WAC 182-513-1635 Tailored Supports for Older Adults (TSOA) — Income Eligibility.

Effective October 6, 2023

1. To determine income eligibility for the tailored supports for older adults (TSOA) program, the medicaid agency or the agency's designee uses the following rules depending on whether the person is single or married.
2. If the TSOA applicant is single:
   1. Determine available income under WAC 182-513-1325;
   2. Exclude income under WAC 182-513-1340; and
   3. Compare remaining gross nonexcluded income to 400 percent of the federal benefit rate (FBR) for the supplemental security income (SSI) cash grant program. To be eligible, a person's gross income must be equal to or less than 400 percent of the FBR.
3. If the TSOA applicant is married:
   1. Determine available income under WAC 182-513-1330 with the exception of subsection (5) of that section;
   2. Exclude income under WAC 182-513-1340;
   3. Compare the applicant's remaining gross nonexcluded income to 400 percent of the FBR. To be eligible, a person's gross income must be equal to or less than 400 percent of the FBR.
4. The FBR changes annually on January 1st.
5. The current TSOA income standard is found on the Washington apple health income and resource standards chart, institutional standards section; see www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/program-standard-income-and-resources.

WAC 182-513-1630 Tailored Supports for Older Adults (TSOA) — Rights and Responsibilities.

Effective July 1, 2017

1. A person applying for or receiving tailored supports for older adults (TSOA) has the right to:
   1. Have TSOA rights and responsibilities explained and provided in writing;
   2. Be treated politely and fairly without regard to race, color, political beliefs, national origin, religion, age, gender (including gender identity and sex stereotyping), sexual orientation, disability, honorably discharged veteran or military status, or birthplace;
   3. Get help with the TSOA application if requested;
   4. Have an application processed promptly and no later than the timelines described in WAC 182-503-0060;
   5. Have at least ten calendar days to give the medicaid agency or the agency's designee information needed to determine eligibility and be given more time if asked for;
   6. Have personal information kept confidential. The agency or the agency's designee may share information with other state and federal agencies for purposes of eligibility and enrollment in other Washington apple health programs;
   7. Get written notice, in most cases, at least ten calendar days before the agency or its designee denies, terminates, or changes eligibility for TSOA;
   8. Ask for an appeal if the person disagrees with the agency or the agency's designee's decision. A person can also ask a department supervisor or administrator to review the decision or action without affecting the right to a fair hearing.
   9. Ask for and get interpreter or translator services at no cost and without delay.
   10. Ask for voter registration assistance;
   11. Refuse to speak to an investigator if the person's case is audited. If the person does not want to let the investigator enter their home, there is no requirement to do so and the person may ask the investigator to come back at another time. Such a request will not affect a person's eligibility for TSOA; and
   12. Get equal access services under WAC 182-503-0120 if eligible.
2. An applicant or recipient of TSOA is responsible to:
   1. Report changes in household or family circumstances as required under WAC 182-513-1650;
   2. Provide the agency or the agency's designee with any information or proof needed to determine eligibility. If the person has trouble getting proof, the agency or the agency's designee helps get the proof needed or contacts other persons or agencies for it;
   3. Provide a valid Social Security number or immigration document number in order to verify identity, citizenship, immigration status, date of birth, and whether the person has other health care coverage. This information is not shared with the department of homeland security;
   4. Complete renewals when requested; and
   5. Cooperate with quality assurance when requested.

WAC 182-513-1625 Tailored Supports for Older Adults (TSOA) — Applications.

Effective October 9, 2023

1. Applications for tailored supports for older adults (TSOA) are submitted:
   1. Online at Washington Connection at www.washingtonconnection.org;
   2. By sending a completed HCA 18-005 application for TSOA form to P.O. Box 45826, Olympia, WA 98605;
   3. By faxing a completed HCA 18-005 application for TSOA form to 1-855-635-8305;
   4. By contacting your local area agency on aging (AAA) office at 1-855-567-0252; or
   5. By contacting your local home and community services (HCS) office. To find your local HCS office, see https://www.dshs.wa.gov/ALTSA/resources.
2. Help filing an application:
   1. The Medicaid agency or the agency's designee provides help with the application or renewal process in a manner that is accessible to people with disabilities, limitations, or other impairments as described in WAC 182-503-0120 and to those who are limited-English proficient as described in WAC 182-503-0110;
   2. For help filing an application:
      1. Contact a local AAA office;
      2. Contact a local HCS office;
      3. Have an authorized representative apply on the person's behalf.
3. The following people can apply for the TSOA program:
   1. The applicant (the person receiving care);
   2. The applicant's spouse;
   3. The applicant's caregiver (person providing in-home caregiver services);
   4. A legal guardian; or
   5. An authorized representative, as defined in WAC 182-500-0010.
4. A phone interview is required to establish TSOA financial eligibility, but may be waived if the applicant is unable to comply:
   1. Due to the applicant's medical condition; and
   2. Because the applicant does not have another person that is able to conduct the interview on the applicant's behalf.
5. The agency or the agency's designee processes TSOA applications using the same timelines under WAC 182-503-0060.
6. TSOA begins on the date the person is determined presumptively eligible for TSOA under WAC 182-513-1620; or on the date all eligibility requirements are established if not found presumptively eligible.
7. When the person withdraws an application for TSOA, or is determined ineligible for TSOA services, the agency or the agency's designee denies the application under WAC 182-503-0080.

