    1. Verification
      1. If Healthplanfinder has not validated the SSN:
        1. Manually access SOLQ;
        2. Recheck and reverify the SSN; and
        3. Do a name/DOB search to see if the client already exists in ACES.
      2. If SOLQ shows that the SSN does not belong to the individual or otherwise does not validate:
        1. Update  the application with "SSN good cause" and approve coverage.
        2. If an Additional Verification letter did not already go out for verification of SSN from Healthplanfinder, send one.
        3. Set a follow-up tickle.
      3. If the individual sends verification, revalidate the SSN through SOLQ.
        1. If SOLQ does not validate the SSN, close coverage.
        2. If the individual does not send verification or otherwise refuses to cooperate, close coverage.
  4. If an individual requests assistance in obtaining an SSN: 
    1. Confirm they are required to provide an SSN based on WAC 182-503-0515(2)
    2. Provide resources to individuals required to provide an SSN:
      1. SSA website
      2. SSA office locator
      3. Individuals in urgent situations can receive assistance from Regional Public Affairs Office:
        1. Phone: 303-844-1888
        2. Email: den.sea.public@affairs.ssa.gov  
  5. Good cause.
    1. An individual can be granted good cause for not providing or applying for an SSN for certain reasons and periods of time. These are the reasons for good cause:
      1. Survivors of domestic violence who fear providing SSNs for themselves and/or their children will put them in danger. Good cause is granted for the certification period and rechecked yearly to see if the survivors feel safe enough to provide an SSN.
      2. Individuals claiming well-established religious objections. The individual must verify they are a member of a recognized religious sect or division of the sect and adheres to the tenets or teachings of the sect or division of the sect and for that reason is conscientiously opposed to applying for or using a national identification number. Good cause is granted for the certification period and rechecked yearly to see if the individual still claims the religious objection.
      3. Exception to rule on a case by case basis.
      4. SSN application pending with SSA. The individual receives coverage when the SSN app is pending with SSA. The agency checks with the individual every 90 days to obtain the issued SSN or check the status of the application. The individual must make substantial and reasonable efforts to supply SSA with the necessary information. The agency will assist the individual with applying for the SSN if the individual requests assistance.
      5. Good cause doesn't include delays due to illness, lack of transportation, temporary absence, or failure to respond to the SSN request.
      6. Every action of the good cause process must be documented in the ACES narrative.
  6. Adoption Cases:
    1. Domestic adoption
      1. When a child is being adopted or given adoption support through Children’s Administration, the child’s SSN is not always entered into ACES for confidentiality reasons. It is verified as valid by the Foster Care unit through FamLink and SOLQ. Actions are documented in the case narrative and in Remarks behind DEM1 screen and the child’s SSA/SSN Referral field is coded with “E” (Exception to Policy).
      2. Do not request an SSN until adoption is finalized.
    2. International adoption
      1. Effective February 27, 2001 adopted children born outside of the U.S. are granted automatic citizenship upon their arrival. Refer to the above procedures to obtain and verify SSN.

ACES procedures

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

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Electing hospice services - DSHS agency and client

Revised date

Notification to the DSHS agency of hospice election

When a client elects hospice services, the hospice agency provides notification to the Health Care Authority (HCA) within five days of the election date using the HCA 13-746 hospice notification form. This form includes the client’s name, the effective date the client elected hospice services, the type of hospice (Medicare or Medicaid), the name of the hospice provider and the name of the facility if the client lives in a facility, including the admission date. 

The hospice agency checks for eligibility using the ProviderOne system. If the client is not active on medicaid, the hospice provider will assist the client in submitting an application (HCA 18-001 or 18-005) with the hospice notification form and release of information (DSHS 14-532). The HCS or DDA financial worker can release the eligibility determination, the award letter(s), participation, and/or other information that the hospice agency needs to bill correctly.

When a client’s hospice status changes, the hospice agency faxes a hospice notification form with the updated information HCA to be scanned into the client’s electronic record and indexed to the appropriate office. Examples include: the client revokes hospice services, the client discharges from a hospice facility or the clients dies. If a client transfers to a different hospice agency, both the old and the new providers are responsible to provide notification to HCA. Once clients do elect Hospice, covered drugs and items are limited under the Hospice program. Certain items are covered in the Hospice daily rate. (WAC 182-551-1210).

Revocation of services. (WAC 182-551-1360) The Hospice provider is responsible to notify HCA of the revocation by completing and faxing a copy of the HCA 13-746 hospice notification form. The Hospice provider is responsible to give the client a copy of the revocation statement and inform the client that the revocation statement must be presented with the client’s current medical identification card when obtaining Medicaid covered services, supplies or both. Client’s need to use this procedure until the department can remove Hospice coding out of the ProviderOne claims payment system.

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Guardianships - deductions to participation, room and board

Revised date
Purpose statement

Describe and clarify rules regarding guardianship-related deductions to a long-term services and support client’s participation or room & board (R&B).

