Washington Medicaid / Apple Health Long Term Care Programs, Benefits & Eligibility Requirements

Summary
Medicaid is a joint federal and state program, so its rules, coverage plans and even its name all vary by state. This article focuses on Washington Medicaid Long Term Care, which is different from regular Medicaid. In Washington, Medicaid is called Apple Health. Apple Health will help pay for long-term care for Washington residents in a nursing home, in their home and in other residential settings through one of three programs – Nursing Home / Institutional Medicaid, Home and Community Based Service (HCBS) Waivers or Aged Blind and Disabled (ABD) Medicaid.

 

Washington Medicaid Long Term Care Programs

Nursing Home / Institutional Medicaid

Washington Medicaid, more commonly called Apple Health, will cover the cost of long term care in a nursing home for eligible Washington residents through its Nursing Home / Institutional Medicaid. This includes payment for room and board, as well as all necessary medical and non-medical goods and services. These can include skilled nursing care, physician’s visits, prescription medication, medication management, mental health counseling, social activities and assistance with the Activities of Daily Living (mobility, bathing, dressing, eating, toileting).

Some of the things that Apple Health won’t cover in a nursing home are a private room, specialized food, comfort items not considered routine (tobacco, sweets and cosmetics, for example), personal reading items, plants, flowers, and any care services not considered medically necessary.

Any Apple Health beneficiary who receives Nursing Home Medicaid coverage must give most of their income to the state to help pay for the cost of the nursing home. They are only allowed to keep a “personal needs allowance” of $72.05 / month. This can be spent on personal items such as clothes, snacks, books, haircuts, cell phones, etc. It cannot be spent on any item that Medicaid covers, including hygiene basics like a toothbrush, soap, deodorant, razors and incontinence supplies, unless the beneficiary wants a specific brand that is not covered by Apple Health. In this case, they could spend their personal needs allowance on the item.

 

Home and Community Based Service (HCBS) Waivers

Home and Community Based Service (HCBS) Waivers will pay for long-term care services and supports that help Apple Health (Washington Medicaid) recipients who require a Nursing Facility Level of Care remain living “in the community” instead of moving to a nursing home. Living “in the community” can mean living in their home, the home of a loved one, an adult family home (comparable to adult foster care) or an assisted living residence. The state of Washington considers a Nursing Facility Level of Care to be necessary if the applicant needs daily nursing care, or if they need substantial assistance with at least two Activities of Daily Living (mobility, bathing, dressing, eating, toileting) or some assistance with at least three Activities of Daily Living. To determine if an applicant requires that level of care, Washington uses the Comprehensive Assessment Reporting Evaluation tool.

Unlike Nursing Home Medicaid, most HCBS Waivers are not an entitlement. This means that even if an applicant is eligible for an HCBS Waiver, they are not guaranteed by law to receive the benefits. Apple Health has two long-term care Waiver programs:

Community Options Program Entry System (COPES) – provides long-term care supports and services in the Apple Health beneficiary’s home, the home of a loved one, an adult family home or an assisted living residence
New Freedom – provides long-term care supports and services for Apple Health beneficiaries who live in King and Pierce Counties and reside in their own home or the home of a loved one

Community Options Program Entry System (COPES)
The Community Options Program Entry System (COPES) will provide long-term care benefits to program participants in their home, the home of a loved one, an adult family home (comparable to adult foster care) or an assisted living residence, but COPES will not pay for room and board in any of these locations. Available benefits include nursing services, adult day care, home modifications, meal delivery and non-medical transportation. A licensed care agency will provide these services and supports based on the applicant’s needs and circumstances.

Like most HCBS Waivers, COPES is not an entitlement. This means that eligible applicants are not guaranteed to receive benefits. Instead, there are a limited number of enrollment spots – approximately 47,560 in 2022. Once those spots are filled, additional eligible applicants are placed on a waiting list until a spot opens.

New Freedom
New Freedom (NF) is a participant-directed HCBS Waiver program for residents of King County and Pierce County who live in their own home or the home of a loved one. New Freedom will not provide benefits in adult family homes or assisted living residences.

