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Chapter 182-514 WAC

Last Update: 1/25/23

LONG-TERM CARE FOR FAMILIES AND CHILDREN

WAC Sections

HTMLPDF182-514-0230Purpose.
HTMLPDF182-514-0240General eligibility.
HTMLPDF182-514-0245Resource eligibility.
HTMLPDF182-514-0250Program for adults age nineteen and older.
HTMLPDF182-514-0260Institutional program for children under age nineteen.
HTMLPDF182-514-0263Non-SSI-related institutional medically needy coverage for pregnant people and people age 20 and younger.
HTMLPDF182-514-0270Involuntary commitment to Eastern or Western State Hospital.
DISPOSITION OF SECTIONS FORMERLY CODIFIED IN THIS TITLE
182-514-0235 Definitions. [Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (P.L. 111-148), 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-06-068, § 182-514-0235, filed 2/28/14, effective 3/31/14. WSR 12-02-034, recodified as § 182-514-0235, filed 12/29/11, effective 1/1/12. Statutory Authority: RCW 74.04.055, 74.04.057, 74.08.090, 74.09.530, and 42 C.F.R. 441.151. WSR 09-06-029, § 388-505-0235, filed 2/24/09, effective 3/27/09.] Repealed by WSR 16-04-087, filed 1/29/16, effective 2/29/16. Statutory Authority: RCW 41.05.021, 41.05.160.
182-514-0255Washington apple health—MAGI-based long-term care program for young adults nineteen and twenty years of age. [Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (P.L. 111-148), 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-06-068, § 182-514-0255, filed 2/28/14, effective 3/31/14. WSR 12-02-034, recodified as § 182-514-0255, filed 12/29/11, effective 1/1/12. Statutory Authority: RCW 74.04.055, 74.04.057, 74.08.090, 74.09.530, and 42 C.F.R. 441.151. WSR 09-06-029, § 388-505-0255, filed 2/24/09, effective 3/27/09.] Repealed by WSR 16-04-087, filed 1/29/16, effective 2/29/16. Statutory Authority: RCW 41.05.021, 41.05.160.
182-514-0265How the department determines how much of an institutionalized individual's income must be paid towards the cost of care. [WSR 12-02-034, recodified as § 182-514-0265, filed 12/29/11, effective 1/1/12. Statutory Authority: RCW 74.04.055, 74.04.057, 74.08.090, 74.09.530, and 42 C.F.R. 441.151. WSR 09-06-029, § 388-505-0265, filed 2/24/09, effective 3/27/09.] Repealed by WSR 14-06-068, filed 2/28/14, effective 3/31/14. Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (P.L. 111-148), 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155.

PDF182-514-0230

Purpose.

(1) This chapter describes eligibility requirements for the Washington apple health (WAH) modified adjusted gross income (MAGI)-based long-term care program (LTC) for children and adults who have been admitted to an institution as defined in WAC 182-500-0050 for at least 30 days. The rules are stated in the following sections:
(a) WAC 182-514-0240 General eligibility;
(b) WAC 182-514-0245 Resource eligibility;
(c) WAC 182-514-0250 Program for adults age 19 and older;
(d) WAC 182-514-0260 Program for children under age 19;
(e) WAC 182-514-0263 Non-SSI-related institutional medically needy coverage for pregnant women and people age 20 and younger.
(f) WAC 182-514-0270 Involuntary commitment to Eastern or Western State Hospital.
(2) A noninstitutional WAH program recipient does not need to submit a new application for LTC coverage if admitted to an institution under this section. Admission to an institution constitutes a change of circumstances. Eligibility is based on institutional status under WAC 182-513-1320.
(3) In this chapter, "medicaid agency" or "agency" means the Washington state health care authority and includes the agency's designee. See chapter 182-500 WAC for additional definitions.
(4) Income standards used in this chapter are listed at www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/program-standard-income-and-resources.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-04-034, § 182-514-0230, filed 1/25/23, effective 2/25/23; WSR 16-04-087, § 182-514-0230, filed 1/29/16, effective 2/29/16. Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (P.L. 111-148), 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-06-068, § 182-514-0230, filed 2/28/14, effective 3/31/14. WSR 12-02-034, recodified as § 182-514-0230, filed 12/29/11, effective 1/1/12. Statutory Authority: RCW 74.04.055, 74.04.057, 74.08.090, 74.09.530, and 42 C.F.R. 441.151. WSR 09-06-029, § 388-505-0230, filed 2/24/09, effective 3/27/09.]