WAC 182-513-1530 Maximum guardianship fee and related cost deductions allowed from a client's participation or room and board on or after June 1, 2018.

WAC 182-513-1530 Maximum guardianship fee and related cost de­ductions allowed from a client's participation or room and board on or after June 1, 2018.

Revised March 1, 2025

  1. General information.
    1. This section sets the maximum guardianship or conservatorship fee and related cost deductions when:
      1. A court order was entered on or after June 1, 2018; or
      2. The client under guardianship or conservatorship began receiving medicaid-fun­ded long-term services and supports on or after June 1, 2018.
    2. This section only applies to a client who is:
      1. Eligible for and receives institutional services under this chap­ter or home and community-based waiver services under chapter 182-515 WAC, and who is required to pay participation under WAC 182-513-1380, 182-515-1509, or 182-515-1514; or
      2. Eligible for long-term services and supports under this chapter or chapter 182-515 WAC, and who is required to pay only room and board.
    3. All requirements of this section remain in full force whether or not the agency appears at a guardianship or conservatorship proceeding.
    4. In this section, the agency does not delegate any authority in determining eligibility or post-eligibility for medicaid clients.
      1. Under the authority granted by chapter 11.130 RCW, the agency does not deduct more than the amounts allowed by this section from partici­pation or room and board.
      2. The eligibility rules under Title 182 WAC remain in full force and effect.
    5. The agency does not reduce a client's participation or room and board under this section for guardianship or conservatorship fees or related costs accumulated during any month that a client was not required to pay:
      1. Participation under WAC 182-513-1380, 182-515-1509, or 182-515-1514; or
      2. Room and board under this chapter or chapter 182-515 WAC.
    6. If the client has another fiduciary, payee, or other princi­pal-agency relationship and the agent is allowed compensation, any monthly guardianship or conservatorship fee approved under this section is reduced by the agent's compensation.
  2. Maximum guardianship fee and related cost deductions.
    1. The maximum guardianship or conservatorship fee and related cost deductions un­der this section include all guardianship or conservatorship services provided to the client, regardless of the number of guardians or conservators appointed to a client during a period of time, or whether the client has multiple guardians appointed at the same time.
    2. Maximum guardianship or conservatorship fees and related cost deductions are as follows:
      1. The total deduction for costs directly related to establish­ing a guardianship or conservatorship for a client cannot exceed $1,850;
      2. The total deduction for all guardianship and conservatorship-related costs cannot exceed $1,200 during any three-year period; and
      3. The amount of the monthly deduction for all guardianship and conservatorship fees cannot exceed $235 per month.
  3. For people under subsection (1)(b)(i) of this section – Par­ticipation deductions.
    1. After receiving the court order, the agency or its designee adjusts the client's current participation to reflect the deductions under WAC 182-513-1380, 182-515-1509, or 182-515-1514.
    2. The amounts of the participation deductions are the amounts under subsection (2) of this section, or the court order, whichever are less.
    3. For clients who pay room and board in addition to participa­tion, if the client's amount of participation is insufficient to allow for the amounts under subsection (2) of this section, then, regardless of any provision of this chapter or chapter 182-515 WAC, the client's room and board will be adjusted to allow the amounts under subsection (2) of this section.
  4. For people under subsection (1)(b)(ii) of this section - Room and board deductions.
    1. The agency adjusts the client's room and board after receiv­ing the court order, regardless of any provision of this chapter or chapter 182-515 WAC.
    2. The amounts of the room and board deductions are the amounts under subsection (2) of this section, or the court order, whichever are less.

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

On or after June 1, 2018

For court orders signed, or clients who begin receiving long-term services and supports (LTSS), on or after June 1, 2018, WAC 182-513-1530 applies. A client is allowed a deduction to their participation, R&B, or both, when that client is required to pay towards their cost of LTSS.

  • Participation deductions for guardianship-related fees and costs are allowed for clients required to pay participation under WAC 182-513-1380, WAC 182-515-1509, or WAC 182-515-1514;
  • R&B deductions are allowed for clients whose only liability for LTSS is R&B under chapter 182-513 WAC (for example, CFC-only, MPC, MCS, or Group 1 home and community-based service (HCBS) waiver)
  • For those clients with participation and R&B, if there is insufficient participation to deduct guardianship-related fees and costs, participation can be reduced to $0, and any remaining amounts can be deducted from R&B.
  • WAC 182-513-1530 (2)(b) maximum guardianship fees, the initial cost of establishing a guardianship can’t exceed $1,850. Subsequent attorney costs and fees after initial establishment is $1,200 in any three-year period. The allowance is either (2)(b)(i) or (2)(b)(ii), but not both. 

Note: 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 Benefit Specialist (PBS) 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 the rule, or the court order, whichever is less. Any exceptions to these amounts are subject to the eligibility ETR WAC 182-503-0090.