New Freedom program participants are given an individualized budget and they can spend it on the long-term care services and supports of their choice. This includes hiring friends and family members as caregivers, as long as they are 18 or older, qualified to provide such care and have a contract with the Washington Department of Social and Health Services. Spouses and legal guardians, however, cannot be hired as caregivers. Available benefits depend on the individual’s needs and circumstances, but they can include adult day care, home and vehicle modifications, in-home nursing assistance, meal delivery, transportation and personal care help with the Activities of Daily Living (mobility, bathing, dressing, eating, toileting).

Program participants who cannot make their own decisions can assign a representative to do so for them, but this representative cannot also be hired as a caregiver. New Freedom program beneficiaries work with “care consultants” to help them manage their budget and find appropriate care. They also work with a financial services agency to help them with payments to caregivers, tax withholding and other financial transactions.

Like most HCBS Waivers, New Freedom is not an entitlement. This means that eligible applicants are not guaranteed to receive benefits. Instead, there are a limited number of enrollment spots – approximately 675 in 2022. Once those spots are filled, additional eligible applicants are placed on a waiting list until a spot opens.

 

Aged Blind and Disabled / Regular Medicaid

Washington’s Aged Blind and Disabled (ABD) Medicaid, also known as Regular Medicaid for Seniors or Apple Health, provides healthcare and personal service benefits to low-income Washington residents who are aged (age 65+) or disabled and live “in the community.” Living “in the community” can mean living in their home, the home of a loved one, an adult family home (comparable to adult foster care) or an assisted living residence. While ABD Medicaid will cover services in all of those settings, it will not cover room and board costs.

ABD Medicaid is an entitlement, which means that anyone who meets the requirements is guaranteed by law to receive the benefits without any wait. This includes a variety of long-term care benefits such as adult day care, prescription assistance, transportation, housekeeping services and personal care assistance with the Activities of Daily Living (mobility, bathing, dressing, eating, toileting). ABD Medicaid beneficiaries qualify for these benefits one at a time. This is different from Nursing Home Medicaid, which makes all of its benefits immediately available for anyone who qualifies. ABD Medicaid recipients in Washington will receive their individualized plan for long-term care services and supports through one of the following programs:

Community First Choice (CFC) Option – provides long-term care assistance to ABD Medicaid recipients who require a Nursing Facility Level of Care
Medicaid Personal Care (MPC) – provides long-term care assistance to ABD Medicaid recipients who do NOT require a Nursing Facility Level of Care
Medicaid Alternative Care (MAC) – provides long-term care assistance to ABD Medicaid recipients who have an unpaid “family” caregiver, require a Nursing Facility Level of Care, are aged 55+ and live in a private home
Specialized Dementia Care Program (SDCP) – provides long-term care assistance to ABD Medicaid recipients with Alzheimer’s or a related dementia and live in an assisted living / memory care residence.
Program of All-Inclusive Care for the Elderly (PACE) – combines Medicaid and Medicare benefits into a single plan for ABD Medicaid recipients who are dual eligible

Community First Choice (CFC) Option
Washington ABD Medicaid beneficiaries who require a Nursing Facility Level of Care (which is not a requirement for ABD Medicaid) can receive long-term care services and supports through the Community First Choice Option, which is also known as CFC or CFCO. The state of Washington considers a Nursing Facility Level of Care to be necessary if the applicant needs daily nursing care, or if they need substantial assistance with at least two Activities of Daily Living (mobility, bathing, dressing, eating, toileting) or some assistance with at least three Activities of Daily Living. To determine if an applicant requires that level of care, Washington uses the Comprehensive Assessment Reporting Evaluation tool.

CFC program benefits include nursing assistance, personal emergency response systems, assistive technology, respite care for primary caregivers and personal care help with the Activities of Daily Living (mobility, bathing, dressing, eating, toileting). Benefits can be provided in the beneficiary’s home, the home of a family member, an adult family home or an assisted living facility, including enhanced adult residential care facilities. While the participant can receive benefits in any of these settings, CFC will not pay for room and board. Program participants can self-direct some of these services, meaning they hire a caregiver of their choice to provide certain benefits, like personal care help. This includes friends and certain family members, as long as they are 18 or older, qualified to provide such care and have a contract with the Washington Department of Social and Health Services. Spouses and legal guardians, however, can not be hired as caregivers.

The Community First Choice Option, like ABD Medicaid itself, is an entitlement program. This means that eligible applicants are guaranteed to receive benefits, without delay, after their application has been processed and accepted.

