Washington Medicaid / Apple Health Tailored Supports for Older Adults (TSOA) Program

Last updated: July 13, 2021

 

Overview of the Tailored Supports for Older Adults Program

The Tailored Supports for Older Adults (TSOA) Program provides long-term care services and supports to WA State residents who are 55+ years old and at risk of nursing home placement. This program provides services for persons with and without unpaid “family caregivers”. Note that the term, “family caregiver”, is a bit misleading. While it does include a spouse or an adult child, caregivers do not have to be related to the care recipient.

TSOA is a Medicaid-funded program, but it is unique, as it serves persons who are not financially eligible for Medicaid. Program benefits are intended to assist seniors in remaining in their homes and to prevent and / or delay the need for more extensive Medicaid-funded long-term care, such as nursing home care. TSOA recognizes the importance of unpaid caregivers in this role, and therefore, provides them with respite care to allow them breaks from caregiving. Other caregiver benefits include support groups, counseling, specialized education and training (i.e., dementia care), massage therapy, and health and wellness consultations.

Specific to program participants without an unpaid caregiver, personal care assistance is available via a home care agency provider. Unfortunately, a family member cannot be paid for providing care.

Care recipients must live in a private home residence. 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.

 The Tailored Supports for Older Adults Program, while Medicaid-funded, is for persons who do not meet Medicaid’s financial criteria.

TSOA 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.

The Tailored Supports for Older Adults Program is a relatively new Medicaid Program that began in 2017. It should not be confused with the Family Caregiver Support Program (FCSP), a non-Medicaid program after which it is modeled. TSOA is authorized under a 1115 Medicaid Demonstration Waiver called the Medicaid Transformation Demonstration (MTD) or Medicaid Transformation Project (MTP). Another program, The Medicaid Alternative Care (MAC) Program also operates under MTP and offers similar supportive benefits as those provided by TSOA. Medicaid in Washington State is called Apple Health.

 

Benefits of the Tailored Supports for Older Adults Program

Program participants can receive up to a maximum of approximately $736 / month in services and supports. A list of potential benefits are listed below.

– 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, evidence-based exercise programs, etc.
– Home Delivered Meals – for the care recipient
– Homemaker Services – housecleaning, yard work, and errands
– Home Safety Evaluation
– Minor Home Modifications – i.e.., addition of grab bars and wheelchair ramps
– Nurse Delegation – specific nursing tasks, such as administering medication, injecting insulin, and blood glucose monitoring, assigned to a home care aide / nursing assistant by a registered nurse. Limited to program participants who do not have an unpaid caregiver.
– Specialized Equipment / Supplies – includes durable medical equipment, adult diapers, reaching aids, bath benches, personal emergency response systems, etc.
– Training / Education / Consultation – for both caregivers and care recipients. May include support groups, dementia training, wellness consultations, financial consultations, fall prevention workshops, etc.
– Personal Care Assistance – includes assistance with activities of daily living, such as bathing, dressing, mobility, toiletry, and eating. Limited to program participants who do not have an unpaid caregiver.
– Respite Care – in-home and out-of-home care to provide an unpaid caregiver a break from caregiving.
– Transportation – non-medical

 

Eligibility Requirements for Tailored Supports for Older Adults Program

Care recipients must be WA State residents who are 55+ years old. Unpaid caregivers must be at least 18 years old. Additional applicant / care recipient eligibility criteria are as follows:

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.

 Many home and community based services Medicaid programs allow a non-applicant spouse a monthly maintenance needs allowance from the applicant spouse, but the Tailored Supports for Older Adults Program does not. In contrast, Washington State’s Community Options Program Entry System (COPES) Waiver does allow a non-applicant spouse a spousal income allowance.

Assets
In 2021, the asset limit is $53,100 for a single applicant. When both spouses are applicants, each spouse is allowed up to $53,100 in assets. When only one spouse is an applicant, the applicant spouse is limited to $53,100 in assets and the non-applicant spouse can have up to $59,890 in assets. This sets a couple’s asset limit at $112,990.

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 Tailored Supports for Older Adults Program. In other words, the look back period is not applicable.

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 TSOA applicants 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 TSOA 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 to TSOA 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 TSOA 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.

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

 

Qualifying When Over the Limits

Remember, the TSOA program is for persons who do not financially qualify for WA State Medicaid. However, there is one exception. The 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, one will be eligible for Medicaid for the remainder of the spend down period. Seniors can access a “medically needy” medical program and still be eligible for TSOA.

As a senior’s need for care becomes more extensive, benefits via the Tailored Supports for Older Adults Program may not be sufficient. One may need to apply for long-term care Medicaid, such as home and community based services via the COPES Medicaid Waiver or nursing home Medicaid. Having income and / or assets over Medicaid’s limit(s) does not mean one cannot still qualify for such care. 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.

Persons over the income limit can become income eligible via the medically needy pathway, as mentioned above.

When persons have assets over the limit, 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 TSOA Program, it does apply to nursing home Medicaid and some home and community based services Medicaid programs. Since TSOA program participants may require more extensive care in the future via long-term care Medicaid, it is critical to avoid violating the look back rule. 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 the Tailored Supports for Older Adults Program

Before You Apply

Prior to applying for the TSOA Program, applicants need to ensure they meet the eligibility criteria for the program. Applying when over the income and / or asset limit(s) will be cause for denial of benefits. While TSOA is a Medicaid-funded program for persons who are not financially eligible for Medicaid, the American Council on Aging does offer 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, bank account balances, 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 Tailored Supports for Older Adults 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 Tailored Supports for Older Adults Program, persons can apply online here and mark the box “Tailored Supports for Older Adults (TSOA)”. Alternatively, persons can fill out a paper application. The Washington Apple Health Application for Tailored Supports for Older Adults (TSOA) application 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.

For additional information about the Tailored Supports for Older Adults Program, click here and here. Persons can also call Washington Living Connections at 1-855-567-0252 or contact their local Area Agencies on Aging (AAA). One’s local AAA office or HCS office can provide application assistance. The Washington State Health Care Authority and the Washington State Department of Social and Health Services’ (DSHS) administer the Tailored Supports for Older Adults Program.

 

Approval Process & Timing

The formal application process for the Tailored Supports for Older Adults 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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