Apple Health for Kids, with and without premiums
Revised December 11, 2014
Eligibility for medical assistance is now "de-linked" from receipt of cash assistance. Assistance unit rules for MAGI-based eligibility for children is described in WAC 182-506-0010. Assistance unit rules for Non-MAGI eligibility programs are found in chapter WAC 182-506-0015.
- For children who are not eligible for MAGI-based coverage under this section, refer to the following categories:
- SSI-related Medical for children who may meet SSI disability criteria services and are ineligible for any other medical program;
- Pregnancy for medical programs for pregnant women;
- Emergency Assistance: Alien Emergency Medical Program for an alien child who is related to a Medicaid program, including the aged, blind, and disabled;
- Long Term Care for children requiring nursing facility or home and community-based services;
- Medical Extensions for a family who has an increase in earned income, spousal support, or child support;
- Spenddown for a child, pregnant woman, or an SSI-related child whose income exceeds program standards. They may be eligible to receive Medically Needy (MN) coverage.
Children found eligible for a categorically needy scope of care medical program are continuously eligible for Categorically Needy (CN) medical for 12 months regardless of changes; except for aging out of the program, moving out of state, failing to pay a required premium, incarceration, or death. (See WAC 182-504-0125.) The scope of coverage is identical for these programs regardless of the source of funding.
Apple Health for Kids
- Newborn Medical (N10): See WAC 182-505-0210 (2). Newborns are automatically entitled to receive CN Medicaid through their first birthday as long as: It is important that a ProviderOne ID be obtained as soon as possible after the day of delivery to ensure there are no interruptions in coverage. Until the baby has their own ProviderOne ID:
- Their mother was eligible for medical (Apple Health or CHIP) on the day of delivery, including any retroactive eligibility determination.
- For MN spenddown pending on the day of delivery, spenddown was met with the labor and delivery expenses, and
- The newborn is a Washington State resident.
It is important that a ProviderOne ID be obtained as soon as possible after the day of delivery to ensure there are no interruptions in coverage.
Until the baby has their own ProviderOne ID:
- Mom is on fee-for-service: The newborn is covered under the mother's ProviderOne ID through the month that includes the baby's 60th day of life or until they are assigned their own ProviderOne ID.
- Mom is on managed care: The newborn is covered under the mother's ProviderOne ID through the month in which the 21st day of life occurs.
- If the newborn's eligibility begins in a month other than the month of birth, the eligibility worker may need to use the retro medical process to approve missing months of eligibility.
- Apple Health for Kids CN coverage (N11/N31): See WAC 182-505-0210 (3). These children receive federal or state-funded CN Medicaid. Federally-funded children are enrolled in a managed care plan while state funded children remain fee-for-service.
- Apple Health for Kids with Premiums CN Coverage (N13/N33): See WAC 182-505-0210 (4). These children receive federal or state funded CN medical, but are required to pay a premium see WAC 182-505-0225. Federally-funded children are enrolled in managed care, while state-funded children remain fee-for-service.
- Apple Health for Kids (MN) Medically Needy coverage (F99, S99, K99): See WAC 182-505-0210 (7). These children receive slightly less coverage than CN Medicaid and do not enroll in managed care. They must meet a spenddown before any services are paid. See Spenddown for more information.
- Children's Institutional coverage (K01, K95, K99): See WAC 182-505-0210(6) WAC 182-514-0230 - 182-514-0265: These children are approved for medical assistance based on institutional rules once they reside or are expected to reside:
- 30 days or longer in a medical institution; or
- 30 days or longer if they are admitted to an inpatient psychiatric treatment program and they are aged eighteen, nineteen or twenty; or
- 90 days or longer if they are admitted to an inpatient psychiatric treatment program and they are age seventeen or younger.
- Children's Alien Medical Program (AMP) coverage (F99): See WAC 182-505-0210 (9): These alien children are eligible for MN coverage for emergency medical services only. Their coverage under F99 does not require an acute and emergent medical need to set up the spenddown.
Note: Nonqualified children under age 19 with family income under 300% FPL are related to and approved for the appropriate Apple Health for Kids program not AMP.
- Eligibility runs through the end of the month in which the individual reaches the age limit of the program.
- When an individual is an Apple Health recipient in the month of their twenty-first birthday and they receive active inpatient psychiatric treatment which extends beyond their twenty-first birthday, they remain eligible for CN or MN coverage under the family institutional medical program (K01, K95) until the date they discharge from the facility or until their twenty-second birthday, whichever happens first.
- When an individual applies in the same month they reach the age limit for the specific program, they can still be approved for the month of application even though they may have already had their birthday.
- Medical coverage for parenting adults of minor dependent children has been "delinked" from cash assistance. Parenting adults need to complete a separate application for medical coverage.
- Adults who are over income for Apple Health for Families (N01) may be eligible for Apple Health for Adults (N05) as described in WAC 182-505-0250.
- Adults who are ineligible for Apple Health for Families (N01) based on citizenship may be eligible for Alien Emergency Medical (N21) as described in WAC 182-507-0110.
- Parenting adults are eligible for Apple Health for Families (N01) even if they are eligible for Medicare and/or age 65 or older.
Individuals may apply for MAGI Medicaid using the following options:
- Online: Healthplanfinder
- Paper: HCA Form 18-001 (Application for Health Care Coverage), can be submitted via:
- Mail: Washington Healthplanfinder, PO Box 946, Olympia WA 98507
- Fax: 1-855-867-4467
- Phone: 1-855-923-4633
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.