WAC 182-513-1620 Tailored Supports for Older Adults (TSOA) - Presumptive Eligibility (PE).

Effective May 29, 2021

1. A person may be determined presumptively eligible for tailored supports for older adults (TSOA) services upon completion of a prescreening interview.
2. The prescreening interview may be conducted by either:
   1. The area agency on aging (AAA); or
   2. By a home and community services intake case manager or social worker.
3. To receive services under presumptive eligibility (PE), the person must meet:
   1. Nursing facility level of care under WAC 388-106-0355;
   2. TSOA income limits under WAC 182-513-1635; and
   3. TSOA resource limits under WAC 182-513-1640.
4. The presumptive period begins on the date the determination is made and:
   1. Ends on the last day of the month following the month of the presumptive eligibility (PE) determination if a full TSOA application is not completed and submitted by that date; or
   2. Continues through the date the final TSOA eligibility determination is made if a full TSOA application is submitted before the last day of the month following the month of the PE determination.
5. If the person applies and is not determined financially eligible for TSOA, there is no overpayment or liability on the part of the applicant for services received during the PE period.
6. The medicaid agency or the agency's designee sends written notice as described in WAC 182-518-0010 when PE for TSOA is approved or denied.
7. A person may receive services under presumptive eligibility only once within a twenty-four-month period.
8. If the department of social and health services establishes a waitlist for TSOA services under WAC 388-106-1975, PE does not apply.

WAC 182-513-1615 Tailored Supports for Older Adults (TSOA) - General Eligibility

Effective July 1, 2017

1. The person receiving care must meet the financial eligibility criteria for tailored supports for older adults (TSOA).
2. To be eligible for the TSOA program, the person receiving care must:
   1. Be age 55 or older;
   2. Be assessed as meeting nursing facility level of care under WAC 388-106-0355;
   3. Meet residency requirements under WAC 182-503-0520;
   4. Live at home and not in a residential or institutional setting;
   5. Have an eligible unpaid caregiver under WAC 388-106-1905, or meet the criteria under WAC 388-106-1910 if the person does not have an eligible unpaid caregiver;
   6. Meet citizenship or immigration status requirements under WAC 182-503-0535. To be eligible for TSOA, a person must be a:
      1. U.S. citizen under WAC 182-503-0535 (1)(c);
      2. U.S. national under WAC 182-503-0535 (1)(d);
      3. Qualifying American Indian born abroad under WAC 182-503-0535 (1)(f); or
      4. Qualified alien under WAC 182-503-0535 (1)(b) and have either met or is exempt from the five-year bar requirement for medicaid.
   7. Provide a valid Social Security number under WAC 182-503-0515;
   8. Have countable resources within specific program limits under WAC 182-513-1640; and
   9. Meet income requirements under WAC 182-513-1635.
3. TSOA applicants who receive coverage under Washington apple health programs are not eligible for TSOA, unless they are enrolled in:
   1. Medically needy program under WAC 182-519-0100;
   2. Medicare savings programs under WAC 182-517-0300;
   3. Family planning program under WAC 182-505-0115;
   4. Family planning only programs under chapter 182-532 WAC; or
   5. The kidney disease program under chapter 182-540 WAC.
4. A person who receives apple health coverage under a categorically needy (CN) or alternative benefit plan (ABP) program is not eligible for TSOA but may qualify for:
   1. Caregiver supports under medicaid alternative care (MAC) under WAC 182-513-1605; or
   2. Other long-term services and supports under chapter 182-513 or 182-515 WAC.
5. The following rules do not apply to services provided under the TSOA benefit:
   1. Transfer of asset penalties under WAC 182-513-1363;
   2. Excess home equity under WAC 182-513-1350;
   3. Client financial responsibility under WAC 182-515-1509;
   4. Estate recovery under chapter 182-527 WAC;
   5. Disability requirements under WAC 182-512-0050;
   6. Requirement to do anything necessary to obtain income under WAC 182-512-0700(1); and
   7. Assignment of rights and cooperation under WAC 182-503-0540

WAC 182-513-1610 Tailored supports for older adults (TSOA) — Overview.

