Program Summary - Medical Programs
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Program Summary - Medical Programs

Revised April 22, 2013

Purpose: This section describes the eligibility requirements for the various medical programs and coverage administered by the department.
WAC 182-503-0505General eligibility requirements for medical programs.
WAC 182-503-0510How a client is determined "related to" a categorical program.
WAC 182-505-0515Medical coverage resulting from a cash grant
WAC 182-508-0005Eligibility for medical care services.

The Health Care Authority (HCA) provides a wide range of medical services based upon a client's circumstances and needs. Not all eligibility groups receive the same range of services. The differences in coverage are displayed in the SCOPE OF CARE category of this manual.

For a comprehensive Medical Assistance Eligibility Overview, you can visit the HCA Eligibility webpage and choose either the Internet-based manual or the PDF version.

The following programs are described briefly in this summary:

Coverage or medical benefits are least restricted under the Medicaid - Categorically Needy (CN) program. "Medicaid" is the federal name for the state and federal funded medical benefit program.

The agency considers a client's application for the least restrictive coverage first and then considers programs in order down to the most restrictive coverage. Most often this meets the program's intent of considering federally-funded programs before state-funded programs. However, there are instances where a client can receive state-funded coverage for brief periods to obtain certain services and be reverted back to the federally-funded program after the special coverage need has been met.


WAC 182-503-0505

WAC 182-503-0505

Effective July 1, 2012

WAC 182-503-0505 General eligibility requirements for medical programs.

  1. Persons applying for benefits under the medical coverage programs established under chapter 74.09 RCW must meet the eligibility criteria established by the department in chapters 388-400 through 388-555 WAC. 

  2. Persons applying for medical coverage are considered first for federally funded or federally matched programs. State-funded programs are considered after federally funded programs and are not available to the client except for brief periods when the state-funded programs offer a broad scope of care which meet a specific client need.

  3. Unless otherwise specified in program specific WAC, the eligibility criteria for each medical program is as follows:

    1. Verification of age and identity (chapters 388-404, 388-406, and 388-490 WAC); and

    2. Residence in Washington state (chapter 388-468 WAC); and

    3. Citizenship or immigration status in the United States (chapter388-424 WAC); and

    4. Possession of a valid Social Security Account Number (chapter 388-476 WAC); and

    5. Assignment of medical support rights to the state of Washington (388-505-0540); and

    6. Cooperation in securing medical support (chapter 388-422 WAC); and

    7. Application for Medicare and enrollment into Medicare's prescription drug program if:

      1. It is likely that the individual is entitled to Medicare; and

      2. The state has authority to pay Medicare cost sharing as described in chapter 388-517 WAC.

    8. Countable resources within program limits (chapters 388-470 and 388-475 and 388-478 WAC); and

    9. Countable income within program limits (chapters 388-450 and 388-475 and 388-478 WAC).

  4. In addition to the general eligibility requirements in subsection (3) of this section, each program has specific eligibility requirements as described in applicable WAC.

  5. Persons living in a public institution,  including a correctional facility, are not eligible for the department's medical coverage programs.  For a person under age twenty or over age sixty-five who is a patient in an institution for mental disease, see WAC 388-513-1315 (13)  for exception.

  6. Persons terminated from SSI or TANF cash grants and those who lose eligibility for categorically needy (CN) medical coverage have their CN coverage continued while their eligibility for other medical programs is redetermined. This continuation of medical coverage is described in chapter 388-434 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 182-503-0510

WAC 182-503-0510

Effective July 1, 2012

WAC 182-503-0510 How a client is determined "related to" a categorical program.

  1. A person is related to the Supplemental Security Income (SSI) program if they are:

a.  Aged, blind, or disabled as defined inchapter 388-475 WAC; or 

b.  Considered as eligible for SSI under  chapter 388-475 WAC; or

c.  Children meeting the requirements of WAC 388-505-0210(5).

 

2.  A person or family is considered to be related to the temporary assistance for needy families (TANF) program if they:

a.  Meet the program requirements for the TANF cash assistance program or the requirements of WAC 388-505-0220; or

b.  Would meet such requirements except that the assistance unit's countable income exceeds the TANF program standards in WAC 388-478-0065.

