Washington Medicaid / Apple Health Specialized Dementia Care Program (SDCP)

Last updated: July 13, 2021

 

Overview of the Specialized Dementia Care Program

The Specialized Dementia Care Program (SDCP) is for WA State residents with Alzheimer’s Disease or a related irreversible dementia who require residential care. Via SDCP, dementia-specific care services are provided in assisted living residences, also called “memory care”, to delay the need for nursing home care. Available benefits include supervision, assistance with activities of daily living (i.e., bathing, dressing, toileting, and eating), and intermittent nursing services. Direct care staff are trained to handle the specific needs of persons with dementia, including sometimes problematic behavior, like wandering, hallucinations, and resistance to care.

Program participants must reside in an assisted living facility contracted by the Washington State Department of Social and Health Services (DSHS) to provide SDCP services. The residence may be a standalone facility, or a separate wing of an assisted living facility designated for dementia-specific care. To be clear, not all assisted living residences in WA participate in this program.

The Specialized Dementia Care Program is not an entitlement program. Meeting the eligibility criteria does not guarantee one will receive dementia-specific care services in an assisted living residence. There must be an available bed in a participating assisted living residence. Additionally, there is limited program funding, and therefore, the number of participating assisted living residences is also limited. This means there may be a waitlist.

The Specialized Dementia Care Program, which may also be called the Specialized Dementia Care Program in Assisted Living Facilities, is a program under the Community First Choice (CFC) Program. CFC is a Medicaid state plan option that was created by the Affordable Care Act (ACA). It is a 1915(k) State Plan Amendment. The Medicaid Program in Washington State is called Washington Apple Health or Apple Health.

 Washington State has a program called the Community Options Program Entry System (COPES) that also provides long-term care for seniors, including those with dementia. Not only can program participants live in assisted living residences, but many home and community based services and supports are available to help seniors remain living in their homes.

 

Benefits of the Specialized Dementia Care Program

Via SDCP, program participants receive a “service package” called Enhanced Adult Residential Care – Specialized Dementia Care (EARC-SDC) services. The available benefits are as follows.

– Activities – for individuals and groups and is specific to the interests of program participants
– Awake Staff – day and night
– Dementia-Trained Staff – in addition to initial training, annual training is required
– Family Coordination – to learn and implement the program participant’s interests and routine
– Medication Management / Administration
– Nursing Services – on an intermittent basis
– Personal Care Assistance (i.e., bathing, dressing, toiletry, eating, mobility)
– Secure Areas – includes outdoor area
– Supervision

While dementia care services are available in assisted living facilities, the cost of room and board is not covered by SDCP.

 

Eligibility Requirements for Specialized Dementia Care Program

Applicants must be diagnosed with Alzheimer’s Disease or a related, irreversible dementia, such as Lewy body dementia, Creutzfeldt-Jakob disease, Pick’s disease, or vascular dementia. Confirmation, either verbal or written, must be provided by a health care provider. Specialized dementia care must be necessary and there must be a bed available in an assisted living facility contracted by DSHS to provide services for the Specialized Dementia Care Program. Furthermore, applicants must be eligible for the state’s Medicaid (Apple Health) plan. The information below is relevant for the elderly (65+ years of age).

 The American Council on Aging provides a quick and easy Washington Medicaid eligibility test for seniors requiring long term care. Start here

 

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. In 2021, a single applicant can have a monthly income up to $794. Persons who have income greater than this amount can be considered under the income eligibility rules for the COPES HCBS (home and community based services) Medicaid Waiver program. This allows for a higher monthly income limit of $2,382. To be clear, this means that an applicant is applying for the COPES Waiver program for long-term care, but will be able to access SDCP via CFC.

When both spouses are applicants, the couple is limited to $1,191 / month in income. If the couple’s monthly income is higher than $1,191, they can apply for COPES to access CFC services, such as SDCP. This allows each spouse up to $2,382 / month in income.

When only one spouse is an applicant, the applicant income limit is $794 / month. The income of the non-applicant spouse is not counted towards the income eligibility of his/her spouse. Applicants who have income in excess of this amount can apply via the COPES Medicaid Waiver and will have an income limit of $2,382 / month. 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.

While there is a 60-month look back rule in which Medicaid checks past asset transfers of persons applying for nursing home Medicaid or home and community based services via a Medicaid waiver, this is not relevant for the Specialized Dementia Care Program. However, if one accesses SDCP via the COPES Medicaid Waiver, the look back rule applies, which means assets should not be given away or sold under fair market value prior to applying for long-term care Medicaid.

 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, WA 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.
– The applicant’s spouse lives in the home.
– The applicant’s disabled or blind child lives in the home.
– The applicant’s minor child (under 21 years old) lives 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) to be eligible for the Specialized Dementia Care Program. The Comprehensive Assessment Reporting Evaluation (CARE) tool is used to determine if this level of care need is met. An applicant must receive a minimum of 3 on the cognitive performance scale. The scale goes from 0 (indicating no impairment) to 6 (indicating extreme impairment). Several factors are considered, such as one’s short-term memory, capability to make decisions, and ability to be understood. Furthermore, from a list of criteria, the applicant must exhibit at least one behavior. Examples include taking items that don’t belong to oneself, wandering, disrobing in public, delusions, becoming easily agitated, being resistant to care, inappropriate toileting, and yelling. The entire list of behaviors can be found on the SDCP Eligibility Checklist.

 

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 Specialized Dementia Care Program prohibits persons from qualifying via this avenue.

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. Persons can also “spend down” assets over the limit on past due bills, household furnishings / appliances, and home modifications. 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 also protects assets from Medicaid’s estate recovery program, preserving them instead for family as inheritance. While some of these strategies, such as Medicaid Asset Protection Trusts, 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 Specialized Dementia Care Program

Before You Apply

Prior to applying for SDCP, applicants need to ensure they meet the Washington State Medicaid 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, previous bank statements, 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

To enroll in the Specialized Dementia Care Program, persons must be eligible for Washington State Medicaid / Apple Health. Seniors who are not already enrolled in WA Medicaid can apply online or via their local Home and Community Services (HCS) 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 contact their HCS case manager to initiate the process of enrolling in SDCP.

For additional information about the Specialized Dementia Care Program, click here. Persons can also call the DSHS Customer Service Center at 1-877-501-2233.

To see a current list of Specialized Dementia Care Program-Contracted assisted living facilities, click here. The Washington State Department of Social and Health Services’ (DSHS) Aging and Long-Term Support Administration (ALTSA) administers the Specialized Dementia Care 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.

Determine Your Medicaid Eligibility

Get Help Qualifying for Medicaid