300 Series reason codes

Revised date

January 4, 2024

Purpose statement

300 Series Reason Code Protocols

Go to the Reason Code Link chart to link directly to a specific reason code or scroll through the list below. For ACES Procedures go to ACES Letters in the ACES User Manual.

On this page: 300-307 | 320-327 | 330-339 | 340-388

300-307

Reason code	Reason code description	WAC references - Classic Apple Health	Free form text - Classic Apple Health	WAC references - MAGI-Based Apple Health
300	Nonpayment of Premium According to our records, you have not paid all required premiums. See WAC rule (Washington Administrative Code):		None required
301	Exceeds Income Standard Your income is over the limit that is allowed for this program. See WAC rule (Washington Administrative Code):	388-478-0060 388-478-0055 388-450-0165 388-450-0162 388-450-0015 388-478-0090	The limit for your household size is $ __.	182-519-0050 182-505-0100 182-512-0010 182-517-0100 182-509-0001
306	Change In Unearned Income The amount of unearned income you get has changed. See WAC rule (Washington Administrative Code):	388-418-0020 388-450-0025 388-450-0162 182-512-0010 388-492-0020 388-492-0030	Your income from (source) has changed from $ __ to $ __.
307	Change In Gross Earned Income The amount of money that you earn has changed. See WAC rule (Washington Administrative Code):	388-450-0030 182-512-0010 388-418-0020	Your gross earned income has changed from $ __ to $ __.

320-327

Reason code	Reason code description	WAC references - Classic Apple Health	Free form text - Classic Apple Health
320	Exceeds Gross Income Limit Your income is higher than the income limit for this program. See WAC rule (Washington Administrative Code):	388-450-0015 388-450-0165 388-478-0060 388-478-0090	The limit for your household size is $ __.
321	Change In Net Deemed Income The amount of income we consider available to you from an outside source has changed. See WAC rule (Washington Administrative Code):	388-450-0100 388-450-0105 388-450-0115 388-450-0120 388-450-0135 388-450-0155 388-450-0130 388-450-0150 388-450-0140 388-450-0160 388-450-0125	We are counting $ __ of (Name)'s income.
323	Change In Home Maintenance Exemption The income amount that you are allowed to keep to pay for home expenses is called a home maintenance allowance. Yours is changing because: You have been getting it for 6 months; Your doctor says you have to stay longer; or The amount of your home expense has changed. See WAC rule (Washington Administrative Code):	388-513-1380	Your home maintenance amount has changed because __. (add specific details, e.g. "Your rent has changed from $ __ to $ __. " Or "On __ (date) __ Dr. __ told us you can't return home before __ .")
327	Change In Recoupment We are taking a different amount from your benefits to repay an overpayment. See WAC rule (Washington Administrative Code):	388-410-0005 388-410-0010 388-410-0015 388-410-0030	None Required

330-339

Reason Code	Reason Code Description	WAC References - Classic Apple Health	Free Form Text - Apple Health
330	Lump Sum Your resources are over the limit for this month because of your lump sum payment. See WAC rule (Washington Administrative Code):	388-450-0245 388-470-0005	You got $ __ from __ on 00/00/00. Your countable resources are now $ __. Your resources cannot be more than $ __ (specify resource limit for household size). If the grant is suspended: We will be subtracting $ __ from next month's grant. This reduction is for one month only. If the grant is terminated: Your lump sum payment is more than the need standard for two months. You can reapply for a cash grant in (month).
332	Change In CPI Allowance Your Personal Needs Allowance (PNA) changed. See WAC rule (Washington Administrative Code):	388-513-1380
334	Your earned income is over the limit for this program	388-478-0035	The limit for your household size is $ __.
335	Change In Uncovered Medical Expense Allocation The amount you can use to pay medical expenses has changed. See WAC rule (Washington Administrative Code):	388-513-1380	The amount you can use to pay for the following medical expenses has changed: (Type of expense) from $ __ to $ __.
336	Change In CSMA / FMMA Allocation The amount we can allow for the maintenance of your family members at home has changed. See WAC rule (Washington Administrative Code):	388-513-1380	Your allocation changed from $ __ to $ __ because __.
339	Medical Extension Ends Your medical extension expired and we did not get your review form. If we get it before the end of the month, we will reconsider our decision. If you have already sent it, let me know. If your medical benefits stop and you decide that you still want them, you need to reapply. See WAC rule (Washington Administrative Code):	388-400-0035 182-523-0100 182-505-0115

340-388

Reason Code	Reason Code Description	WAC References - Classic Apple Health	Free Form Text - Classic Apple Health	WAC References - MAGI-Based Apple Health	Free Form Text - MAGI-Based Apple Health
340	QMB Ineligible - Client Is Not Institutional Related You are no longer eligible for assistance that pays for all or part of your Medicare costs and premiums. The department must count your income differently when you are no longer eligible for Long-Term Care Services, such as Nursing Facility Care, COPES or CAP/OBRA Services. See WAC rule (Washington Administrative Code):	388-450-0005	None Required
341	The state supplemental payment rate for all SSI recipients has changed. See WAC rule (Washington Administrative Code):	388-478-0055	None Required
342	Medical coverage stopped because you are 3 months behind in premium payments. Medical can't start again until the premiums are paid. Premiums aren't required for a child who is pregnant, an American Indian or Alaska Native. If your family income decreases, medical coverage without a premium may be available. HPF Health care coverage stopped because you are three months behind in premium payments. Washington Apple Health with premiums coverage can't start again until the premiums are paid.	182-505-0225	None Required	182-505-0225	None Required
343	The amount of Third-Party Resources you get has changed. See WAC rule (Washington Administrative Code):	388-501-0200	The amount of your third party resource has changed from $ __ to $ __.
388	WA Fund CAP For Q1 Already Reached Washington gets a limited amount of money for the Qualified Individual (QI-1) Program. There are no more funds available for this year. You can reapply in December for next year. See WAC rule (Washington Administrative Code):	182-517-0300	None Required

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Non-Grant Medical Assistance (NGMA) overview

Revised date

April 11, 2022

Purpose statement

To describe the procedures to obtain a determination of disability or blindness that enables adults not receiving other assistance to be related to Medicaid on the basis of disability or blindness.

