Apple Health for pregnant individuals

Revised date

WAC 182-505-0115 Washington apple health -- Eligibility for pregnancy and after-pregnancy coverage.

WAC 182-505-0115 Washington apple health -- Eligibility for pregnancy and after-pregnancy coverage.

Effective June 24, 2022.

  1. A pregnant person is eligible for Washington apple health pregnancy coverage if the person:
    1. Meets citizenship or immigration status under WAC 182-503-0535;
    2. Meets Social Security number requirements under WAC 182-503-0115;
    3. Meets Washington state residency requirements under WAC 182-503-0520 and 182-503-0525; and
    4. Has countable income at or below the limit described in:
      1. WAC 182-505-0100 to be eligible for categorically needy (CN) coverage; or
      2. WAC 182-505-0100 to be eligible for medically needy (MN) coverage. MN coverage begins when the pregnant person meets any required spenddown liability as described in WAC 182-519-0110.
  2. A noncitizen pregnant person who does not meet the requirements in subsection (1)(a) or (b) of this section is eligible for apple health pregnancy coverage if they meet countable income standards for CN or MN coverage as described in subsection (1)(d) of this section.
  3. The assignment of medical support rights as described in WAC 182-503-0540 does not apply to pregnant people.
  4. A person who was eligible for and covered under any CN or MN scope of coverage apple health program on the last day of pregnancy remains continuously eligible for after-pregnancy coverage for 12 months, beginning the month after their pregnancy ends. This includes people who meet an MN spenddown liability with expenses incurred no later than the date the pregnancy ends.
  5. Pregnancy coverage has CN scope of care for all people except those enrolled through the MN program who have MN scope of care. A person's after-pregnancy coverage has the same scope of coverage as their pregnancy coverage.
  6.   A person who does not meet the requirements in subsection (4) of this section may qualify for after-pregnancy coverage if they:
    1. Apply for and meet all requirements of the apple health pregnancy coverage program other than pregnancy; and
    2. Apply any time during their 12-month postpartum period to receive ongoing medical coverage until the end of the 12th month after their pregnancy ends. 

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.

Clarifying Information

  1. First Steps
    1. First Steps is the commonly used term for Maternity Support Services. It is a package of services for pregnant individuals who receive Apple Health. Sometimes the pregnant individual’s health care coverage is also referred to as First Steps. First Steps referrals are completed behind the scenes through the following process:
      1. Pregnant individuals enrolled in a managed care plan are informed of the First Steps program through their Managed Care Organization (MCO). The MCO sends the HCA First Steps program manager at HCA a list of all the newly identified pregnant individuals.
      2. Pregnant individuals who are not enrolled in a managed care plan are identified through ProviderOne.
      3. The First Steps program manager sends the lists from i and ii to the First Steps providers.
  2. Household size:
    1. Consider the unborn child(ren) when determining the household size. Add one person for each unborn child. This applies to all Apple Health programs.
  3. Income:
    1. Pregnant individuals with income over the MAGI standard of 193% FPL can choose between purchasing health care coverage through a Qualified Health Plan (QHP) or enroll in the medically needy program (MN). 
  4. Resources:
    1. There is no resource standard for MN (P99).
  5. Continuous Eligibility:
    1. Apple Health pregnancy coverage has continuous eligibility. Changes in income do not affect Apple Health coverage for pregnant individuals during the certification period.
    2. Changes in income are considered prior to the spenddown being met for MN (P99) coverage.
  6. Pregnancy Verification:
    1. Accept self-attestation for pregnancy and estimated due date (EDD)
  7. Applicants who apply after the pregnancy ends:
    1. As of June 2022, individuals who were not on an Apple Health program may now apply for postpartum coverage named After-Pregnancy Coverage (APC) if they had a pregnancy end within the last 12 months.
    2. The individual may be eligible for APC up to twelve months even if they are determined eligible retroactively to cover the pregnancy after the pregnancy ends.
  8. Case Pending Spenddown:
    1. When a pregnant individual applies for medical before the pregnancy ends but does not meet spenddown until the day the pregnancy ends, the individual is considered eligible for Apple Health coverage at the time the pregnancy ends. Therefore, the individual is eligible for After-Pregnancy Coverage.
  9. Medicare Eligible Pregnant Individuals:

Individuals who are receiving or eligible for Medicare and become pregnant may be eligible for Apple Health if their income is below the standard of 193% FPL.

