Long-term care is expensive, more than most can afford. Unfortunately, very few consider this when planning for retirement. There are just three ways to pay for this expense: 1) long-term care insurance, 2_ out of pocket, or 3) Medicaid. The term "Medicaid" is used to describe long-term care services generally. Technically, that is not accurate. The Medicaid program is a federal program and covers nursin g home only care. This, "Institutional Medicaid" has been a cornerstone of long-term care funding in the United States since its inception in 1965 as part of the Social Security Amendments. Initially focused on providing care in nursing homes, this program has evolved over the decades to encompass a broader range of institutional settings. The primary purpose of institutional Medicaid is to provide coverage for long-term care services to elderly and disabled individuals who require extensive care and meet specific financial eligibility criteria.
The Medicaid statute does allow states to provide less expensive and, in many cases, more appropriate care at home or in assisted living facilities if the states apply for a "waiver" to the nursing home only rule. Nearly every state has done so and the approved programs are called "waiver programs" and offer services such as personal care, home health services, and adult day care. This approach often proves more cost-effective than institutional care while promoting independence and allowing individuals to age in place. It also enables more person-centered care planning, tailoring services to the specific needs and preferences of each individual.
In Washington, the waiver program is called Community Options Program Entry System (COPES). This article will explain the key aspects of the COPES program, including eligibility requirements, covered services, and application process.
What is COPES?
To qualify for COPES, applicants must meet both financial and functional eligibility criteria:
Financial Eligibility
Income Limit: The applicant's monthly income must not exceed 300% of the Federal Benefit Rate (FBR). As of 2023, this limit is $2,742 per month for an individual.
Resource Limit: The applicant's countable resources must not exceed $2,000 for an individual or $3,000 for a couple (if both spouses are applying). Some resources are exempt, including: the primary residence (up to a certain equity value), one vehicle, personal belongings and household goods and certain burial funds or burial plots
Spousal Resource Allowance: If only one spouse is applying, the non-applicant spouse may keep additional resources, known as the Community Spouse Resource Allowance (CSRA).
Functional Eligibility
Applicants must require a nursing home level of care, as determined by an assessment conducted by the Department of Social and Health Services (DSHS). This means they need assistance with activities of daily living (ADLs) such as bathing, dressing, eating, or mobility.
Covered Services
COPES can provide a wide range of services. Here's a more detailed look at each:
Personal Care Assistance:
Help with Activities of Daily Living (ADLs) such as bathing, dressing, eating, toileting, and transferring, as well as Instrumental Activities of Daily Living (IADLs) like meal preparation, housekeeping, and medication management.
Home Health Aide Services:
Assistance with health-related tasks under the supervision of a nurse or therapist. This can include monitoring vital signs, assisting with prescribed exercises, or changing simple dressings.
Adult Day Health Services:
Structured programs in a community setting that offer health, social, and therapeutic activities during the day, allowing caregivers respite and helping participants maintain or improve their level of functioning.
Home-Delivered Meals:
Nutritionally balanced meals delivered to the home for individuals who have difficulty preparing their own meals.
Transportation to Medical Appointments:
Non-emergency medical transportation to help individuals attend necessary medical appointments.
Environmental Modifications:
Home adaptations that increase independence and safety, such as installation of grab bars, wheelchair ramps, or walk-in showers.
Personal Emergency Response Systems:
Electronic devices that enable individuals to call for help in an emergency.
Respite Care:
Short-term care provided to the individual to give their regular caregiver a break. This can be provided in-home or in an approved out-of-home setting.
Skilled Nursing:
It's important to note that skilled nursing services under COPES are limited. COPES primarily covers long-term care needs rather than acute medical needs. Skilled nursing under COPES might include:
Nurse delegation (training and oversight of caregivers performing certain nursing tasks)
Wellness education
Medication management However, more intensive skilled nursing services are typically covered under different Medicaid programs.
Distinction for Intensive Skilled Nursing:
Intensive skilled nursing services, such as wound care, intravenous therapy, or rehabilitation after a hospital stay, are generally covered under the federal institutional Medicaid program or Medicaid's Home Health benefit. These programs have different eligibility rules and coverage criteria compared to COPES.