Effective July 1, 2017

1. The tailored supports for older adults (TSOA) program 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) to a person who:
   1. Meets nursing facility level of care described in WAC 388-106-0355; and
   2. Meets the functional requirements under WAC 388-106-1900 through 388-106-1990.
2. For the purposes of TSOA, the applicant is the person receiv­ing care even though services may be authorized to the person provid­ing care. TSOA does not provide Washington apple health coverage.

WAC 182-513-1605 Medicaid alternative care (MAC) — Eligibility.

Effective July 1, 2017

1. The person receiving care must meet the financial eligibility criteria for medicaid alternative care (MAC).
2. To be eligible for MAC services, the person receiving care must:
   1. Be age 55 or older;
   2. Be assessed as meeting nursing facility level of care under WAC 388-106-0355, and choose to receive services under the MAC program instead of other long-term services and supports;
   3. Meet residency requirements under WAC 182-503-0520;
   4. Live at home and not in a residential or institutional setting;
   5. Have an eligible unpaid caregiver under WAC 388-106-1905;
   6. Meet citizenship and immigration status requirements under WAC 182-503-0535 (2)(a) or (b); and
   7. Be eligible for either:
      1. A noninstitutional medicaid program, which provides categorically needy (CN) or alternative benefit plan (ABP) scope of care under WAC 182-501-0060; or
      2. An SSI-related CN program by using spousal impoverishment protections institutionalized (SIPI) spouse rules under WAC 182-513-1660.
3. An applicant whose eligibility is limited to one or more of the following programs is not eligible for MAC:
   1. The medically needy program under WAC 182-519-0100;
   2. The medicare savings programs under WAC 182-517-0300;
   3. The family planning program under WAC 182-505-0115;
   4. The family planning only programs under chapter 182-532;
   5. The medical care services (MCS) program under WAC 182-508-0005;
   6. The alien emergency medical (AEM) program under WAC 182-507-0110 through 182-507-0120;
   7. The state funded long-term care for noncitizens program under WAC 182-507-0125;
   8. The kidney disease program under chapter 182-540 WAC; or
   9. The tailored supports for older adults (TSOA) program under WAC 182-513-1610.
4. The following rules do not apply to services provided under the MAC benefit:
   1. Transfer of asset penalties under WAC 182-513-1363;
   2. Excess home equity under WAC 182-513-1350; and
   3. Estate recovery under chapter 182-527 WAC.

WAC 182-513-1600 Medicaid Alternative Care (MAC)

Effective July 1, 2017

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.

1. For services included with the MAC benefit package, see WAC 388-106-1900 through 388-106-1990.
2. For financial eligibility for MAC services, see WAC 182-513-1605.

WAC 182-526-0540 Correction of clerical errors in an initial order.

Effective March 16, 2017

1. A clerical error is a mistake that does not change the intent of the initial order.
2. The administrative law judge (ALJ) may correct clerical errors in the initial order by entering a corrected initial order. The ALJ may correct clerical errors in response to a request by one of the parties.
3. Some examples of clerical error are:
   1. Missing or incorrect words or numbers;
   2. Dates inconsistent with the decision or evidence in the record such as using May 3, 2004, instead of May 3, 2014; or
   3. Math errors when adding the total of an overpayment.
4. If the ALJ does not agree that the initial order contains one or more clerical errors, the ALJ enters a written order denying the request for a corrected order.

WAC 182-526-0405 Stipulations.

Effective February 1, 2013

1. A stipulation is an agreement among two or more parties that certain facts or evidence is correct or authentic.
2. If an administrative law judge (ALJ) accepts a stipulation, the ALJ must enter it into the record.
3. A stipulation may be made before or during the hearing.
4. A party may change or reject a stipulation after it has been made.
5. To change or reject a stipulation, a party must show the administrative law judge that:
   1. The party did not intend to make the stipulation or was mistaken when making it; and
   2. Changing or rejecting the stipulation does not harm the other parties.