Washington State / Apple Health Medicaid Alternative Care (MAC) Program

Last updated: July 13, 2021

 

Overview of WA Medicaid Alternative Care (MAC) Program

Washington State’s Medicaid Alternative Care (MAC) Program provides supportive services for unpaid “family” caregivers of a senior 55+ years old who is at risk of institutionalization (nursing home admission). While the word “family” encompasses close relatives, such as spouses and grown children, it also extends to persons unrelated to the care recipient, like close family friends. MAC Program benefits assist caregivers in continuing to provide care for the care recipient while also delaying and / or preventing the need for more extensive Medicaid-funded long term care, such as home and community based services via the COPES Waiver or nursing home Medicaid. Available services and supports include respite care, which allows caregivers a break from their caregiving duties, caregiver training and education, specialized equipment such as bath benches, and home delivered meals for the care recipient.

Care recipients must live in a private home. This can be the care recipient’s home or the home of a family member or friend. To be clear, they cannot live in an adult family home (similar to adult foster care) or an assisted living facility.

MAC services are not an entitlement, which means meeting the program’s eligibility criteria does not guarantee one will receive benefits. While the program does not limit the number of participant enrollment slots, the program does have limited funding. If the funding has been exhausted for the year, a waitlist will form.

Another program, The Tailored Supports for Older Adults (TSOA), offers similar services and supports as those provided by the Medicaid Alternative Program. While it is also a Medicaid program, it is unique in that is intended for persons who are not financially eligible for Medicaid. It also differs from MAC in that a TSOA program beneficiary is not required to have an unpaid caregiver. Furthermore, TSOA allows applicants to have higher income and asset limits.

  The Medicaid Alternative Care (MAC) Program is a relatively new Medicaid Program that began in 2017. It should not be confused with a non-Medicaid program, the Family Caregiver Support Program (FCSP), after which it is modeled. MAC is authorized under a 1115 Medicaid Demonstration Waiver called the Medicaid Transformation Demonstration (MTD) or Medicaid Transformation Project (MTP). Medicaid in Washington State is called Apple Health.

 

Benefits of WA Medicaid Alternative Care (MAC) Program

WA State Medicaid Alternative Care Program participants can receive up to a maximum of approximately $736 / month in services and supports. Follows is a list of potential benefits.

– Adult Day Care / Adult Day Health Care
– Health Maintenance / Therapy Supports – to enable a caregiver to continue to provide care or a program participant to remain living at home. May include massage therapy, acupuncture, counseling, evidence-based exercise programs, etc.
– Home Delivered Meals – limited to the care recipient
– Home Safety Evaluation
– Homemaker Services – housecleaning, yard work, and errands
– Minor Home Modifications – i.e., addition of grab bars and wheelchair ramps
– Non-Medical Transportation
– Specialized Equipment / Supplies – includes durable medical equipment, adult diapers, reaching aids, bath benches, personal emergency response systems, etc.
– Training / Education / Consultation – for caregivers and care recipients. May include support groups, dementia training, wellness consultations, financial consultations, fall prevention workshops, etc.
– Respite Care – in-home & out-of-home and daytime & overnight care to provide an unpaid caregiver a break from caregiving.

 

Eligibility Requirements for WA Medicaid Alternative Care (MAC) Program

The MAC Program is for WA State residents who are 55+ years old, at risk of institutionalization, have an unpaid caregiver, and are eligible for traditional Medicaid-funded long-term services and supports (i.e., COPES Waiver or the CFC Program) but choose not to enroll. Caregivers must be 18+ years old, but do not have to be residents of Washington. Additional eligibility criteria are as follows:

 Persons enrolled in the Medicaid Alternative Care Program cannot simultaneously enroll in Community First Choice (CFC), Medicaid Personal Care (MPC), the Community Options Program Entry System Waiver (COPES), or the New Freedom (NF) Medicaid Waiver.
Financial Criteria: Income, Assets & Home Ownership

Income
The applicant income limit is equivalent to 100% of the Federal Benefit Rate (FBR), which increases on an annual basis in January. As of 2021, the income limit for a single applicant is $794 / month. Married couples, regardless of if one or both spouses are applicants, can have a monthly income up to $1,191.

