Modified Adjusted Gross Income (MAGI) - based institutional Apple Health
Institutional coverage for individuals eligible under a MAGI based program
With the exception of N21 and N25 (both AEM), all MAGI based/N track programs determined by the Health Benefit Exchange (HBE) provide nursing facility coverage or Medicaid Personal Care (MPC) coverage if functionally eligible.
Individuals on MAGI based N track programs do not pay participation toward the cost of care.
For individuals needing services in a medical institution such as a hospital, nursing facility or Children's Long-term Inpatient Program (CLIP) and are not eligible for a MAGI based program determined by the HBE (N track) because income is over the standard, there is an institutional medical program called MAGI-based long term care program. In ACES this program is under the K track.
This program uses MAGI income and resource methodology.
The eligibility for this program is determined by the DDA-LTC Specialty Unit.
Eligibility for this program is described below.
How does a person become eligible for Apple Health MAGI-based long term care? (K-track)
The person must meet institutional status by residing in an institution for 30 days or longer. For the agency to use institutional rules in a hospital setting, the person must have been in the medical facility continuously for 30 days. If a person discharges from hospital to a nursing home with no break, the hospital days count towards the 30 day limit. A person admitted to a nursing facility must meet nursing facility level of care.
How do I apply for Apple Health MAGI-based long-term care (K-track)?
Apply online at the Washington Healthplanfinder website. On the Additional Screening Questions page, answer yes to question that asks if anyone in the household needs long-term care and indicate that you or the applicant is residing in a hospital or other medical facility setting.
For hospitals applying on behalf of a patient:
Send a follow-up email to K01App@hca.wa.gov and provide the following information:
- Subject line: "K01 App - Child's first name and last name"
- Email template (Required information):
- HPF Application Number
- Name of the head of household and DOB
- Date admitted to the hospital
- Date of discharge (if known)
- Will this child be in the facility for 30 days or longer?
- Your contact information and an AREP form or client release if the applicant wants the agency to be able to discuss the application with you.
Note: By submitting the online application HCA can ensure that coverage is looked at for all household members and enables HCA to open continued coverage for the child at discharge. If the child is eligible for MAGI medicaid in the Washington Healthplanfinder, no additional information is needed.
If facilities receive a paper application (18-001), these should be imaged and emailed to K01App@hca.wa.gov.
What about citizenship – is this program just for US citizens?
US citizens, US nationals, and non-citizens who are lawfully admitted for permanent residence who have met the 5 year ban are eligible. Children under the age of 19 may be eligible without regard to citizenship. Non citizen children are not eligible for coverage under the medically needy (MN) program, only the categorically needy (CN) program.
Adults may qualify under the Alien Emergency Medical (AEM) K03 program if they meet the requirements under the acute and emergent criteria for inpatient hospitalization.
Please refer to Clarifying Information under the AEM chapter on Apple Health Alien Medical programs for instructions on how to process applications.
Whose income is counted?
Once the person has met the 30 day requirement, only the income of the institutionalized person is counted. For adults, this means the income of their spouse is not included in the eligibility determination. For children, the income of their parents is not included in the eligibility determination, but do count any income they get in their own name, including social security income or other MAGI-based income received by the child.
What is the maximum income limit?
This is dependent upon the age of the individual person. See below:
- Children age 18 and younger - 210% of the FPL (federal poverty level).
- Adults 19 and older - 133% FPL.
- Pregnant applicants - 193% FPL
What if income is over the CN standard – is medically needy coverage available?
Medically needy (MN) coverage is available for children and adults through the age of 21. There is no MN coverage for adults over the age of 21 (unless the person is already in treatment in an inpatient psychiatric facility in which case they remain eligible until they discharge or turn 22, whichever occurs first).
What about assets? Is there a resource limit?
There is no asset test.
When is K01 (institutional medical) considered for adults?
K01 can be used for an adult if they meet the following criteria and the person is not eligible for MAGI based N-track medical through the HBE:
- They must have been hospitalized or reside in a medical facility for 30 days or longer
- Their individual net countable income is below 133% FPL per month or 193% FPL per month for pregnant applicants.
- They do not have to meet disability criteria for the K01 program.
What about long term psychiatric treatment?
Adults between the age of 21 and 65 are not eligible for Medicaid if they are admitted to a long term psychiatric treatment program at Western or Eastern State hospital. Children and adults under the age of 21 do qualify for Medicaid coverage for inpatient psychiatric treatment. If the person is in treatment and turns 21 at the facility, they can stay open on Medicaid until they discharge or until they turn 22 whichever happens first. (Adults age 65 and older may also qualify for Medicaid under the SSI-related long-term care program).
How long does eligibility last?
K01 is categorically needy (CN) medical coverage and is initially approved with a 12 month certification. Children under the age of 19 remain continuously eligible for the full 12 months even if they discharge from the facility. Non-institutional MAGI- based health care coverage should be opened for any remaining months of the certification period. Adults age 19 or older will have eligibility re-determined when they leave the facility.
What happens if the family is over income at the time of renewal?
If a child discharges from a medical facility and has already been approved under the K01 program, HCA will change this to a children’s medical program at discharge without the requirement to submit a review. They will get the balance of their certification under the CN medical program. If the review is due after their discharge and the family is over income for a non-institutional medical program, the family may choose to have a medically spenddown case or enroll the child into a qualified health plan through the Health Benefit Exchange if eligible.
What happens when the renewal has not been sent back?
If a required renewal is due and the individual fails to follow through with the process, the case will be closed.
What about post-eligibility? Does the person have to pay towards the cost of care?
Those eligible under MAGI-based long-term care don't pay toward the cost of care.
What else should the client be aware of?
The person may be subject to Estate Recovery provisions for long-term care services received.
If a child is eligible under the premium based Apple Health for Kids program, the Agency re-determines eligibility under K01 so that the family doesn't pay a premium for that child and the child can receive a year of CN coverage.
Is an institutional award letter issued for MAGI-based programs?
For MAGI-based programs determined by the HBE, (N-track programs in ACES), no institutional award letter is issued.
For nursing facilities and hospitals, these are paid as a claim through Provider One.
For MAGI-based programs through the K-track program, an institutional award letter will be issued by HCA.
Managed Care and Long-term Care: scroll to: Nursing Home Admissions under a modified adjust gross income (MAGI) medical group.