WAC 182-512-0050 SSI-related medical -- General information.

WAC 182-512-0050 SSI-related medical -- General information.

Effective April 14, 2014.

The agency (which includes its designee for purposes of this chapter) provides health care coverage under the Washington apple health (WAH) categorically needy (CN) and medically needy (MN) SSI-related programs for SSI-related people, meaning those who meet at least one of the federal SSI program criteria as being:
1. Age sixty-five or older;
2. Blind with:
  1. Central visual acuity of 20/200 or less in the better eye with the use of a correcting lens; or
  2. A field of vision limitation so the widest diameter of the visual field subtends an angle no greater than twenty degrees.
3. Disabled:
  1. "Disabled" means unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment, which:
    1. Can be expected to result in death; or
    2. Has lasted or can be expected to last for a continuous period of not less than twelve months; or
    3. In the case of a child seventeen years of age or younger, if the child suffers from any medically determinable physical or mental impairment of comparable severity.
  2. Decisions on SSI-related disability are subject to the authority of:
    1. Federal statutes and regulations codified at 42 U.S.C. Section 1382c and 20 C.F.R., parts 404 and 416, as amended; and
    2. Controlling federal court decisions, which define the OASDI and SSI disability standard and determination process.
A denial of Title II or Title XVI federal benefits by SSA solely due to failure to meet the blindness or disability criteria is binding on the agency unless the applicant's:
1. Denial is under appeal in the reconsideration stage in SSA's administrative hearing process, or SSA's appeals council; or
2. Medical condition has changed since the SSA denial was issued.
The agency considers a person who meets the special requirements for SSI status under Sections 1619(a) or 1619(b) of the Social Security Act as an SSI recipient. Such a person is eligible for WAH CN health care coverage under WAC 182-510-0001.
Persons referred to in subsection (1) must also meet appropriate eligibility criteria found in the following WAC and EA-Z Manual sections:
1. For all programs:
  1. WAC 182-506-0015, Medical assistance units;
  2. WAC 182-504-0015, Categorically needy and WAC 182-504-0020, Medically needy certification periods;
  3. Program specific requirements in chapter 182-512 WAC;
  4. WAC 182-503-0050, Verification;
  5. WAC 182-503-0505, General eligibility requirements for medical programs;
  6. WAC 182-503-0540, Assignment of rights and cooperation;
  7. Chapter 182-516 WAC, Trusts, annuities and life estates.
2. For LTC programs:
  1. Chapter 182-513 WAC, Long-term care services;
  2. Chapter 182-515 WAC, Waiver services.
3. For WAH MN, chapter 182-519 WAC, Spenddown;
4. For WAH HWD, program specific requirements in chapter 182-511 WAC.
Aliens who qualify for medicaid coverage, but are determined ineligible because of alien status may be eligible for programs as specified in WAC 182-507-0110.
The agency pays for a person's medical care outside of Washington according to WAC 182-501-0180.
The agency follows income and resource methodologies of the supplemental security income (SSI) program defined in federal law when determining eligibility for SSI-related medical or medicare savings programs unless the agency adopts rules that are less restrictive than those of the SSI program.
Refer to WAC 182-504-0125 for effects of changes on medical assistance for redetermination of eligibility.

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

An applicant who isn’t receiving a Title II cash payment based on a disability established by the Social Security Administration (SSA) may be eligible for SSI-related medical coverage under the Non Grant Medical Assistance (NGMA) overview program. Eligibility staff submit a request to DDS to determine whether a disability exists for the purposes of medical coverage only. If the individual is claiming disability, but is eligible for Medicaid through another program such as children’s medical, family medical, or ABD cash, a NGMA decision is only necessary if the individual is applying for long term services and supports based on disability (such as a Home and Community Services (HCS) or Developmental Disability Administration (DDA) home and community based waiver) or for the HWD program. See more information about HWD below.

Note: If an applicant is eligible for SSI, or SSDI, do not refer for a NGMA decision. If an individual has been denied for SSI or SSDI in the last year, do not refer for a NGMA unless the individual provides proof that their medical condition has worsened or that they have a new disabling condition.

DDS doesn’t consider the Substantial Gainful Activity (SGA) test when determining if an individual meets the functional disability criteria. However, when the department receives a disability approval for an applicant, financial staff must take SGA into consideration when determining the medical program for which an individual may be eligible. If earned income (gross earnings after deductions for impairment related work expenses or blind work expenses) is under SGA and/or the individual receives federal cash benefits based on disability or blindness, several programs may provide health care coverage. If earned income is above SGA and the individual does not receive federal cash benefits, then Apple Health for Workers with Disabilities (HWD) (S08), which waives the SGA test, may provide coverage.

Note: HWD may also provide coverage for an individual meeting program requirements, whose assets exceed the resource test that applies to certain programs.