Before June 1, 2018

WAC 388-79A-001 Definitions.

WAC 388-79A-001 Definitions.

Revised June 1, 2018

The following definitions apply to this chapter:

  1. "Client" means a person who is eligible for and is receiving medicaid-funded long-term care.
  2. "Guardianship fees" or "fees" means necessary fees charged by a guardian for services rendered on behalf of a client.
  3. "Participate" or "participation" means the amount a client 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:
    1. WAC 182-513-1380 for a client residing in a medical institution, as defined under WAC 182-500-0050;
    2. WAC 182-515-1509 for a client receiving home and community services (HCS) waivered services in an alternate living facility (ALF), as defined under WAC 182-513-1100, or in an at-home setting; or
    3. WAC 182-515-1514 for a client receiving developmental disability administration (DDA) waivered services in an ALF, as defined under WAC 182-513-1100, or in an at-home setting.
  4. "Related costs" or "costs" means necessary costs paid by the guardian, including attorney fees.

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 388-79A-005 Maximum Amount of Guardianship Fees and Related Costs for a Long-term Care Medicaid Eligible Client.

WAC 388-79A-005 Maximum amount of guardianship fees and related costs for a long-term care medicaid eligible client.

Revised March 8, 2019

  1. As mandated by RCW 43.20B.460 and in accordance with RCW 11.92.180, the maximum amount of guardianship fees and related costs must not exceed the limits of this section when the person under guardianship is:
    1. A medicaid eligible client, residing in:
      1. A medical institution, as defined under WAC 182-500-0050;
      2. An alternate living facility (ALF), as defined under WAC 182-513-1100; or
      3. An at-home setting; and
    2. Required under chapter 182-513 WAC or chapter 182-515 WAC to participate towards the cost of long-term care.
  2. The maximum amount of guardianship fees and related costs must not exceed the limits of WAC 388-79A-010​ when:
    1. The most recent court order establishing or continuing a guardianship was entered before June 1, 2018; and
    2. The client under guardianship was receiving medicaid-funded long-term care before June 1, 2018.
  3. For all other clients not described under subsection (2) of this section, the maximum amount of guardianship fees and related costs must not exceed the limits under WAC 182-513-1530.

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 388-79A-010 Maximum guardianship fees and related costs before June 1, 2018.

WAC 388-79A-010 Maximum guardianship fees and related costs before June 1, 2018

Revised June 1, 2018

  1. This section sets the maximum guardianship fees and related costs when:
    1. The court order was entered before June 1, 2018; and
    2. The client under guardianship was receiving medicaid-funded long-term care before June 1, 2018.
  2. For court orders entered before June 1, 2018, where the order establishes or continues a legal guardianship for a client:
    1. Guardianship fees must not exceed $175 per month;
    2. Costs directly related to establishing a guardianship for a client must not exceed $700; and
    3. Costs to maintain the guardianship must not exceed $600 during any three-year period.

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 388-79A-015 Procedure for allowing guardianship fees and related costs from client participation before June 1, 2018.

WAC 388-79A-015 Procedure for allowing guardianship fees and related costs from client participation before June 1, 2018.

Revised June 1, 2018

  1. This section describes the procedure for allowing guardianship fees and related costs from client participation when:
    1. A court order was entered before June 1, 2018; and
    2. The client under guardianship was receiving medicaid-funded long-term care before June 1, 2018.
  2. The medicaid agency or the agency's designee, after receiving the court order, adjusts the client's current participation to reflect the amounts, as allowed under WAC 182-513-1380, 183-515-1509, or 183-515-1514.
  3. A client's participation cannot be prospectively or retrospectively reduced to pay guardianship fees and related costs incurred:
    1. Before the client's long-term care medicaid eligibility effective date;
    2. During any time when the client was not eligible for or did not receive long-term care services; or
    3. After the client has died.
  4. The fees and costs allowed by the court at the final accounting must not exceed the amounts advanced and paid to the guardian from the client's participation if:
    1. The court, at a prior accounting, allowed the guardian to receive guardianship fees and related costs from the client's participation in advance of services rendered by the guardian; and
    2. The client dies before the next accounting.

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.

For those clients who began receiving LTSS prior to June 1, 2018, and also has a court order signed before June 1, 2018, chapter 388-79A WAC applies.

Effective June 1, 2018, chapter 388-79A was amended to end the previous requirement of notification (by the guardian) to DSHS on proposed guardianship orders, and also end the procedure to exceed the maximum deductions allowed per rule. Any clients subject to chapter 388-79A will have their deductions allowed per the signed order.

Note: R&B deductions are NOT allowed per rule under this chapter. As long as a court order is subject to chapter 388-79A WAC, an ETR must be approved to reduce R&B.

