Medical Assistance - Adult Medical
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Medical Assistance - Adult Medical


Revised November 14, 2013



Purpose: This section provides information about medical programs for adults who do not qualify for family medical programs.

WAC 182-508-0001Washington apple health -- Coverage options for adults not eligible under modified adjusted gross income (MAGI) methodologies.

IMPORTANT NOTE

   

On October 1, 2013, the new MAGI methodology replaced the legacy Medicaid net income methodology for determining eligibility for the MAGI-based Family, Pregnant Women, and Child medical programs. MAGI methodology follows Internal Revenue Service (IRS) rules for counting income -- in other words, if it is included in adjusted gross income (AGI), it is countable income -- with certain exceptions.

In addition, on October 1, 2013, the new Adult medical program started to accept applications for coverage to begin on January 1, 2014, using the MAGI methodology.

Please see the ACA Transition Plan for more information.

If you have clients who wish to apply for the MAGI-based Family, Pregnant Women, Child, or Adult medical programs, they can apply in the following ways:

Washington Healthplanfinder
PO Box 946
Olympia, WA 98507

Clients who have questions regarding their eligibility for MAGI-based medical assistance should call the Medical Eligibility Determination Service at the Health Care Authority at 1-855-923-9357. Clients who have questions about applying online for MAGI-based medical assistance should call the Health Benefit Exchange at 1-855-923-4633.

While the WACs on this page have been updated (or noted as repealed where applicable) effective October 1, 2013, the Clarifying Information below does not reflect the new Adult medical program.

 



WAC 182-508-0001

WAC 182-508-0001

Effective October 1, 2013

WAC 182-508-0001 Washington apple health -- Coverage options for adults not eligible under modified adjusted gross income (MAGI) methodologies.



(1) This chapter provides information on eligibility determinations for adults who:

(a) Need a determination of eligibility on the basis of being aged, blind, or disabled;

(b) Need a determination of eligibility based on the need for long-term institutional care or home and community based services;

(c) Are excluded from coverage under a modified adjusted gross income (MAGI)-based program as referenced in WAC 182-503-0510 on the basis of medicare entitlement;

(d) Are not eligible for health care coverage under Chapter 182-505 WAC due to citizenship or immigration requirements; or

(e) Are not eligible for health care coverage under Chapter 182-505 WAC due to income which exceeds the applicable standard for coverage.

(2) The agency determines eligibility for Washington apple health (WAH) non-institutional categorically needy (CN) coverage under Chapter 182-512 WAC for an adult who is age sixty-five or older, or who meets the federal blind or disabled criteria of the federal SSI program, and:

(a) Meets citizenship/immigration, residency, and Social Security number requirements as described in Chapter 182-503 WAC ; and

(b) Has CN countable income and resources that do not exceed the income and resource standards in WAC 182-512-0010.

(3) The agency determines eligibility for WAH health care for workers with disabilities (HWD) CN coverage for adults who meet the requirements described in WAC 182-511-1050, as follows:

(a) Are age sixteen through sixty-four, and

(b) Meet citizenship/immigration, residency, and Social Security number requirements as described in Chapter 182-503 WAC;

(c) Meet the federal disability requirements described in WAC 182-511-1150;

(d) Have net income that does not exceed the income standard described in WAC 182-511-1060; and

(e) Are employed full or part time (including self-employment) as described in WAC 182-511-1200.

(4) The agency determines eligibility for WAH long-term care CN coverage for adults who meet the institutional status requirements defined in WAC 182-513-1320 under the following rules:

(a) When the person receives coverage under a MAGI-based program and needs long-term care services in an institution, the agency follows rules described in Chapter 182-514 WAC.

(b) When the person meets aged, blind, or disabled criteria as defined in WAC 182-512-0050 and needs long-term care services, the agency follows rules described in:

(i) Chapter 182-513 WAC for an adult who resides in an institution; and

(ii) Chapter 182-515 WAC for an adult who is determined eligible for WAH home and community based waiver services.

(5) The agency determines eligibility for WAH non-institutional CN or medically needy (MN) health care coverage for an adult who resides in an alternate living facility under rules described in WAC 182-513-1305.

(6) The agency determines eligibility for WAH CN coverage under institutional rules described in Chapters 182-513 WAC and 182-515 WAC for an adult who :

(a) Has made a voluntary election of hospice services; and

(b) Is not otherwise eligible for non-institutional CN or MN health care coverage or for whom hospice is not included in the benefit service package available to the person, and

(c) Meets the aged, blind, or disabled criteria described in WAC 182-512-0050.

(7) The agency uses the following rules to determine eligibility for an adult under the WAH MN program:

(a) Non-institutional WAH MN is determined under Chapter 182-519 WAC for an adult with countable income that exceeds the applicable CN standard.

(b) WAH MN long term care coverage is determined under WAC 182-514-0255 for an adult age nineteen or twenty who:

(i) Meets institutional status requirements described in WAC 182-513-1320;

(ii) Does not meet blind or disabled criteria described in WAC 182-512-0050, and

(iii) Has countable income that exceeds the applicable CN standard.

(c) WAH MN long term care coverage is determined under WAC 182-513-1395 for an aged, blind, or disabled adult who resides in an institution and has countable income that exceeds the special income level (SIL).

(8) An adult is eligible for WAH MN coverage when he or she:

(a) Meets citizenship/immigration, residency, and Social Security number requirements as described in WAC 182-503-0505; and

(b) Has MN countable income that does not exceed the effective MN income standards in WAC 182-519-0050, or meets the excess income spenddown requirements in WAC 182-519-0110; and

(c) Meets the countable resource standards in WAC 182-519-0050; and

(d) Is sixty-five years of age or older or meets the blind or disabled criteria of the federal SSI program.

