Modified Adjusted Gross Income (MAGI) based institutional care
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Modified Adjusted Gross Income (MAGI) based institutional care


Revised November 21, 2014



Institutional coverage for individuals eligible under a MAGI based program

With the exception of N21 and N25 (both AEM), all MAGI based/N track programs determined by the Health Benefit Exchange (HBE) provide nursing facility coverage or Medicaid Personal Care (MPC) coverage if functionally eligible.

Individuals on MAGI based N track programs do not pay participation toward the cost of care.

For individuals needing services in a medical institution such as a hospital, nursing facility or Children's Long-term Inpatient Program (CLIP) and are not eligible for a MAGI based program determined by the HBE (N track) because income is over the standard, there is an institutional medical program called MAGI-based long term care program.  In ACES this program is under the  K track. 

This program uses MAGI income and resource methodology. 

The eligibility for this program is determined by the DDA-LTC Specialty Unit.   

Eligibility for this program is described below.


182-514-0230 Washington apple health—MAGI-based long-term care program.
182-514-0235 Definitions.
182-514-0240 Washington apple health -- General eligibility requirements for MAGI-based long-term care program.
182-514-0245 Washington apple health—Resource eligibility for MAGI-based long-term care program.
182-514-0250 Washington apple health—MAGI-based long-term care program for adults age twenty-one or older.
182-514-0255 Washington apple health -- MAGI-based long-term care program for young adults nineteen and twenty years of age.
182-514-0260 Washington apple health -- MAGI-based long-term care coverage for children eighteen years of age or younger.
182-514-0265 Washington apple health -- How the agency or its designee determines how much of an institutionalized person's income must be paid towards the cost of care for the MAGI-based long-term care program.
182-514-0270 When an involuntary commitment to Eastern or Western State Hospital is covered by medicaid.

How does a person become eligible for WAH MAGI-based long term care? (K track/K01)

The person must meet institutional status by residing in an institution for 30 days or longer.  For the Department to use institutional rules in a hospital setting, the client must have been in the facility continuously for 30 days.  If a client discharges from hospital to a nursing home with no break, the hospital days count towards the 30 day limit. Individuals admitted to a nursing facility must meet nursing facility level of care but a Home and Community Services social worker will not be involved in doing an assessment for someone who is eligible under a MAGI-based program.   

For children under the age of 18 entering a psychiatric facility, the child must be admitted for a minimum of 90 days.


How do I apply for WAH MAGI-based long-term care (K track/K01)?

Option 1:

Apply online at the Washington healthplanfinder website.  On the Additional Screening Questions page, answer yes to question that asks if anyone in the household needs long-term care and indicate that you or the applicant is residing in a hospital or other facility setting.

 

For hospitals applying on behalf of a patient:

 

Send a follow-up email to K01Applications@dshs.wa.gov and provide the following information:

·         Name of the Head of household and DOB.

·         Name and DOB of the child applying.

·         Date admitted to the hospital and date expected to discharge (if known).

·         Your contact information

·         Signed client release or AREP form if the client wants DSHS to be able to discuss the application with you.    

Note:  By submitting the online application DSHS can ensure that coverage is looked at for all household members and enables us to open continued coverage for the child at discharge.   If the child is eligible for MAGI medicaid in the Washington Healthplanfinder, no additional information is needed.

Option 2:

Mail a completed HCA 18-001 form to PO Box 45826, Olympia, WA 98504 along with the attached cover sheet so the HCS imaging unit knows to assign the application to the DDA-LTC specialty unit.  This will ensure that applications are sent directly to the unit so processing can be expedited.  These applications are also forwarded to the Health Benefit Exchange (HBE) to ensure medicaid is considered for all household members.

 

Note:  Do not mail applications or fax applications to the CSD imaging unit.  HCA 18-001 applications that are sent to the Community Services Division and not to HCS are sent directly to the Health Benefit Exchange for processing and are not imaged to the LTC specialty unit to work.

 

Option 3:

1-855-635-8305 is a direct fax number to the HCS imaging hub.   Fax the HCA 18-001 application with a K01 cover sheet directly to our imaging hub for processing (we will forward to the Health Benefit Exchange as well).


Cover sheet used by Hospitals and medical institutions when referring a K01 application to the DDA LTC Specialty Unit

Hospitals and other medical institutions need to cut/paste the following text into a word document and attach a cover sheet to accompany all HCA 18-001 applications applying for the MAGI-based long term care program (K track in ACES).  The 18-001 is found on the forms menu.

The cover sheet will ensure the 18-001 gets assigned to the DDA LTC specialty unit. 

 

K01 COVER SHEET

(to accompany 18-001 applications)

TO: HCS HIU (HOTMAIL)

Mail to: PO BOX 45826, OLYMPIA, WA 98504 

Or fax to: 1-855-635-8305

 

DATE:

CLIENT NAME (CHILD):

 

PLEASE FORWARD APPLICATION TO HEALTHPLANFINDER AND FORWARD ASSIGNMENT IN DMS TO THE LONG TERM CARE SPECIALTY UNIT (@LTC/157)


What about citizenship – is this program just for US citizens?

US citizens and US nationals and non-citizens who are lawfully admitted for permanent residence who

have met the 5 year ban are eligible.   Children under the age of 19 may be eligible without regard to

citizenship.  Non citizen children are not eligible for coverage under the medically needy (MN) program,

only the categorically needy (CN) program. 