For example:
- They may not have the same financial eligibility criteria as COPES.
- They often require a doctor's order and are time-limited, based on medical necessity.
- They're designed for short-term, acute needs rather than long-term care. If an individual needs both long-term care services (covered by COPES) and intensive skilled nursing, they might receive services through multiple Medicaid programs simultaneously, each with its own rules and processes.
Care Management:
While not a direct service, COPES provides ongoing care management. A case manager helps assess needs, develop and implement care plans, and coordinate services.
It's important to note that the exact services available may vary based on the individual's assessed needs and the specific COPES waiver program they're enrolled in. The care plan, developed with a case manager, will outline which services are authorized for each individual.
Application Process: How to Apply for Medicaid LTSS
You can apply for Medicaid LTSS through several methods:
- Online at www.washingtonconnection.org.
- By phone by calling 1-800-422-3263.
- In person at your local DSHS office (find locations here).
- By mail or fax, using forms available online or at DSHS offices
How Financial Eligibility Works
When you submit a Medicaid application to the Department of Social and Health Services (DSHS) in Washington State, it sets in motion a comprehensive review process. The goal is to determine whether you meet both the financial and functional eligibility criteria for Medicaid long-term care services.
Let's start with the financial side. DSHS will examine your income and resources as of the first day of the month in which you're seeking coverage. This is known as the "snapshot" approach. Washington State does indeed use this method, which provides a clear point-in-time picture of your financial situation.
Special Rules for Married Applicants
For married couples where only one spouse is applying (known as the "institutional spouse"), DSHS takes a snapshot of the couple's combined countable resources as of the first day of the first month of continuous institutionalization. This snapshot is used to determine the Community Spouse Resource Allowance (CSRA), which is the amount of resources the non-applying spouse (the "community spouse") can keep.
The Community Spouse Resource Allowance (CSRA) is a protection for the spouse of someone applying for Medicaid for long-term care. It allows the community spouse (the spouse not applying for care) to retain some of the couple’s resources, even when the other spouse qualifies for Medicaid.
CSRA Limits: Each year, Medicaid updates the limits for the amount a community spouse can keep. For example, in Washington state, the CSRA allows a community spouse to retain up to $148,620 (for 2022) in assets while the spouse receiving care qualifies for Medicaid.
Example:
If a couple has $200,000 in countable assets, the spouse receiving long-term care must reduce their portion of the resources to meet Medicaid eligibility rules, but the community spouse can keep $148,620 under the CSRA.
2. Standard Income Allowance (SIA)
The Standard Income Allowance (SIA) refers to the amount of income the community spouse can retain from the institutionalized spouse’s income. This helps prevent impoverishment of the community spouse.
Monthly Income Allowance: In Washington, the SIA is capped at around $3,435 per month (2022), depending on the actual needs and the state you reside in.
Example:
If the community spouse’s monthly income is less than the SIA limit, they can retain some of the institutionalized spouse’s income to meet their own living expenses.
3. Transfer Penalties
Medicaid imposes penalties on any gifts or transfers of assets for less than fair market value within a specific look-back period before applying for LTSS. The look-back period is typically five years.
- Penalty Calculation: If an individual transfers assets during this period, Medicaid will impose a penalty, delaying the start of benefits. The penalty period is calculated based on the total value of assets transferred, divided by the average monthly cost of care in the state (this is called the penalty divisor).
Example:
Suppose an individual gifts $100,000 to their children three years before applying for Medicaid. If the state’s average cost of nursing home care is $10,000 per month, the penalty would be 10 months ($100,000 ÷ $10,000), meaning Medicaid would not cover care for 10 months.
Avoiding Transfer Penalties:
- Work with an elder law attorney to reduce penalties by planning asset transfers carefully.
- Consider funding irrevocable trusts or paying for outstanding medical bills as ways to reduce assets without triggering penalties.
Your Assets
Now, let's talk about resources. DSHS divides your assets into two categories: countable and exempt. Countable resources are those that are considered available to pay for your care. Exempt resources, on the other hand, are not counted towards your resource limit.
Here's a list of common exempt resources:
Your primary residence: This is exempt as long as you intend to return home or your spouse or dependent relative lives there. There's an equity value limit, which as of 2023 is $688,000 in Washington State.
