Question and Answers on Applications for Long-Term Care Services and Supports

An LTSS application should be submitted at least 45 days before coverage is needed, if possible.

• For example, if coverage is needed May 1st, the application should be submitted no later than March 15 if possible. It should include a note saying that the applicant wants coverage to start May 1.

• Submitting an application as far in advance as possible should allow time for the HCS eligibility determination process. During this process, an HCS financial worker will determine financial eligibility and an HCS social worker will assess functional eligibility. Assuming both are met, the social worker will establish the needed level of care and authorize services.

Note: Some HCS offices have been taking longer than 45 days to process applications. You may wish to submit your application earlier than 45 days, if possible, before you need coverage. Submit a note with your application saying when you want coverage to begin.

Assuming an applicant is both financially and functionally eligible, the effective date of LTSS coverage will depend on where the services are provided.

• Nursing facility– For services provided in nursing facilities, the effective date of coverage is ordinarily the first day of the month of application. Retroactive coverage for nursing facilities may also be available for up to three months before the month of application if the applicant was eligible during those months. (Note: A nursing facility is commonly known as a nursing home.)

• Residential settings– When services are provided in a person's own home, in an adult family home, or in an assisted living facility, two important differences arise. First, the effective date of coverage is not the first day of the month of application. Instead, coverage begins when HCS has established the applicant's level of care and approved a contract signed by the long-term care provider. Second, retroactive coverage is not available outside of nursing facilities. Because of these differences, it is especially important for an applicant who seeks long-term care coverage outside of a nursing home to submit an application no less than 45days before the date coverage is needed.

The timing of the application raises additional issues for applicants who pay privately for care in their own homes, adult family homes or assisted living facilities and want to convert to Medicaid.

• For example, assume that a resident of an adult family home has been privately paying for care, but can no longer afford to do so. The applicant applies late in the month of April for coverage to begin in May. On May 1st, the applicant is financially eligible for Medicaid but, because of the date that the application was submitted, HCS does not establish the level-of-care until May 15th.

• Establishing eligibility is a two-part process. The applicant must be financially eligible. The applicant must also be assessed by HCS to determine how much and what kind of care the applicant needs. This information is used to determine how much the adult family home will be paid. In such a situation, the resident would owe the adult family home for care provided May 1-14 even though the resident was financially eligible for Medicaid during that time.

Usually an applicable must be "resource eligible" (meaning resources fall with applicable limits) at of 12 a.m. on the first day of a given month in order to establish eligibility for any part of that month.

• Within the month of application, an applicant can reduce excess resources and become eligible by paying outstanding medical bills or by funding a permitted burial account.

• Care must be taken to ensure that excess resources are spent before the end of the month or the applicant will not be eligible in the month of application. DSHS cannot pay for services received that month, even if the client becomes eligible in the next month.

Note: An applicant who wants to reduce resources to become eligible for LTSS coverage should consult an experienced attorney who is knowledgeable about Medicaid rules. An applicant who does not follow the rules when reducing resources may be declared ineligible for LTSS coverage for a significant period of time.

• You can apply online at www.washingtonconnection.org

• Application forms for all long-term care programs are available at local DSHS offices. You can find your local DSHS office at: www.dshs.wa.gov/office-locations

• You can apply over the phone by calling 1-800-422-3263.

• You can download and print a paper copy of the application at: www.hca.wa.gov/assets/free-or-low-cost/18-005.pdf

• You can apply by mailing your application to the address in the application materials. If you mail your application, you should use mail with tracking so you have proof it was delivered.

• You can also fax your application. A fax number is in the application materials. Be sure to save your fax confirmation showing when you faxed your application.

• You can also submit your completed application to any DSHS office. Make a copy of your application and have a DSHS worker stamp your copy showing the date your application was submitted.

For additional information about Medicaid long-term care coverage, see these other publications:

• Questions and Answers on the COPES Program

• Questions and Answers on Medicaid for Nursing Home Residents

• Questions and Answers on the Community First Choice Program; and

• Questions and Answers on the TSOA and MAC Programs.