Worker responsibilities

On receipt of request for a Medicaid decision:
1. Review the referral and Equal Access Services information and arrange for a telephone interview with the applicant or their representative if necessary.
2. Confirm the applicant is claiming blindness or disability. If the claim does not appear to meet SSI criteria, explains this to the applicant or representative and suggest the application be withdrawn. Obtain a withdrawal request if the applicant or representative agrees. Explain the following points about the determination process:
  1. DDS makes the determination of blindness or disability.
  2. The standard of promptness date is 60 days, but additional time may be required.
  3. The individual has a right to request a hearing if they disagree with the decision and it will be the responsibility of DDS to defend the decision.
  4. The individual is required to pay a monthly premium if earning more than the current SGA amount and eligible for coverage only under the HWD program.
Review of Financial Information:
1. If the applicant is not working, and the applicant’s countable resources meet the following resource standards, complete a NGMA decision referral. The applicant is not eligible for HWD, if not working, but may be eligible for coverage under another Medicaid program. If the individual is under age 65 and not eligible for Medicare, coverage might also be available under the new adult group based on the MAGI methodology. See Health care for adults in the Apple Health eligibility manual.
  1. For SSI related categorically needy (CN) (WAC 182-512-0010)
    1. One person $2,000.
    2. Married couple $3,000.
  2. For SSI related medically needy (MN) (WAC 182-512-0150)
    1. Add $50 for each additional family member.
  3. For Long Term Care programs, see WAC 182-513-1395.
    Non-Grant Medical Assistance (NGMA) - Examples
If the applicant is working, and their income is over SGA standard or their resources exceed the standard described in 2.(a) above, forward the application, using the contact information listed below WAC 182-511-1150 Health care for workers with disabilities (HWD) -- Disability requirements in the HWD chapter.
Send the following forms to the applicant for completion and signature.
Medical Disability Report and Decision, DSHS 14-144A.
Medical Information Release Form SSA 827.
Initiate a NGMA referral to DDS through the Barcode NGMA application. Each referral contains the following:
1. Transmittal Summary, DSHS 14-144.
2. Medical Disability Report and Decision, DSHS 14-144A.
3. Medical Information Release Form SSA 827.
Request retroactive approval if applicant had a medical need in any of the three months before the month of application and meets financial eligibility for each of the retroactive months.
Medical Records. DDDS support staff or adjudicators obtain medical records directly from DMS for initial applications and reconsiderations. DO NOT SEND PAPER MEDICAL RECORDS.
Note: The Administrative Hearing Coordinator is still required to send a paper copy of an Administrative Hearings packet to the DDS adjudicator.
Previous NGMA Packet. If the individual is reapplying or requesting continued NGMA benefits:
1. Initiate a redetermination referral to DDS through the Barcode NGMA application.
2. Document all actions in ACES.
3. Pend the application until a decision is received from DDS. Document the reason for delays beyond 60 days from the date of application in ACES.
When DDS returns the disability determination form 14-144:
1. If the individual meets the disability criteria, open medical care in the appropriate category, based on income and resources per WAC 182-508-0001.
2. Enter the end date and the determination date on the DEM2 ACES screen, and send a request for a redetermination to DDS at least 30 days prior to the review end date.
3. If the reexam has been waived by DDS, no end date is required.
4. If the applicant does not meet the disability criteria, consider the applicant for all other medical programs, or allow the individual to provide new medical information to be forwarded to DDS for reconsideration.
See Administrative Hearing chapter (Chapter 182-526 WAC) for hearing and reconsideration procedures. For additional information, see Non-Grant Medical Assistance (NGMA) hearings and Special Procedures on Non-Grant Medical Assistance and Health Care Authority hearings.

Definitions

Aged: Age 65 or older.
Blind: A corrected central visual acuity of 20/200 or a 20 degree field of vision limitation.
Disability: the inability to engage in any substantial gainful activity (SGA) by reason of any medically determinable physical or mental impairment(s) which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.
Disability Determination Services (DDS):The state entity that uses federal criteria to determine disability or blindness under an agreement with the Social Security Administration.
Apple Health for Workers with Disabilities (HWD): An Apple Health program that enables many people with disabilities to work and keep their health care.
Non Grant Medical Assistance (NGMA): The process through which the department makes a disability determination for individuals who are not receiving Title II cash benefits based on disability.
Substantial Gainful Activity (SGA): A person who is earning more than a certain monthly amount (net of impairment-related work expenses) is ordinarily considered to be engaging in SGA.

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Time to process

Revised date

December 23, 2022

Purpose statement

To provide the time limits for processing applications for health care coverage.

WAC 182-503-0060 Washington apple health (WAH)-- Application processing times.

WAC 182-503-0060 Washington apple health -- Application processing times.

Effective August 8, 2021

We process applications for Washington apple health medicaid within forty-five calendar days, with the following exceptions:
1. If you are pregnant, we process your application within fifteen calendar days;
2. If you are applying for a program that requires a disability decision, we process your application within sixty calendar days; or
3. The modified adjusted gross income (MAGI)-based apple health application process using Washington Healthplanfinder may provide faster or real-time determination of eligibility for medicaid.
For calculating time limits, "day one" is the day we get an application from you that includes at least the information described in WAC 182-503-0005(8). If you give us your paper application during business hours, "day one" is the day you give us your application. If you give us your paper application outside of business hours, "day one" is the next business day. If you experience technical difficulties while attempting to give us your application in Washington Healthplanfinder, "day one" is the day we are able to determine, based on the evidence available, that you first tried to submit an application that included at least the information described in WAC 182-503-0005(8).
We determine eligibility as quickly as possible and respond promptly to applications and information received. We do not delay a decision by using the time limits in this section as a waiting period.
If we need more information to decide if you can get apple health coverage, we will send you a letter within twenty calendar days of your initial application that:
1. Follows the rules in chapter 182-518 WAC;
2. States the additional information we need; and
3. Allows at least ten calendar days to provide it. We will allow you more time if you ask for more time or need an accommodation due to disability or limited-English proficiency.
Good cause for a delay in processing the application exists when we acted as promptly as possible but:
1. The delay was the result of an emergency beyond our control;
2. The delay was the result of needing more information or documents that could not be readily obtained;
3. You did not give us the information within the time frame specified in subsection (1) of this section.
Good cause for a delay in processing the application does NOT exist when:
1. We caused the delay in processing by:
  1. Failing to ask you for information timely; or
  2. Failing to act promptly on requested information when you provided it timely; or
2. We did not document the good cause reason before missing a time frame specified in subsection (1) of this section.

