Program Summary - Medical Programs
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Program Summary - Medical Programs


Revised May 2, 2014



Purpose: This section describes the eligibility requirements for the various medical programs and coverage administered by the department.

WAC 182-503-0505Washington apple health -- General eligibility requirements.
WAC 182-503-0510Washington apple health -- Program summary.
WAC 182-505-0515REPEALED -- Medical 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 October 1, 2013

WAC 182-503-0505 Washington apple health -- General eligibility requirements.



(1) Persons applying for Washington apple health (WAH) programs established under chapter 74.09 RCW must meet the eligibility criteria in chapters 182-500 through 182-527 WAC.

(2) Persons applying for WAH are considered first for federally funded or federally matched programs. State-funded programs are considered after the person is determined ineligible for federally funded and federally matched programs.

(3) Unless otherwise specified in a program specific WAC, the eligibility criteria for each WAH program are as follows:

(a) Age and identity (WAC 182-503-0050);

(b) Residence in Washington state (WAC 182-503-0520 and 182-503-0525);

(c) Citizenship or immigration status in the United States (WAC 182-503-0535);

(d) Possession of a valid Social Security account number (WAC 182-503-0515);

(e) Assignment of medical support rights to the state of Washington (WAC 182-503-0540);

(f) Application for medicare and enrollment into medicare's prescription drug program if:

(i) It is likely that the person is entitled to medicare; and

(ii) The state has authority to pay medicare cost sharing as described in chapter 182-517 WAC.

(g) For persons whose eligibility is not on the basis of modified adjusted gross income (MAGI) methodology, countable resources must be within specific program limits (chapters 182-512, 182-513, 182-515, 182-517, and 182-519 WAC); and

(h) Countable income within program limits:

(i) For MAGI-based WAH programs, see WAC 182-505-0100;

(ii) For the WAH refugee program, see WAC 182-507-0110;

(iii) For the WAH medical care services program, see WAC 182-508-0150;

(iv) For WAH for workers with disabilities (HWD), see WAC 182-511-0060;

(v) For the WAH SSI-related program, see WAC 182-512-0010;

(vi) For WAH long-term care programs, see WAC 182-513-1300 and 182-515-1500;

(vii) For WAH medicare savings programs, see WAC 182-517-0100; and

(viii) For the WAH medically needy program, see WAC 182-519-0050.

(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 in a public institution, including a correctional facility, are not eligible for WAH programs, except in the following situations:

(a) The person is under age twenty or over age sixty-five and is a patient in an institution for mental disease (see WAC 182-513-1315(13)); or

(b) The person receives inpatient hospital services outside of the public institution or correctional facility.

(6) Persons terminated from SSI or who lose eligibility for categorically needy (CN) coverage have their CN coverage continued while their eligibility for other health care programs is redetermined. See WAC 182-504-0125.

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 October 1, 2013

WAC 182-503-0510 Washington apple health -- Program summary.



(1) The agency categorizes Washington apple health (WAH) programs into three groups based on the income methodology used to determine eligibility:

(a) Those that use a modified adjusted gross income (MAGI)-based methodology described in WAC 182-509-0300, called MAGI-based WAH programs;

(b) Those that use an income methodology other than MAGI, called non-MAGI-based WAH programs, which include:

(i) Supplemental security income (SSI)-related WAH programs;

(ii) Temporary assistance for needy families (TANF)-related WAH programs; and

(iii) Other WAH programs not based on MAGI, SSI, or TANF methodologies.

(c) Those that provide coverage based on a specific status or entitlement in federal rule and not on countable income, called deemed eligible WAH programs.

(2) MAGI-based WAH programs include the following:

(a) WAH parent and caretaker relative program described in WAC 182-505-0240;

(b) MAGI-based WAH adult medical program described in WAC 182-505-0250, for which the scope of coverage is called the alternative benefits plan (ABP) described in WAC 182-500-0010;

(c) WAH for pregnant women program described in WAC 182-505-0115;

(d) WAH for kids program described in WAC 182-505-0210 (3)(a);

(e) Premium-based WAH for kids described in WAC 182-505-0215;

(f) WAH long-term care for children and adults described in chapter 182-514 WAC; and

(g) WAH alien emergency medical program described in WAC 182-507-0110 through 182-507-0125 when the person is eligible based on criteria for a MAGI-based WAH program.

(3) Non-MAGI-based WAH programs include the following:

(a) SSI-related programs which use the income methodologies of the SSI program (except where the agency has adopted more liberal rules than SSI) described in chapter 182-512 WAC to determine eligibility:

(i) WAH for workers with disabilities (HWD) described in chapter 182-511 WAC;

(ii) WAH SSI-related programs described in chapters 182-512 and 182-519 WAC;

(iii) WAH long-term care and hospice programs described in chapters 182-513 and 182-515 WAC;

(iv) WAH medicare savings programs described in chapter 182-517 WAC; and

(v) WAH alien emergency medical (AEM) programs described in WAC 182-507-0110 and 182-507-0125 when the person meets the age, blindness or disability criteria specified in WAC 182-512-0050.

(b) TANF-related programs which use the income methodologies based on the TANF cash program described in WAC 388-450-0170 to determine eligibility, with variations as specified in WAC 182-509-0001(5) and program specific rules:

(i) WAH refugee medical assistance (RMA) program described in WAC 182-507-0130; and

(ii) WAH medically needy (MN) coverage for pregnant women and children who do not meet SSI-related criteria.

(c) Other programs:

(i) WAH breast and cervical cancer program described in WAC 182-505-0120;

(ii) WAH TAKE CHARGE program described in WAC 182-532-0720; and

(iii) WAH medical care services described in WAC 182-508-0005.

(4) Deemed eligible WAH programs include:

(a) WAH SSI medical program described in chapter 182-510 WAC, or a person who meets the medicaid eligibility criteria in 1619b of the Social Security Act;

(b) WAH newborn medical program described in WAC 182-505-0210(2);

(c) WAH foster care program described in WAC 182-505-0211;

(d) WAH medical extension program described in WAC 182-523-0100; and

(e) WAH family planning extension described in WAC 182-505-0115(5).

(5) A person is eligible for categorically needy (CN) health care coverage when the household's countable income is at or below the categorically needy income level (CNIL) for the specific program.

(6) If income is above the CNIL, a person is eligible for the MN program if the person is:

(a) A child;

(b) A pregnant woman; or

(c) SSI-related (aged sixty-five, blind or disabled).

(7) MN health care coverage is not available to parents, caretaker relatives, or adults unless they are eligible under subsection (6) of this section.

(8) A person who is eligible for the WAH MAGI-based adult program listed in subsection (2)(b) of this section is eligible for ABP health care coverage as defined in WAC 182-500-0010. Such a person may apply for more comprehensive coverage through another WAH program at any time.

(9) For the other specific program requirements a person must meet to qualify for WAH, see chapters 182-503 through 182-527 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 182-505-0515

WAC 182-505-0515

Effective October 1, 2013

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



REPEALED ON OCTOBER 1, 2013.

  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 January 1, 2014

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

  1. A person is eligible for Washington apple health (WAH) medical care services (MCS) coverage to the extent of available funds if the person is determined by the department of social and health services to be eligible for benefits under either the aged, blind, or disabled program as described in WAC 388-400-0060 or the housing and essential needs referral program as described in WAC 388-400-0070.
  2. 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 MEDICALHEALTHCARE 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 MEDICALPREGNANCY 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: May 2, 2014