Thanks for attending a Very Special Public Benefits Training!
This brand-new training has been a long time coming! We heard community feedback that there needs to be practical and approachable public information on how unhoused elders or people with disabilities can access long-term care placement.
We have been working with knowledgeable program employees and advocates from:
- DSHS’s Aging and Long-Term Support Administration
- City of Seattle’s Aging & Disability Services
- Northwest Justice Project
- Solid Ground
- Evergreen Treatment Services – REACH
Keep reading for information on how to access services available for disabled and elderly community members, how to be placed in a residential long-term care facility, and advocacy tips and tricks for Case Managers and care advocates to ensure their clients’ needs get met.
What Is Long-Term Care? How Can Residential Services Help?
In Washington, the Aging & Long-Term Support Administration (ALTSA) assesses eligibility for residential long-term care and provides ongoing case management.
ALTSA provides connection to long-term care in residential settings such as:
- Adult Family Homes
- Adult Residential Care
- Enhanced Adult Residential Care
- Assisted Living Facilities
Services available vary depending on residential care setting:
Note that these settings are not nursing homes, as they allow a higher level of independence when doing daily activities such as preparing and eating meals and provide less intensive medical services. These settings may be ideal for someone who is disabled or elderly, wants to maintain some degree of independence, and needs professional support to maintain Activities of Daily Living (ADLs) or Instrumental Activities of Daily Living (IADLs), such as:
- Bathing
- Dressing
- Toileting
- Shopping for personal needs
- Laundry
- Preparing meals
- …And other activities that are essential to maintaining quality of life.
To be eligible for services, a person must be low-income, 18 years or older, disabled or blind, and in need of long-term care services.
Your application for long-term care depends on your age, income, and disability status.
Classic Medicaid applicants are those who are:
- Age 65 or older
- Blind or disabled (as determined by the Social Security Administration)
- A resident of WA
- Assessed by ALTSA to need a level of care that could warrant placement in a nursing facility or residential facility
- Low-Income (specific income limits vary depending on the program) and have fewer than $2,000 in resources.
Tailored Support for Older Adults (TSOA) applicants are those who:
- Are Age 55 or older
- Have Limited income ($2,742/month as of Jan. 1, 2023)
- Assessed by ALTSA to need a level of care that could warrant placement in a nursing facility or residential facility
- Have higher level of resources than a Classic Medicaid applicant – up to $53,100.
If you are eligible for Classic Medicaid or the TSOA program, you can apply:
- Online – washingtonconnection.org
- Via Mail – Print form 18-005 and mail to DSHS Home and Community Services, P.O. Box 45826, Olympia, WA 98504-5826
- Via Fax – Fax form 18-005 to 1-855-635-8305
- In person or via phone – Locate your local DSHS CSO and its contact information on the DSHS website.
MAGI (Apple) Medicaid applicants are those who are:
- Age 19-64
- Low-income and eligible for MAGI Medicaid as determined by DSHS
- U.S. citizens, or meet other citizenship requirements
- Are not entitled to Medicare
- *MAGI Medicaid applicants are not eligible for residential long-term care placement, but may access in-home personal care services and others provided by the Community First Choice program
If you are eligible for MAGI (Apple) Medicaid, you can apply:
- Online – wahealthplanfinder.org
- Via Mail – Print form 18-001P and mail to Washington Healthplanfinder, PO Box 946, Olympia WA 98507
- Via Fax – Fax form 18-001P to 1-855-867-4467
- Via Phone – 1-855-923-4633
To prepare for an assessment, ALTSA recommends having copies of medical visit summaries, medical records that document diagnoses, overall health, and ability to perform ADLs and IADLs. They also encourage applicants to share as much information as possible, as more personal information, while sometimes challenging to share, can more likely grant eligibility.
Once someone submits their application, ALTSA will verify eligibility in two parts:
- Functional eligibility – does a person need a level of care that could warrant placement in a long-term care site such as a nursing home or residential facillty?
- Financial eligibility – does a person have such a financial need that they qualify for subsidized care?
Financial eligibility is processed by an ALTSA financial evaluator, while functional eligibility is processed by a social worker. These processes often take place at the same time and take place in person, in settings like an applicant’s home, a shelter, or a DSHS office. The eligibility assessment processes are often complete within 30 days; however they may take longer in order to confirm caregivers or residential placement.
Kayla Adams of ETS REACH recommends Case Managers and client advocates take a hands-on approach during the application process and inform of all program requirements.
One important expectation to share with applicants is the existence of a Personal Needs Allowance, which is applied to any resident who receives earned or unearned income (such as SSI or SSDI income). This policy confiscates a resident’s income in exchange for residency and full services, disbursing an allowance of about $100 per month to the resident. Another important expectation to share with property-owning applicants is the state’s right to the applicant’s estate once they are placed in a residential treatment facility.
While ALTSA intends to create a process that accommodates a diverse range of needs, it is possible that residential care settings may make additional requirements of an applicant prior to placement or once the resident has been placed, such as the requirement that a resident establish behavioral health supports, undergo substance use treatment, or appoint a payee prior to placement.
