Medicaid & COPES

Medicaid & COPES – The Basics
Medicaid is available to certain individuals and families who qualify based on federal and state eligibility requirements.  Funds are sent directly to the health care provider rather than to you as a consumer.  Within the State of Washington, you are required to provide a co-payment to the provider from your own, monthly income.

Although federally funded, Medicaid is a state administered program.  Each state sets its own guidelines regarding eligibility requirements and determines which services are covered.  In the State of Washington an individual or a couple must:

  • Fall below certain monthly income parameters
  • Their assets must fall below a certain aggregate level before applying for assistance

There are two slightly different programs in the State of Washington.  One is called Medicaid, which provides for care in a nursing home.  The other program is called COPES (Community Options Program Entry System).  The COPES program was designed to keep people in their own homes with in-home care services; however, today the program has been expanded to include care in an assisted living community or an adult care home.  The eligibility requirements and application processes for both programs are very similar.

Qualification for Medicaid/COPES
To qualify for these entitlements, a person must need significant help with their activities of daily living (ADL’s) or a person must require supervision due to memory loss.

  • Medicaid is designed for people who require medical care or housing and care services.
  • Medicaid is not designed for people who require only housing.  If you are a low or lower-income senior and have no care needs, Medicaid/COPES is not for you.

Application Process
The application itself is not a complex process, but completing the application correctly is critical to obtaining benefits in a timely manner.  Also, the amount of information you need to consider when applying for benefits is immense.  The Washington LawHelp website www.washingtonlawhelp.org is helpful in explaining the details of eligibility and how the programs work.

Consider enlisting the help of an attorney or financial specialist with extensive Medicaid expertise to help guide you through the process.

Finding a Provider who Accepts Medicaid/COPES
For many people, this is one of the most difficult parts of the process.  Many people qualify for the assistance, but locating a provider or a care community who accepts Medicaid/COPES may be a bit trickier.  What makes it particularly difficult to find a provider who accepts Medicaid/COPES is that a large percentage of providers are contracted to accept this entitlement, but that doesn’t mean they are actually willing to admit a Medicaid/COPES person at that specific point in time.

Skilled Nursing: 
Most all skilled nursing facilities will readily accept Medicaid at this point in time.  Due to declining occupancy rates in nursing homes, the industry is interested in welcoming any type of payment source.

Assisted Living: 
Most assisted living communities are not contracted with DSHS to be able to accept Medicaid/COPES.  These providers have elected not to participate in the program because of the low reimbursement rates paid by the state – typically far below the rate the provider receives from everyone else.  The providers will either limit their acceptance of Medicaid/COPES to people who are already living in their building, who have outlived their savings, or they don’t have a contract with DSHS to accept Medicaid/COPES.

Adult Care Homes: 
Many adult care homes accept Medicaid. The reimbursement rate to the adult care home is also low, so providers are becoming more cautious about admitting a person with heavy care needs. A larger number of homes are willing to admit a resident who can pay privately for one to five plus years and then convert to Medicaid/COPES.

You may find it helpful to speak to your Care Manager at DSHS to see if he/she may know of a home accepting Medicaid/COPES.