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


Revised February 10, 2014



WAC 182-514-0230Washington apple health—MAGI-based long-term care program.
WAC 182-514-0235Definitions.
WAC 182-514-0240Washington apple health -- General eligibility requirements for MAGI-based long-term care program.
WAC 182-514-0245Washington apple health—Resource eligibility for MAGI-based long-term care program.
WAC 182-514-0250Washington apple health -- MAGI-based long-term care program for adults age twenty-one or older.
WAC 182-514-0255Washington apple health -- MAGI-based long-term care program for young adults nineteen and twenty years of age.
WAC 182-514-0260Washington apple health -- MAGI-based long-term care coverage for children eighteen years of age or younger.
WAC 182-514-0265Washington 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.
WAC 182-514-0270When an involuntary commitment to Eastern or Western State Hospital is covered by medicaid.

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.


WAC 182-514-0230

WAC 182-514-0230

Effective October 1, 2013

WAC 182-514-0230 Washington apple health—MAGI-based long-term care program.



(1) The sections that follow describe the eligibility requirements for the Washington apple health (WAH) modified adjusted gross income (MAGI)-based long-term care program for children and adults who are admitted for a long-term stay to a medical institution, an inpatient psychiatric facility or an institution for mental diseases (IMD):

(a) WAC 182-514-0235 Definitions;

(b) WAC 182-514-0240 General eligibility requirements for the WAH MAGI-based long-term care program;

(c) WAC 182-514-0245 Resource eligibility for WAH MAGI-based long-term care program;

(d) WAC 182-514-0250 WAH MAGI-based long-term care programs for adults twenty-one years of age or older;

(e) WAC 182-514-0255 WAH MAGI-based long-term care program for young adults nineteen and twenty years of age;

(f) WAC 182-514-0260 WAH MAGI-based long-term care program for children eighteen years of age or younger;

(g) WAC 182-514-0265 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 WAH MAGI-based long-term care program; and

(h) WAC 182-514-0270 When an involuntary commitment to Eastern or Western State Hospital is covered by Washington apple health.

(2) Recipients of a noninstitutional WAH children's program as described in WAC 182-505-0210 or 182-505-0211 do not need to submit a new application for long-term care coverage when admitted to an institution. The agency or its designee treats the admittance to the institution as a change of circumstances and determines eligibility based upon the anticipated length of stay.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.
WAC 182-514-0235
WAC 182-514-0235

Effective October 1, 2013

WAC 182-514-0235 Definitions.



The following terms are used in WAC 182-514-0230 through 182-514-0270:

"Categorically needy (CN) medical" - Full scope of care medical benefits. CN medical may be either federally funded under Title XIX of the Social Security Act or state-funded.

"Federal benefit rate (FBR)" - The payment standard set by the Social Security administration for recipients of supplemental security income (SSI). This standard is adjusted annually in January. Institutional standards and effective date can be found at: http://www.dshs.wa.gov/manuals/eaz/sections/LongTermCare/LTCstandardspna.shtml.

"Federal poverty level" - The income standards published annually by the federal government in the Federal Register found at http://aspe.hhs.gov/poverty/index.shtml. Institutional standards and effective date can be found at: http://www.dshs.wa.gov/manuals/eaz/sections/LongTermCare/LTCstandardspna.shtml.

"Legal dependent" - A minor child, seventeen years of age and younger, and an individual eighteen years of age and older claimed as a dependent for income tax purposes; or a parent of either the applicant or the applicant's spouse claimed as a dependent for income tax purposes; or the brother or sister (including half and adoptive siblings) claimed by either the applicant or the applicant's spouse as a dependent for income tax purposes.

"Medical institution" See WAC 182-500-0050.

"Medically needy income level (MNIL)" - The standard used by the agency to determine eligibility under the medically needy medicaid program. The effective MNIL standards are described in WAC 182-519-0050.

"Medically needy (MN)" See WAC 182-500-0070.

"Personal needs allowance (PNA)" - An amount designated to cover the expenses of an individual's clothing and personal incidentals while living in a medical institution, inpatient psychiatric facility, or institution for mental diseases. PNA standards are found at: http://www.dshs.wa.gov/manuals/eaz/sections/LongTermCare/ltcstandardsPNAchartsubfile.shtml.