PDF182-514-0240

General eligibility.

(1) To be eligible for modified adjusted gross income (MAGI)-based long-term care (LTC) coverage under this section, a person must:
(a) Meet institutional status under WAC 182-513-1320;
(b) Meet the general eligibility requirements under WAC 182-503-0505, unless the applicant is a noncitizen, in which case WAC 182-503-0505 (3)(c) and (d) do not apply;
(c) Have countable income below the applicable standard described in WAC 182-514-0250(2) or 182-514-0260(3), unless the applicant is eligible as medically needy;
(d) Satisfy the program requirements in WAC 182-514-0250 and 182-514-0260; and
(e) Meet the nursing facility level of care under WAC 388-106-0355 if admitted to a nursing facility for nonhospice care. Hospice patients are exempt from this requirement.
(2) A person age nineteen or older who does not meet the citizenship or immigration requirements under WAC 182-503-0535 to qualify for medicaid must meet the criteria in subsection (1) of this section and:
(a) Have a qualifying emergency condition and meet the requirements under WAC 182-507-0115 and 182-507-0120; or
(b) Meet the requirements under WAC 182-507-0125 if the person needs LTC coverage in a nursing facility.
(3) If a person meets institutional status, the medicaid agency counts only income received by the person or on behalf of the person when determining eligibility.
(4) A person who meets the federal aged, blind, or disabled criteria may qualify for coverage under chapter 182-513 WAC.
(5) A person who receives supplemental security income (SSI) is not eligible for the MAGI-based LTC program.
(6) If a person does not meet institutional status, the agency determines the person's eligibility for a noninstitutional medical program.
(7) A person eligible for categorically needy or medically needy coverage under a noninstitutional program who is admitted to a nursing facility for fewer than thirty days is only approved for coverage for the nursing facility room and board costs if the person meets the nursing facility level of care as described under WAC 388-106-0355.
(8) A MAGI-based LTC recipient is not required to pay toward the cost of care.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-04-087, § 182-514-0240, filed 1/29/16, effective 2/29/16. Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (P.L. 111-148), 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-06-068, § 182-514-0240, filed 2/28/14, effective 3/31/14. WSR 12-02-034, recodified as § 182-514-0240, filed 12/29/11, effective 1/1/12. Statutory Authority: RCW 74.04.055, 74.04.057, 74.08.090, 74.09.530, and 42 C.F.R. 441.151. WSR 09-06-029, § 388-505-0240, filed 2/24/09, effective 3/27/09.]


PDF182-514-0245

Resource eligibility.

Applicants for and recipients of the modified adjusted gross income (MAGI)-based long-term care program are exempt from the transfer-of-asset evaluation under WAC 182-513-1363, and there is no resource test.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-04-087, § 182-514-0245, filed 1/29/16, effective 2/29/16. Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (P.L. 111-148), 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-06-068, § 182-514-0245, filed 2/28/14, effective 3/31/14. WSR 12-02-034, recodified as § 182-514-0245, filed 12/29/11, effective 1/1/12. Statutory Authority: RCW 74.04.055, 74.04.057, 74.08.090, 74.09.530, and 42 C.F.R. 441.151. WSR 09-06-029, § 388-505-0245, filed 2/24/09, effective 3/27/09.]


