1. What is the ACA?

The Affordable Care Act (ACA) was signed in to law on March 23, 2010 by President Obama. This new health reform bill required the majority of all Americans to obtain health insurance beginning in January 2014. Under the ACA, health reform will make health care more affordable, guarantee choices when purchasing health insurance through a new Health Benefit Exchange, expand health coverage to more Americans and enhance the quality of care.

2. How does the Health Benefit Exchange impact Medicaid?

The Health Benefit Exchange provides a new option to apply for health coverage through an online application portal. The Exchange also can help families enroll in a Qualified Health Plan (QHP). More information on additional aspects of the Exchange can be found on the Health Benefit Exchange page.

3. What is the definition of MAGI?

Modified Adjusted Gross Income - MAGI is the methodology for calculation of income for certain Medicaid programs (see below) which closely mirrors how the IRS determines adjusted gross income for tax purposes. MAGI replaces multiple income disregards with one 5% income disregard for all programs and removes asset/resource limits. Household composition mirrors federal tax filing rules in most situations. This simplified income calculation is used to determine Medicaid eligibility and also by the Exchange to determine Premium Tax Subsidy Credits for those who do not qualify for Medicaid.

4. Are all MAGI-related determinations, including Advanced Premium Tax Credit (APTC) subsidies, made using the ACES Rules Engine (eligibility determination system)?

Yes, these determinations are made using a rules engine created by DSHS/ESA in partnership with HCA and the Exchange.

5. Is there a tool available that will provide estimates for the Advanced Premium Tax Credit (APTC) subsidy program?

Yes, the Kaiser Family Foundation has a link on their website that provides "general estimates" for the APTC program at Health Reform Subsidy Calculator

6. Under the ACA which medical groups must use MAGI methodology for eligibility determinations?

  • Children
  • Families (parents/ caretaker relatives)
  • Pregnant women
  • Adults

7. What if an individual has filed federal taxes including someone living outside of the country? (such as a seasonal farm worker) Can they claim this person in their household size?

If the question is, do they get to increase their household size when determining which standard to use for their own Medicaid application, the answer would be, yes, if they intend to claim the person as a dependent on their current year's tax return, they can include that person in their application for purpose of establishing the income standard to use. REMINDER: Anyone residing outside of WA State would not be eligible to receive Medicaid, but could be included in the household size.

8. What is the definition of the "newly eligible" adult group?

This group is made up of individuals who:

  • Are age 19 up to 65 who are not eligible for a current Medicaid program
    • Have income under 138% FPL
    • Meet citizenship requirements
    • Are not incarcerated
    • Are not entitled to Medicare

9. Which current medical groups do not follow MAGI methodology?

The following groups do not follow MAGI methodology and continue to receive "classic Medicaid" under the existing eligibility rules:

  • SSI Cash Recipients
  • Aged, Blind or Disabled Individuals
  • Foster Care Children

10. Does the Medicare Savings Program fall under the "classic" Medicaid eligibility?

Yes. The Medicare Savings Program falls under "classic" Medicaid and the rules remain unchanged.

11. When were MAGI methodology rules implemented?

The use of MAGI methodology began on October 1, 2013 for children, pregnant women and families. Coverage for the newly eligible adult group began on January 1, 2014.

12. Under the ACA, what is required for the development of a new simplified application for medical?

The new application must be one of the following:

  • The application developed by Health & Human Services (HHS) Secretary in accordance with the ACA; or
  • An alternative single streamlined application developed by Washington state that has been approved by the HHS Secretary

13. Who must use the Application for Health Care Coverage (HCA 18-001P)?

The Application for Health Care Coverage (HCA 18-001P) must be used by individuals applying for Medicaid, CHIP and the Advanced Premium Tax Credit Subsidy program. To apply for "Classic Medicaid" requires completion of the Application for Long-Term Care and Aged, Blind or Disabled Coverage (HCA 18-005).

14. How can an application be submitted for health care coverage?

An application for health care coverage can be submitted via the following methods:

  • Online - preferred method via Healthplanfinder
  • By telephone
  • Via mail or facsimile
  • Paper

15. What is the alternative for non-English speakers or those without digital access or literacy?

The Healthplanfinder web portal will be available in Spanish. Applicants who need assistance may contact the Healthplanfinder customer support center using an interpreter service. Letters are available in the supported languages.

16. How do individuals applying for Medicaid through the Healthplanfinder web portal access food stamps and cash assistance?

At the end of the application for health care coverage, families will be offered the option to be referred to Washington Connection web portal to apply or inquire about other public assistance programs.

17. Do outreach workers have the ability to use the Healthplanfinder web portal to assist clients with applying for health care coverage?

