DEPARTMENT OF

SOCIAL AND HEALTH SERVICES

(Aging and Long-Term Support Administration)

MAC AND TSOA SERVICES

The following definitions apply to MAC and TSOA services:

"Care plan" means the plan developed by the department in TCARE or GetCare that summarizes the services described in WAC 388-106-1915 that you chose to receive.

"Care receiver" means an adult age fifty-five and over who has been authorized for MAC or TSOA services.

"Caregiver" means a spouse, relative, or friend (age eighteen and over) who has primary responsibility for the care or supervision of an adult who meets eligibility criteria and does not receive direct, public, or private payment such as a wage for the caregiving services they provide.

"Caregiver assistance services" are services that take the place of those typically performed by an unpaid caregiver in support of unmet needs the care receiver has for assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs).

"GetCare" means a statewide web-based information system that includes a client management component for use by area agencies on aging (AAA) and other aging and disability network partners.

"GetCare assessment" is a process where the department gathers information for an individual without a caregiver in the following areas: functional needs, diagnoses and conditions, behavior health supports, oral health, and nutritional health to assist the individual with choosing step three services.

"GetCare screening" is a process where the department gathers information for an individual without a caregiver in order to determine risk scores. The information covers the following areas: function needs, fall risk, availability of informal help, memory and decision making issues, and emotional well-being. The risk scores are used to determine if the individual is referred for a full GetCare assessment.

"Health maintenance and therapies" are clinical or therapeutic services that assist the care receiver to remain in their home or the caregiver to remain in their caregiving role and provide high quality care. Services are provided for the purpose of preventing further deterioration, improving, or maintaining current level of functioning.

"Identity discrepancy" means a negative psychological state that occurs when the activities and responsibilities that a caregiver assumes with regard to the care receiver are inconsistent with the caregiver's expectations or personal norms concerning these activities and responsibilities.

"MAC" means medicaid alternative care, which is a federally funded program authorized under section 1115 of the Social Security Act. It enables an array of person-centered services to be delivered to unpaid caregivers caring for a medicaid eligible person who lives in a private residence (such as their own home or a family member's home) and chooses to receive community based services.

"Medicaid transformation project demonstration" refers to the authority granted to the state by the federal government under section 1115 of the Social Security Act. This waiver is a five year demonstration to support health care systems prepare for and implement health reform and provide new targeted medicaid services to eligible individuals with significant needs. It includes MAC and TSOA programs.

"Personal assistance services" are supports involving the labor of another person to help the care receiver complete activities of daily living and instrumental activities of daily living that they are unable to perform independently. Services may be provided in the care receiver's home or to access community resources.

"RDAD" means reducing disability in Alzheimer's disease. This program is designed to improve the ability of the person with memory problems to complete activities of daily living while also helping family members provide assistance to the person.

"Service provider" means an agency or organization contracted with the department.

"Specialized medical equipment and supplies" are goods and supplies needed by the care receiver that are not covered under the medicaid state plan, medicare, or private insurance.

 "TCARE" means tailored caregiver assessment and referral which is an evidence-based caregiver coordination process designed to assist department assessors who work with family caregivers to support adults living with disabilities. TCARE is designed to tailor services to the unique needs of each caregiver to help reduce stress, depression, and burdens associated with caregiving.

"TCARE assessment" is a part of the TCARE process where department assessors gather responses to all of the TCARE screening questions as well as additional questions focused on both the caregiver's experience and the care receiver's situation such as memory issues, behavioral needs, assistance needs with activities of daily living and instrumental activities of daily living, and diagnoses/conditions.

"TCARE screening" is a part of the TCARE process that gathers information from the caregiver to determine scores and ranges for the caregiver's identity discrepancy, burdens, uplifts, and depression. The ranges are used to determine if the caregiver is referred for a full TCARE assessment.

"Training and education" are services and supports to help caregivers gain skills and knowledge to implement services and supports needed by the care receiver to remain at home and skills needed by the caregiver to remain in their role.

"TSOA" means tailored supports for older adults, which is a federally-funded program approved under section 1115 of the Social Security Act. It enables the delivery of person-centered services to:

(1) Caregivers who care for an eligible person as defined in WAC 388-106-1910; and

(2) Eligible persons as defined in WAC 388-106-1910, without a caregiver.

