Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-513 - Client not in own home-Institutional medical › Section 182-513-1100 - Definitions related to long-term services and supports (LTSS)

Current through Register Vol. 24-14, July 15, 2024
This section defines the meaning of certain terms used in
				  chapters 182-513 and 182-515 WAC. Within these chapters, institutional, home
				  and community-based services (HCBS) waiver, program of all-inclusive care for
				  the elderly (PACE), and hospice in a medical institution are referred to
				  collectively as long-term care (LTC). Long-term services and supports (LTSS) is
				  a broader definition which includes institutional, HCBS waiver, and other
				  services such as medic-aid personal care (MPC), community first choice (CFC),
				  PACE, and hospice in the community.
* See chapter 182-516 WAC for definitions related to trusts,
				  annuities, life estates, and promissory notes.
* See chapter 388-106 WAC for long-term care services
				  definitions.
* See WAC
				  182-513-1405 for long-term care
				  partnership definitions.
* See chapter 182-500 WAC for additional apple health
				  eligibility definitions.
"Adequate consideration"
means that the fair
				  market value (FMV) of the property or services received, in exchange for
				  transferred property, approximates the FMV of the property transferred.
"Administrative costs"
or
"costs"
means necessary costs paid by the guardian including attorney fees.
"Aging and long-term support administration
				  (ALTSA)"
means the administration within the Washington state department
				  of social and health services (DSHS).
"Alternate living facility (ALF)"
is not an
				  institution under WAC
				  182-500-0050; it is one of the
				  following community residential facilities:
(a) Adult family home (AFH) licensed under
				chapter 70.128 RCW.
(b) Adult
				residential care facility (ARC) licensed under chapter 18.20 RCW.
(c) Assisted living facility (AL) licensed
				under chapter 18.20 RCW.
(d)
				Behavioral health adult residential treatment facility (RTF) licensed under
				chapter 246-337 WAC.
(e) Intensive
				behavioral health treatment facility (IBHTF) is an RTF licensed under chapter
				246-337 WAC.
(f) Developmental
				disabilities administration (DDA) group home (GH) licensed as an adult family
				home under chapter 70.128 RCW or an assisted living facility under chapter
				18.20 RCW.
(g) Enhanced adult
				residential care facility (EARC) licensed as an assisted living facility under
				chapter 18.20 RCW.
(h) Enhanced
				service facility (ESF) licensed under chapter 70.97 RCW.
(i) Facility for children and youth 20 years
				of age and younger where a state-operated living alternative program, as
				defined under chapter 71A.10 RCW, is operated.
(j) Group care facility for medically complex
				children licensed under chapter 74.15 RCW.
(k) Staffed residential facility licensed
				under chapter 74.15 RCW.
"Assets"
means all income and resources of a
				  person and of the person's spouse, including any income or resources which that
				  person or that person's spouse would otherwise currently be entitled to but
				  does not receive because of action:
(a) By that person or that person's
				spouse;
(b) By another person,
				including a court or administrative body, with legal authority to act in place
				of or on behalf of the person or the person's spouse; or
(c) By any other person, including any court
				or administrative body, acting at the direction or upon the request of the
				person or the person's spouse.
"Authorization date"
means the date payment
				  begins for long-term services and supports (LTSS) under WAC
				  388-106-0045.
"Clothing and personal incidentals (CPI)"
means
				  the cash payment (under WAC
				  388-478-0090,
				  388-478-0006, and
				  388-478-0033) issued by the
				  department for clothing and personal items for people living in an ALF or
				  medical institution.
"Community first choice (CFC)"
means a medicaid
				  state plan home and community-based service developed under the authority of
				  section 1915(k) of the Social Security Act under chapter 388-106 WAC.
"Community options program entry system (COPES)"
means a medicaid home and community-based services (HCBS) waiver program
				  developed under the authority of section 1915(c) of the Social Security Act
				  under chapter 388-106 WAC.
"Community spouse (CS)"
means the spouse of an
				  institutionalized spouse.
"Community spouse resource allocation (CSRA)"
means the resource amount that may be transferred without penalty from:
(a) The institutionalized spouse (IS) to the
				community spouse (CS); or
(b) The
				spousal impoverishment protections institutionalized (SIPI) spouse to the
				spousal impoverishment protections community (SIPC) spouse.
"Community spouse resource evaluation"
means the
				  calculation of the total value of the resources owned by a married couple on
				  the first day of the first month of the institutionalized spouse's most recent
				  continuous period of institutionalization.