Medicaid Personal Care (MPC)
The Medicaid Personal Care (MPC) program provides long-term care services and supports to Washington ABD Medicaid recipients who require some help with the Activities of Daily Living (mobility, bathing, dressing, eating, toileting), but don’t require a Nursing Facility Level of Care. MPC program participants must need extensive assistance with one of the Activities of Daily Living, or minimal assistance with at least three of them. The state of Washington uses the Comprehensive Assessment Reporting Evaluation tool to make this determination.

MPC benefits include select nursing services and personal care help with the Activities of Daily Living (mobility, bathing, dressing, eating, toileting) as well as the Instrumental Activities of Daily Living (cleaning, shopping, cooking, transportation, communication). MPC program participants can receive these benefits while living in their home, the home of a loved one, an adult family home or an assisted living facility, but MPC will not pay for room and board in any of these locations.

The Medicaid Personal Care program, like ABD Medicaid itself, is an entitlement program. This means that eligible applicants are guaranteed to receive benefits, without delay, after their application has been processed and accepted.

Medicaid Alternative Care (MAC)
Washington ABD Medicaid recipients who have a “family” caregiver, live in a private home, are age 55 or older and require a Nursing Facility Level of Care can receive long-term services and supports through the Medicaid Alternative Care (MAC) program. For MAC program purposes, “family” includes friends as well as relatives, like spouses and adult children. “Family” caregivers must be age 18 or older, but they do not need to be Washington state residents.

The state of Washington considers a Nursing Facility Level of Care to be necessary if the applicant needs daily nursing care, or if they need substantial assistance with at least two Activities of Daily Living (mobility, bathing, dressing, eating, toileting) or some assistance with at least three Activities of Daily Living. To determine if an applicant requires that level of care, Washington uses the Comprehensive Assessment Reporting Evaluation tool.

MAC program benefits include adult day care, minor home modifications, durable medical equipment, meal delivery, homemaker services, and training and respite care for the caregiver. These benefits can be provided in a private home, but not in an adult family home (comparable to adult foster care) or an assisted living residence.

Washington ABD Medicaid recipients who are enrolled in the MAC program cannot be simultaneously enrolled in the Community First Choice Option, Medicaid Personal Care, Community Options Programs Entry System or New Freedom programs.

The MAC program has limited funding, and once that limit has been reached for the year, the program does not accept new applicants, even if they are eligible. Instead, those eligible applicants are placed on a waiting list and will then be accepted into the MAC program once funds are available.

Specialized Dementia Care Program (SDCP)
Washington ABD Medicaid beneficiaries who have been diagnosed with Alzheimer’s Disease or a related, irreversible dementia such as Lewy body dementia, Creutzfeldt-Jakob disease, Pick’s disease or vascular dementia can receive long-term care services and supports through the Specialized Dementia Care Program (SDCP). Program applicants must also require a Nursing Facility Level of Care to be eligible for this program, and the state of Washington uses the Comprehensive Assessment Reporting Evaluation (CARE) tool to determine if this level of care is necessary. Applicants must also receive a minimum score of three (out of six) on the cognitive performance scale of the CARE assessment. Plus, applicants must exhibit at least one behavior that demonstrates cognitive impairment, such as taking items that don’t belong to them, wandering, disrobing in public, delusions, yelling, inappropriate toileting or being resistant to care.

Each SDCP participant receives an individualized service package tailored to their needs. Available benefits include 24/7 supervision, dementia-trained staff, medication management, intermittent nursing services and personal care help with the Activities of Daily Living (mobility, bathing, dressing, eating, toileting).

SDCP benefits are only available to Washington residents who live in an assisted living facility, although the program will not pay for room and board in the facility, which may also be called a “memory care” unit. This can be a standalone residence, or a section of an assisted living facility designed for dementia-specific care. Not all assisted living facilities in Washington participate in this program. Since there are a limited number of spaces in participating facilities, there are a limited number of spaces in this program.