 

3.  Persons related to SSI or to TANF are eligible for categorically needy (CN) or medically needy (MN) medical coverage if they meet the other eligibility criteria for these medical programs. See chapters 388-475, 388-505 and 388-519 WAC for these eligibility criteria.

 

4.  Persons related to SSI or to TANF and who receive the related CN medical coverage have redetermination rights as described in WAC 388-503-0505(6).

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 182-505-0515

WAC 182-505-0515

Effective January 1, 2012

WAC 182-505-0515 Medical coverage resulting from a cash grant

  1. Families or individuals eligible for SSI, SSI state supplement or TANF cash grants are automatically eligible for categorically needy (CN) medical coverage. These clients receive medical coverage benefits without making a separate application. Certification for CN medical coverage parallels that for the cash benefits.
  2. Upon termination of cash benefits as described in subsection (1) of this section, medical coverage continues until the client's eligibility for other medical coverage can be completed. Continuing medical coverage is terminated if the client does not cooperate with the eligibility re-determination process. 
  3. Individuals eligible for state financial assistance (SFA) cash grants may receive medical coverage for:

a.  An emergent medical condition as described in WAC 388-438-0110; or

b.  Pregnancy as described in WAC 388-462-0015.

 

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 182-508-0005

WAC 182-508-0005

Effective October 14, 2012

WAC 182-508-0005 Eligibility for medical care services.

(1)  An individual is eligible for medical care services (MCS) benefits to the extent of available funds if the individual:

(a)  Completes an interview with the agency or its designee; 

(b)  Is incapacitated as required under WAC 182-508-0010 through 182-508-0120;

(b)  Is at least eighteen years old or, if under eighteen, a member of a married couple;

(c)  Is in financial need according to MCS' income and resource rules in chapter 182-509 WAC.  The agency or the agency's designee determines who is in the individual's assistance unit according to WAC 182-506-0020;

(d)  Meets the medical care services citizenship/alien status requirements under WAC 182-503-0532;

(e)  Provides a Social Security number as required under WAC 388-476-0005;

(f) Resides in the state of Washington as required under WAC 182-503-0520;

(g)  Reports changes of circumstances as required under WAC 182-504-0100; and

(h)  Completes a mid-certification review and provides proof of any changes as required under WAC 182-504-0040.

(2)  An individual is not eligible for MCS benefits if the individual:

(a)  Is eligible for temporary assistance for needy families (TANF) benefits.

(b)  Refuses or fails to meet a TANF rule without good cause.

(c)  Refuses to or fails to cooperate in obtaining federal aid assistance without good cause.

(d)  Refuses or fails to participate in drug or alcohol treatment as required in WAC 182-508-0220.

(e)  Is eligible for Supplemental Security Income (SSI) benefits.

(f)  Is an ineligible spouse of an SSI recipient.

(g)  Refuses or fails to follow a Social Security Administration (SSA) program rule or application requirement without good cause and SSA denied or terminated the individual's benefits.

(h)  Is fleeing to avoid prosecution of, or to avoid custody or confinement for conviction of, a felony, or an attempt to commit a felony as described in WAC 182-503-0560.

(i)  Is eligible for  a categorically needy (CN) medicaid program.

(j)  Refuses or fails to cooperate with CN medicaid program rules or requirements.

(3)  An individual who resides in a public institution and meets all other requirements may be eligible for MCS depending on the type of institution.  A "public institution" is an institution that is supported by public funds, and a governmental unit either is responsible for it or exercises administrative control over it.

(a)  An individual may be eligible for MCS if the individual is:

(i)  A patient in a public medical institution; or

(ii)  A patient in a public mental institution and is sixty-five years of age or older.

(b)  An individual is not eligible for MCS when the individual is in the custody of or confined in a public institution such as a state penitentiary or county jail, including placement:

(i)  In a work release program; or

(ii)  Outside of the institution including home detention.

4.  If an enrollment cap exists under WAC 182-508-0150, a waiting list of persons may be established.

 

 

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.