"Spenddown" See WAC 182-500-0100.

"Title XIX" See WAC 182-500-0105.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.
WAC 182-514-0240
WAC 182-514-0240

Effective October 1, 2013

WAC 182-514-0240 Washington apple health -- General eligibility requirements for MAGI-based long-term care program.



(1) This section applies to applicants for long-term care services under the Washington apple health (WAH) MAGI-based longterm care program. Additional rules may apply based upon a person's age at the time he or she applies for long-term care services and whether the facility the person is admitted to is a medical institution, inpatient psychiatric facility, or an institution for mental diseases (IMD). Additional rules are described in WAC 182-514-0245 through 182-514-0265.

(2) The following requirements apply to be eligible for WAH MAGI-based long-term care coverage under this section:

(a) Institutional status described in WAC 182-513-1320. A person meets institutional status if he or she is admitted to:

(i) A medical institution and resides, or is likely to reside, there for thirty days or longer, regardless of age;

(ii) An inpatient psychiatric facility or IMD and resides, or is likely to reside, there for thirty days or longer and is eighteen through twenty years of age; or

(iii) An inpatient psychiatric facility or IMD and resides, or is likely to reside, there for ninety days or longer and is seventeen years of age or younger.

(b) General eligibility requirements described in WAC 182-503-0505 (with the exception that subsections (3)(c) and (d) of that section do not apply to noncitizen applicants who are eligible under one of the WAH alien medical programs described in chapter 182-507 WAC) and the person meets one of the following:

(i) Be a child and meet the program requirements under WAH for kids as described in WAC 182-505-0210. For the purposes of this section, a person is considered a child through the age of twenty-one;

(ii) Be an adult nineteen through sixty-four years of age who meets the criteria in WAC 182-505-0250;

(iii) Be pregnant and meet the program requirements for the WAH pregnancy program as described in WAC 182-505-0115;

(iv) Meet the WAH alien medical program requirements as described in WAC 182-507-0110 (with the exception that for MAGI-based long-term care services, alien medical coverage may be authorized for children through twenty-one years of age) and:

(A) Have a qualifying emergency condition; and

(B) For payment for long-term care services and room and board costs in the institution, request prior authorization from the aging and long-term support administration (ALTSA) if the person is admitted to a nursing facility.

(c) Have countable income below the applicable standard described in WAC 182-514-0250(4), 182-514-0255(3), or 182-514-0260(4);

(d) Contribute income remaining after the post eligibility process described in WAC 182-514-0265 towards the cost of care in the facility, if applicable; and

(e) Be assessed as needing nursing facility level of care as described in WAC 388-106-0355 if the admission is to a nursing facility. (This does not apply to nursing facility admissions under the hospice program.)

(3) Once the agency or its designee determines a person meets institutional status, it does not count the income of parent(s), a spouse, or dependent child(ren) when determining countable income. Only income received by the person in his or her own name is counted for the initial eligibility determination.

(4) A person who is not a United States citizen or a qualified alien does not need to provide or apply for a Social Security number or meet the citizenship requirements under WAC 182-503-0535 as long as the requirements in subsection (2) of this section are met.

(5) A person who meets the federal aged, blind or disabled criteria may qualify for institutional benefits with income of up to three hundred percent of the federal benefit rate (FBR). Rules relating to institutional eligibility for an aged, blind or disabled person are described in WAC 182-513-1315.

(6) If a person does not meet institutional status, the agency or its designee determines his or her eligibility for a noninstitutional WAH medical program. A person who is determined eligible for CN or medically needy (MN) coverage under a noninstitutional program who is admitted to a nursing facility for less than thirty days is approved for coverage for the nursing facility room and board costs, as long as the person is assessed by ALTSA as meeting nursing home level of care as described in WAC 388-106-0355.

(7) Parents and caretaker relatives who meet the criteria under WAC 182-505-0240 are not eligible for the WAH MAGI-based long-term care program and must have eligibility determined under SSI-related institutional rules described in chapter 182-513 WAC.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.
WAC 182-514-0245
WAC 182-514-0245

Effective October 1, 2013

WAC 182-514-0245 Washington apple health—Resource eligibility for MAGI-based long-term care program.



(1) There is no resource test for applicants or recipients of the Washington apple health (WAH) modified adjusted gross income (MAGI)-based long-term care program.