"Comprehensive assessment reporting evaluation (CARE)
				  assessment"
means the evaluation process defined under chapter 388-106
				  WAC used by a department designated social services worker or a case manager to
				  determine a person's need for long-term services and supports (LTSS).
"Continuing care contract"
means a contract to
				  provide a person, for the duration of that person's life or for a term in
				  excess of one year, shelter along with nursing, medical, health-related, or
				  personal care services, which is conditioned upon the transfer of property, the
				  payment of an entrance fee to the provider of such services, or the payment of
				  periodic charges for the care and services involved.
"Continuing care retirement community"
means an
				  entity which provides shelter and services under continuing care contracts with
				  its members and which sponsors or includes a health care facility or a health
				  service.
"Dependent"
means a minor child, or one of the
				  following who meets the definition of a tax dependent under WAC
				  182-500-0105: Adult child,
				  parent, or sibling.
"Developmental disabilities administration
				  (DDA)"
means an administration within the Washington state department of
				  social and health services (DSHS).
"Developmental disabilities administration (DDA) home
				  and community-based services (HCBS) waiver"
means a medicaid HCBS waiver
				  program developed under the authority of section 1915(c) of the Social Security
				  Act under chapter 388-845 WAC authorized by DDA. There are five DDA HCBS
				  waivers:
(a) Basic Plus;
(b) Core;
(c) Community protection;
(d) Children's intensive in-home behavioral
				support (CIIBS); and
(e) Individual
				and family services (IFS).
"Equity"
means the fair market value of real or
				  personal property less any encumbrances (mortgages, liens, or judgments) on the
				  property.
"Fair market value (FMV)"
means the price an
				  asset may reasonably be expected to sell for on the open market in an
				  agreement, made by two parties freely and independently of each other, in
				  pursuit of their own self-interest, without pressure or duress, and without
				  some special relationship (arm's length transaction), at the time of transfer
				  or assignment.
"Guardianship fees"
or
"fees"
means
				  necessary fees charged by a guardian for services rendered on behalf of a
				  client.
"Home and community-based services (HCBS) waiver
				  programs authorized by home and community services (HCS)"
means medicaid
				  HCBS waiver programs developed under the authority of Section 1915(c) of the
				  Social Security Act under chapter 388-106 WAC authorized by HCS. There are
				  three HCS HCBS waivers: Community options program entry system (COPES), new
				  freedom consumer directed services (New Freedom), and residential support
				  waiver (RSW).
"Home and community-based services (HCBS)"
means
				  LTSS provided in the home or a residential setting to persons assessed by the
				  department.
"Institutional services"
means services paid for
				  by Washington apple health, and provided:
(a) In a medical institution;
(b) Through an HCBS waiver; or
(c) Through programs based on HCBS waiver
				rules for post-eligibility treatment of income under chapter 182-515
				WAC.
"Institutionalized individual"
means a person
				  who has attained institutional status under WAC
				  182-513-1320.
"Institutionalized spouse"
means a person who,
				  regardless of legal or physical separation:
(a) Has attained institutional status under
				WAC 182-513-1320; and
(b) Is legally married to a person who is not
				in a medical institution.
"Life care community
" see continuing care
				  community.
"Likely to reside"
means the agency or its
				  designee reasonably expects a person will remain in a medical institution for
				  30 consecutive days. Once made, the determination stands, even if the person
				  does not actually remain in the facility for that length of time.
"Long-term care services"
see "Institutional
				  services."
"Long-term services and supports (LTSS)"
includes institutional and noninstitutional services authorized by the
				  department.
"Medicaid alternative care (MAC)"
is a
				  Washington apple health benefit authorized under Section 1115 of the Social
				  Security Act. It enables the medicaid agency and the agency's designees to
				  deliver an array of person-centered long-term services and supports (LTSS) to
				  unpaid caregivers caring for a medicaid-eligible person who meets nursing
				  facility level of care under WAC
				  388-106-0355 and
				  182-513-1605.
"Medicaid personal care (MPC)"
means a medicaid
				  state plan home and community-based service under chapter 388-106 WAC.
"Most recent continuous period of institutionalization
				  (MRCPI)"
means the current period an institutionalized spouse has
				  maintained uninterrupted institutional status when the request for a community
				  spouse resource evaluation is made. Institutional status is determined under
				  WAC 182-513-1320.