Worker Responsibilities

Upon receipt of a court order: if it was signed on or after June 1, 2018, or if the client began LTSS after June 1, 2018, allow the deductions per WAC 182-513-1530 or the court order, whichever is less.

Most (if not all) clients subject to chapter 388-79A WAC have current allowed deductions. Continue to allow these deductions until a new court order is received. Ensure an ETR is approved prior to allowing or continuing to allow a deduction to R&B.

Forward any ETR requests from the guardian to your regional guardianship designee.

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Medicare coinsurance days

Revised date
Purpose statement

This clarification is based on the Dear Nursing Home Administrator letter NH #2010-001 sent 3/26/2010

Reimbursement rates for Medicaid clients enrolled in Medicare

For Medicaid clients enrolled in fee for service medicare (not Medicare Advantage plans), Medicare will pay in full for up to the first twenty days of nursing facility care at the full Medicare rate. For the first day and up to eighty days thereafter (i.e. the hundred and first day), the amount paid by Medicare will be reduced by the client's coinsurance responsibility. The department will pay up to the Medicaid rate for the coinsurance days. This is described in WAC 182-502-0110 (3) and 1902 n of the Social Security Act

Reimbursement rates for Qualified Medicare Beneficiaries (QMB) only clients

QMB-only clients are not eligible for Medicaid under the categorically needy (CN) or medically needy (MN) programs, but are eligible for payment of Medicare cost sharing expenses.

(NOTE: A QMB only client may apply for a CN or MN program if medicaid is needed beyond the Medicare days in the nursing facility).

The department will pay for Medicare coinsurance charges for QMB-only residents, up to the medicaid nursing facility reimbursement rate. It will not be necessary for a QMB-only resident to apply for Medicaid services for payment of coinsurance expense during Medicare coinsurance days. QMB-only clients are not required to pay participation. They will not be issued a Medicaid award letter. An award letter is not required in order to bill the Department for these expenses. Providers should refer to the nursing home billing instructions at the following link for instructions on how to bill for QMB-only claims:

Health Care Authority Billing Instructions (Provider Guides)

Nursing Facilities Billing Instructions (Provider Guides)

How to bill Medicare Crossovers in ProviderOne

Reimbursement rates for Medicaid clients enrolled in Medicare Part C (Advantage) plans

For Medicaid clients enrolled in Medicare Part C plans, payment for Medicare days including coinsurance days may vary depending on the Medicare C plan. The department will pay up to the Medicaid rate for coinsurance days.

Medicaid client participation during Medicare days including coinsurance days

Facilities may not collect participation from Medicaid clients during Medicare days, including Medicare coinsurance days. Client participation which is indicated on the DSHS Medicaid award letter is only applicable for Medicaid days.

Client participation is not an eligibility factor for Medicare coverage. This includes cases where the Medicaid rate is higher than the Medicare coinsurance rate and DSHS is billed for the coinsurance up to the Medicaid rate. Clients or their representatives are responsible to report if their resources exceed Medicaid standards when clients are in Medicare status as they are not participating their monthly income toward the cost of care during Medicare days.

Please note: The department cannot use Medicaid funds to pay the recipient's coinsurance responsibility beyond the amount Medicaid would pay for the service and cannot allow nursing facilities to write off the unpaid amounts as bad debts on their Medicaid cost reports.

Nursing Home Providers may contact the Nursing Home Billing Unit at the Health Care Authority with questions regarding the billing during Medicare days.

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Income Best Estimate guide

Revised date

Proof of income

Obtain proof of income (e.g., pay stub, employer statement, tax return) from the individual to answer the following questions.

Subject Questions
Rate of pay
  • Does the individual receive a salary or an hourly wage?
    • If hourly, what is the hourly wage and how many hours does the individual work each pay period?
  • Is the individual paid by the piece?
    • If paid for piecework, how much is the individual paid for each piece and how many pieces do they normally complete each pay period?
  • Does the individual receive tips or commissions?
Pay dates
  • What are the individual's pay periods?
  • What are the individual's pay dates?
  • Is the individual paid on the same day each week?
  • Is the individual paid on specific days of each month?
Past income
  • If unable to anticipate expected hours or pay rate, look at past income:
    • Do the last 3 months represent what the individual should get?
    • Do the last 30 days represent what the individual should get?
  • Should special circumstances be considered when looking at past income?
    • If the individual has a new job, is there a partial first check?
    • Does one of the pay periods include a time the individual had leave without pay due to illness or other reasons?
    • Did one pay period include overtime because the individual worked extra hours for a sick coworker?
    • Is the income higher or lower than normal due to seasonal fluctuations?
Recent changes
  • Has the individual recently lost their job?
    • When will the individual get their last check?
    • Will the individual get any money from "cashing out" vacation, sick pay, or retirement benefits?
    • Will the individual get any severance pay, unemployment compensation, or retirement benefits?
  • Has there been a recent employment change:
    • From full-time to part-time?
    • In the number of hours worked?
    • In the individual's wage or salary?
    • From one job to another?
  • Has the individual received overtime pay or bonuses?
  • Have there been other changes that would impact eligibility or benefit level?
Changes expected during the certification period
  • Are the hours going to go up or down?
  • Is the income ending?
  • Has the individual’s job just started?
  • Will they receive more paychecks next month than they did this month?