(1) You are eligible to receive MAC services if you, as a care receiver, meet the following criteria:

(a) Are age fifty-five or older;

(b) Meet nursing facility level of care as defined in WAC 388-106-0355;

(c) Meet medicaid financial eligibility requirements as defined in WAC 182-513-1605;

(d) Have an unpaid caregiver who:

(i) Is age eighteen or older;

(ii) Has participated in the following:

(A) Care plan for step one services;

(B) TCARE screening and care plan for step two services; or

(C) TCARE assessment and care plan for step three services;

(e) Live in a private residence (such as your own home or a family member's home) and choose to receive community based services; and

(f) Do not receive any other medicaid funded long-term services and supports (LTSS) while receiving MAC services.

(2) The department may use preliminary information you provide through a presumptive eligibility screening to determine if you, as the care receiver, meet the eligibility criteria in subsection (1) of this section in order to receive services while the formal eligibility determination is being completed. This is called presumptive eligibility.

(a) Your presumptive eligibility period ends the last day of the month following the month when your MAC services were first authorized.

(b) In the event the department implements a wait list under WAC 388-106-1970 for MAC services, your presumptive eligibility ends.

(c) You may only receive services under presumptive eligibility once within a twenty-four month period.

(d) Under presumptive eligibility you may receive services as described in WAC 388-106-1915.

(1) You are eligible to receive TSOA services if you, as a care receiver, meet the following criteria:

(a) Are age fifty-five or older;

(b) Meet nursing facility level of care as defined in WAC 388-106-0355;

(c) Meet financial eligibility requirements defined in WAC 182-513-1615 or 182-513-1620;

(d) Live in a private residence (such as your own home or a family member's home) and choose to receive community based services; and

(e) Meet the criteria in either (e)(i) or (ii) of this subsection:

(i) Have an unpaid caregiver who is age eighteen or older and has participated in the following:

(A) A care plan for step one services;

(B) A TCARE screening and care plan for step two services; or

(C) A TCARE assessment and care plan for step three services; or

(ii) You do not have an available caregiver and have participated in the following:

(A) A care plan for step one services;

(B) A GetCare screening and care plan for step two services; or

(C) A GetCare assessment and care plan for step three services.

(2) The department may use preliminary information you provide through a presumptive eligibility screening to determine if you, as the care receiver, meet the eligibility criteria in subsection (1) of this section in order to receive services while the formal eligibility determination is being completed. This is called presumptive eligibility.

(a) Your presumptive eligibility period ends with the earlier date of:

(i) The day the decision was made on your TSOA application; or

(ii) The last day of the month following the month in which your presumptive eligibility services were authorized if you did not submit your TSOA application.

(b) In the event the department implements a wait list under WAC 388-106-1970 for TSOA services, your presumptive eligibility ends.

(c) You may only receive services under presumptive eligibility once within a twenty-four month period.

(d) Under presumptive eligibility you may receive services as described in WAC 388-106-1915.

MAC and TSOA services include the following three benefit levels referred to as steps. Caregivers and care receivers may receive services under any of the three steps depending upon their requests and needs identified in the screening process for step two and the assessment process for step three. Steps do not need to be used in order. For example, an individual may begin services at step two or three. In general, step one services are used by caregivers or care receivers requesting lesser supports than those using step three services.

(1) Step one: After the department obtains your demographics and approves your program eligibility, you may receive the following services:

(a) Information and referrals to family caregiver or community resources;

(b) A selection of the following services up to a one time limit of two hundred and fifty dollars:

(i) Training and education, which includes but is not limited to:

(A) Support groups;

(B) Group training;

(C) Caregiver coping and skill building training;

(D) Consultation on supported decision making;

(E) Caregiver training to meet the needs of the care receiver;

(F) Financial or legal consultation; and

(G) Health and wellness consultation;

(ii) Specialized medical equipment and supplies for the care receiver, which includes but is not limited to:

(A) Supplies;

(B) Specialized medical equipment;

(C) Assistive technology;

(iii) Caregiver assistance services, which includes but is not limited to short term respite to allow the caregiver to attend an educational event or training series; and

(iv) Health maintenance and therapy supports, which may include but are not limited to:

(A) Adult day health;

(B) RDAD and evidence based exercise programs;

(C) Health promotion and wellness services; and

(D) Counseling related to caregiving role.