(2) The transfer of asset evaluation described in WAC 182-513-1363 does not apply to applicants or recipients who are eligible under the WAH MAGI-based long-term care program.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.
WAC 182-514-0250
WAC 182-514-0250

Effective October 1, 2013

WAC 182-514-0250 Washington apple health -- MAGI-based long-term care program for adults age twenty-one or older.



(1) A person twenty-one years of age or older must meet the requirements in WAC 182-505-0250 to qualify for Washington apple health (WAH) modified adjusted gross income (MAGI)-based long-term coverage under this section.

(2) The categorically needy income level (CNIL) for health care coverage under this section is one hundred thirty-three percent of federal poverty level. A person's countable income (after a standard five percentage point income disregard) must be at or below this amount to be eligible.

(3) Countable income for categorically needy (CN) coverage under this section is determined using the MAGI methodologies described in chapter 182-509 WAC.

(4) If the person's income exceeds the standards to be eligible under the WAH MAGI-based CN long-term care program, he or she is not eligible for medically needy coverage under this section.

(5) A person, age twenty-one through sixty-four years of age who is admitted to an institution for mental diseases (IMD) is not eligible for coverage under this section.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.
WAC 182-514-0255
WAC 182-514-0255

Effective October 1, 2013

WAC 182-514-0255 Washington apple health -- MAGI-based long-term care program for young adults nineteen and twenty years of age.



(1) Persons nineteen and twenty years of age must meet the requirements in WAC 182-505-0210 to qualify for the Washington apple health (WAH) modified adjusted gross income (MAGI)-based long-term care program.

(2) The categorically needy income level (CNIL) is two hundred ten percent of the federal poverty level. A person's countable income (after a standard five percentage point income disregard) must be at or below this amount to be eligible.

(3) Countable income for categorically needy (CN) coverage under this section is determined using the MAGI methodologies described in chapter 182-509 WAC.

(4) The agency or its designee approves CN health care coverage under this section for twelve calendar months.

(5) If a person's countable income exceeds the standard described in subsection (3) of this section, the agency or its designee determines whether the person is eligible for coverage under the WAH institutional medically needy (MN) program.

(6) If the person is a medicaid applicant or recipient in the month of his or her twenty-first birthday and receives active inpatient psychiatric or inpatient chemical dependency treatment which extends beyond his or her twenty-first birthday, the agency or its designee approves or continues WAH CN or MN health care coverage until the date the person is discharged from the facility or until his or her twenty-second birthday, whichever occurs first.

(7) Young adults eligible under the provisions of this section may be required to contribute a portion of their income towards the cost of care as described in WAC 182-514-0265.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.
WAC 182-514-0260
WAC 182-514-0260

Effective October 1, 2013

WAC 182-514-0260 Washington apple health -- MAGI-based long-term care coverage for children eighteen years of age or younger.



(1) Children eighteen years of age or younger must meet the requirements in WAC 182-514-0240 to qualify for the Washington apple health (WAH) modified adjusted gross income (MAGI)-based long-term care program.

(2) When a child eighteen years of age or younger is eligible for the premium-based WAH for kids program as described in WAC 182-505-0210, the agency or its designee redetermines his or her eligibility using the provisions of this section so that the child's family is not required to pay the premium.

(3) The categorically needy income level (CNIL) for WAH long-term care coverage under this section is two hundred ten percent of the federal poverty level (after a standard five percentage point income disregard).

(4) Countable income for categorically needy (CN) coverage under this section is determined using the MAGI methodologies described in chapter 182-509 WAC.

(5) The agency or its designee approves CN health care coverage under this section for twelve calendar months. If the child is discharged from the facility before the end of his or her certification period, the child remains continuously eligible for CN health care coverage through the end of the original certification date, unless he or she ages out of the program, moves out of state, is incarcerated, or dies.

(6) If a child is not eligible for CN health care coverage under this section, the agency or its designee determines the child's eligibility for health care coverage under the WAH institutional medically needy (MN) program described in WAC 182-513-1395.

(7) MN coverage is only available for a child who meets the citizenship requirements under WAC 182-503-0535.

