Washington State Medicaid (Apple Health) Community Options Program Entry System (COPES) Waiver

Last updated: June 11, 2021

 

Overview of the Washington COPES Medicaid Waiver

Washington State’s Community Options Program Entry System Waiver (COPES Waiver) provides home and community-based services (HCBS) for elderly and disabled residents who are at risk of being institutionalized (being placed in a nursing home). While the benefits received vary based on the needs and circumstances of the program participant, the intention is to increase independence and delay and / or prevent nursing home admissions. Benefits may include meal delivery, adult day care, non-medical transportation, and home modifications for safety and accessibility purposes. Furthermore, this program provides assistance to nursing home residents relocating to community living.

Program participants can receive COPES benefits in a variety of living situations. This includes one’s private home, the home of a friend or relative, an adult family home (similar to adult foster care), or an assisted living residence.

Many long-term care Medicaid programs allow program participants the option of self-directing their own care, specifically hiring the caregiver of their choosing. Unfortunately, this is not an option through the COPES Waiver.

The COPES Waiver is not an entitlement program, which means meeting eligibility requirements does not equate to immediate receipt of program benefits. Instead, the waiver has a limited number of participant enrollment slots, and when these slots are full, a waitlist for program participation forms.

The statewide Community Options Program Entry System (COPES) Waiver is a 1915(c) Home and Community Based Services (HCBS) Medicaid waiver. Medicaid in Washington State is called Apple Health.

 What are 1915(c) HCBS Medicaid Waivers?
Historically Medicaid only paid for long-term care in nursing homes. 1915(c) HCBS Medicaid Waivers allow states to offer benefits outside of these institutions. “HCBS” stands for “Home and Community Based Services. The goal of HCBS is to delay or prevent institutionalization and to that end, care may be provided in one’s home, the home of a relative, assisted living, or adult foster care / adult family living. Waivers can target specific groups who require a nursing home level of care and are at risk of institutionalization such as the elderly, disabled, or persons with Alzheimer’s. Waivers are not entitlements. This means that meeting eligibility criteria does not guarantee receipt of benefits, as there are a limited number of slots for program participants.

 

Benefits of the COPES Medicaid Waiver

Persons enrolled in the COPES Waiver receive medical benefits, such as physician visits, x-rays, laboratory work, and hospitalization via the state’s Apple Health (Medicaid) plan. The following home and community based services are available via the WA COPES Medicaid Waiver. An individual care plan will determine which long-term services and supports a program participant will receive.

– Adult Day Care / Adult Day Health Care – daytime supervision and care assistance in a group-based community setting
– Client Support Training / Wellness Education
– Community Choice Guiding – i.e., determining needs and finding / utilizing community resources
– Community Support: Goods & Services – one time fees for persons transitioning from a nursing home to community living (i.e., security deposit, utility deposits, essential household furnishings)
– Durable Medical Equipment / Supplies – i.e., wheelchairs, walkers, lift chairs, bath benches, hand-held shower heads
– Home-Delivered Meals
– Home Modifications – i.e., lift systems, wheelchair ramps, grab bars, widening of doorways
– Nursing Services
– Skilled Nursing
– Transportation – non-medical and medical

While program participants can reside in an assisted living residence or adult family home, COPES will not pay for room and board.

 Washington State seniors can simultaneously receive long-term care benefits via the COPES Medicaid Waiver and the Community First Choice (CFC) Program. It is through CFC that many persons receive personal care assistance, as it is not available via the COPES Waiver. Learn more about CFC here.

 

Eligibility Requirements for the COPES Medicaid Waiver

The COPES Waiver is for Washington residents who are elderly (65+) or younger (18-64) if blind or disabled and at risk of nursing home placement. Disabled persons who enroll in the waiver prior to the age of 65 can continue to receive program benefits upon turning 65. Additional eligibility criteria can be found below.

 The American Council on Aging provides a free, quick and easy WA Medicaid eligibility test for seniors that require long term care. Begin here

 

Financial Criteria: Income, Assets & Home Ownership

Income
The applicant income limit is equivalent to 300% of the Federal Benefit Rate (FBR), which increases on an annual basis in January. In 2021, an applicant, regardless of marital status, can have a monthly income up to $2,382. When both spouses are applicants, each spouse is considered individually, with each spouse allowed income up to $2,382 / month. When only one spouse is an applicant, the income of the non-applicant spouse is not counted towards the income eligibility of his/her spouse. Furthermore, monthly income from the applicant spouse can be transferred to the non-applicant spouse as a spousal income allowance, also called a monthly maintenance needs allowance. The maximum amount that can be transferred is $3,260 / month (effective January 2021 – December 2021) and is intended to ensure the non-applicant spouse has a minimum monthly income of this amount. Non-applicant spouses who have their own income equal to or greater than this amount are not entitled to a spousal income allowance.