 While many home and community based services Medicaid programs allow a non-applicant spouse to retain a larger portion of a couple’s income and assets, the Medicaid Alternative Care Program does not. In contrast, Washington State’s COPES Medicaid Waiver does allow a non-applicant spouse a monthly maintenance needs allowance from his/her applicant spouse and a community spouse resource allowance.

Assets
In 2021, the asset limit is $2,000 for a single applicant. For married couples, the asset limit is slightly higher at $3,000. This hold true whether one or both spouses are applicants.

Some assets are not counted towards Medicaid’s asset limit. These generally include an applicant’s primary home, household furnishings and appliances, personal effects, and a vehicle.

While there is a 60-month look back rule in which Medicaid checks past asset transfers of those applying for nursing home Medicaid or home and community based services via a Medicaid waiver, this is not relevant for the Medicaid Alternative Care Program. In other words, the look back period is not applicable.

 To determine if you might have assets over Medicaid’s countable limit, and if so, receive an estimate of the amount, use our spend down calculator.  

Home Ownership
The home is often the highest valued asset a Medicaid applicant owns, and many persons worry that Medicaid will take their home. Fortunately, for eligibility purposes, Washington State Medicaid considers the home exempt (non-countable) for MAC program applicants / beneficiaries in the following circumstances.

– The applicant lives in the home or has “intent” to return to the home.
– The applicant’s spouse lives in the home.
– The applicant has a dependent relative living in the home.

Unlike many WA State Medicaid programs that offer long-term care, the MAC Program does not have a home equity interest limit for home exemption. Home equity interest is the current value of the home minus any outstanding mortgage.

The Medicaid estate recovery program, in which following the death of a long-term care Medicaid beneficiary Medicaid attempts reimbursement of care costs, is irrelevant in regards to MAC Program beneficiaries. This means Medicaid will not try to take the home following the individual’s death.

 

Medical Criteria: Functional Need

An applicant must require a nursing facility level of care (NFLOC) to be eligible for MAC services. The Comprehensive Assessment Reporting Evaluation (CARE) tool is used to determine if this level of care need is met. To meet the care need, one must require daily nursing care OR require assistance with their activities of daily living / ADLs (i.e., transferring from the bed to a chair, repositioning oneself in bed, mobility / getting from one place to another, eating, toileting, bathing, and medication management). One must require substantial assistance with at least 2 ADLs or require some assistance with 3 or more ADLs. Relevant to some persons with Alzheimer’s disease or a related dementia, cognitive impairments, such as memory loss, lack of focus, and difficulty making plans, can result in the need for assistance with ADLs. In this case, the individual must require supervision as well as substantial assistance with one ADL. A diagnosis of dementia in and of itself does not mean one will meet a NFLOC.

 

Qualifying When Over the Limits

Having income and / or assets over Medicaid’s limit(s) does not mean an applicant cannot still qualify for WA State Medicaid. There are a variety of planning strategies that can be used to help persons who would otherwise be ineligible to become eligible. Some of these strategies are fairly easy to implement, and others, exceedingly complex. Below are the most common.

While Washington State has a Spenddown Program that permits Medicaid applicants to spend “excess” income on medical expenses in order to meet Medicaid’s income limit, the Medicaid Alternative Care Program prohibits persons from qualifying via this avenue.

When persons have assets over the limits, Irrevocable Funeral Trusts (IFTs) are an option. IFTs are pre-paid funeral and burial expense trusts that Medicaid does not count as assets. Persons can also “spend down” assets on home improvements (i.e., updating plumbing, replacing a water heater), home modifications (i.e., adding a first floor bedroom, addition of grab bars), and replacing an older car with a newer one. There are many other options when the applicant has assets exceeding the limit.