PDF182-514-0250

Program for adults age nineteen and older.

(1) To qualify for coverage under the modified adjusted gross income (MAGI)-based long-term care (LTC) program under this section, a person age nineteen or older must be eligible for one of the following Washington apple health (WAH) programs:
(a) WAC 182-505-0240 Washington apple health—Parents and caretaker relatives;
(b) WAC 182-523-0100 Washington apple health—Medical extension;
(c) WAC 182-505-0250 Washington apple health—MAGI-based adult medical;
(d) WAC 182-505-0115 Washington apple health—Eligibility for pregnant women; or
(e) WAC 182-507-0110 Washington apple health—Alien medical programs.
(2) The categorically needy (CN) income level for health care coverage under this section is the applicable standard for the program the person receives after the standard five percentage point income disregard. See WAC 182-505-0100 for standards based on the federal poverty level.
(3) The medicaid agency determines countable income for CN coverage under this section using MAGI methodology under chapter 182-509 WAC.
(4) The agency approves CN coverage under this section for twelve calendar months.
(5) A person is ineligible for medically needy (MN) coverage under this section if the person's income exceeds CN eligibility standards, unless the person is age nineteen, twenty, or pregnant.
(6) If a person who is age nineteen, twenty, or pregnant is not eligible for CN coverage under this section, the agency determines eligibility for MN coverage under WAC 182-514-0263.
(7) A person who applies for or receives MAGI-based LTC coverage at Eastern or Western State Hospital in the month of his or her twenty-first birthday and who receives active inpatient psychiatric treatment that will likely continue through the person's twenty-first birthday is eligible for CN coverage until:
(a) The facility discharges the person; or
(b) The end of the month in which the person turns age twenty-two, whichever occurs first.
(8) Except for a person described in subsection (7) of this section, a person who is admitted to Eastern or Western State Hospital who is older than age twenty but younger than age sixty-five is not eligible for WAH coverage.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-04-087, § 182-514-0250, filed 1/29/16, effective 2/29/16. Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (P.L. 111-148), 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-06-068, § 182-514-0250, filed 2/28/14, effective 3/31/14. WSR 12-02-034, recodified as § 182-514-0250, filed 12/29/11, effective 1/1/12. Statutory Authority: RCW 74.04.055, 74.04.057, 74.08.090, 74.09.530, and 42 C.F.R. 441.151. WSR 09-06-029, § 388-505-0250, filed 2/24/09, effective 3/27/09.]


PDF182-514-0260

Institutional program for children under age nineteen.

(1) To qualify for the modified adjusted gross income (MAGI)-based long-term care (LTC) program under this section, you (a child under age nineteen) must meet:
(a) The general eligibility requirements in WAC 182-514-0240; and
(b) Program requirements under WAC 182-505-0210 or 182-505-0117.
(2) If you are eligible for the premium-based children's program under WAC 182-505-0215, we redetermine your eligibility under this section so that your family is not required to pay the premium.
(3) The categorically needy (CN) income level for LTC coverage under this section is two hundred ten percent of the federal poverty level after the standard five percentage point income disregard.
(4) To determine countable income for CN coverage under this section, we apply the MAGI methodology under chapter 182-509 WAC.
(5) We approve CN coverage under this section for twelve calendar months (certification period). If you are discharged from the facility before the end of the certification period, you remain continuously eligible for CN coverage through the certification period, unless you age out of the program, move out-of-state, or die.
(6) If you are not eligible for CN coverage under this section, we determine your eligibility for coverage under the institutional medically needy program described in WAC 182-514-0263.
(7) The institution where you reside may submit an application on your behalf and may act as your authorized representative if you are:
(a) In a court-ordered, out-of-home placement under chapter 13.34 RCW; or
(b) Involuntarily committed to an inpatient treatment program by a court order under chapter 71.34 RCW.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-12-017, § 182-514-0260, filed 5/30/17, effective 6/30/17; WSR 16-04-087, § 182-514-0260, filed 1/29/16, effective 2/29/16. Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (P.L. 111-148), 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-06-068, § 182-514-0260, filed 2/28/14, effective 3/31/14. WSR 12-02-034, recodified as § 182-514-0260, filed 12/29/11, effective 1/1/12. Statutory Authority: RCW 74.04.055, 74.04.057, 74.08.090, 74.09.530, and 42 C.F.R. 441.151. WSR 09-06-029, § 388-505-0260, filed 2/24/09, effective 3/27/09.]