Assets
In 2021, the asset limit is $2,000 for a single applicant. For married couples, with both spouses as applicants, the asset limit is $3,000. When only one spouse is an applicant, the assets of both the applicant and non-applicant spouse are limited, though the non-applicant spouse is allocated a larger portion of the assets to prevent spousal impoverishment. (Unlike with income, Medicaid considers the assets of a married couple to be jointly owned). In this case, the applicant spouse can retain up to $2,000 in assets and the non-applicant spouse can keep up to $130,380. This larger allocation of assets to the non-applicant spouse is called a community spouse resource allowance.

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.

Assets should not be given away or sold under fair market value within 60-months of long-term care Medicaid application. This is because Medicaid has a look back rule and violating it results in a penalty period of Medicaid ineligibility.

 To determine if you might have assets over Medicaid’s countable limit, and if so, receive an estimate of the amount, use our Medicaid 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) in the following circumstances.

– The applicant lives in the home or has “intent” to return to the home and his / her home equity interest is no greater than $603,000. Home equity interest is the current value of the home minus any outstanding mortgage.
– A spouse lives in the home.
– The applicant has a disabled or blind child living in the home.
– The applicant has a child under 21 years old living in the home.

To learn more about the potential of Medicaid taking the home, click here.

 

Medical Criteria: Functional Need

An applicant must require a nursing facility level of care (NFLOC). For the COPES Waiver, the Comprehensive Assessment Reporting Evaluation (CARE) tool is used to determine if this level of care need is met. Persons must require daily nursing care OR assistance with their activities of daily living / ADLs (i.e., transferring from the bed to a chair, repositioning oneself in bed, mobility, eating, toileting, bathing, and medication management). With ADLs, substantial assistance with at least 2 or some assistance with 3 or more is required. 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. In this case, supervision is required as well as substantial assistance with one ADL. A diagnosis of dementia in and of itself does not mean one will meet a NFLOC.

For more information about long-term care Medicaid in Washington State, click here.

 

Qualifying When Over the Limits

Having income and / or assets over Medicaid’s limit(s) does not mean an applicant cannot still qualify for Apple Health (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.

Washington State has a Medically Needy Medicaid Program for Medicaid applicants who have high medical expenses relative to their income. Also known as a spend-down program, applicants are permitted to spend “excess” income on medical expenses and health care premiums, such as Medicare Part B, in order to meet Medicaid’s income limit. The amount that must be “spent down” each month can be thought of as a deductible. Once one’s “deductible” has been met for the spend down period, the COPES Waiver will pay for care services and supports.

When persons have assets over the limits, trusts are an option. Irrevocable Funeral Trusts are pre-paid funeral and burial expense trusts that Medicaid does not count as assets. Another option are annuities that turns countable assets into a stream of income. 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 to meet Medicaid’s financial eligibility criteria without violating Medicaid’s 60-month look back period and jeopardizing Medicaid eligibility. Furthermore, there are additional planning strategies that not only help one meet Medicaid’s financial criteria, but can also protect assets from Medicaid’s estate recovery program, preserving them instead for family as inheritance. While some of these strategies do violate the look back rule and should be implemented well in advance of the need for long-term care, there are some workarounds. WA State Medicaid planners are well aware of them, and therefore, it is highly suggested persons consult one for assistance in qualifying for Medicaid when over the income and / or asset limit(s). Find a Medicaid planner.

 

How to Apply for the COPES Medicaid Waiver

Before You Apply

Prior to submitting an application for the COPES Waiver, applicants need to ensure they meet the eligibility criteria. 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, bank statements up to 60-months prior to application, proof of income, and 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.

Since the COPES Waiver is not an entitlement program, there may be a waitlist for program participation. The COPES Waiver is approved for a maximum of approximately 47,560 program participants per year. In the case of a waitlist, it is thought that an applicant’s access to a participant slot is based on the date of Medicaid application.

 

Application Process

To apply for the COPES Medicaid Waiver, WA State residents can apply online here or via their Home and Community Services (HHS) office. Contact information by county can be found here. The Washington Apple Health Application for Aged, Blind, Disabled / Long-Term Care Coverage is available here. A functional needs assessment is completed as part of the application process.
www.washingtonconnection.org

Additional information about the COPES Medicaid Waiver, though not necessarily intended for a consumer audience, can be found here.

The Washington State Department of Social and Health Services’ (DSHS) Aging and Long-Term Support Administration (ALTSA) administers the COPES Medicaid Waiver.

 

Approval Process & Timing

The Medicaid application process 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. Furthermore, as wait-lists may exist, approved applicants may spend many months waiting to receive benefits.

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