Program of All-Inclusive Care for the Elderly (PACE)
Elderly (age 65+) Washington residents who have ABD Medicaid can coordinate their medical, social service and non-medical personal needs into one comprehensive plan and delivery system using the Program of All-Inclusive Care for the Elderly (PACE). PACE is intended to help Washington residents who need a Nursing Facility Level of Care but want to keep residing and receiving care in the community. This program can be used by people who are “dual eligible” for Medicaid and Medicare and will help them coordinate the care from those two programs. PACE is not a statewide program in Washington, but this Washington Department of Social and Health Services webpage lists the zip codes where it is available and has the locations of Washington PACE offices. The National PACE Association also has a program locator tool.

 

Tailored Supports for Older Adults Program

Tailored Supports for Older Adults (TSOA) is a Medicaid-funded program that provides long-term care assistance to Washington residents who are not financially eligible for Washington Medicaid, which is called Apple Health. For 2022, individuals can have up to $53,100 in countable assets (bank accounts, retirement accounts, stocks, bonds, cash) and be eligible for TSOA. Apple Health applicants, on the other hand, are only allowed to have between $2,000 and $3,000 in assets. For a married TSOA applicant with only spouse applying, the non-applicant spouse is allowed to have $59,890 in assets, bringing the allowable asset total to $112,990 ($53,100 + $59,890). To be clear, Apple Health also allows non-applicant spouses to keep more assets ($137,400 for Nursing Home Medicaid applicant spouses, and $59,890 for HCBS Waiver spouses).

The 2022 income limit for TSOA is $2,523 / month per applicant, which is the same as the 2022 income limit for Washington’s Nursing Home Medicaid and Home and Community Based Service Waivers.

The application process for TSOA is also less strict than the Apple Health process since there is no “look-back” period for TSOA, which means the state won’t look back at past financial records to make sure the applicant did not give away assets. The TSOA rules on home ownership are also more lenient since there is no home equity interest limit required for exemption. The asset limit, income limit, look-back period and home exemption are all explained in greater detail below.

TSOA applicants must be age 55+ and live in a private residence, not an assisted living facility or adult family home (comparable to adult foster care). And they must require a Nursing Facility Level of Care. The state of Washington considers a Nursing Facility Level of Care to be necessary if the applicant needs daily nursing care, or if they need substantial assistance with at least two Activities of Daily Living (mobility, bathing, dressing, eating, toileting) or some assistance with at least three Activities of Daily Living. To determine if an applicant requires that level of care, Washington uses the Comprehensive Assessment Reporting Evaluation tool.

TSOA benefits include adult day care, respite care for unpaid caregivers, meal delivery, minor home modifications, specialized medical equipment, non-medical transportation and personal care assistance with the Activities of Daily Living (mobility, bathing, dressing, eating, toileting). TSOA program participants can receive up to approximately $743 / month in benefits.

The same online portal, Washington Connection, is used to apply to the TSOA program that is used to apply for Apple Health.

 

Eligibility Criteria For Washington Medicaid’s Long Term Care Programs

To be eligible for Washington Medicaid, which is called Apple Health, a person has to meet certain financial requirements and functional (medical) requirements. The financial requirements vary by the applicant’s marital status, if their spouse is also applying for Apple Health, and what program they are applying for – Nursing Home / Institutional Medicaid, Home and Community Based Service (HCBS) Waivers or Aged Blind and Disabled (ABD) Medicaid / Regular Medicaid.

  The easiest way to find the most current Apple Health (Washington Medicaid) eligibility criteria for one’s specific situation is to use our Medicaid Eligibility Requirements Finder tool.

 

Washington Medicaid Nursing Home Medicaid Eligibility Criteria

Financial Requirements
Washington residents have to meet an asset limit and an income limit in order to be financially eligible for Nursing Home Medicaid through Apple Health (Washington Medicaid). For a single applicant in 2022, the asset limit is $2,000, which means they must have $2,000 or less in countable assets. Countable assets include bank accounts, retirement accounts, stocks, bonds, certificates of deposit, cash and any other assets that can be easily converted to cash. An applicant’s home does not always count as an asset (see the red box below for more details), and there are other non-countable assets like funeral trusts and Medicaid-approved annuities. The 2022 income limit for a single applicant is $2,523 / month. Almost all income is counted – IRA payments, pension payments, Social Security benefits, property income, alimony, wages, salary, stock dividends, etc. COVID-19 stimulus checks and Holocaust restitution payments are not considered income. However, Nursing Home Medicaid recipients are only allowed to keep $72.05 / month of their income as a “personal needs allowance” and must give the state the rest to help offset nursing home costs.