MEDICAID - CATEGORICALLY NEEDY MEDICAL COVERAGE (CN)

The CN medical programs are funded with federal-state matched Medicaid (or Title XIX) dollars. They are called Categorically Needy (CN) because their needs fall into certain program categories created by federal or state law. Those categories are:

  1. Aged, Blind or Disabled persons who are eligible for CN if they are eligible for or relatable to the Supplemental Security Income program in the following ways:

    1. Receiving an SSI grant;

    2. Eligible for an SSI grant but not receiving the cash; or

    3. Not eligible for an SSI grant, but eligible for "SSI-related" medical coverage based on a determination of disability for non-grant medical assistance (NGMA), which is completed by the HRSA Division of Disability Determination Services (DDDS). See "Worker Responsibilities" that follows WAC 182-512-0150 and NGMA Section of the E A-Z manual.  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 CN 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 program requirements are met.

  2. Persons eligible for or relatable to Temporary Assistance to Needy Families (TANF) are eligible for CN medical coverage as follows:

    1. Receiving TANF cash benefits;

    2. Eligible for TANF cash benefits but choosing not to receive a cash grant; and

    3. Not eligible for a TANF cash grant but eligible for "TANF-related" medical-only coverage as described in those portions of the manual.

  3. Effective October 1, 2002, a person receiving State Family Assistance (SFA) cash benefits is not eligible for a medical program, other than for pregnancy or for Alien Emergency Medical.  After October 2002, any reference to SFA medical is inadvertent and is not intended to imply continuing medical coverage.  Also effective October 1, 2002, medical coverage under the Children's Health (F08) program is eliminated.  After that date any reference to medical coverage under Children's Health (F08) medical is inadvertent and is not intended to imply continuing medical coverage.

  4. Persons receiving Refugee Program benefits as described in REFUGEE PROGRAMS.

These are the programs that provide the broadest scope of medical coverage. They are intended to cover all of a client's services that are "Medically Necessary" and covered by HRSA.  The coverage is discussed in detail in SCOPE OF CARE.


NOTE: Medical coverage associated with the ADATSA program is discussed later in this summary.

CN COVERAGE FOR PERSONS NOT ELIGIBLE FOR CASH ASSISTANCE

Families or individuals who are not eligible for either TANF or SSI cash may still be eligible for CN medical-only coverage. There are CN medical programs based on the Federal Poverty Level (FPL) which are discussed later in this category. In addition, these families or individuals can be "related" to the categorical programs as provided under WAC 182-503-0510 and they may be considered for Medically Needy (MN) coverage. For more information see ADULT MEDICAL and FAMILY MEDICAL.

  1. Aged, Blind or Disabled Persons:

Primarily, this category applies to persons eligible for or receiving Supplemental Security Income (SSI) as administered by the Social Security Administration. However, persons who are Aged, Blind or Disabled and not eligible for SSI may be eligible for CN or MN coverage as "related" individuals under WAC 182-503-0510.

Some persons may be receiving benefits from Medicare. In addition to the programs listed on page one, there are MEDICARE SAVINGS PROGRAMS which may benefit clients.

Programs for persons under these categories are discussed in detail in the ADULT MEDICAL,  SSI-RELATED MEDICAL, HEALTHCARE FOR WORKERS WITH DISABILITIES (HWD), SCOPE OF CARE and  MEDICARE portions of this manual.

  1. Children's CN Medical:

Medical programs for children and options other than CN coverage are discussed in detail in FAMILY MEDICAL.

The various types of coverage provided under the children's programs are discussed in SCOPE OF CARE. In addition, special coverage available for children is discussed in HEALTHY KIDS.

Regarding eligibility determination, special attention may need to be paid to children with separate income or resources. This subject is discussed at MEDICAL ASSISTANCE UNITS - SNEEDE / KIZER.