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Institutional

Revised date
Purpose statement

Definition of medical institutions used in institutional Medicaid rule.

WAC 182-500-0050 Washington apple health definitions -- I.

WAC 182-500-0050 Washington apple health definitions -- I.

Effective April 23, 2022

"Ineligible spouse" see "spouse" in WAC 182-500-0100.

"Institution" means an entity that furnishes (in single or multiple facilities) food, shelter, and some treatment or services to four or more people unrelated to the proprietor. Eligibility for Washington apple health program may vary depending upon the type of institution in which an individual resides. For the purposes of apple health programs, "institution" includes all the following:

  1. "Institution for mental diseases (IMD)" -- A hospital, nursing facility, or other institution of more than 16 beds that is primarily engaged in providing diagnosis, treatment or care of people with mental diseases, including medical attention, nursing care and related services. An IMD may include inpatient substance use disorder (SUD) facilities of more than 16 beds which provide residential treatment for SUD.
  2. "Intermediate care facility for individuals with intellectual disabilities (ICF/IID)" -- An institution or distinct part of an institution that is:
    1. Defined in 42 CFR 440.150;
    2. Certified to provide ICF/IID services under 42 CFR 483, Subpart I; and
    3. Primarily for the diagnosis, treatment, or rehabilitation for people with intellectual disabilities or a related condition.
  3. "Medical institution" -- An entity that is organized to provide medical care, including nursing and convalescent care. The terms "medical facility" and "medical institution" are sometimes used interchangeably throughout Title 182 WAC.
    1. To meet the definition of medical institution, the entity must:
      1. Be licensed as a medical institution under state law;
      2. Provide medical care, with the necessary professional personnel, equipment, and facilities to manage the health needs of the patient on a continuing basis under acceptable standards; and
      3. Include adequate physician and nursing care.
    2. Medical institutions include:
      1. "Hospice care center"--An entity licensed by the department of health (DOH) to provide hospice services. Hospice care centers must be medicare-certified, and approved by the agency or the agency's designee to be considered a medical institution.
      2. "Hospital"--Defined in WAC 182-500-0045.
      3. "Nursing facility (NF)"--An entity certified to provide skilled nursing care and long-term care services to medicaid recipients under Social Security Act Sec. 1919(a), 42 U.S.C. Sec. 1396r. Nursing facilities that may become certified include nursing homes licensed under chapter 18.51 RCW, and nursing facility units within hospitals licensed by DOH under chapter 70.41 RCW. This includes the nursing facility section of a state veteran's facility.
      4. "Psychiatric hospital"--An institution, or a psychiatric unit located in a hospital, licensed as a hospital under applicable Washington state laws and rules, that is primarily engaged to provide psychiatric services for the diagnosis and treatment of mentally ill people under the supervision of a physician.
      5. "Psychiatric residential treatment facility (PRTF)" -- A nonhospital residential treatment center licensed by DOH, and certified by the agency or the agency's designee to provide psychiatric inpatient services to medicaid-eligible people age 21 and younger. A PRTF must be accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or any other accrediting organization with comparable standards recognized by Washington state. A PRTF must meet the requirements in 42 CFR 483, Subpart G, regarding the use of restraint and seclusion.
      6. "Residential habilitation center (RHC)"--A residence operated by the state under chapter 71A.20 RCW that serves people who have exceptional care and treatment needs due to their developmental disabilities by providing residential care designed to develop individual capacities to their optimum. RHCs provide residential care and may be certified to provide ICF/MR services and nursing facility services.
    3. Medical institutions do not include entities licensed by the agency or the agency's designee as adult family homes (AFHs) and boarding homes. AFHs and boarding homes include assisted living facilities, adult residential centers, enhanced adult residential centers, and developmental disability group homes.
  4. "Public institution" means an entity that is the responsibility of a governmental unit or over which a governmental unit exercises administrative control.
    1. Public institutions include:
      1. Correctional facility -- An entity such as a state prison, or city, county, or tribal jail, or juvenile rehabilitation or juvenile detention facility.
      2. Eastern and Western State mental hospitals. (Medicaid coverage for these institutions is limited to people age 21 and younger, and people age 65 and older.)
      3. Certain facilities administered by Washington state's department of veteran's affairs (see (b) of this subsection for facilities that are not considered public institutions).
    2. Public institutions do not include intermediate care facilities, entities that meet the definition of medical institution (such as Harborview Medical Center and University of Washington Medical Center), or facilities in Retsil, Orting, and Spokane that are administered by the department of veteran's affairs and licensed as nursing facilities.

