LONG-TERM SERVICES AND SUPPORTS (LTSS) PRESUMPTIVE ELIGIBILITY (PE)

"Acute care hospital" as defined in chapter 182-550 WAC, may offer inpatient services, outpatient services, continuous nursing services, pharmacy services, food services, and necessary ancillary services. These hospitals may offer specialized patient care services including alcoholism and chemical dependency units or services.

"Care plan" means the document generated using the presumptive eligibility assessment screening tool in CARE that identifies the long-term services and supports you are eligible to receive during the presumptive eligibility period.

"Community psychiatric hospital" means a specialized psychiatric hospital or psychiatric unit within a community hospital that is certified to provide involuntary evaluation and treatment services.

"Diversion" means you have discharged from a local community psychiatric facility onto HCS LTSS and have a 90- or 180-day commitment order for further involuntary treatment; or you are detained through the Involuntary Treatment Act and are stabilized and discharged onto LTSS prior to the need to petition for a 90- or 180- day commitment order.

"LTSS" means Long-term Services and Supports as defined in WAC 182-513-1100.

"MPC" means Medicaid Personal Care which is defined as personal care services in WAC 388-106-0010.

"NFLOC" means nursing facility level of care as defined in WAC 388-106-0355.

"PE screening" means the functional and financial assessment completed using the presumptive eligibility screening tool within CARE to determine presumptive eligibility for LTSS NFLOC PE services or LTSS MPC PE services.

"Presumptive eligibility" means a determination made using a screening process completed by the department to gather preliminary information to determine if you meet the eligibility criteria described in WAC 388-106-1805 and 388-106-1815 of this section to receive services while the final eligibility determination is being completed. This is also known as PE.

You are eligible to receive LTSS NFLOC PE services if you meet the following criteria based upon the attested information in your PE screening:

(1) Meet functional eligibility requirements as defined in WAC 388-106-0355 (1)(a), (b), (c), or (d); and

(2) Meet financial eligibility requirements as defined in WAC 182-513-1315; and

(3) Will be discharging from an acute care hospital or diverting from a community psychiatric hospital; or

(4) Have discharged or diverted from an acute care hospital or community psychiatric hospital in the last 30 days; and

(5) Live in your own home as defined in WAC 388-106-0010; and

(6) Are not receiving any other medicaid funded long-term services and supports.

You may receive the following services under LTSS NFLOC PE:

(1) Up to a maximum of 103 hours a month of personal care services as defined in WAC 388-106-0010;

(2) Nurse delegation, as defined in WAC 388-106-0270;

(3) Personal Emergency Response System (PERS), as defined in WAC 388-106-0270;

(4) Home delivered meals, as defined in WAC 388-106-0300;

(5) Specialized medical equipment and supplies, as defined in WAC 388-106-0300;

(6) Assistive/Adaptive technology and equipment, as defined in WAC 388-106-0270;

(7) Community transition or sustainability services as defined in WAC 388-106-0270, which are nonrecurring set-up items and services to assist with expenses to move from an acute care hospital or diversion from a psychiatric hospital stay to an in-home setting and may include:

(a) Security deposits that are required to lease an apartment or home;

(b) Activities to assess need, arrange for, and obtain needed resources, including essential household furnishings;

(c) Set-up fees or deposits for utility or services access, including telephone, electricity, heating, water, and garbage;

(d) Services necessary for your health and safety such as pest eradication and one-time cleaning prior to occupancy;

(e) Moving expenses; and

(f) Minor home accessibility modifications necessary for hospital discharge.

(8) Community choice guide: specialty services providing assistance and support to ensure an individual's successful transition to the community or maintenance of independent living, as defined in WAC 388-106-0300; and

(9) Supportive Housing as defined in WAC 388-106.

You are eligible to receive LTSS MPC PE services if you meet the following criteria based upon the attested information in your PE screening:

(1) Meet functional eligibility requirements as defined in WAC 388-106-0210; and

(2) Meet financial eligibility requirements as defined in WAC 182-513-1225; and

(3) Will be discharging from an acute care hospital or diverting from a community psychiatric hospital; or

(4) Have discharged or diverted from an acute care hospital or community psychiatric hospital in the last 30 days; and

(5) Live in your own home as defined in WAC 388-106-0010; and

(6) Are not receiving any other medicaid funded long-term services and supports.

Under LTSS MPC PE you may receive up to 34 hours per month of personal care services as defined in WAC 388-106-0010.

The following types of providers can provide long-term care services:

(1) Individual providers (IPs) as defined in WAC 388-115-0503, who provide services to clients in the client's own home.

(2) Home care agencies that provide services to clients in the client's own home. Home care agencies must be licensed under chapter 70.127 RCW and chapter 246-335 WAC and contracted with the department.

(3) Providers who have contracted with the department to perform other services.

The department will authorize LTSS NFLOC PE or LTSS MPC PE services when you:

(1) Are found both financially and functionally eligible for PE services by completing your PE screening which includes the amount of participation toward the cost of your care that you must pay (if any);

(2) Have given consent for services and approved your care plan; and

(3) Have chosen a DSHS qualified provider(s), per WAC 388-71-0510.

(1) Your LTSS NFLOC PE or LTSS MPC PE services end with the earlier date of:

(a) The date the decision was made on your application as defined in WAC 388-106-0010;

(b) The date you were confirmed by a CARE assessment to not meet functional eligibility criteria as defined in WAC 388-106-0355 or 388-106-0210; or

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

(2) You may only receive LTSS NFLOC PE or LTSS MPC PE services once within a 24-month period.

You can receive LTSS NFLOC PE or LTSS MPC PE services:

(1) In your own home as defined in WAC 388-106-0010;

(2) While you are out of your home accessing the community or working while:

(a) within the state of Washington; or

(b) in a recognized out-of-state bordering city as defined in WAC 182-501-0175.

(1) If you receive LTSS MPC PE services you are not required to pay toward the cost of care for those services.

(2) If you receive LTSS NFLOC PE, you may be required to pay toward the cost of your care as outlined in WAC 182-515-1509. You are allowed to keep some of your income for a maintenance allowance.

Applicants do not have an administrative hearing right as defined in chapter 388-02 WAC on LTSS NFLOC PE or LTSS MPC PE eligibility determinations.

ETRs will not be granted for LTSS NFLOC PE or LTSS MPC PE eligibility determinations or service determinations.