Adults may qualify under the Alien Emergency Medical (AEM) K03 program if they meet the requirements under the acute and emergent criteria for inpatient hospitalization. 

A non-citizen adult who needs placement into a nursing home may be eligible under the K03 program if they meet the following criteria:  

 

·         They meet the nursing facility level of care based on an assessment by the department’s social worker; and

·         Prior authorization is requested from the Karen LaBonte - program manager at Home & Community Services responsible for the state funded nursing facility program; and

·         There is a funding available within the allocated funds for the program.


Whose income is counted?

Once the client has met the 30 day (or 90 days for psychiatric inpatient) requirement, only the income of the institutionalized person is counted.  For adults, this means we do not look at the income of their spouse when we determine.  For children, we do not look at the income of their parents but do count any income they get in their own name, including social security income or other MAGI-based income received by the child.


What is the maximum income limit?

This is dependent upon the age of the client.   See below:

  • Children age 20 and younger - 210% of the FPL (federal poverty level).
  • Adults 21 and older - 133% FPL.

 


What if income is over the CN standard – is medically needy coverage available?

Medically needy (MN) coverage is available for children and adults through the age of 21.  There is no

MN coverage for adults over the age of 21 (unless the client is already in treatment in an inpatient

psychiatric facility in which case they remain eligible until they discharge or turn 22, whichever occurs first.


What about assets? Is there a resource limit?

There is no asset test.

Note:  WAC 182-514-0245 will be amended once written guidance from Centers for Medicare and Medicaid Services (CMS) is received.  Based on verbal guidance, there currently is no asset test for MAGI-based long-term care programs. 


When would we look at K01 (institutional medical) for adults? I thought this was just for children?

We can use K01 for an adult if they meet the following criteria and the individual is not eligible for MAGI

based N track medical through the HBE:

 

  • They must have been hospitalized or reside in a medical facility for 30 days or longer
  • Their individual net countable income is below 133% FPL per month.
  • They do not have to meet disability criteria for the K01 program. 

 

 

 


What about long term psychiatric treatment?

Adults between the age of 21 and 65 are not eligible for Medicaid if they are admitted to a long term psychiatric treatment program at Western or Eastern State hospital.  Children and adults under the age of 21 do qualify for Medicaid coverage for inpatient psychiatric treatment.  If the client is in treatment and turns 21 at the facility, they can stay open on Medicaid until they discharge or until they turn 22 whichever happens first.  (Adults age 65 and older may also qualify for Medicaid under the SSI-related long-term care program).


How long does eligibility last?

K01 is categorically needy medical coverage (CNP) and is initially approved with a 12 month

certification.  Children under the age of 19 remain continuously eligible for the full 12 months even if they

discharge from the facility.  Non-institutional MAGI- based health care coverage should be opened for

any remaining months of the certification period.  Adults age 19 or older will have eligibility re-determined

when they leave the facility. 


What happens if the family is over income at the time of renewal?

If a child discharges from a medical facility and has already been approved under the K01 program, the

LTC specialty unit will change this to a children’s medical program at discharge without the requirement

to submit a review.  They will get the balance of their certification under the CN medical program.  If the

review is due after their discharge and the family is over income for a non-institutional medical program,

the family may choose to have a medically spenddown case or enroll the child into a qualified health plan

through the Health Benefit Exchange if eligible.


What happens when the renewal has not been sent back?

If a required renewal is due and the client fails to follow through with the process, the case will be closed.


What about post-eligibility? Does the client have to pay towards the cost of care?

MAGI-based long-term care clients do not pay toward the cost of care.   

 

Note:  WAC 182-514-0265  will be amended once written guidance from Centers for Medicare and Medicaid Services (CMS) is received.  Based on verbal guidance, there currently is no post eligibility treatment of income (PETI), in Washington called participation for MAGI-based long-term care programs.


What else should I be aware of?

The client may be subject to Estate Recovery provisions for long-term care services received. .

If a child is eligible under the premium based Apple Health for Kids program, the department re-determines eligibility under K01 so that they do not pay a premium and may get a year of CN coverage.       

 


Is an institutional award letter issued for MAGI based programs?

For MAGI-based programs determined by the HBE , (N track programs in ACES), no institutional award letter is issued.

For nursing facilities and hospitals, these are paid as a claim through Provider One.

For MAGI-based programs through the K track program, an institutional award letter will be issued by the DDA LTC specialty unit.


Washington Apple Health Managed Care and LTC:  scroll to:  Nursing Home Admissions under a modified adjust gross income (MAGI) medical group.  


Does MAGI-based Washington Apple Health cover services outside of a medical institution?

Yes.  Individuals that are eligible for MAGI-based medical determined by the Health Benefit Exchange (HBE) can receive Medicaid Personal Care (MPC) authorized by Home and Community Services (HCS) or Developmental Disabilities Administration (DDA) if functionally eligible.

Medicaid Personal Care

MAGI-based programs are not an eligibility group in Home and Community Based (HCB) Waivers authorized by HCS or DDA, therefore individuals needing services under a HCB Waiver must be determined eligible based on Chapter 182-515 WAC and must submit an HCA 18-001 plus a HCA 18-005 in order to be considered for a HCB Waiver. 


Desk Tool Charts

Insert PDF Medical program chart and LTC here

Insert PDF ACES codes for MPC here

Modification Date: November 21, 2014