Long-term services and supports (LTSS) manual

Modified Adjusted Gross Income (MAGI) - based institutional Apple Health

Revised Date: 
May 15, 2018

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.

WAC 182-514-0230 Purpose.

Effective February 29, 2016.

  1. This chapter describes eligibility requirements for the Washington apple health (WAH) modified adjusted gross income (MAGI)-based long-term care program (LTC) for children and adults who have been admitted to an institution as defined in WAC 182-500-0050 for at least thirty days. The rules are stated in the following sections:
    1. WAC 182-514-0240 General eligibility;
    2. WAC 182-514-0245 Resource eligibility;
    3. WAC 182-514-0250 Program for adults age nineteen and older;
    4. WAC 182-514-0260 Program for children under age nineteen;
    5. WAC 182-514-0263 Non-SSI-related institutional medically needy coverage for pregnant women and people age twenty and younger.
    6. WAC 182-514-0270 Involuntary commitment to Eastern or Western State Hospital.
  2. A noninstitutional WAH program recipient does not need to submit a new application for LTC coverage if admitted to an institution under this section. Admission to an institution constitutes a change of circumstances. Eligibility is based on institutional status under WAC 182-513-1320.
  3. In this chapter, "medicaid agency" or "agency" means the Washington state health care authority and includes the agency's designee. See chapter 182-500 WAC for additional definitions.
  4. Income standards used in this chapter are listed at https://www.hca.wa.gov/health-care-services-and-supports/program-standard-income-and-resources.

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 182-514-0240 General eligibility.

Effective February 29, 2016.

  1. To be eligible for modified adjusted gross income (MAGI) - based long-term care (LTC) coverage under this section, a person must:
    1. Meet institutional status under WAC 182-513-1320;
    2. Meet the general eligibility requirements under WAC 182-503-0505, unless the applicant is a noncitizen, in which case WAC 182-503-0505 (3) (c) and (d) do not apply;
    3. Have countable income below the applicable standard described in WAC 182-514-0250 (2) or 182-514-0260 (3), unless the applicant is eligible as medically needy;
    4. Satisfy the program requirements in WAC 182-514-0250 and 182-514-0260; and
    5. Meet the nursing facility level of care under WAC 388-106-0355 if admitted to a nursing facility for nonhospice care.  Hospice patients are exempt from this requirement.
  2. A person age nineteen or older who does not meet the citizenship or immigration requirements under WAC 182-503-0535 to qualify for medicaid must meet the criteria in subsection (1) of this section and:
    1. Have a qualifying emergency condition and meet the requirements under WAC 182-507-0115 and 182-507-0120; or
    2. Meet the requirements under WAC 182-507-0125 if the person needs LTC coverage in a nursing facility.
  3. If a person meets institutional status, the medicaid agency counts only income received by the person or on behalf of the person when determining eligibility.
  4. A person who meets the federal aged, blind, or disabled criteria may qualify for coverage under chapter 182-513 WAC.
  5. A person who receives supplemental security income (SSI) is not eligible for the MAGI-based LTC program.
  6. If a person does not meet institutional status, the agency determines the person's eligibility for a noninstitutional medical program.
  7. A person eligible for categorically needy or medically needy coverage under a noninstitutional program who is admitted to a nursing facility for fewer than thirty days is only approved for coverage for the nursing facility room and board costs if the person meets the nursing facility level of care as described under WAC 388-106-0355.
  8. A MAGI-based LTC recipient is not required to pay toward the cost of care.

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 182-514-0245 Resource eligibility.

Effective February 29, 2016.

Applicants for and recipients of the modified adjusted gross income (MAGI)-based long-term care program are exempt from the transfer-of-asset evaluation under WAC 182-513-1363, and there is no resource test. 

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 182-514-0260 Institutional program for children under age nineteen.

Effective July 1, 2017

  1. To qualify for the modified adjusted gross income (MAGI)-based long-term care (LTC) program under this section, you (a child under age nineteen) must meet:
    1. The general eligibility requirements in WAC 182-514-0240; and
    2. Program requirements under WAC 182-505-0210 or 182-505-0117.
  2. If you are eligible for the premium-based children's program under WAC 182-505-0215, we redetermine your eligibility under this section so that your family is not required to pay the premium.
  3. The categorically needy (CN) income level for LTC coverage under this section is two hundred ten percent of the federal poverty level after the standard five percentage point income disregard.
  4. To determine countable income for CN coverage under this section, we apply the MAGI methodology under chapter 182-509 WAC.
  5. We approve CN coverage under this section for twelve calendar months (certification period). If you are discharged from the facility before the end of the certification period, the child remains continuously eligible for CN coverage through the certification period, unless you age out of the program, move out-of-state, or die.
  6. If you are not eligible for CN coverage under this section, we determine your eligibility for coverage under the institutional medically needy program described in WAC 182-514-0263.
  7. The institution where you reside may submit an application on your behalf and may act as your authorized representative if you are:
    1. In a court-ordered, out-of-home placement under chapter 13.34 RCW; or
    2. Involuntarily committed to an inpatient treatment program by a court order under chapter 71.34 RCW.

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 182-514-0270 Involuntary commitment to Eastern or Western State Hospital.

Effective February 29, 2016.

  1. A person who is involuntarily committed to Eastern or Western State Hospital under chapter 71.34 RCW is eligible for categorically needy (CN) coverage if the person:
    1. Is under age twenty-one;
    2. Meets institutional status under WAC 182-513-1320; and
    3. Has countable income below:
      1. Two hundred ten percent of the federal poverty level if under age nineteen; or
      2. One hundred thirty-three percent of the federal poverty level if age nineteen or twenty.
  2. A person who is involuntarily committed or receives MAGI-based long-term care coverage at Eastern or Western State Hospital in the month of the person's twenty-first birthday and receives active inpatient psychiatric treatment that will likely continue through the person's twenty-first birthday, is eligible for CN coverage until:
    1. The facility discharges the person; or
    2. The end of the month in which the person turns twenty-two, whichever occurs first.

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.

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.