One vehicle: This is fully exempt regardless of value if it's used for transportation of the applicant or a member of their household.
Personal and household items: Things like clothing, furniture, and appliances are generally exempt.
Life insurance policies: These are exempt if the total face value of all policies is $1,500 or less. If it's more, only the cash surrender value counts as a resource.
Burial spaces: Burial plots for you and your immediate family members are exempt.
Burial funds: This is where things get a bit more complex, so let's dive deeper.
Burial funds are an important consideration in Medicaid planning. Washington allows for the following burial-related exemptions:
Prepaid burial plans: If you have an irrevocable prepaid burial plan, it's fully exempt regardless of value.
Burial fund allowance: Up to $1,500 can be set aside for burial expenses. This can be in the form of a revocable burial contract, a bank account clearly designated for burial expenses, or life insurance policies designated for burial expenses.
Burial space items: Items like caskets, headstones, and burial vaults are exempt if they're fully paid for and held for use for the individual or their immediate family members.
It's important to note that if you have life insurance policies that you're counting towards your burial funds, the $1,500 exemption applies to the combined face value of the policies, not the cash surrender value.
As DSHS reviews your application, they'll ask for documentation to verify your resources. This might include bank statements, property deeds, vehicle registrations, life insurance policies, and burial contracts. They'll carefully examine these documents to ensure all resources are properly categorized and valued.
For income, DSHS will look at all sources, including Social Security, pensions, annuities, and any other regular payments you receive. They'll compare your gross monthly income to the relevant income standard for the program you're applying for.
Remember, the snapshot approach means that any changes to your resources after the first of the month won't affect your eligibility for that month. However, you're required to report any changes in your circumstances to DSHS, as they can affect your ongoing eligibility.
The financial eligibility determination process can be complex, especially when it comes to exempt resources and burial funds. Many applicants find it helpful to consult with an elder law attorney or a Medicaid planning specialist to ensure they're making the most of available exemptions and presenting their financial situation accurately to DSHS.
Alongside this financial review, DSHS will also conduct a functional assessment to determine your level of care needs. This assessment looks at your ability to perform activities of daily living and your overall health status.
By thoroughly examining both your financial situation and your care needs, DSHS aims to make an accurate determination of your eligibility for Medicaid long-term care services. This process, while detailed and sometimes time-consuming, is designed to ensure that Medicaid resources are allocated to those who truly need them while providing important protections for community spouses and families.
Important Considerations
Look-Back Period: Medicaid has a 5-year look-back period for asset transfers. Any gifts or transfers for less than fair market value during this period may result in a penalty period of ineligibility.
Estate Recovery: After the recipient's death, the state may seek to recover Medicaid expenses from their estate. However, there are protections for surviving spouses and certain hardship waivers.
Spousal Impoverishment Protection: There are provisions to prevent the impoverishment of the community spouse (the spouse not receiving COPES), including the Monthly Maintenance Needs Allowance (MMNA) and the CSRA mentioned earlier.
Ongoing Eligibility: Recipients must continue to meet both financial and functional eligibility criteria. Regular reassessments will be conducted.
Choice of Providers: COPES recipients generally have the freedom to choose their care providers, which may include family members in some cases (excluding spouses).
Great Resource
Washington Law Help: This site offers various fact sheets and pamphlets related to Medicaid and long-term care services. For updated changes, you can explore:
- Questions and Answers on the COPES Program
- Questions and Answers on Medicaid for Nursing Home Residents
- Questions and Answers on the Community First Choice Program
- Questions and Answers on the TSOA and MAC Programs(5106en_questions-and-an…).
To find the most recent updates, including the October 2022 changes, checking these resources or contacting local agencies like the Department of Social and Health Services (DSHS) would be the best approach.
Conclusion
The COPES program offers a valuable alternative to nursing home care for many Washington residents. By allowing individuals to receive care in their homes or community settings, it promotes independence and quality of life. However, the eligibility rules and application process can be complex. It's often beneficial to consult with an elder law attorney or a DSHS representative to navigate the process effectively and ensure you're making the best decisions for your long-term care needs.