For married applicants with both spouses applying, the 2022 asset limit for Nursing Home Medicaid is $3,000 combined, and the income limit is $5,046 / month combined. For a married applicant with just one spouse applying, the 2022 asset limit is $2,000 for the applicant spouse and $137,400 for the non-applicant spouse, and the income limit is $2,523 / month for the applicant. The income of the non-applicant spouse is not counted.

Apple Health Nursing Home Medicaid applicants are not allowed to give away their assets in order to get under the asset limit. To make sure they don’t, Washington has a “look-back” period of five years. This means the state will look back into the previous five years of the applicant’s financial records to make sure they have not given away assets.

Functional Requirements
The functional, or medical, criteria for Nursing Home Medicaid in Washington is needing a Nursing Facility Level of Care (NFLOC), which means the applicant requires the kind of full-time care that can only be provided in a nursing home. The state of Washington considers a Nursing Facility Level of Care to be necessary if the applicant needs daily nursing care, or if they need substantial assistance with at least two Activities of Daily Living (mobility, bathing, dressing, eating, toileting) or some assistance with at least three Activities of Daily Living. To determine if an applicant requires that level of care, Washington uses the Comprehensive Assessment Reporting Evaluation tool.

 

Washington Home and Community Based Service (HCBS) Waivers Eligibility Criteria

Financial Requirements
Washington residents have to meet an an asset limit and an income limit in order to be financially eligible for Home and Community Based Service (HCBS) Waivers. For a single applicant in 2022, the asset limit for HCBS Waivers in Washington is $2,000, which means they must have $2,000 or less in countable assets. Countable assets include bank accounts, retirement accounts, stocks, bonds, certificates of deposit, cash and any other assets that can be easily converted to cash. An applicant’s home does not always count as an asset (see the red box below for more details), and there are other non-countable assets like funeral trusts and Medicaid-approved annuities. The 2022 income limit for a single applicant is $2,523 / month. Almost all income is counted – IRA payments, pension payments, Social Security benefits, property income, alimony, wages, salary, stock dividends, etc. COVID-19 stimulus checks and Holocaust restitution payments are not considered income.

For married applicants with both spouses applying, the 2022 asset limit for HCBS Waivers in Washington is $3,000 combined, and the income limit is $2,523 / month per spouse. For a married applicant with just one spouse applying, the 2022 asset limit is $2,000 for the applicant spouse and $59,890 for the non-applicant spouse, and the income limit is $2,523 / month for the applicant. The income of the non-applicant spouse is not counted.

HCBS Waiver beneficiaries in Washington may not be entitled to keep all of their income. Instead, they may only be allowed to keep a small personal needs allowance depending on where they live, their marital status and any Medicare or spousal allowance expenses they may have.

HCBS Waiver applicants are not allowed to give away their assets in order to get under the asset limit. To make sure they don’t, Washington has a “look-back” period of five years. This means the state will look back into the previous five years of the applicant’s financial records to make sure they have not given away assets.

Functional Requirements
The functional, or medical, criteria for Home and Community Based Service (HCBS) Waivers in Washington is needing a Nursing Facility Level of Care (NFLOC), which means the applicant requires the kind of full-time care that can only be provided in a nursing home. The state of Washington considers a Nursing Facility Level of Care to be necessary if the applicant needs daily nursing care, or if they need substantial assistance with at least two Activities of Daily Living (mobility, bathing, dressing, eating, toileting) or some assistance with at least three Activities of Daily Living. To determine if an applicant requires that level of care, Washington uses the Comprehensive Assessment Reporting Evaluation tool.

 

Washington Aged Blind and Disabled Medicaid Eligibility Criteria

Financial Requirements
Washington residents have to meet an asset limit and an income limit in order to be financially eligible for Aged Blind and Disabled (ABD) Medicaid / Regular Medicaid. For a single applicant in 2022, the asset limit is $2,000, which means they must have $2,000 or less in countable assets. Countable assets include bank accounts, retirement accounts, stocks, bonds, certificates of deposit, cash and any other assets that can be easily converted to cash. An applicant’s home does not always count as an asset (see the red box below for more details), and there are other non-countable assets like funeral trusts and Medicaid-approved annuities. The 2022 income limit for a single applicant is $841 / month. Almost all income is counted – IRA payments, pension payments, Social Security benefits, property income, alimony, wages, salary, stock dividends, etc. COVID-19 stimulus checks and Holocaust restitution payments are not considered income.