"Institution for mental diseases (IMD)" see "institution" in this section.
"Institution review board" - A board or committee responsible for reviewing research protocols and determining whether:

  1. Risks to subjects are minimized;
  2. Risks to subjects are reasonable in relation to anticipated benefits, if any, to subjects, and the importance of the knowledge that may reasonably be expected to result;
  3. Selection of subjects is equitable;
  4. Informed consent will be sought from each prospective subject or the subject's legally authorized representative;
  5. Informed consent will be appropriately documented;
  6. When appropriate, the research plan makes adequate provision for monitoring the data collected to ensure the safety of subjects;
  7. When appropriate, there are adequate provisions to protect the privacy of subjects and to maintain the confidentiality of data; and
  8. When some or all of the subjects are likely to be vulnerable to coercion or undue influence, such as children, prisoners, pregnant people, mentally disabled persons, or economically or educationally disadvantaged persons, additional safeguards have been included in the study to protect the rights and welfare of these subjects.

"Institutionalized spouse" see "spouse" in WAC 182-500-0100.

"Intermediate care facility for individuals with intellectual disabilities (ICF/IID)" see "institution" in this section.

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

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Family and dependent allocation

Revised date
Purpose statement

Describes how the spousal and dependent allocation is determined in post-eligibility for institutional and HCB waiver programs.

WAC 182-513-1385 Determining the community spouse monthly maintenance needs allowance and dependent allowance in post-eligibility treatment of income for long-term care (LTC) programs.

WAC 182-513-1385 Determining the community spouse monthly maintenance needs allowance and dependent allowance in post-eligibility treatment of income for long-term care (LTC) programs.

Effective February 25, 2023

  1. This section describes how to calculate the monthly maintenance needs allowance (MMNA) in post-eligibility treatment of income for long-term care (LTC) programs for a community spouse or dependent of the institutionalized individual.
  2. The community spouse MMNA 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, unless a greater amount is calculated under subsection (5) of this section. The MMNA standards may change each January and July based on the consumer price index.
  3. The community spouse MMNA is allowed only to the extent that the institutionalized spouse's income is made available to the community spouse, and is calculated as follows:
    1. The minimum MMNA as calculated in subsection (4)(a) of this section plus excess shelter expenses as calculated in subsection (4)(b) of this section;
      1. The total under (a) of this subsection cannot be less than the minimum MMNA; and
      2. If the total under subsection (4)(a) of this section exceeds the maximum MMNA, the maximum MMNA is the result under subsection (4)(a) of this section; and(b) The total under subsection (4)(a) of this section is reduced by the community spouse's gross income. The result is the MMNA.
  4. The minimum MMNA and excess shelter expense values are calculated as follows:
    1. The minimum MMNA is 150 percent of the two-person federal poverty level (FPL); and
    2. If excess shelter expenses are less than zero, the result is zero. Excess shelter expenses are calculated as follows:
      1. Add:
        1. Mortgage or rent, which includes space rent for mobile homes;
        2. Real property taxes;
        3. Homeowner's insurance;
        4. Required maintenance fees for a condominium, cooperative, or homeowner's association that are recorded in a covenant; and
        5. The food assistance standard utility allowance (SUA) under WAC 388-450-0195 minus the cost of any utilities that are included in (b)(i)(D) of this subsection.
      2. Subtract the standard shelter allocation from the total in (b)(i) of this subsection. The standard shelter allocation is 30 percent of 150 percent of the two-person FPL. The result is the value of excess shelter expenses.
  5. The amount allocated to the community spouse may be greater than the amount determined in subsection (3) of this section, but only if:
    1. A court order has been entered against the institutionalized spouse approving a higher MMNA for the support of the community spouse; or
    2. A final order has been entered after an administrative hearing has been held under chapter 182-526 WAC ruling the institutionalized spouse or the community spouse established the community spouse needs income, above the level otherwise provided by the MMNA, due to exceptional circumstances causing significant financial duress.
  6. If a final order establishes that the conditions identified in subsection (5)(b) of this section have been met, then an amount of allocated resources under subsection (3) of this section will be substituted by an amount adequate to provide such an MMNA.
  7. The agency or its designee determines the dependent allowance for dependents of the institutionalized individual or the institutionalized individual's spouse. The amount the agency allows depends on whether the dependent resides with the community spouse.
    1. For each dependent who resides with the community spouse:
      1. Subtract the dependent's income from 150 percent of the two-person FPL;
      2. Divide the amount determined in (a)(i) of this subsection by three;
      3. The result is the dependent allowance for that dependent.
    2. For each dependent who does not reside with the community spouse:
      1. The agency determines the effective MNIL standard based on the number of dependent family members in the home;
      2. Subtracts each dependent's separate income;
      3. The result is the dependent allowance for the dependents.
    3. Child support received from a noncustodial parent is the child's income.