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

Example: Olaf applies for SSI-Related Apple Health due to a disability. DSHS finds that he is financially eligible but Olaf does not provide any medical documentation. DSHS refers the application to the Division of Disability Determination Services (DDDS). DDDS sends a request for the medical information to Olaf’s doctor. The doctor does not respond. DDDS sends another request for the missing information, and the doctor gives the medical information more than 60 days after Olaf applied. There is good cause for not processing the application within 60 days because Olaf and his doctor, and not DSHS or DDDS, caused the delay.

Aces Procedures

See:

Standards of Promptness

Standards of Promptness - When is there good cause for not processing an application by the SOP date?

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Care Delivery - managed care

Revised date

December 15, 2014

Purpose statement

To explain managed care and provide a link to the various services.

WAC 182-538-060 Managed care choice and assignment

WAC 182-538-060 Managed care choice and assignment.

Effective October 25, 2020

The medicaid agency requires a client to enroll in integrated managed care (IMC) when that client:
1. Is eligible for one of the Washington apple health programs for which enrollment is mandatory;
2. Resides in an area where enrollment is mandatory; and
3. Is not exempt from IMC enrollment and the agency has not ended the client's managed care enrollment, consistent with WAC 182-538-130.
American Indian and Alaska native (AI/AN) clients and their descendants may choose one of the following:
1. Enrollment with a managed care organization (MCO) available in their regional service area;
2. Enrollment with a PCCM provider through a tribal clinic or urban Indian center available in their area; or
3. The agency's fee-for-service system for physical health or behavioral health or both.
To enroll with an MCO or PCCM provider, a client may:
1. Enroll online via the Washington Healthplanfinder at https://www.wahealthplanfinder.org ;
2. Call the agency's toll-free enrollment line at 800-562-3022; or
3. Go to the ProviderOne client portal at https://www.waproviderone.org/client and follow the instructions.
An enrollee in IMC must enroll with an MCO available in the regional service area where the enrollee resides.
All family members will be enrolled with the same MCO, except family members of an enrollee placed in the patient review and coordination (PRC) program under WAC 182-501-0135 need not enroll in the same MCO as the family member placed in the PRC program.
An enrollee may be placed into the PRC program by the MCO or the agency. An enrollee placed in the PRC program must follow the enrollment requirements of the program as stated in WAC 182-501-0135.
When a client requests enrollment with an MCO or PCCM provider, the agency enrolls a client effective the earliest possible date given the requirements of the agency's enrollment system.
The agency assigns a client who does not choose an MCO or PCCM provider as follows:
1. If the client was enrolled with an MCO or PCCM provider within the previous six months, the client is reenrolled with the same MCO or PCCM provider;
2. If (a) of this subsection does not apply and the client has a family member enrolled with an MCO, the client is enrolled with that MCO;
3. The client is reenrolled within the previous six months with their prior MCO plan if:
  1. The agency identifies the prior MCO and the program is available; and
  2. The client does not have a family member enrolled with an agency-contracted MCO or PCCM provider.
4. If the client has a break in eligibility of less than two months, the client will be automatically reenrolled with his or her previous MCO or PCCM provider and no notice will be sent; or
5. If the client cannot be assigned according to (a), (b), (c), or (d) of this subsection, the agency:
  1. Assigns the client according to agency policy, or this rule, or both;
  2. Does not assign clients to any MCO that has a total statewide market share of forty percent or more of clients who are enrolled in apple health IMC. On a quarterly basis, the agency reviews enrollment data to determine each MCO's statewide market share in apple health IMC;
  3. Applies performance measures associated with increasing or reducing assignment consistent with this rule and agency policy or its contracts with MCOs.
6. If the client cannot be assigned according to (a) or (b) of this subsection, the agency assigns the client as follows:
  1. If a client who is not AI/AN does not choose an MCO, the agency assigns the client to an MCO available in the area where the client resides. The MCO is responsible for primary care provider (PCP) choice and assignment.
  2. For clients who are newly eligible or who have had a break in eligibility of more than six months, the agency sends a written notice to each household of one or more clients who are assigned to an MCO. The assigned client has ten calendar days to contact the agency to change the MCO assignment before enrollment is effective. The notice includes:
    1. The agency's toll-free number;
    2. The toll-free number and name of the MCO to which each client has been assigned;
    3. The effective date of enrollment; and
    4. The date by which the client must respond in order to change the assignment.
An MCO enrollee's selection of a PCP or assignment to a PCP occurs as follows:
1. An MCO enrollee may choose:
  1. A PCP or clinic that is in the enrollee's MCO and accepting new enrollees; or
  2. A different PCP or clinic participating with the enrollee's MCO for different family members.
2. The MCO assigns a PCP or clinic that meets the access standards set forth in the relevant managed care contract if the enrollee does not choose a PCP or clinic.
3. An MCO enrollee may change PCPs or clinics in an MCO for any reason, with the change becoming effective no later than the beginning of the month following the enrollee's request.
4. An MCO enrollee may file a grievance with the MCO if the MCO does not approve an enrollee's request to change PCPs or clinics.
5. MCO enrollees required to participate in the agency's PRC program may be limited in their right to change PCPs (see WAC 182-501-0135).

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.

Note: Information on managed care service areas including how to change plans can be found on the HCA Managed Care website.

