Classic (non-MAGI) based programs manual

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Application for Medicare

Revised Date: 
December 12, 2018

Purpose: To clarify the Medicaid eligibility requirement to apply for Medicare.

WAC 182-503-0505 Washington apple health -- General eligibility requirements.

WAC 182-503-0505 Washington apple health -- General eligibility requirements.

Effective April 27, 2019.

  1. When you apply for Washington apple health programs established under chapter 74.09 RCW, you must meet the eligibility criteria in chapters 182-500 through 182-527 WAC.
  2. When you apply for apple health, we first consider you for federally funded or federally matched programs. We consider you for state-funded programs after we have determined that you are ineligible for federally funded and federally matched programs.
  3. Unless otherwise specified in a program specific WAC, the eligibility criteria for each program are as follows:
    1. Age (WAC 182-503-0050);
    2. Residence in Washington state (WAC 182-503-0520 and 182-503-0525);
    3. Citizenship or immigration status in the United States (WAC 182-503-0535);
    4. Possession of a valid Social Security account number (WAC 182-503-0515);
    5. Assignment of medical support rights to the state of Washington (WAC 182-503-0540);
    6. Application for medicare and enrollment into medicare's prescription drug program if:
      1. You are likely entitled to medicare; and
      2. We have authority to pay medicare cost sharing as described in chapter 182-517 WAC.
    7. If your eligibility is not based on modified adjusted gross income (MAGI) methodology, your countable resources must be within specific program limits (chapters 182-512, 182-513, 182-515, 182-517, and 182-519 WAC); and
    8. Countable income within program limits:
      1. For MAGI-based programs, see WAC 182-505-0100;
      2. For the refugee program, see WAC 182-507-0130;
      3. For the medical care services program, see WAC 182-508-0005;
      4. For the health care for workers with disabilities (HWD) program, see WAC 182-511-1000;
      5. For the SSI-related program, see WAC 182-512-0010;
      6. For long-term care programs, see chapters 182-513 and 182-515 WAC;
      7. For medicare savings programs, see WAC 182-517-0100; and
      8. For the medically needy program, see WAC 182-519-0050.
  4. In addition to the general eligibility requirements in subsection (3) of this section, each program has specific eligibility requirements as described in applicable WAC.
  5. If you are in a public institution, including a correctional facility, you are not eligible for full scope apple health coverage, except in the following situations:
    1. If you are age twenty-one or younger or age sixty-five or older and are a patient in an institution for mental disease (see WAC 182-513-1317(5)); or
    2. You receive inpatient hospital services outside of the public institution or correctional facility.
  6. We limit coverage for people who become residents in a public institution, under subsection (5) of this section, until they are released.
  7. If you are terminated from SSI or lose eligibility for categorically needy (CN) or alternative benefits plan (ABP) coverage, you receive coverage under the apple health program with the highest scope of care for which you may be eligible while  we determine your eligibility for other health care programs.  See WAC 182-504-0125. 

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

Application for Medicare

Application for and enrollment into Medicare is a condition of eligibility for individuals who apply for Apple Health coverage, as long as the agency is able to pick up the cost of the premiums on the individual's behalf. Every month Apple Health eligible individuals age 65 and older who are not already receiving Medicare are asked to provide proof of application for Medicare through an automated BarCode process.

End Stage Renal Disease

The Medicare Buy-in Unit also sends letters requesting proof of application for Medicare under the End Stage Renal Disease Program (ESRD) to selected Medicaid kidney dialysis individuals who receive three consecutive months of treatment. The same process outlined above is used. The individual's letter is slightly different but still requires the individual to provide proof of application. The individual's kidney dialysis provider, (for example Northwest Kidney Dialysis Center), is also notified that they need to assist their individual with the Medicare/ESRD application process.

Individuals who fail to provide proof of application for Medicare to the Medicare Buy-in Unit under the authority of WAC 182-504-0505 and 0540 can be terminated from Apple Health assistance, including individuals who receive SSI or long-term care services. Individuals closed for noncooperation with application to Medicare will show in ACES and ProviderOne as closed for reason code 266, noncooperation with TPL.

Note: The Medicare Buy-in Unit is careful to give nearly 90 days in the two-letter process before they send an action request in BarCode to DSHS to propose termination of Apple Health coverage.

Worker Responsibilities

Every month Apple Health eligible individuals age 65 and older not already receiving Medicare are asked to provide proof of application for Medicare. The Medicare Buy-in unit in Olympia (call 1-800-562-3022) manages this workload. The following process is followed:

  1. Individuals are mailed a letter generated by barcode around the 20th of the month asking for proof of application for Medicare.
  2. The letter is provided in the individual's primary language and in English to the individual and to the individual's authorized representative. Only the English version is stored in DMS.
  3. All letters have a business reply postage paid return envelope addressed to the Medicare Buy-in Unit for returning the proof of Medicare application. Verification can be returned to any DSHS office or mailed to the DSHS Imaging Center. 
  4. Thirty days or more after the first letter is sent, the Medicare Buy-in Unit works the ticklers to review for proof of application for Medicare.
  5. If no proof is received, a second letter is sent to the individual requesting proof of application for Medicare and again ticklers are set for the Medicare Buy-in Unit to review the case for proof.
  6. If no proof is received from the second letter, the Medicare Buy-in Unit generates an action request to the worker of record asking that the individual be sent a termination of Medicaid notice under WAC 182-503-0505 General Eligibility and WAC 182-503-0540 Non Cooperation with Third Party Liability.
  7. Proof Received After Termination – If the former recipient provides verification of application for Medicare their Medicaid case can be re-activated. If the verification comes in during the period of the original certification period the case should be opened with no further contact with the individual. If verification is received after the original certification period ends than a new application is necessary.

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