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 WACs used to determine post-eligibility treatment of income (PETI), also called participation calculation:

WAC 182-515-1509 for HCS CN Waiver programs (Commonly referred as the COPES WAC)
WAC 182-515-1514 for DDD CN Waiver programs
WAC 182-513-1380 Participation (residing in medical institutions)

In post-eligibility, the community spouse and family allocation is allowed as a deduction when determining participation. The basic community spouse maintenance and family allocation standard is 150% of the 2-person FPL increases annually on July 1.

We allow this deduction to the extent income of the institutionalized spouse is made available to, or for the benefit of, the community spouse or dependent. If the institutionalized spouse refuses or we have evidence the spousal maintenance or family allocation is not made available to the spouse or dependents, we do not give the allocation. Indicate "waive spousal allowance" on the LTCX screen.

If the community spouse or dependent does not provide verification of their gross income and shelter costs needed to determine the spousal and dependent allocation, do not deny or terminate the case. Do not allow the allowance and indicate in the notice that in order to allow the possible deduction, the agency needs verification of the spousal/dependent income. Once verification is provided, we would allow the deduction the first of the following month for HCB Waivers and in the month verification is provided for institutional programs.

The dependent rule states:

A monthly maintenance needs amount for each minor or dependent child, dependent parent, or dependent sibling of your community or institutional spouse. The amount the department allows is based on the living arrangement of the dependent. If the dependent:

  1. Resides with your community spouse, the amount is equal to one-third of the community spouse allocation as described in WAC 182-513-1380 (5)(b)(i)(A) that exceeds the dependent family member's income (child support received from a noncustodial parent is considered the child's income);
  2. Does not reside with the community spouse, the amount is equal to the Standards - LTSS based on the number of dependent family members in the home less their separate income (child support received from a noncustodial parent is considered the child's income).

What is a dependent?

A dependent for deeming purposes is the same as a dependent for Federal income tax purposes. If a dependent is claimed on the community spouse or institutional spouse's personal income tax return, a family allocation can be considered.
A dependent does not need to be living with the client or the community spouse to be considered for a family allocation.

Dependent residing with the community spouse

For each dependent we take the community spouse income and family allocation standard (150% of the 2 person FPL) minus that dependents income. Then we divide that figure by 3. The result is the dependent allocation allowed for that dependent.

For more than one dependent we do the same computation indicated above for each dependent.

Example #1

COPES client living with the community spouse and 3 minor children.

Child #1 has $300 Social Security and $300 child support

Child #2 has $300 Social Security

Child #3 has $300 Social Security

Computation for the dependent deeming based on the 7/1/2009 community spouse income and family allocation of $1822. (see LTC standard chart for current CS income and family allocation):

Child #1

$1,822 (7/1/2009 CS and family allocation standard)

-$600 child's income

= $1,222 divided by 3 = $407.33 available to deem to child #1

Child #2

$1,822

- $300 child's income

= $1,522 divided by 3 = $507.33 available to deem to child #2.

Child #3

$1,822

-$300

= $1,522 divided by 3 = $507.33 available to deem to child #3

Example #2

Nursing Home client. Community spouse has a dependent sibling residing with her that is claimed on the income tax return. She also has a 19 year old and 14 year old child living with her.

Dependent #1 sibling has $100 per month gross earnings

Dependent #2 19 year old child has $500 per month gross earnings

Dependent #3 14 year old child has no income

Computation:

Dependent #1

$1,822 CS income and family allocation

- $100 income

= $1,722 divided by 3 = $574 available to deem to dependent #1

Dependent #2

$1,822

- $500 income

= $1,322 divided 3 = $440.47 available to deem to dependent #2

Dependent #3

$1,822 divided by 3 = $607.33 available to deem to dependent #3

Note: The dependent and their income is coded on the LTCX screen in ACES.

Dependent not residing with the community spouse

When the dependent does not reside with the community spouse the

calculation standard is the MNIL and based on the number of dependents minus the

dependents income.

Example #1

COPES client with 2 dependent children. Child #1 is 18 and has $100 income. Child #2 is 15 and has $300 child support income.

Calculation:

MNIL/$674.00 (Standard is based on 1/2009 standards, see LTC standard chart for current MNIL)

- both dependents total income of $400

= $274.00 available to deem to the 2 dependents

Why are the 2 calculations so different?

The calculation when the dependents are living with the community spouse are based on the spousal impoverishment act. When there is no community spouse as part of the household, the spousal impoverishment rules do not apply.