182-538 Chapters

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Allowable practitioners

Revised date

July 25, 2014

The following are a list of allowable practitioners for Classic (non-MAGI) Medicaid.

ARNP Advanced Registered Nurse Practitioner
CRN Certified Registered Nurse
D.C. Chiropractor
D.D.S. Dentist, Denturist, Orthodontist, Periodontist
D.O. Osteopath
D.P.M. Podiatrist
Dental Hygienist
Electrotherapist
Hydro therapist
Inhalation/Respiratory Therapist
LPN Licensed Practical Nurse
M.D. Physician
Midwife
Naturopath
O.D. Optometrist
Occupational therapist
Optician
P.A. Physician Assistant
Pharmacist
Psychologist/Psychiatrist
Speech therapist
X-ray Technician

Allowable practitioners, with a documented referral from an M.D., D.O., D.D.S., or ARNP

Acupuncturist
Dietician

Practitioners not allowable

Herbalist
Homeopath
Holistic Healer
Hypnotist
Masseur or Manipulator
Psychic or Faith Healer
Sanipractor
Veterinarian
Practitioners not recognized under Washington State law

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Managed care and long-term care

Revised date

April 11, 2022

Purpose statement

The Washington Apple Health (AH) managed care organization (MCO) plan is responsible to pay for nursing facility (NF) days that are qualifying rehabilitative and skilled nursing services. Long-term care nursing facility services (sometimes called custodial care or long term care) is paid by Aging and Long Term Supports Administration (ALTSA) as a fee for service once AH MCO coverage days end. This section gives instructions for the Public Benefit Specialist (PBS) when a client enrolled into AH MCO admits into a NF.

Program of all-inclusive care for the elderly (PACE) information.

Note: The instructions below are intended for Home and Community Service (HCS) and Developmental Disability Administration (DDA) LTC specialty Public Benefit Specialists. This section includes information for HCS and DDA social workers and case managers.

HCS and DDA do not determine medicaid eligibility for clients on a MAGI based medical programs (N track in ACES). The eligibility is done through the Health Benefit Exchange (HBE).

The HCS and DDA financial worker determines eligibility for SSI-related Aged, Blind, Disabled medicaid which includes Community First Choice (CFC), Institutional, and Home and Community Based (HCB) Waiver medical programs.

Consult the Overview - Long-term and Supports chart.

What are rehabilitative services or skilled nursing services?

Rehabilitative services can last for a few days to several weeks as long as a physician determines a client is in need and is responding to rehabilitation.

During rehabilitation days and skilled nursing days in a NF when the client has AH managed care, the client does not pay participation toward the cost of care. The AH MCO plan is responsible to pay the NF for qualified skilled nursing and rehabilitation days. Clients that are near the Medicaid resource limit, may need to be monitored by the Public Benefit Specialist (PBS). This is the same process as a Medicare/Medicaid client receiving NF services under Medicare.

Once the MCO deems the stay is no longer medically necessary and not covered by the plan, the NF needs to notify the Public Benefit Specialist via the DSHS 15-031 notice of action and request a social service intake as ALTSA is responsible to determine NFLOC in order to authorize the payment for the services once AH MCO coverage ends and coverage as a long-term care service begin.

What are long-term care services in a NF?

Long-term care services in a NF are when an individual does not meet the criteria for skilled nursing or rehabilitation. Most long-term care assists people with support services, (Sometimes this is called custodial care). The correct term is long term care or institutional services.

The AH MCO contract does not cover custodial long-term care services in a nursing facility. Long-term care services in a NF are approved by Home and Community Services (HCS) for medicaid eligible clients that meet nursing facility level of care (NFLOC). Medicaid eligibility for individuals needing long-term care services over 29 days is described in WAC 182-513-1315.

Who is enrolled in a Washington Apple Health (AH) Managed Care Organization (MCO)?

All categorically needy (CN) and alternate benefit plan (ABP) medicaid clients are enrolled or may be enrolled into an AH MC plan. There are some exceptions such as:

Individuals on Medicare
Individuals with an approved HCA exemption requested by the client due to tribal status.

Note: A medical benefit covered under the AH MCO plan or the fee for service (FFS) medicaid program is a covered service. If an AH MCO client chooses to go outside the MCO network without MCO approval for a covered medical service, the client will be responsible to pay out-of-pocket. This cost is not allowed to reduce participation because it is medical care covered under the state's Medicaid plan. See WAC 182-513-1350 and Allowable medical expenses.

Note: All Apple Health medicaid clients including those on Medicare are enrolled in a behavioral health MCO for coverage of behavioral health services.

Nursing Home admissions under a Modified Adjusted Gross Income (MAGI) Medical group

The instructions for financial workers below are limited to individuals on SSI-related (Aged, Blind and Disabled) Medicaid programs.

Individuals active on a MAGI-based program determined by the Health Benefit Exchange (HBE) are eligible to receive nursing facility services as part of the state plan or alternate benefit plan (ABP). The only exception is the AEM MAGI programs called N21 and N25 in ACES. AEM does not cover NF care.

The AH MCO plan is responsible to pay for rehabilitation and skilled nursing in a NF. Once rehabilitation ends, the NF is paid by Provider One as a claim.

No NF award letter is issued for a client receiving N track MAGI based medical.

No participation is paid to the NF provider for MAGI based clients.

How does a client change a Washington Apple Health Managed Care plan?

A client can choose to change plans by contacting Health Care Authority (HCA) by the Provider One portal or calling 1-800-562-3022.

Any issues regarding coverage needs to be addressed directly to the plans. For a complete list of current plans, see Apple Health Managed Care Medical Programs

How do I check to see if a Medicaid client is currently on an Apple Health (AH) managed care MCO plan?