(8) The facility where the child resides may submit an application on the child's behalf and may act as an authorized representative if the child is:

(a) In a court ordered, out-of-home placement under chapter 13.34 RCW; or

(b) Involuntarily committed to an inpatient treatment program by a court order under chapter 71.34 RCW.

(9) Children who are eligible for WAH MAGI-based long-term care coverage under the provisions of this section may be required to contribute a portion of their income towards the cost of care as described in WAC 182-514-0265.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.
WAC 182-514-0265
WAC 182-514-0265

Effective October 1, 2013

WAC 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.



(1) A person who resides in a medical institution, inpatient psychiatric facility, or an institution for mental diseases (IMD) may be required to pay a portion of their income towards the cost of care. This section explains how the agency or its designee calculates how much a person pays to the facility under the Washington apple health (WAH) modified adjusted gross income (MAGI)-based long-term care program. This process is known as the post-eligibility process. If a person does not have income, he or she does not have to pay.

(2) The agency or its designee determines available income by considering a person's total gross income before any mandatory deductions from earnings. Income that was not counted in the initial eligibility process under the MAGI methodology is counted for the post-eligibility process unless the income is excluded under WAC 182-513-1340.

(3) The following income allocations and exemptions are deducted from the person's total gross income to determine his or her available income. The agency or its designee uses the rules described in WAC 182-513-1380 to calculate the amount of these allocations and exemptions, with the exception that the deduction of wages stated in WAC 182-513-1380 (4)(c) is not allowed.

(a) A personal needs allowance (PNA) and maintenance allocation. The combined totals of all of the following deductions cannot exceed the medically needy income level (MNIL):

(i) PNA as allowed under WAC 182-513-1300;

(ii) Mandatory federal, state, or local income taxes owed by the person; and

(iii) Court ordered guardianship fees and administrative costs, including attorney fees, as described in chapter 388-79 WAC.

(b) Income garnished to comply with a court order for child support.

(c) Community spouse allocation.

(d) Family maintenance allocation if married with dependents.

(e) Legal dependent allocation for an unmarried person with dependents. The maximum allocation is based upon the MNIL standard for the number of dependents minus the dependent's income.

(f) Medical expense allocation. The agency or its designee allows a deduction for unpaid medical expenses for which the individual is still liable. Medical expenses allowed for this allocation are described in WAC 182-513-1350.

(g) Housing maintenance exemption:

(i) A person who is financially responsible for the costs of maintaining a home while he or she is in an institution is allowed a deduction, limited to a six-month period, of up to one hundred percent of the one-person poverty level per month, when a physician has certified that the person is likely to return to the home within the six-month period.

(ii) A person eighteen years of age or younger is not eligible for the housing maintenance exemption unless the housing expense is the person's financial responsibility. Children are not financially responsible for the housing expenses incurred by their parents.

(4) A person may keep a personal needs allowance of up to the effective MNIL in the month he or she admitted and in the month the person discharged from the facility. See WAC 182-519-0050 for the effective MNIL standards.

(5) Any income remaining is called the person's responsibility toward the cost of care and must be paid to the facility. This amount is also called the person's participation.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.
WAC 182-514-0270
WAC 182-514-0270

Effective October 1, 2013

WAC 182-514-0270 When an involuntary commitment to Eastern or Western State Hospital is covered by medicaid.



(1) A person who is admitted to Eastern or Western State Hospital for inpatient psychiatric treatment is eligible for categorically needy (CN) health care coverage in limited circumstances.

(2) To be eligible under this program, a person must:

(a) Be twenty years of age or younger, or sixty-five years of age or older;

(b) Meet institutional status under WAC 182-513-1320;

(c) Be involuntarily committed to an inpatient treatment program by a court order under chapter 71.34 RCW;

(d) Have countable income below:

(i) Two hundred ten percent of the federal poverty level if age twenty years or younger; or

(ii) The SSI-related CN income level if age sixty-five years or older and have countable resources below the standard described in WAC 182-512-0010.

(3) A person who receives active psychiatric treatment in Eastern or Western State Hospital at the time of his or her twenty-first birthday continues to be eligible for CN health care coverage until the date he or she is discharged from the facility or until the person's twenty-second birthday, whichever occurs first.

(4) A person between the age of twenty-one and sixty-five, with the exception of subsection (3) of this section, is not eligible for federally funded health care coverage through Washington apple health.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

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: February 10, 2014