Overview of the WA Medicaid Personal Care Program
Washington State’s Medicaid Personal Care (MPC) Program is intended for elderly and disabled residents who require personal care assistance, but do not require a nursing home level of care. Via MPC, program participants receive assistance with their activities of daily living (ADLs) and instrumental activities of daily living (IADLs). This includes bathing, dressing, mobility, medication management, toilet use, meal preparation, eating, and common housework. Limited nursing services may also be available.
Program participants have the option of receiving in-home personal care services from a licensed care agency worker or an “individual provider”. The individual provider option allows program participants to self-direct their own care, which means they hire, supervise, and can even fire, the caregiver of their choosing. While friends and select relatives can be hired as the individual provider, they must be 18+ years old, meet state and federal requirements to provide such care, and have a contract with the Washington State Department of Social and Health Services (DSHS). Program participants, unfortunately, cannot hire their spouse.
Eligible persons can live in a variety of settings and receive care assistance via MPC. This includes one’s home, the home of a relative or friend, an adult family home (similar to adult foster care), or an assisted living facility.
MPC services are an entitlement, which means meeting the state’s Medicaid eligibility requirements guarantees one will receive benefits. Put differently, there is never a wait list to receive Medicaid Personal Care benefits.
The Medicaid Personal Care Program is part of Washington State’s regular Medicaid program. The Medicaid Program in Washington State is called Washington Apple Health or Apple Health.
Benefits of the WA Medicaid Personal Care Program
Follows is a list of potential benefits available via the WA State Medicaid Personal Care Program.
– Nurse Delegation – specific nursing tasks assigned by a registered nurse to a home care aide / nursing assistant (i.e., medication administration, insulin injections, monitoring of blood glucose, ostomy care). This service is only available in some residential settings.
– Nursing Services – health assessments, health care referrals and coordination, etc.
– Personal Care Services – assistance with bathing, toiletry, mobility, eating, light housecleaning, meal preparation, essential shopping, etc.
– Caregiver Management Training – training for program participants who hire their own caregiver
While services are available in adult family homes and assisted living facilities, the cost of room and board is not covered by MPC.
Eligibility Requirements for the WA Medicaid Personal Care Program
The MPC Program is for WA state residents of that are elderly or disabled and require assistance with their daily living activities. Additional eligibility criteria follows and is relevant for seniors 65+ years of age.
Financial Criteria: Income, Assets & Home Ownership
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.
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 Personal Care Program. In other words, the look back period is not applicable.
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.
– 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 MPC 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.
However, after the passing of the program beneficiary, Medicaid will try to recover the care costs for which was paid via the Medicaid estate recovery program. This is often done through the sale of the deceased beneficiary’s home. Learn more about the potential of Medicaid taking the home here.Medical Criteria: Functional Need
Unlike with many Medicaid long-term care programs, a nursing facility level of care (NFLOC) is not required. In fact, the Medicaid Personal Care Program is not available to persons who require a NFLOC. However, applicants must require assistance with their activities of daily living (ADLs) as determined by the Comprehensive Assessment Reporting Evaluation (CARE) assessment tool. To meet the functional requirement, an applicant must require extensive assistance with one ADL, such as personal hygiene, dressing, toileting, transferring, and mobility. Persons may also meet the functional criteria if they require minimal assistance, which includes the need for supervision, with at least three 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. However, a diagnosis of dementia in and of itself does not mean one will meet the functional criteria.
Qualifying When Over the Limits
Having income and / or assets over Medicaid’s limit(s) does not mean an applicant cannot still qualify for 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 Medicaid Personal Care Program will pay for care services.
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. Furthermore, while Medicaid’s 60-month look back rule does not apply to the Medicaid Personal Care Program, it does apply to nursing home Medicaid and other long-term care Medicaid programs. Commonly, persons require more extensive care as time passes, and therefore, it is critical one not violate the look back rule. Therefore, while there are many planning strategies, they 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 the WA Medicaid Personal Care Program
Before You Apply
Prior to submitting an application for the Medicaid Personal 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.
To enroll in the Medicaid Personal Care Program, applicants must be eligible for Washington State Medicaid (Apple Health). Individuals not already enrolled in Medicaid can apply online or via their local Home and Community Services (HHS) office. Contact information for local offices can be found here and a Washington Apple Health Application for Aged, Blind, Disabled / Long-Term Care Coverage can be downloaded here.
Persons already enrolled in Medicaid should call their case manager or their local HHS office to initiate a functional assessment for MPC services.
For additional information about the Medicaid Personal Care Program, click here. The Washington State Department of Social and Health Services’ (DSHS) Aging and Long-Term Support Administration (ALTSA) and Developmental Disabilities Administration (DDA) administers the MPC Program.
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.