Worker Responsibilities

  1. MN (P99) VERSUS QHP – PROCESSED BY MEDS STAFF
    Pregnant individuals are identified through a barcode report run by MEDS staff.
    1. Send a letter through Healthplanfinder (HPF) offering medically needy (MN) coverage by meeting a spenddown.  Included in this letter is the denial text if no response is received.
    2. If the pregnant individual responds via phone call:
      1. Ask if they incur childcare costs; pay out child support; and if retroactive coverage is needed;
      2. Process P99 in ACES.
    3. If the pregnant individual responds via mail:
      1. Process P99 in ACES.
  2. End of the pregnancy:
    1. For MAGI, click on the report a change link in the Healthplanfinder and update the pregnancy end date to the date the pregnancy ended.
    2. For P99, if the pregnancy ends before the expected due date through birth, miscarriage, or termination, correct the estimated date of delivery on the DEM1 Screen in ACES to ensure a timely program change to After-Pregnancy Coverage.
      1. Adjust the review date to ensure the individual gets additional CN coverage if the pregnancy ends in a month later than the expected due date.
  3. Newborn Medical Coverage:

Note: It is important to add the newborn to Apple Health for Newborns (N10) as soon as possible after birth, so the baby has its own client identification number. This can avoid coverage problems for the baby.

  • If the birthing parent is on Apple Health (Medicaid) without a managed care plan (also known as fee-for-service) at the time of the baby's birth, the newborn will also be on fee-for-service under the birthing parent's client ID through the month of the newborn's 60th day of life.
  • Managed care organizations (MCOs) will only cover a newborn on the birthing parent’s client ID up to a maximum of 21 days after the birth of the baby. After that, a newborn must have their own client identification number, or the only medical coverage the newborn receives is fee-for-service, up through the month that includes the baby’s 60th day of life, or until the newborn is assigned their own client ID number, whichever is earlier.
  • Once the newborn has been issued their own client ID number, the newborn cannot use the birthing parent's client ID. Individuals who have questions regarding their eligibility for MAGI-based medical assistance should call the Medical Eligibility Determination Service at the Health Care Authority at 855-562-3022. Individuals who have questions about applying online for MAGI-based medical assistance should call the Health Benefit Exchange at 855-923-4633.

WAC 182-505-0117 Washington apple health -- Eligibility for pregnant minors.

WAC 182-505-0117 Washington apple health -- Eligibility for pregnant minors.

Effective June 24, 2022.

  1. For the purposes of this rule, "minor" means a person under the age of 19.
  2. A pregnant minor who meets Washington state residency requirements under WAC 182-503-0520 and 182-503-0525 is eligible for the Washington apple health for kids program.
  3. The medical assistance unit (MAU) of a pregnant minor is the pregnant minor.
  4. There are no income standards and no resource tests for a pregnant minor to be eligible for apple health for kids.
  5. To ensure reimbursement from the U.S. Department of Health and Human Services, every pregnant minor applicant for apple health for kids must provide their Social Security number, unless they are exempt under WAC 182-503-0515, and must provide their citizenship or immigration status. The immigration status of a pregnant minor who is an undocumented alien (see WAC 182-503-0530) will not be disclosed to any third party.
  6. The assignment of rights as described in WAC 182-503-0540 does not apply to pregnant minors.
  7. A pregnant minor covered by the apple health for kids program has a one-year certification period. If a minor has their 19th birthday during their pregnancy, they are automatically enrolled in apple health for pregnancy coverage through the end of the month their pregnancy ends. They are eligible for after-pregnancy coverage for 12 months, beginning the first day of the month after their pregnancy ends.

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.

Clarifying Information

A pregnant teen in the Washington Apple Health for Pregnant Teens program will receive full scope health care coverage under Apple Health for Kids, with retroactive coverage to the estimated beginning of the pregnancy and with a certification period as follows:

  • If they remain under age 19 over the course of their pregnancy, they will be given a 1 year certification period.
  • If they turn 19 before the end of their pregnancy, their coverage will continue through the end of their pregnancy and they will be eligible for After-Pregnancy Coverage (APC) through the end of the twelfth month after the end of their pregnancy.

