General eligibility requirements that apply to all Apple Health programs

Introduction overview

Revised Date: 
September 8, 2015

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

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

Effective July 1, 2017.

  1. The agency categorizes Washington apple health programs into three groups based on the income methodology used to determine eligibility:
    1. Those that use a modified adjusted gross income (MAGI)-based methodology described in WAC 182-509-0300, called MAGI-based apple health programs;
    2. Those that use an income methodology other than MAGI, called non-MAGI-based apple health programs, which include:
      1. Supplemental security income (SSI)-related apple health programs;
      2. Temporary assistance for needy families (TANF)-related apple health programs; and
      3. Other apple health programs not based on MAGI, SSI, or TANF methodologies.
    3. Those that provide coverage based on a specific status or entitlement in federal rule and not on countable income, called deemed eligible apple health programs.
  2. MAGI-based apple health programs include the following:
    1. Apple health parent and caretaker relative program described in WAC 182-505-0240;
    2. MAGI-based apple health 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;
    3. Apple health for pregnant women program described in WAC 182-505-0115;
    4. Apple health for kids program described in WAC 182-505-0210 (3)(a);
    5. Premium-based apple health for kids described in WAC 182-505-0215;
    6. Apple health long-term care for children and adults described in chapter 182-514 WAC; and
    7. Apple health 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 apple health program.
  3. Non-MAGI-based apple health programs include the following:
    1. 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:
      1. Apple health for workers with disabilities (HWD) described in chapter 182-511 WAC;
      2. Apple health SSI-related programs described in chapters 182-512 and 182-519 WAC;
      3. Apple health long-term care and hospice programs described in chapters 182-513 and 182-515 WAC;
      4. Apple health medicare savings programs described in chapter 182-517 WAC; and
      5. Apple health 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.
    2. 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:
      1. Apple health refugee medical assistance (RMA) program described in WAC 182-507-0130; and
      2. Apple health medically needy (MN) coverage for pregnant women and children who do not meet SSI-related criteria.
    3. Other programs:
      1. Apple health breast and cervical cancer program described in WAC 182-505-0120;
      2. Apple health TAKE CHARGE program described in WAC 182-532-0720;
      3. Medical care services described in WAC 182-508-0005;
      4. Apple health for pregnant minors described in WAC 182-505-0117; and
      5. Apple health kidney disease program described in chapter 182-540 WAC.
  4. Deemed eligible apple health programs include:
    1. Apple health 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;
    2. Newborn medical program described in WAC 182-505-0210(2);
    3. Foster care program described in WAC 182-505-0211;
    4. Medical extension program described in WAC 182-523-0100; and
    5. 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:
    1. A child;
    2. A pregnant woman; or
    3. 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 apple health 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 apple health program at any time.
  9. For the other specific program requirements a person must meet to qualify for apple health, 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.

Introduction

In general, Washington Apple Health (Medicaid) programs are broken into the following types:

Apple Health MAGI Medicaid: AdultChildren'sFamily and Pregnancy programs

Individuals may apply for MAGI Medicaid using the following options:

If an individual wants help applying for MAGI Medicaid, he or she can work with a Navigator or call Healthplanfinder Customer Support at 1-855-923-4633.

Apple Health Non-MAGI (Classic) Medicaid: Longer-Term Care/Aged, Blind, Disabled programs

Individuals may apply for Classic Medicaid using the following options:

For Long-Term Care

Nursing home care, in-home personal care, assisted living facility and adult family home programs

For Aged, Blind, Disabled Coverage

Disability-based Washington Apple Health, Refugee coverage and coverage for seniors 65+, and programs that help pay for Medicare premiums and expenses

  • Online: Washington Connection
  • Paper: HCA Form 18-005 (Application for LTC/ABD), which can be submitted via:
    • Mail: DSHS - Community Services Division, PO Box 11699, Tacoma WA 98411-6699
    • Fax: 1-888-338-7410
  • In-person: Visit a local CSO.
  • Questions? Contact the Community Services Division Customer Support Contact Center at 1-877-501-2233

Income levels (such as those based on Federal Poverty Level (FPL) and Cost of Living Adjustments (COLA)) and specific program standards change yearly, but in different months. We updated the guide regularly to reflect income level and program standard changes. Please understand that, while the information in this publication is current at the time of publication, some of these standards will change before the next publication date.

We list each program's identifier after each program name on the following pages.

Health Care Authority (HCA)

The single state agency responsible for providing access to Apple Health coverage for Washington residents and state employees.

Apple Health Managed Care

Washington's prepaid comprehensive system of medical and health care services provided through a designated health care plan that contracts with Health Care Authority.

Classic Medicaid

The term used to describe the non-MAGI Medicaid health care programs administered by the Department of Social and Health Services (DSHS). This includes Long-Term Care services and Aged, Blind or Disabled coverage.

Federal Poverty Level (FPL)

A guideline for determining governmental program eligibility based on the Consumer Price Index guide from the year just completed. Many health care coverage program eligibility limits are based on a percentage of the FPL.

Fee-For-Service

A health care service delivery system where health care providers are paid for each service (like an office visit, test, or procedure). Individuals who are not covered by Apple Health Managed Care are covered by Medicaid fee-for-service.

Medicaid

The federally matched medical aid programs under Title XIX of the Social Security Act (and Title XXI of the Social Security Act for the Children's Health Insurance Plan) that cover the Categorically Needy (CN), Medically Needy (MN) and the Alternative Benefits Plan (ABP) programs.

Modified Adjusted Gross Income (MAGI)

The methodology used for calculating income and determining household composition to determine eligibility for Apple Health for Adults, Kids, Families and Caretaker Relatives, and Pregnant Women. This method follows federal income tax filing rules with a few exceptions and has no resource or asset limits.

ProviderOne

The online payment system for health care providers serving individuals enrolled in an Apple Health program.

Scope of Care

The scope of care describes which medical and health care services are covered by the particular Apple Health program. There are 4 categories of scope of care:

  • Categorically Needy (CN): The broadest, most comprehensive scope of health care services covered.
  • Alternative Benefits Plan (ABP): The same scope of care as CN, applicable to the Apple Health for Adults program.
  • Medically Needy (MN): The scope of care covering slightly fewer health care services than CN. MN is available to individuals who qualify for disability-based Apple Health, Apple Health for Long-Term Care, or Apple Health for Kids or Pregnant Women, except that their income and/or resources are above the applicable Apple Health program limits.3
  • Medical Care Services (MCS): The scope of care covering fewer health care services than MN. MCS is a state-funded medical program available to incapacitated adults who are not eligible for Apple Health programs with CN, ABP, or MN scope of care.

Washington Apple Health

The brand name for all Washington State medical assistance programs, including Medicaid. The brand name may be shortened to "Apple Health".