ALTSA recognizes that residential care facilities are especially likely to refuse placement if an applicant uses any substances, including tobacco. ALTSA recommends applicants who use substances access recovery support via the Washington Recovery Help Line, which can be reached at 1-866-789-1511.
Applicants are welcome to do their own research to determine if residential placement is right for them – DSHS has a comprehensive pamphlet that details different types of residential settings, and Adult Family Home Council of WA State has an online search tool.
ALTSA understands that application and placement can be complicated, and in response offers an excellent brochure that details the process in effort to help an applicant make an informed decision.
What Other Long-Term Care Services Are There?
In addition to residential long-term care services, qualifying applicants can also receive in-home and supplemental support, as administered in King County by Seattle Aging and Disability Services (ADS).
While ALTSA determines eligibility for all services, residential and in-home, ADS provides ongoing case management for in-home and supplemental support.
Applicants may be eligible for Community First Choice services, which are available for those who are not found to need residential-level care, but still need support while remaining in their home. Such services and goods include:
- In-Home Personal Care services, where a professional caregiver assists them to meet their Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs) such as bathing, dressing, and personal needs shopping.
- Personal Emergency Response System devices, which act to alert emergency services if someone needs medical assistance in their home or community – up to $550 can be allotted to a device every year.
- Skilled Acquisition Training, where a community member can get personal training on how to perform tasks for oneself such as cooking, budgeting, laundry, other household tasks, or specific personal hygiene tasks in order to maintain independence.
Additionally, applicants may also be available for COPES services, which can include:
- Adult Day Care
- Adult Day Health (such as nursing, physical therapy, or occupational therapy)
- Grocery delivery as provided by Chicken Soup Brigade
- Specialized mental health care as provided by Sound Generations
- Support from a Community Choice Guide, who acts as a temporary case manager as a person is stabilizing in community setting after institutionalization or hospitalization. Goods and services include:
- Moving expenses
- Payment of housing security deposit
- Accessibility adaptations in a new home
- Essential household furnishings
- And more!
What Can I Do If Something Goes Wrong?
As our experts from ALTSA have covered, the application process can be extensive, and sometimes there are complications even when benefits have been awarded. Benefit denials and terminations happen despite a person’s need for services, but advocacy tools can help!
When a person is denied for long-term care services, it is typically because their financial and functional assessments have determined they don’t fit specific criteria, such as exceeding resource or income limits, or lacking medical evidence that an applicant needs care.
DSHS is required to send a denial letter in these cases, which must include the specific reason for denial and an applicant’s right to a hearing.
Sometimes an applicant is awarded a reduced number of hours for in-home services that is insufficient. DSHS will send a Planned Action Notice document to alert of this.
Sometimes these decisions are erroneous! By contacting DSHS and sharing clarifying information, benefits can be awarded or adjusted without a formal appeals process.
Legal advocates are also seeing an increase in some cases where someone can be awarded residential treatment and then forcibly discharged from their long-term care facility. Stated reasons for this include:
- Decline in health
- Improvement in health
- Health of safety risks to self or others
- Nonpayment
- Facility closing
Additionally, legal advocates see cases where a person is discharged due to behavioral challenges more likely experienced by those who have experienced homelessness. To learn more about involuntary discharges, check out our blog on the subject.
One solution to denied, reduced, or terminated benefits is a legal request called Exception to Rule. This is an informal appeal tool that can be used in scenarios when an applicant’s situation is unique, and determinations based on assessments do not fully capture their need for care. Examples include unique and chronic medical conditions that are hard to measure, such as long COVID or other factors. To request an Exception to Rule, contact your Long-Term Care Case Manager and submit additional medical records or provider testimony. Visit washingtonlawhelp.org for more information on the Exception to Rule request.
Sometimes, the most effective advocacy tool is an administrative hearing, in which an independent party can review your case before deciding if DSHS or a care facility has made a mistake. Note that if benefits are being reduced or terminated, you can request continued coverage within 10 days of DSHS’s notice. You can request a hearing via:
- WA Office of Administrative Hearings (OAH) – must be filed within 90 days of benefits change
- Call 1-800-583-8271 or visit online at www.oah.wa.gov
- Health Care Authority Board of Appeals (if the client loses their OAH case) – must be filed within 21 calendar days from OAH decision
- Call 360-725-0910 or visit online at www.hca.wa.gov/about-hca/board-appeals
Note that administrative appeals can also be a valid space to resolve resource concerns caused by gifts or inheritance and exemptions to estate recovery. Check out the presentation for more details.
Client Advocate Tips & Tricks
Kayla Adams from ETS REACH finishes this conversation with helpful recommendations for service providers guiding their clients through long-term care applications and services.
Kayla encourages client advocates to respect their client’s agency, understanding that they may reject services due to adverse requirements such as ceasing substance use, the Personal Needs Allowance, and estate recovery. She stresses for advocates to be honest with clients about all parts of the application and services and to support their client with transition into care if it is right for them. For case management support, she recommends trainings provided by King County Behavioral Health and Recovery Division.
Kayla also shared a Mini-Assessment tool for Case Managers, which can be helpful to prepare for an assessment!