ACES online has current real time data from Provider One on managed care. ACES online does not show historical data on any changes that have occurred in AH MCO such as change in an AH MCO plan, exemption data, enrollment/discharge dates.

To see the current AH MCO status, go to ACES online and check the details tab. Scroll down to "Medical Information" section. Check to see if one of the AH MCO plans is indicated.

Nursing Facility providers check for AH MCO plans searching in the client benefit inquiry under managed care information. If the client is on AH MCO, it will show up under Plan/PCCM Name.

When are long-term care clients disenrolled from Washington Apple Health (AH) Managed Care Organization (MCO) plan?

Developmental Disabilities Administration (DDA) RHC clients are disenrolled from AH MCO once they are in the institution over 29 days. The AH MCO plan does not cover services in a DDA state institution.

Once the client is disenrolled from AH MCO, they are considered a "fee for service" (FFS) client.

Note: The AH MCO plans do not cover long term services and supports (LTSS) for clients living in the community or residential settings. These services are not included in the AH MCO contract and considered a "carve out". In home care or residential services are authorized by either Home and Community Services (HCS) or the Developmental Disabilities Administration (DDA). AH MCO clients receiving services authorized by DDA or HCS get their prescription drugs, durable medical equipment, physician services and other medical services through their AH MCO plan.

Public Benefit Specialist responsibilities

If the NF admission is a AH MCO client, do a barcode tickler for 30 days from the date of admission to check the status.
Submit a 65-10 referral through barcode to social service for a NFLOC determination. Even though it is not required for AH MCO rehabilitation days, it is required to generate a NF award letter when doing a program change once a client is institutionalized 30 days or more.

Short Stays

Do not issue a short stay letter for an AH MCO client unless the NF has submitted a DSHS 15-031 indicating rehabilitation days or skilled nursing days through the AH MCO plan has ended with an end date.
If the admission is under 30 days, and rehabilitation days has ended, indicate the day after the rehabilitation end date as the authorization date on the STAY screen. Add text to the short stay letter AH MCO rehabilitation day ends on XX-XX-19XX (enter date).
A confirmation of NFLOC is required by the HCS SW before a short stay letter is issued.
Most short stay NF admissions are considered rehabilitation. If the entire short stay is under AH MCO rehabilitation or skilled nursing status, do not issue a short stay letter.
Indicate in the ACES narrative "AH MCO Rehab Admit" with the date.

See Short stay information for NF admissions not under AH MCO

30 days or more admissions

Once a classic aged, blind, disabled (ABD) AH MCO client is in a NF 30 days or more, make the necessary changes in the ACES system.
The authorization date on the INST for a recipient is normally the first date DSHS was notified of the admission. If the PBS has information from the NF via DSHS 15-031 NOA that the rehabilitation days have ended, indicate the day after the rehab end date as the authorization date on the INST screen.
ACES will issue an award letter even though the client may still be receiving rehabilitative services under the AH MCO . Indicate in the text of the award letter "Washington Apple Health Managed Care Rehabilitation Admission".
During rehabilitation days paid by the AH MCO, the client does not participate toward the cost of care. If the client is close to the resource limit, monitor the resources with the same process used as Medicare days in the NF.
Indicate in the ACES narrative "AH Managed Care rehab admit" and the date, if the NF reports AH MCO rehabilitation ends, indicate AH MCO rehab end date.

Example: Short Stay #1

S02/SSI related client, not on Medicare admits to a NF on 11/5/2016. 15-031 NOA from NF indicates the 11/5/2016 admission under AH MCO rehabilitation. A 2nd NOA from the NF indicates a discharge date of 11/20/2016 back home. In this example, a short stay letter is not needed. A NFLOC determination from the HCS SW is not needed. The NF admission is covered by the AH MCO. Added CFC to note.

Example: Short Stay #2

S02/SSI related client, on Medicare admits to a NF on 11/5/2016. 15-031 NOA from NF indicates the 11/5/2016 admission date. A 2nd NOA from the NF indicates a discharge date of 11/20/2016 back home. In this example, the client is not on AH MCO because the client is on medicare. A short stay award letter is needed in order for the NF to bill. Send a 65-10 referral for NFLOC. Once NFLOC is received, indicate the admission and discharge on the STAY screen in ACES in order to generate a short stay letter.

Example: Short Stay #3.

S02/SSI related client not on Medicare admits to a NF on 11/5/2016. 15-031 NOA from NF indicates 11/5/2016 admission under AH MCO rehabilitation. A 2nd NOA from the NF indicates rehabilitation days end on 11/20/2016. The FW sends a 65-10 to the HCS SW for a NFLOC determination. Set a barcode tickler to check the status on 12/4/2016. 3rd NOA from NF received indicating client discharged home on 12/1/2016. 14-443 received by the FW from the SW indicating NFLOC and discharged home on 12/1/2016 on MPC services. FW uses the short stay screen to issue the NF A/L. The payment authorization date on the STAY screen is 11/21/2016 (the day after the AH MCO rehabilitation days end). Update the INST with MPC service information.

Example: 30 day or more admission #1

S02/SSI related client not on Medicare admits to a NF on 11/5/2016. 15-031 NOA from NF indicates 11/5/2016 admission under AH MCO rehabilitation. A 2nd NOA from the NF indicates rehabilitation days end on 12/1/2016. The FW sends a 65-10 to the HCS SW for a NFLOC determination. Set a barcode tickler to check the status on 12/15/2016. 14-443 received by the FW from the SW indicating NFLOC and no discharge plan. FW does a program change from S02 to L02. The payment authorization date on the INST screen is 12/2/2016 (the day after the AH MCO rehabilitation days end). Once the program change is completed, the NF award letter is generated.