"Noninstitutional medicaid"
means any apple
				  health program not based on HCBS waiver rules under chapter 182-515 WAC, or
				  rules based on a person residing in an institution for 30 days or more under
				  chapter 182-513 WAC.
"Nursing facility level of care (NFLOC)"
is
				  described in WAC
				  388-106-0355.
"Participation"
means the amount a person must
				  pay each month toward the cost of long-term care services received each month;
				  it is the amount remaining after the post-eligibility process under WAC
				  182-513-1380,
				  182-515-1509, or
				  182-515-1514. Participation is
				  not room and board.
"Penalty period"
or
"period of
				  ineligibility"
means the period of time during which a person is not
				  eligible to receive services that are subject to transfer of asset
				  penalties.
"Personal needs allowance (PNA)"
means an amount
				  set aside from a person's income that is intended for personal needs. The
				  amount a person is allowed to keep as a PNA depends on whether the person lives
				  in a medical institution, ALF, or at home.
"Presumptive eligibility (PE)"
for long-term
				  services and supports is described in WAC
				  182-513-1110.
"Program of all-inclusive care for the elderly
				  (PACE)"
provides long-term services and supports (LTSS), medical, mental
				  health, and substance use disorder (SUD) treatment through a
				  department-contracted managed care plan using a personalized plan of care for
				  each enrollee.
"Roads to community living (RCL)"
is a
				  demonstration project authorized under Section 6071 of the Deficit Reduction
				  Act of 2005 (P.L.
				  109-171) and extended through the Patient
				  Protection and Affordable Care Act (P.L. 111-148).
"Room and board"
means the amount a person must
				  pay each month for food, shelter, and household maintenance requirements when
				  that person resides in an ALF. Room and board is not participation.
"Short stay"
means residing in a medical
				  institution for a period of 29 days or fewer.
"Significant financial duress"
means, but is not
				  limited to, threatened loss of, or financial burden from, basic shelter, food,
				  or medically necessary health care. It means that a member of a couple has
				  established to the satisfaction of a hearing officer that the community spouse
				  needs income above the level permitted by the community spouse maintenance
				  standard to provide for medical, remedial, or other support needs of the
				  community spouse to permit the community spouse to remain in the
				  community.
"Special income level (SIL)"
means the monthly
				  income standard that is 300 percent of the supplemental security income (SSI)
				  federal benefit rate.
"Spousal impoverishment protections"
means the
				  financial provisions within Section 1924 of the Social Security Act that
				  protect income and assets of the community spouse through income and resource
				  allocation. The allocation process is used to discourage the impoverishment of
				  a spouse due to the other spouse's need for LTSS. This includes services
				  provided in a medical institution, HCBS waivers authorized under 1915(c) of the
				  Social Security Act, and through September 30, 2027, services authorized under
				  1115 and 1915(k) of the Social Security Act.
"Spousal impoverishment protections community (SIPC)
				  spouse"
means the spouse of a SIPI spouse.
"Spousal impoverishment protections institutionalized
				  (SIPI) spouse"
means a legally married person who qualifies for the
				  noninstitutional categorically needy (CN) Washington apple health SSI-related
				  program only because of the spousal impoverishment protections under WAC
				  182-513-1220.
"State spousal resource standard"
means the
				  minimum CSRA standard for a CS or SIPC spouse.
"Tailored supports for older adults (TSOA)"
is a
				  federally funded program approved under Section 1115 of the Social Security
				  Act. It enables the medicaid agency and the agency's designees to deliver
				  person-centered long-term services and supports (LTSS).
"Third-party resource (TPR)"
means funds paid to
				  or on behalf of a person by a third party, where the purpose of the funds is
				  for payment of activities of daily living, medical services, or personal care.
				  The agency does not pay for these services if there is a third-party resource
				  available.
"Transfer"
means, in the context of long-term
				  care eligibility, the changing of ownership or title of an asset, such as
				  income, real property, or personal property, by one of the following:
(a) An intentional act that changes ownership
				or title; or
(b) A failure to act
				that results in a change of ownership or title.
"Uncompensated value"
means the fair market
				  value (FMV) of an asset on the date of transfer, minus the FMV of the
				  consideration the person receives in exchange for the asset.
"Undue hardship"
means a person is not able to
				  meet shelter, food, clothing, or health needs. A person may apply for an undue
				  hardship waiver based on criteria under WAC
				  182-513-1367.