Individuals enrolled in Apple Health (Medicaid), Public Employees Benefits Board, and School Employees Benefits Board coverage - and those accessing behavioral health services - will not experience a disruption in care due to the federal government shutdown. In addition, health care providers will continue to be paid for the services they provide. We will continue to monitor the situation closely and share updates if anything changes.
Institutional coverage for individuals eligible under a MAGI based program:
With the exception of Alien Emergency Medical and Apple Health Expansion, all MAGI-based N-track programs provide nursing facility coverage or Medicaid Personal Care (MPC) coverage, if functionally eligible.
Individuals who are needing services in a medical institution such as a hospital, nursing facility or Children's Long-term Inpatient Program (CLIP) and exceed the income limit for N-track programs may be eligible under the MAGI-based long-term care program, otherwise known as K01.
The eligibility for this program described below is determined by staff at the Health Care Authority (HCA).
Effective February 25, 2023.
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.
Effective February 29, 2016.
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.
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.
Effective July 1, 2017
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.
Effective February 29, 2016.
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.
The person meets institutional status when they have resided in a medical institution or based on department assessment or likely to reside in a medical institution for 30 consecutive days or more. 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.
Apply online at the Washington Healthplanfinder website. On the Additional Screening Questions page, answer yes to the 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 assisting a patient with an application:
If free Apple Health coverage is not approved, send a follow-up email to K01App@hca.wa.gov and provide the following information:
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 free Apple Health coverage 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.
US citizens, US nationals, and noncitizens who are lawfully admitted for permanent residence who have met the 5-year bar may be eligible. Children under the age of 19 may be eligible without regard to citizenship.
Adults who are hospitalized 30 days or more 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.
Once the person has met the 30-day requirement, only the countable MAGI-based income of the institutionalized person is counted.
This is dependent upon the age of the individual person. See below:
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).
There is no asset test.
K01 can be used for an adult if they meet the following criteria, and the person is not eligible for MAGI based coverage through the Washington Healthplanfinder:
Adults between the age of 21 and 65 are not eligible for Apple Health if they are admitted to a long-term psychiatric treatment program at Western or Eastern State hospital. Persons under the age of 21 may qualify for coverage for inpatient psychiatric treatment. If the person is in treatment and turns 21 at the facility, Apple Health can stay open until they discharge or they turn 22 whichever happens first. (Adults age 65 and older may also qualify for Medicaid under the SSI-related long-term care program).
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. Children under age 6 are continuously eligible through the month they turn 6. Noninstitutional MAGI- based health care coverage should be opened for any remaining months of the certification period. Adults aged 19 or older will have eligibility redetermined when they leave the facility.
If a child discharges from a medical facility and is active on a K01, HCA will change this to Apple Health for Kids without premiums for the remainder of their certification period. At renewal, if the family is over income for a noninstitutional medical program, they may choose to enroll the child into a spenddown and/or a qualified health plan through Washington Healthplanfinder if eligible.
If the individual fails to submit a completed renewal, the medical coverage will close at the end of the certification period.
A MAGI-based long-term care recipient is not required to pay toward the cost of care.
The person may be subject to Estate Recovery provisions for long-term care services received.
If a child is eligible for Apple Health for Kids with Premiums, the Agency redetermines eligibility under K01 so the family does not pay a premium and the child can receive a year of CN coverage.
For MAGI-based N-track programs through Washington Healthplanfinder, no institutional award letter is issued.
For nursing facilities and hospitals, these are paid as a claim through Provider One.
For MAGI-based K-track programs, 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.