Example: 30 day or more admission #2

S02/SSI related client not on Medicare admits to a NF on 11/5/2016. 15-031 NOA from NF indicates 11/5/2016 admission under AH MCO rehabilitation. Set a barcode tickler for 12/5/2016 to check the status. 14-443 sent by SW to FW indicating NFLOC, will be in NF 30 days or more and client is still considered under rehabilitation status. The FW will need to do a program change from S02 to L02 as over 30 days. The FW does not know when AH MCO rehabilitation days end, so indicate the first date it was known the client was admitted into the NF. Once the program change is completed, the NF award letter is generated.

Nursing Facility Responsibilities

The NF is responsible to check the system to see if a Medicaid client is enrolled in an AH MCO plan prior to admission into the NF. WAC 182-501-0200 Third Party Resources and WAC 182-502-0100 General Conditions of payment describe that Medicaid fee for service is the payer of last resort.
The NF is responsible to get a preapproval and contract with the AH MCO before admitting an AH MCO client into the NF.
The NF will send a DSHS 15-031 to the DSHS Public Benefit Specialist and indicates if the admission is under an AH MCO.
The NF provider needs to consult the Apple Health NF billing guide for billing instructions.

Provider Billing Guides:

Health Care Authority Nursing Facility Provider Billing Guide
ProviderOne Billing and Resource Guide (includes provider notices)

Other managed care information: MCS admissions into a nursing facility

Medical Care Services (MCS) program formally Disability Lifeline-Unemployable (DL-U) (formally GA-U). Instructions for managed care and MCS-State fund medical and nursing home admissions. A nursing home award letter and NFLOC determination will be needed for NF admissions under the MCS program as this group is not enrolled into managed care.

Other LTC insurance, Third party resources information

LTC Medicare, LTC insurance, Third Party Resources, LTC partnership and SHIBA information

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Equitable estoppel

Revised date

November 2, 2023

WAC 182-526-0495 Equitable estoppel.

WAC 182-526-0495 Equitable estoppel.

Effective March 16, 2017

Equitable estoppel is a legal doctrine that may be used only as
1. an affirmative defense to prevent the health care authority (HCA) from collecting an overpayment. Equitable estoppel may not be used to require HCA to continue to provide something or to require HCA to take action contrary to a statute.
There are five elements of equitable estoppel. A party asserting the doctrine of equitable estoppel must prove all of the following five elements by clear and convincing evidence:
1. HCA made a statement or took an action or failed to take an action, which is inconsistent with a later claim or position by HCA.
2. The party reasonably relied on HCA's original statement, action or failure to act.
3. The party will be injured to its detriment if HCA is allowed to contradict the original statement, action or failure to act.
4. Equitable estoppel is needed to prevent a manifest injustice. Factors to be considered in determining whether a manifest injustice would occur include, but are not limited to, whether:
  1. The party cannot afford to repay the money to HCA;
  2. The party gave HCA timely and accurate information when required;
  3. The party did not know that HCA made a mistake;
  4. The party is free from fault; and
  5. The overpayment was caused solely by an HCA mistake.
5. The exercise of government functions is not impaired.
If the administrative law judge (ALJ) concludes that the party has proven all of the elements of equitable estoppel by clear and convincing evidence, HCA is estopped or prevented from taking action or enforcing a claim of overpayment against that party.

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

Two court cases (Chaplin v. Sugarman and Kramerevsky v. DSHS) established that an administrative law judge (ALJ) in Washington State may apply equitable estoppel in administrative hearings. Equitable estoppel is a legal principle which means that, in certain cases, the ALJ can order the agency to stop doing something because it is not fair to an individual.

The agency, in consultation with Legal Services, the Office of the Attorney General and the Office of Administrative Hearings, has developed a stipulation and agreed order of dismissal which can be used to take the place of a formal hearing and written decision by an ALJ.

An individual may raise the issue of equitable estoppel in any hearing.

The Stipulation and Agreed Order of Dismissal should be considered for cases which meet all of the following conditions:

The sole issue for hearing is the fairness of the collection of an overpayment, and
Neither party (appellant or agency) is disputing any fact affecting the outcome of the case. There is agreement about the amount and the facts of the overpayment; and
The agency is satisfied that all elements of estoppel have been established by the appellant with "clear, cogent, and convincing" evidence. This means that the fact is proven by the evidence to be highly probable.

The purpose of the stipulation is to avoid unnecessary hearings on overpayments which would likely result in an equitable estoppel finding. A hearing is unnecessary only when the agency agrees that the appellant has established the case for equitable estoppel and the appellant agrees to the facts of the overpayment. If either party disputes any fact affecting the outcome of the case, a hearing should be held, and a formal decision made by the ALJ.

Worker responsibilities

Review each hearing request on an overpayment, to determine if equitable estoppel is a factor. If yes, apply the following guidelines to determine if the case is appropriate for use of the stipulation and agreed order.

Guidelines for Establishment of Equitable Estoppel:

Element #1:

An admission, statement, or act by the agency, which is inconsistent with a later claim. The agency made a statement, took action, or failed to act and later found that it was incorrect. The individual is informed after the fact that the error was made.

Factors which may be used as evidence of element #1:

The agency had all the information available to correctly determine eligibility.
The individual received the coverage.
The agency has assessed an overpayment.

Element #2:

An action by the individual on the faith of the agency's admission, statement, or act. The individual must have taken some action that was reasonable given the circumstances (i.e., utilized the COPES services).

Factors which may be used as evidence of element #2:

The individual's belief in the agency's action was reasonable.

Element #3:

An injury to the individual arising from permitting the agency to contradict or repudiate such admission, statement, or act. The individual experiences either a loss or a detrimental change in their position because the agency reverses a decision regarding eligibility. Depending on the specific circumstances of the case, the imposition of a debt that could not be anticipated or avoided by the individual may establish injury.

