Third Party Coverage-Health insurance premium program

Revised April 29, 2013

Clarifying Information

Payment of Private Health Insurance

DSHS offers a premium payment program to help pay for Medicaid clients health insurance premiums. For those that have access to private health insurance, we may pay premiums for the entire family as long as someone has DSHS medical. Insurance policies covered include:

• Individual policies
• Employer sponsored plans
• COBRA policies

Insurance policies not covered:  Any policy for a Medicare eligible client.

How to Apply

1. Clients or DSHS staff can call the toll-free line at 1-800-562-3022 ext 15473
2. Or visit and download the application at the following website: http://hrsa.dshs.wa.gov/PremiumPymt/index.shtm 
3. Any applicant who declares ‘other medical coverage’ on the Medicaid application must complete the DSHS 14-194 Medical Coverage Information form. The DMS system automatically assigns the DSHS 14-194 Medical Coverage Form to the coordination of benefits unit and financial staff does not need to mail the form to HRSA/COB.

Making a referral for a premium

Download an application for DSHS premium payment program, DSHS 13-705.

1. Mail-Send all mail requests to Coordination of Benefits, P.O. Box 45518 Olympia WA 98599.
2. Fax- Application may be faxed toll free to: 1-877-893-3810.
3. E-mail - Submit referrals by e-mail to: HRSACOBpremiumpayments@dshs.wa.gov

Please include the following information:

• A statement that the client is asking HRSA to pay private health insurance premiums.
• Client name (Last, First, MI)
• Client identification number (ACES)
• Authorized representative (AREP), if applicable
• Insurance company name
• Policy/Subscriber number
• Amount of insurance premium and whether the amount is paid monthly or quarterly

1. COB premium specialist reviews for type of program, type of insurance, medical need, and cost effectiveness of paying the client's premium.
2. Premium payments are prospective and cannot be retroactive for any months they were approved for medicaid.
3. Allow 30 days for processing.  Client will be notified by mail with a copy to the CSO.

Contact Coordination of Benefits (COB) Premium Unit:

Early Intervention Program for HIV-AIDS clients

If an applicant who has been diagnosed with HIV or AIDS is not eligible for department medical programs, there is another resource available.  The Department of Health HIV Client Services Program funds a contract to assist persons who have HIV and/or AIDS with ongoing medical insurance premiums, or to acquire insurance.  For more information about this program contact the Early Intervention Program (EIP) at DOH at 1-877-376-9216, or go to HIV Client Services Program or Evergreen Health Insurance Program.  

Worker Responsibilities

Premium payment program and spenddown

Health insurance premiums that are being paid on a client's behalf by the Premium Payment Program at HRSA are still considered an income deduction for the medically needy program.  Indicate the amount of the health insurance premium on the MEDX screen in ACES.  Medicare premiums and related co insurance expenses are not indicated on the MEDX screen in ACES but may be used toward spenddown as the expenses are incurred.

Effective April 2009, Medicare Part C premiums are no longer be allowed as a health insurance deduction on the MEDX screen.  All Medicare premium expenses under Part A, Part B, Part C and Part D are entered as a spenddown expense in ACES online as the expenses are incurred.  For initial applications, allow the first two months of premiums as a deduction if the client has incurred the expense and they do not have coverage under a Medicare Savings Program that is paying the expense on their behalf.  

Some Public Programs use non federal dollars to purchase private health insurance on behalf of their clients. When a Public program verifies payment of a health insurance premium on behalf of a Spenddown client, the worker needs to redetermine eligibility under the MN program using the expense as an income deduction and not a spenddown expense. In some cases clients will become eligible for Medically Needy (MN) with no spenddown liability and should be approved for a 12 month certification.  In others, the spenddown liability will be reduced by the health insurance premium amount.  Make sure a new letter is generated to indicate this change. 

Department of Health (DOH) HIV/AIDS early intervention program and the Evergreen Health Insurance Program are considered Public Programs for Spenddown.  DOH will verify expenses incurred  or paid by these programs on behalf of Spenddown clients.  These expenses are to be used toward meeting the client's spenddown liability.