(9) WAH MN coverage is available for an aged, blind, or disabled ineligible spouse of an SSI recipient. See WAC 182-519-0100 for additional information.

(10) An adult who does not meet citizenship or alien status requirements described in WAC 182-503-0535 may be eligible for the WAH alien emergency medical program as described in WAC 182-507-0110.

(11) An adult is eligible for the state-funded medical care services (MCS) program when the he or she meets the requirements under WAC 182-508-0005.

(12) A person who is entitled to Medicare is eligible for coverage under a Medicare Savings Program or the state-funded buy-in program when he or she meets the requirements described in Chapter 182-517 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.

CLARIFYING INFORMATION

  1. For working age adults (18 - 64) with disabilities who are working and have income and/or resources that exceed other SSI-related program requirements, an additional Categorically Needy eligibility group (S08) is available when net income does not exceed the 220% federal poverty level. See Healthcare for Workers with Disabilities (HWD). HWD may also be used to access most waiver programs administered by the ADSA Divisions of Developmental Disabilities and Home and Community Services when all other requirements are met.   

  2. There is no AFDC or TANF related Medically Needy program for adults. CSO staff may encounter an inappropriate MN option prompted by ACES. Such a prompt should be disregarded for adults not related to TANF or SSI.

  3. Clients eligible for the ABD program have the same CN medical coverage as SSI related clients while their determination for SSI eligibility is pending at the Social Security Administration.

  4. When clients lose SSI medical (S01) because their SSI cash stops due to the seven year rule (non-citizen clients may receive SSI cash for a maximum of 7 years), their eligibility for other medical programs must be determined before their medical is terminated.

  5. See SCOPE OF CARE for listings of medical services available to recipients of specific adult medical programs.

  6. For information on the Refugee Medical program see REFUGEE.

  7. The ALIEN EMERGENCY MEDICAL program requires an emergency medical condition or need. See EMERGENCY ASSISTANCE - MEDICAL for more information.

  8. There are special programs (e.g., kidney centers and AIDS insurance program) for which an adult may be eligible. For the Kidney Disease Program see WAC 388-540. For the AIDS insurance program see THIRD PARTY LIABILITY.


WORKER RESPONSIBILITIES

1.      Determine eligibility for federally-funded programs before considering a state-funded program. The order is as follows:

a.       Categorically Needy

b.      Medically Needy

c.       Alien emergency medical

d.       State-funded medical (MCS, ADATSA).

2.      Continue SSI medical (S01) for clients who have lost their SSI cash payments due to the seven year rule (non-citizens may only receive SSI cash for up to 7 years) until their eligibility for other medical programs is determined.  Clients are sent an eligibility review from state office.  Follow these steps:

a.       If the eligibility review is not returned, close the AU making sure to follow 10 day advance and adequate notice rules.

b.      If the eligibility review is returned and the client wants:

  1. Medical only, check the disability review end date, and 

A.    If the date is in the future and the client meets the eligibility requirements for SSI-related (S02) medical, open that program with a review end date matching the month of the disability end review date.

B.     If the date is due or there is no end date, send a review referral to Social Services for a non-grant medical assistance (NGMA) review by DDDS.  See subsection #3 below.

  1. Both cash and medical, and the client appears eligible for ABD, open an ABD  AU.  Code the ACES DEM2 screen Disability/Incapacity type "D" (or "A", if the client is 65 or older) and code the Approval Source:

A.    "OP" for a 3 month certification, pending a DDDS disability decision, or

B.     "OI" or "OW" if the future disability review end date is known.

C.     Encourage the client to apply for citizenship, since the SSI can be reopened if the client is a citizen and aged or remains disabled.  SSI is more beneficial to the client than DL-U; the client receives more cash and receives CN Medicaid.

3.      Review the application to determine if a potential disability is claimed.

a.       Refer for a disability determination if the client has claimed to have a disability or health problems that limit their ability to work. See instructions that follow examples below when initiating the referral.

b.      Don’t refer for a disability determination based solely on unpaid medical bills or when no disability or health problems are claimed.

 


EXAMPLE

Emerald applied for food and medical benefits. She indicated a medical emergency on her application, and explained at her financial interview that she had gone to the emergency room after falling off a ladder and now has a large hospital bill.  The ER took X-rays, stitched up a gash, and kept her overnight for observation. Emerald states she is feeling fine now and has returned to work without any problem. Don’t refer for disability determination.


EXAMPLE

Gregory applied for medical benefits. He did not list a disability but he did mark that he was unable to work because of a health problem. Refer for a disability determination.


EXAMPLE

Bethany applied for food and medical benefits. At her interview she states she is currently working, but has not been feeling well for a while now. Bethany states she is now missing work because of her health. Refer for a disability determination.


4.   Initiate a disability determination referral if appropriate. See the "Worker Responsibilities" section
      that follows WAC 388-475-0150 and the NGMA Section of the Social Services Manual

  1. A disability referral is not appropriate if the client is already eligible for SSI or SSA due to a disability. Do not make a referral; refer to CN medical instructions.
  2. A disability referral is not appropriate if the client has a disability determination referral pending.

5.      Pend the application for 30 days and inform the client that a determination may take up to 60 days.

6.   Take immediate action on the determination decision (DSHS 14-144(X). Social Services return the financial worker's copy as soon as it is received. The DSHS 14-144(X) is the Transmittal Summary and Disability Determination Notice issued by the Division of Disability Determination Services (DDDS).

 
Modification Date: November 14, 2013