  1. CN Coverage in Special Situations:

Some clients who are not eligible for TANF cash benefits may be eligible for medical coverage. These groups include:

  1. Teen parents who are not in an approved living situation and/or are not meeting school requirements; 

  2. Persons who have reached the 60-month TANF cash benefit limit;

  3. Families not eligible for TANF because they do not meet the work quarter requirements

  4. Persons who are not cooperating with WorkFirst activities

  5. Fleeing felons

  6. Persons moving from state to state (state hopping)

  7. Persons convicted of welfare fraud

  1. Pregnant Women:

CN medical coverage includes a full scope of coverage for pregnant women. This is discussed in SCOPE OF CARE. The programs are detailed in FAMILY MEDICAL and PREGNANCY.

Women who are pregnant and who have income equal to or less than 185% FPL usually are eligible for the CN program. The pregnant woman can be eligible at any time during her pregnancy. Once eligible, the woman continues to be eligible throughout the pregnancy regardless of changes in income and household composition.

When a woman is pregnant and not eligible for cash assistance, the medical programs consider the unborn child or children in determining the size of the woman's family. Unlike cash assistance programs, the medical program considers the unborn child or children as if they are born and living with the mother. This is discussed in detail in the PREGNANCY portion of this manual.

If a pregnant woman is not eligible for CN coverage, she is considered for the Medically Needy program which is discussed on the following pages. Medically Needy coverage may involve SPENDDOWN.

  1. Refugees

The Refugee Program, which is 100% federally funded, provides coverage for persons who have been granted asylum in the U.S. as a refugee or asylee. These individuals may receive cash benefits and Categorically Needy (CN) medical coverage for a maximum of eight months. Refugee families and single refugees are eligible for these cash and medical benefits.

Refugees / asylees who have income and/or resources above the limits for cash grants may be eligible for MN (Medically Needy). This program is detailed in the REFUGEE category.

Refugees and asylees who have been in the U.S. for more than eight months are determined eligible for medical benefits in the same manner as for U.S. citizens.

  1. Aliens

There are medical programs which provide benefits for persons who are non-citizens (aliens). These programs are discussed in detail in the CITIZENSHIP/ALIEN STATUS, EMERGENCY ASSISTANCE, ADULT MEDICAL, or SSI-RELATED MEDICAL,  PREGNANCY and FAMILY MEDICAL categories.

MEDICALLY NEEDY MEDICAL COVERAGE (MN)

The MN medical programs are funded with federal-state matched Medicaid dollars. They were established to provide medical coverage for those individuals whose income exceeded the more limited income standards required to qualify for CN coverage.

The program applies to persons who are aged, blind, disabled, refugees, pregnant women or children.

The applicant for Medically Needy coverage may:

  1. Meet all other program requirements except their income falls between the income limits for CN coverage and the Medically Needy Income Level (MNIL). These persons are eligible for MN coverage for up to twelve months at a time with no spenddown.

  2. Meet all program requirements except for their income. In this case, the applicant's income exceeds the MNIL. They may "become" eligible through the process of SPENDDOWN. See SPENDDOWN for more information.

The following are examples of persons who could be eligible for MN coverage:

  • Pregnant women not eligible for CN coverage because their income is above 185 % of the Federal Poverty Level (FPL) and their resources are below the MN resource standards

  • Children not eligible for CN coverage because their income is above 300 % of FPL.

See the SCOPE OF CARE for information about the differences in coverage between CN and MN.

Medical Care Services

The MCS program provides medical benefits to persons who are physically and/or mentally incapacitated and unemployable for more than 90 days.  This program differs from ABD in that no disability application is pending with the Social Security Administration.  Eligible persons receive limited medical care coverage under the state-funded Medical Care Services (MCS) program.

MCS- Immigrants

Immigrants determined to meet eligibility requirements for MCS are eligible for state-funded medical coverage under MCS.

See MEDICAL CARE SERVICES for more information.

ADATSA

The ADATSA program provides medical benefits, treatment, and support for a person incapacitated from gainful employment due to alcoholism or drug addiction. Eligible persons receive limited medical coverage under MCS. A medical only ADATSA program exists for persons waiting to get into treatment.

See CHEMICAL DEPENDENCY for more information on ADATSA treatment.

 

Modification Date: April 22, 2013