CMS standards including spousal impoverishment

Spousal Impoverishment

Things to remember about the dependent allocation

  1. If the dependent is applying for their own medical benefits, any actual income deemed from the institutional individual to the dependent is considered the dependent's income. Code the deemed income as OC under the income in ACES 3G or the UNER screen in ACES mainframe and document this deemed income from the institutional individual in the remarks.
  2. The dependent allocation follows the order of post eligibility deductions in WAC 182-513-1380 for institutional (residing in a medical institution) services, WAC 182-515-1509 for HCS CN Waiver programs, or WAC 182-515-1514 for DDD Waiver programs. The institutional individual may not have enough income to deem the maximum amount available for the family allocation based on the amount of income and the deductions allowed. For cases with a community spouse, the community spouse (CS) is allowed up to the CS income and family allocation minus the CS income before the dependent deduction. In addition the CS may get additional deeming up to the CS maintenance standard due to excess shelter.

Child Support received by the institutionalized individual

WAC 182-513-1340 (10) states child support payments received from an absent parent for a child living in the home is income of the child.

Back child support received for a child no longer living in the home is considered income.

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Eligibility for hospice as a service

Revised date

Programs that cover Hospice as a service?

A client must be eligible for a categorically needy (CN) or medically needy (MN) program to receive hospice care. Examples include but are not limited to the following:

  • CN noninstitutional medicaid in an alternative living facility (G03)
  • Health Care for Workers with Disabilities (HWD) (S08)
  • MAGI based CN with the exception of N21 or N25
  • Home and Community Based (HCB) Waivers (L21, L22)
  • Community First Choice (CFC) (L51, L52)
  • Foster care medicaid (D01, D02, D26)
  • SSI medicaid (S01)
  • SSI related (S02, S95, S99 in active status)

Note: A client who has met their spenddown under MN is eligible for hospice as a service.

  • Clients must meet the hospice diagnostic criteria plus medicaid eligibility criteria in order to receive hospice services.
  • Clients who are in a current base period and have not met their spend-down, do not have to reapply to get hospice but they do have to meet their spenddown before Hospice can be approved.
  • If a client is eligible for a noninstitutional CN program, the hospice provider bills the Medicaid Agency the same as any other service.
  • If the client is residing in a medical institution such as a nursing facility or hospice care center, the case must be coded as hospice on the institutional care screen in ACES 3G in order to set the hospice flag on the program in ACES.online. If income is over the Special Income Limit (SIL), the case will trickle to an MN program.

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Apple Health medical extension for families and caretaker relatives

Revised date
Purpose statement

This category describes the Health Care Extension (N02) available to parenting/caretaker (N01) adults when their N01 coverage ends due to increased earnings or collection of spousal support.

WAC 182-523-0100 Washington apple health--Medical extension

WAC 182-523-0100 Washington apple health--Medical extension.

Effective December 28, 2019

  1. A parent or caretaker relative who was eligible for and who received coverage under Washington apple health for parents and caretaker relatives, described in WAC 182-505-0240, in any three of the last six months is eligible, along with all dependent children living in the household, for twelve months' extended health care coverage if the person becomes ineligible for coverage due to increased earnings or hours of employment.
  2. A person remains eligible for apple health medical extension unless:
    1. The person:
      1. Moves out of state;
      2. Dies; or
      3. Leaves the household.
    2. The family:
      1. Moves out of state;
      2. Loses contact with the agency or its designee or the whereabouts of the family are unknown; or
      3. No longer includes an eligible dependent child as defined in WAC 182-503-0565(2).
  3. When a person or family is determined ineligible for apple health coverage under subsection (2)(a)(i) through (iii) or (b)(i) or (ii) of this section during the medical extension period, the agency or its designee redetermines eligibility for the remaining household members as described in WAC 182-504-0125 and sends written notice as described in chapter 182-518 WAC before apple health medical extension is terminated.

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

Health Care Extension

  • Health Care Extension (N02) is CN coverage given only to parent/caretaker adults who become ineligible for Washington Apple Health Family (N01) coverage because of an increase in earned income or spousal support.
  • To qualify the adult must be eligible for Washington Apple Health Family (N01) coverage in three of the preceding six months.
  • Health Care Extension (N02) coverage is certified for twelve months. However, eligibility is not continuous. Changes in household circumstances may effect eligibility.
  • There is no renewal of the Health Care Extension (N02).

WAC 182-523-0130 Medical extension--Redetermination

WAC 182-523-0130 Medical extension--Redetermination.

Effective August 24, 2014

  1. When the agency or its designee determines the family or an individual family member is ineligible during the medical extension period, the agency or its designee must determine if they are eligible for another medical program.
  2. Children are eligible for twelve month continuous eligibility beginning with the first month of the medical extension period.
  3. When a family reports a reduction of income, the family may be eligible for the Washington apple health for parents and caretaker relatives program (described in WAC 182-505-0240) instead of medical extension benefits.
  4. When a medical extension period is ending, the family is required to complete a renewal of eligibility as described in WAC 182-504-0035.
  5. Postpartum and family planning extensions are described in WAC 182-505-0115.

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 individual receives a review at the end of the Health Care Extension certification period. Adults aren't eligible for consecutive N02 certifications.

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