(2) Step two: After the department obtains your demographics, approves your program eligibility, and completes a GetCare or TCARE screening, you may receive the following:

(a) Information and referrals to family caregiver or community resources;

(b) The following services up to an annual limit of five hundred dollars minus any expenditures for step one services:

(i) Training and education, which includes but is not limited to:

(A) Support groups;

(B) Group training;

(C) Caregiver coping and skill building training;

(D) Consultation on supported decision making;

(E) Caregiver training to meet the needs of the care receiver;

(F) Financial or legal consultation; and

(G) Health and wellness consultation;

(ii) Specialized medical equipment and supplies for the care receiver, which includes but is not limited to:

(A) Supplies;

(B) Specialized medical equipment;

(C) Assistive technology; and

(D) Personal emergency response system (PERS);

(iii) Caregiver assistance services, which include but are not limited to:

(A) Short-term respite to allow the caregiver to attend an educational event or training series;

(B) Housework/errands and yard work;

(C) Home delivered meals for the care receiver;

(D) Minor home modifications and repairs to the care receiver's home;

(E) Home safety evaluation of the care receiver's home; and

(F) Transportation, only in conjunction with the delivery of a service;

(iv) Health maintenance and therapy supports, which include but are not limited to:

(A) Adult day health;

(B) RDAD and evidence based exercise programs;

(C) Health promotion and wellness services; and

(D) Counseling related to the caregiving role;

(v) Personal assistance services for the TSOA without an unpaid caregiver, which include but are not limited to:

(A) Adult day care;

(B) Transportation, only in conjunction with the delivery of a service;

(C) Housework/errands and yard work;

(D) Home delivered meals;

(E) Home safety evaluation of the care receiver's home; and

(F) Minor home modifications and repairs to the care receiver's home.

(3) Step three:

(a) For MAC and TSOA care receivers with caregivers:

(i) You may receive information and referrals to family caregiver or community resources.

(ii) After the department has obtained your demographics and approved your program eligibility, the caregiver must complete a TCARE assessment in order to access step three services. In order to qualify for a TCARE assessment, the TCARE screening must result in at least three medium scores or one high score for the TCARE burdens. TCARE uses an evidence-based algorithm to identify a primary goal based on the caregiver's answers to the TCARE assessment questions. An individualized care plan will be developed that uses the strategies and services recommended by the TCARE assessment and contains the services chosen by the caregiver up to the limits established in WAC 388-106-1920.

(iii) The Xs in the table below indicate the services that may be available for each strategy as defined in WAC 388-106-1930 and recommended by the TCARE assessment:

(b) For TSOA care receivers who do not have an available caregiver:

(i) You may receive information and referrals to community resources.

(ii) After the department has obtained your demographics and approved your program eligibility, you must complete a GetCare assessment in order to access step three services. In order to qualify for a GetCare assessment, the GetCare screening must result in a risk score of moderate or high. An individualized care plan will then be developed based upon the needs identified in the assessment and the services you have selected up to the limits established in WAC 388-106-1920.

(iii) The services available include services noted in subsections (1) and (2) of this section (except for subsections (1)(b)(iii) and (2)(b)(iii) of this section) and the following personal assistance services:

(A) Personal care; and

(B) Nurse delegation.

(1) The maximum amount of step three services you and your caregiver may receive in MAC and TSOA is an average of five hundred and fifty dollars per month not to exceed three thousand three hundred dollars in a six month period unless the department authorizes additional funds through an exception to rule under WAC 388-440-0001.

(2) If you are a care receiver who does not have an available unpaid caregiver and you are receiving TSOA personal assistance services, the maximum amount of step three services you may receive per month is five hundred and fifty dollars unless the department authorizes additional funds through an exception to rule under WAC 388-440-0001.

The three primary goals for caregivers identified in TCARE are:

(1) Maintain current identity: The goal appropriate for caregivers who experience modest levels of identity discrepancy and stress and are willing and able to continue in their current role. Suggested support services will help caregivers make small adjustments in their personal norms and the manner in which they undertake their caregiving responsibilities.

(2) Embrace caregiver identity: The goal appropriate for caregivers who are likely to benefit from embracing a stronger identity as a caregiver and releasing, to some degree, their commitment to a familial identity. Suggested support services will encourage the caregiver to accept a greater identity with the caregiver role.

(3) Reduce caregiver identity: The goal appropriate for caregivers who are engaged in a level of caregiving that requires emotional or physical resources beyond their capability. Suggested support services will encourage caregivers to explore ways to reduce workload and stress related to their caregiving role.

The purpose of the TCARE assessment is to gather critical information about the caregiving context, identity, strengths, problems and concerns. This data is used to identify strategies and goals to address the caregiver's burdens and stresses. Program limits are established in WAC 388-106-1915.

The five strategies in TCARE are:

(1) Strategy A: Change personal rules for care, which entails encouraging and helping the caregiver to change or adjust their personal rules or norms.

(2) Strategy B: Reduce or minimize work load, which focuses on reducing the amount or intensity of a caregiver's work load and therefore aligns the caregiver's behaviors with their expectations.

(3) Strategy C: Support positive self-appraisal, which focuses on offering positive affirmation and assuring the caregiver that the behaviors that they must engage in as a caregiver are consistent with their norms.