Inadequate planning or improperly implementing a Medicaid planning strategy can result in a denial or delay of Medicaid benefits. Professional Medicaid planners are educated in the planning strategies available in Washington State to meet Medicaid’s financial eligibility criteria without jeopardizing Medicaid eligibility. While Medicaid’s 60-month look back rule does not apply to the Medicaid Alternative Care Program, it does apply to nursing home Medicaid and some home and community based services Medicaid programs. Commonly, seniors require more extensive care as time passes, which makes it critical to avoid violating the look back rule. Furthermore, while Medicaid’s estate recovery program is not relevant to MAC, it is relevant to many other Medicaid long-term care programs. Medicaid planners can assist in planning techniques that preserve one’s assets for family as inheritance should more extensive Medicaid-funded long-term care be required.

While there are many planning strategies, some should only be implemented with careful planning and well in advance of the need for long-term care. However, there are some workarounds, and Medicaid planners are aware of them. For these reasons, it is highly suggested one consult a Medicaid planner for assistance in qualifying for Medicaid when over the income and / or asset limit(s). Find a Medicaid planner.

 

How to Apply for WA Medicaid Alternative Care (MAC) Program

Before You Apply

Prior to applying for the Medicaid Alternative Care Program, applicants need to ensure they meet the eligibility criteria for Washington State Medicaid. Applying when over the income and / or asset limit(s) will be cause for denial of benefits. The American Council on Aging offers a free Medicaid eligibility test to determine if one might meet Medicaid’s eligibility criteria. Take the Medicaid eligibility test.

As part of the application process, applicants will need to gather documentation for submission. Examples include copies of Social Security and Medicare cards, proof of income, copies of life insurance policies, property deeds, and pre-need burial contracts. Unfortunately, a common reason applications are held up is required documentation is missing or not submitted in a timely manner.

 

Application Process

Applicants of the Medicaid Alternative Care Program may be eligible for program benefits the same day of inquiry. This is possible through a process called presumptive eligibility, which allows persons to begin receiving services prior to completing the formal application process.

With presumptive eligibility, a short over-the-phone screening of financial means and functional ability is completed, and if it is determined an applicant meets the program’s criteria, services will be immediately available. To determine presumptive eligibility, an applicant should call their local Home and Community Services (HCS) office or Area Agency on Aging (AAA) office. Contact information for both offices by county can be found here.

Presumptive eligibility only approves program benefits for up to approximately 60 days. This allows applicants to receive needed services while giving them time to formally apply for the program. As long as an application for TSOA has been submitted, presumptive eligibility continues until the formal determination of program eligibility is completed. If an application is not submitted, presumptive eligibility ends the end of the month following the month one became presumptively eligible.

To formally apply for the Medicaid Alternative Care Program, persons can apply online here and mark the box “Health Care Coverage: Everyone applying is 65 or older, blind or disabled”. Alternatively, persons can fill out a paper application. The Washington Apple Health Application for Aged, Blind, Disabled / Long-Term Care Coverage can be found here. Completed applications can be mailed, faxed, or taken to one’s Home and Community Services (HCS) office. The mailing address and fax number are listed on the application, and contact information for HCS offices by county can be found here.

Persons can contact their local HCS office or Area Agency on Aging (AAA) office with questions or to request assistance with the application process.

For additional information about the Medicaid Alternative Care Program, click here. A downloadable brochure can be found here.  The Washington State Health Care Authority and the Washington State Department of Social and Health Services’ (DSHS) administer the Medicaid Alternative Care Program.

 

Approval Process & Timing

The formal application process for the Medicaid Alternative Care Program can take up to 3 months, or even longer, from the beginning of the application process through the receipt of the determination letter indicating approval or denial. Generally, it takes one several weeks to complete the application and gather all of the supportive documentation. If the application is not properly completed, or required documentation is missing, the application process will be delayed even further. In most cases, it takes between 45 and 90 days for the Medicaid agency to review and approve or deny one’s application. Based on law, Medicaid offices have up to 45 days to complete this process (up to 90 days for disability applications). However, despite the law, applications are sometimes delayed even further.

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