Yes. An outreach worker may assist a client with completing a health care coverage application online as long as the client is present.

18. How is income verified using MAGI methodology for Medicaid?

Income is verified under the MAGI methodology for Apple Health (Medicaid) by using:

  • Automated data match
  • If no data match is available then self-attestation will be accepted

19. Is there an asset/resource test for MAGI Medicaid?

No. There are no asset/resource limits under MAGI methodology.

20. How does a client proceed if they are not sure of their income (such as self-employment), but believe the data match is inaccurate or out of date?

Answering the series of MAGI questions through the Healthplanfinder web portal will guide the applicant smoothly through the income portion of the application. They have the option to contact an HCA eligibility worker with questions about income calculation.

21. Which data sources are used during the data match to determine application and renewal eligibility?

The agency uses the IRS - Federal Data Hub as well as current state systems such as Employment Security, SSA and TALX (The Work Number).

22. Can providers use the Federal Hub to obtain IRS MAGI information for their own business purposes?

No. IRS information is protected and can only be used by HCA and the Exchange to determine MAGI. This information can only be used for this purpose and cannot be shared.

23. What is the length of the "reasonable opportunity period" during which individuals can present documentation to resolve data match discrepancies?

Self-attestation is accepted; therefore the reasonable opportunity period only applies to citizenship/alien status. HCA continues to use the centralized citizenship team to work with families to obtain documents they need, so it is business as usual for this population.

24. What is self-attestation?

This is an income declaration by a client when no data match is found or the information is outdated or incorrect. A series of questions are asked through the Healthplanfinder application process to assist the family in declaring their self-attested income at the time of application.

25. If "self-attestation" is used, how does the agency ensure correct eligibility?

The agency uses data matching and a strong "post-eligibility" review process to ensure eligibility for Medicaid and CHIP is correct and the household is enrolled in the correct program.

26. Does HCA accept self-attestation and/or data matching for eligibility renewals?

Healthplanfinder completes a data match for all renewals. If the data match shows that the household's income remains below the Medicaid standard - the case will be recertified without any further action by the family. A notification will be sent sharing the income and household composition used to determine a continuation of benefits and will also ask the family to report any changes if the information stated on the letter is incorrect. For households where a data match shows income above the Medicaid standard - the family will be sent a pre-populated renewal form and asked to update and return the paper form or update their renewal online through the Healthplanfinder web portal. Other options for completing a renewal are provided for those households who do not have access to the internet.

27. Are recipients of Apple Health continuously eligible for Medicaid coverage until renewal time, regardless of changes in income and household composition? How will changes in income and household composition be handled throughout the year?

Pregnant women and children have continuous eligibility. There is no continuous eligibility for adults. Changes can be reported via: 1) online 2) phone 3) mail

28. Under the MAGI methodology, are. Under the MAGI methodology, are there any changes to the medical benefits renewal process?

In an attempt to reduce the number of families who lose Medicaid for failure to complete the renewal process the following steps will be in place:

  • Automated renewal using an electronic data match to verify income
  • 12 month certification periods
  • Pre-populated review form to be sent when data match shows income above the Medicaid standard

29. Are the length of recertification periods remaining the same?

All those under MAGI have a one-year certification period. This eliminates the six month mid-certification review previously required for family medical.

30. Many individuals do not qualify for Medicaid when they also have Medicare and income in excess of $733 per month. They must meet a spenddown first before being eligible for Medicaid. Does the MAGI tool reduce the number of individuals on spend down?

Medicaid expansion includes the requirement to provide coverage to single adults and parents/caretaker relatives who have countable income below 138% of the federal poverty level as long as those individuals are not otherwise entitled to Medicare and are under the age of 65. To the extent that the state has many single adults with disabilities who are not yet eligible for Medicare, those clients would move into full Medicaid coverage under the new eligibility criteria and would no longer have to meet a spenddown if their net income was over $733 per month. MAGI did not change how we determine eligibility for clients who are age 65 or older or who are entitled to Medicare.

31. Does the federal poverty level (FPL) income apply in determining eligibility for Medicaid instead of the current threshold of $733?

The 138% FPL will apply only to the adult/parent group. Higher FPLs continue to apply for pregnant women and children in our state. Any person who remains subject to a spenddown will continue to have their eligibility based on the medically needy income level in effect on that date (currently $733).

32. Does Apple Health for Adults include individuals with less than 5 years legal residency?

No, the 5 year residency rule will continue to be in effect.

33. Where can I find more information about Medicaid Expansion under the ACA?

You may obtain additional information about Medicaid Expansion at Health Care Reform Medicaid Expansion.