Any pregnant teen will be eligible for WAH for Pregnant Teens as long as they are:

  1. Under age 19; and
  2. Meets residency requirements under WAC 182-503-0520.

The pregnant teen will be treated as their own assistance unit, with no income or resource limits. As a result, pregnant teens in this program will not need to provide their parents’ income or asset information.

To apply, complete the paper application "Application for Pregnant Teen Health Care Coverage" (Form HCA 14-430) or submit by mail or fax to:

Medical Eligibility Determination Services (MEDS)
P.O. Box 45531
Olympia, WA 98504-5531

Fax: 360-725-1898

WAC 182-505-0120 Washington apple health breast and cervical cancer treatment program for women--Client eligibility.

WAC 182-505-0120 Washington apple health breast and cervical cancer treatment program for women--Client eligibility.

Effective September 14, 2015

  1. Effective April 1, 2014, a woman is eligible for categorically needy (CN) coverage under the Washington apple health (WAH) breast and cervical cancer treatment program (BCCTP) only when she:
    1. Has been screened for breast or cervical cancer under the department of health's breast, cervical, and colon health program (BCCHP);
    2. Requires treatment for breast cancer, cervical cancer, or a related precancerous condition;
    3. Is under sixty-five years of age;
    4. Is not eligible for other WAH-CN coverage, including coverage under the MAGI-based adult group;
    5. Is uninsured or does not otherwise have creditable coverage;
    6. Meets residency requirements under WAC 182-503-0520;
    7. Meets Social Security number requirements under WAC 182-503-0515;
    8. Is a U.S. citizen, U.S. national, qualifying American Indian born abroad, or qualified alien under WAC 182-503-0535; and
    9. Meets the income standard set by the BCCHP in DOH form 342-031.
  2. The certification period for breast and cervical cancer treatment covered under this section is twelve months, as provided in WAC 182-504-0015. To remain continuously enrolled, the client must renew her eligibility before the certification period ends. Eligibility for BCCTP coverage under subsection (1)(b) of this section continues throughout the course of treatment as certified by the BCCHP. Retroactive coverage may be available under WAC 182-504-0005. 

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.

Clarifying Information

  1. The Department of Health (DOH) administers and determines eligibility for the CDC-BCCEDP program for the State of Washington through their Breast and Cervical Health Program. Although men may be diagnosed with breast cancer, the federal requirements of this program limit medical coverage for individuals whose sex assigned at birth is female.
  2. This program provides breast and cervical cancer screening services for low-income individuals. In addition, CDC directly contracts with certain tribal entities for this screening service.
  3. Access to this program is only available through the above channels. When an individual meets the eligibility criteria, prime contractors (via CDC-BCCEDP facilities) fax the DOH 345-214 consent form/application to Medical Eligibility Determination Services (MEDS) eligibility staff to screen, process, and maintain the S30 program in ACES.
  4. Individuals not eligible for BCCTP due to citizenship or immigration status requirements (described in WAC 182-505-0120(1), are eligible for medical coverage under the Alien Emergency Medical Program rules. Individuals related to the BCCTP Medicaid program who require cancer treatment meet AEM condition criteria.

 

Worker Responsibilities

When contacted about this program, refer all inquiries to the nearest local DOH/Breast and Cervical Health provider for individuals requesting screening services for breast and cervical cancer and/or has not yet been diagnosed. The Department of Health website provides a list of screening clinics. At their website, click the appropriate county.

  1. If an application/review is received in the local CSO indicating breast cancer; screen S02, determine eligibility for the SSI-related program and refer the individual to the local BCCTP provider.
  2. Send an email to AskMAGI@hca.wa.gov when a woman is active on BCCTP (S30), applies, and is determined eligible for another CN medical program in order to terminate BCCTP (S30) coverage.
  3. If an individual applies in the local CSO and is found eligible for ABD cash assistance, they continue to be eligible for CN coverage, however, not under the BCCTP program. Send an email to AskMAGI@hca.wa.gov to notify MEDS to terminate coverage under the BCCTP program. At incapacity review, determine whether the individual is still receiving the prescribed course of treatment for breast or cervical cancer.

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