PDF182-514-0263

Non-SSI-related institutional medically needy coverage for pregnant people and people age 20 and younger.

(1) Medically needy (MN) coverage under this section is only available for people age 20 and younger or pregnant people. The medicaid agency determines a client who meets SSI-related criteria under WAC 182-512-0050 eligible for institutional MN coverage under WAC 182-513-1395. If a client meets requirements in both this section and WAC 182-513-1395, the client may choose which program to enroll in for coverage.
(2) A client whose income exceeds the categorically needy (CN) standards under WAC 182-514-0250 and 182-514-0260 is:
(a) Eligible for MN coverage with no spenddown if the client's countable income (CI) is equal to or less than the department-contracted daily rate times the number of days in the institution;
(b) Eligible for MN coverage after a spenddown under WAC 182-519-0110 is met if the client's CI is above the department-contracted daily rate times the number of days in the institution but less than the institution's private rate;
(c) Not eligible for payment of long-term care services provided by the institution if the person's CI exceeds the institution's private rate;
(d) Responsible for paying up to the monthly state rate for the facility as participation in the cost of care; and
(e) Allowed to keep a monthly personal needs allowance (PNA) under WAC 182-513-1105. Current PNA and long-term care standards can be found at the agency's program standard for income and resources web page.
(3) If a client's CI exceeds the institution's private rate, the agency determines eligibility for medical coverage under chapter 182-519 WAC.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-12-033, § 182-514-0263, filed 5/24/22, effective 6/24/22. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 c 270. WSR 17-23-039, § 182-514-0263, filed 11/8/17, effective 1/1/18. Statutory Authority: RCW 41.05.021, 41.05.160. WSR 16-04-087, § 182-514-0263, filed 1/29/16, effective 2/29/16.]


PDF182-514-0270

Involuntary commitment to Eastern or Western State Hospital.

(1) A person who is involuntarily committed to Eastern or Western State Hospital under chapter 71.34 RCW is eligible for categorically needy (CN) coverage if the person:
(a) Is under age twenty-one;
(b) Meets institutional status under WAC 182-513-1320; and
(c) Has countable income below:
(i) Two hundred ten percent of the federal poverty level if under age nineteen; or
(ii) One hundred thirty-three percent of the federal poverty level if age nineteen or twenty.
(2) A person who is involuntarily committed or receives MAGI-based long-term care coverage at Eastern or Western State Hospital in the month of the person's twenty-first birthday and receives active inpatient psychiatric treatment that will likely continue through the person's twenty-first birthday, is eligible for CN coverage until:
(a) The facility discharges the person; or
(b) The end of the month in which the person turns twenty-two, whichever occurs first.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-04-087, § 182-514-0270, filed 1/29/16, effective 2/29/16. Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (P.L. 111-148), 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-06-068, § 182-514-0270, filed 2/28/14, effective 3/31/14. Statutory Authority: RCW 41.05.021, 74.09.035, and 2011 1st sp.s. c 36. WSR 12-19-051, amended and recodified as § 182-514-0270, filed 9/13/12, effective 10/14/12. Statutory Authority: RCW 74.04.055, 74.04.057, 74.08.090, 74.09.530, and 42 C.F.R. 441.151. WSR 09-06-029, § 388-505-0270, filed 2/24/09, effective 3/27/09.]