For married applicants, the 2022 asset limit for Washington ABD Medicaid is $3,000 combined between the two applicants/spouses, and the income limit is a combined $1,261 / month. These limits are used for both married couples with both spouses applying for ABD Medicaid and married couples with only one spouse applying.

Applicants for ABD Medicaid through Apple Health (Washington Medicaid) are not allowed to give away their assets in order to get under the asset limit. To make sure they don’t, Washington has a “look-back” period of five years. This means the state will look back into the previous five years of the applicant’s financial records to make sure they have not given away assets.

Functional Requirements
The functional requirements for Washington Aged Blind and Disabled (ABD) Medicaid / Regular Medicaid are being disabled, blind or aged (65 or over). The state of Washington will use the Comprehensive Assessment Reporting Evaluation tool to conduct an evaluation of ABD Medicaid applicants and their ability to perform the Activities of Daily Living (mobility, bathing, dressing, eating, toileting) to determine the kind of long-term care services the beneficiary needs and the state will cover.

 How Washington Medicaid Counts the Home
One’s home is often their most valuable asset, and if counted toward Washington’s Medicaid asset limit, it would likely cause them to be over the limit for eligibility. However, in some situations the home is not counted against the asset limit. If the applicant lives in their home and the home equity interest is less than $955,000 (as of 2022), then the home is exempt from the asset limit. Home equity interest is portion of the home’s equity value that the applicant owns, and the home’s equity value is the current value of the home minus any outstanding mortgage / debt against the home. If the applicant’s spouse, minor child, or blind or disabled child of any age lives there, the home is exempt regardless of the applicant’s home equity interest, and regardless of where the applicant lives. If none of the above-mentioned people (applicant, applicant’s spouse, minor child, or blind or disabled child of any age) live in the home, the home can be exempt if the applicant/beneficiary files an “intent to return” home and the home equity interest is at or below $955,000. These rules apply to all three types of Medicaid.

 

Applying For Washington Medicaid Long Term Care Programs

The first step in applying for an Apple Health (Washington Medicaid) Long Term Care program is deciding which of the three programs discussed above you or your loved one wants to apply for – Nursing Home / Institutional Medicaid, Home and Community Based Service (HCBS) Waivers or Aged Blind and Disabled (ABD) Medicaid / Regular Medicaid.

The second step is determining if the applicant meets the financial and functional criteria, also discussed above, for that Long Term Care program. Applying for Apple Health (Washington Medicaid) when not financially eligible will result in the application, and benefits, being denied.

During the process of determining financial eligibility, it’s important to start gathering documentation that clearly details the financial situation for the Apple Health applicant. These documents will be needed for the official Medicaid application. Necessary documents include five years of quarterly bank statements from all accounts; the most recent monthly or quarterly statements from all investments, IRAs, 401Ks, annuities and any other financial accounts; a letter from the Social Security Administration showing the applicant’s gross Social security income and deductions; tax forms to verify income streams including wages, pensions, royalties and interest; lists of items of any trusts; proof life insurance (if the applicant has any) and a list of beneficiaries; Power of Attorney documentation.

After financial eligibility requirements are checked and double checked, documentation is gathered, and functional eligibility is clarified, Washington residents can apply for Apple Health online at Washington Connection. They can also call the Department of Social and Health Services (DSHS) at 877-501-2233. Or they can print out an application here, and return it to their local DSHS office.

 

Choosing a Washington Medicaid Nursing Home

After an applicant has been approved for Nursing Home Medicaid through Apple Health (Washington Medicaid), they need to choose which Medicaid-approved nursing home they will live in. Even though Nursing Home Medicaid is an entitlement, Apple Health will only cover stays and care in approved nursing homes. Washington residents can find and compare nursing homes using this Washington Department of Social and Health Services Nursing Home Locator. They can also use Nursing Home Compare, which is a federal government website that has information about more than 15,000 nursing homes across the country. All of the nursing homes on this site are either Medicaid- or Medicare-approved.