(4) Strategy D: Reduce generalized stress, which focuses on giving the caregiver tools and skills to cope with daily stresses of caregiving.

(5) Strategy E: Improve overall health, which encourages the caregiver to seek appropriate health services.

You may receive MAC and TSOA services:

(1) In your own home; and

(2) In the community setting, where the authorized service occurs, within the state of Washington or in a recognized out-of-state bordering city as defined in WAC 182-501-0175.

Your MAC or TSOA services will be authorized when you:

(1) Have completed initial requirements for intake including but not limited to screenings and assessments;

(2) Are found to be at least presumptively eligible, both financially and functionally;

(3) Have chosen a provider(s) qualified for payment; and

(4) Have given consent for services and approved your care plan.

Your MAC or TSOA services may begin as early as the date authorized by the department.

(1) In order to remain eligible for MAC and TSOA services, you, as the care receiver must:

(a) Remain functionally eligible as defined in WAC 388-106-0355 and financially eligible as defined in WAC 182-513-1605, 182-513-1615, and 182-513-1620; and

(b) Have your functional and financial eligibility reviewed at least annually.

(2) If eligibility laws, regulations, or rules change, and if you as the caregiver or the care receiver do not meet the changed eligibility requirements, the department will terminate services, even if your circumstances have not changed. You will receive advance notice of any termination or change in your services and an opportunity to appeal.

You, as a caregiver or a care receiver, will not be required to pay toward the cost of your MAC or TSOA services. This means that neither estate recovery nor participation towards cost of care are required.

You, as the care receiver may be employed and receive MAC or TSOA services.  Your caregiver may be employed in roles other than caregiving and receive services under MAC or TSOA.

The services you may receive under MAC or TSOA will not include the following:

(1) Rent;

(2) Groceries;

(3) Car repairs;

(4) Utility bills;

(5) Household appliances;

(6) Vacation expenses;

(7) Entertainment items such as TVs, radios, computers, cell phones;

(8) Pet care items;

(9) Gift cards; and

(10) Any services not defined in WAC 388-106-1915.

The following providers may provide MAC and TSOA services:

(1) Durable medical equipment vendors and adult day health providers that have a core provider agreement with the health care authority; and

(2) Providers who are contracted with the department to provide goods and services.

(1) The department will implement a statewide wait list if program expenditures or enrollment exceeds availability of demonstration funding.

(2) If the department implements a wait list for new MAC and TSOA applicants:

(a) We will stop conducting presumptive eligibility determinations and financial and functional eligibility assessments.

(b) We may reduce benefit limits for step one, two, and three to maintain department spending within available demonstration funding. If we reduce benefit limits, individuals currently receiving benefits will maintain their current benefit level, including those with approved presumptive eligibility.

(c) If additional funding becomes available, applicants on a wait list for MAC or TSOA services will be considered on a first come first serve basis based upon their request date for MAC or TSOA services.

(1) The department will deny or terminate MAC or TSOA services if you are not eligible for services pursuant to WAC 388-106-1905, 388-106-1910, and 388-106-1945.

(2) The department may deny or terminate your MAC or TSOA services if, after exhaustion of standard case management activities and the approaches delineated in the department's challenging cases protocol, which must include an attempt to reasonably accommodate your disability or disabilities, one or more of the following conditions exist:

(a) Your rights and responsibilities as a client of the department are reviewed with you by a department representative under WAC 388-106-1300 and 388-106-1303, and you refuse to accept those services identified in your care plan that are vital to your health, welfare, or safety.

(b) You choose to receive services in your own home and you or others in your home demonstrate behaviors that are substantially likely to cause serious harm to you or your care provider.

(c) You choose to receive services in your own home and hazardous conditions in or immediately around your home jeopardize the health, safety, or welfare of you or your provider. Hazardous conditions include but are not limited to the following:

(i) Threatening, uncontrolled animals (such as dogs);

(ii) The manufacture, sale, or use of illegal drugs;

(iii) The presence of hazardous materials (such as exposed sewage, evidence of a methamphetamine lab).

(3) The department will terminate services if the department does not receive written consent of the care plan within sixty days of the completion of your care plan. Written consent for step one and step two care plans may also be provided by secure email or other electronic means.

Yes, you may request an administrative hearing based on the rules outlined in WAC 388-106-1305 to contest the department's decisions regarding MAC or TSOA services.

Yes. You, as the care receiver, may choose to apply for traditional medicaid long term services and supports such as community first choice, community option program entry system (COPES), new freedom, and residential support waiver, instead of services under the MAC program. You must contact your case manager who will assist you with this process.