Factors which may be used as evidence of injury:

Spent the money on items they would not have otherwise bought and which are not an available resource.
Paid outstanding debts they would not otherwise have paid.
Failed to use an available family or community resource due to the receipt of the benefits. Food Banks, help from relatives, the Salvation Army.

Element #4:

Equitable estoppel is necessary to prevent a manifest injustice. The overpayment is clearly unfair to the individual based on the way that it occurred and repayment would compromise the individual's ability to meet basic needs.

Factors which can be used as evidence of element #4:

The individual cannot repay the overpayment without drawing on funds needed for basic requirements.
It is clear that the individual acted in good faith by following the rules required to maintain eligibility.
1. The individual reported income timely and accurately.
2. The overpayment was solely due to agency error; and
3. The individual has "clean hands", meaning they are without fault. The individual fulfilled all their responsibility to inform the agency of changes in their circumstances.

Element #5:

Applying equitable estoppel will not impair the exercise of governmental powers. Element #5 will be considered to be met unless there is an extraordinary circumstance. This element must be considered on a case-by-case basis. The cumulative effect of equitable estoppel applied to many cases is not permitted.

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Confidentiality information

Revised date

July 25, 2014

Purpose statement

To describe HCA's rules regarding confidential information and whom HCA discloses confidential information to.

Clarifying information

The following information is considered confidential:
1. Information contained in case records:
  1. Names, birth dates, marital status, employment status, personal history;
  2. Location, current address and telephone number;
  3. Types of services being received, amounts of benefits and fair hearing activity;
  4. Social Security numbers; and
  5. Medical or psychiatric information.
2. Information about third parties:
  1. Information about the identity of individuals who have filed complaints; and
  2. The identity of individuals who have provided information under condition of remaining anonymous.
3. Information available from other agencies:
  1. Employment or benefit information from the Employment Security Department;
  2. Information from the Social Security Administration; and
  3. Birth information from Vital Statistics.
Confidential information except chemical dependency treatment information may be provided to a person who works directly with:
1. Federal- or state-funded public assistance programs including the federal food stamp program when used for the administration of the programs;
2. The child support program under Title IV-D of the Social Security Act when used for the administration of the child support program; or
3. Local, state or federal law enforcement agencies. Information will be released to a local, state, or federal law enforcement agency only when the request:
  1. Identifies the person making the request including their authority to do so;
  2. Identifies the individual;
  3. Provides the Social Security number of the individual;
  4. States the request is an official duty or that finding and apprehending the individual is an official duty;
  5. Describes the violation being investigated; and
  6. Limits the requested information to the address of the individual.
Release information to the U.S. Consulate (U.S. Department of State) only when the individual has provided a written release for the information requested.
At the individual's request information provided by the individual or previously given to an individual may be disclosed to the individual or their representative.
Information provided by third parties may be disclosed to the individual or the individual's representative when:
1. A fair hearing has been requested on an issue related to the information; or
2. The Public Disclosure Coordinator determines that:
  1. The release is necessary; and
  2. The information was provided with the understanding that it might be released.
Information relating to the identity of third parties who have filed complaints regarding individuals (or other) and/or who have provided information on condition of anonymity must not be released unless required by a court order.
Information may be released to individuals or agencies with valid releases of information signed and dated by the individual. A release of information is valid if it is:
1. Signed by the individual, presented within any time frames mentioned on the release;
2. Presented by the individual to whom the release is made out; and
3. A request for information that can be legitimately released.
Information other than chemical dependency treatment information may be disclosed to any administrative division of HCA when the purpose of the request for information is to administer the programs of HCA.
Routine transfers of information are subject to the same criteria.
Information may be disclosed to outside agencies only for purposes directly connected with the administration of HCA programs. Outside agencies who receive confidential information are bound by the same rules as HCA.
The following information may be disclosed to medical providers:
1. Proof that the individual is eligible for medical assistance;
2. Dates of eligibility;
3. The PIC code with the tie breaker;
4. The program for which the individual is eligible; and
5. Medicare eligibility status.
The following information may not be disclosed to medical providers:
1. Individual names and addresses;
2. Medical services provided;
3. Social and economic conditions or circumstances;
4. Agency evaluation of personal information; and
5. Medical data.
Confidential information cannot be provided for:
1. Commercial or political purposes
2. Personal purposes by any employees of the department.

Worker responsibilities

Disclosure to third parties: HCA must disclose to anyone making inquiry whether or not a named individual is currently receiving Apple Health coverage. HCA's response is limited to a "yes" or "no" answer. Further information is prohibited without a release from the individual.
Disclosure to courts of law: Information can only be disclosed with a court order.
Disclosure to government officials: Treat requests from government officials like any other third-party request. Refer the request to the HCA public disclosure coordinator.
Special situations:
1. Translators and contractors must be informed of the rules regarding confidentiality and are bound by those rules to the same degree as a department employee.
2. See Civil Rights and Complaints for rules and procedures related to the rights and responsibilities of an individual receiving public assistance.
3. See Equal Access for rules and procedures for equal access services.

Clarifying information

Disclosing information to parents with visitation rights or legal custody

Disclosure of the address of a child covered by Apple Health to a parent who is not in the child's household is governed by RCW 74.04.060, 26.23.120 and 74.12.

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Hospice and long-term services and supports (LTSS) programs

Revised date

February 14, 2018

LTSS programs (HCS and DDA HCB Waivers)

LTSS programs such as CFC, COPES, PACE, New Freedom and DDD Waiver programs take precedence over Hospice. ACES is coded under the primary HCB Waiver service and participation is applied toward the Waiver program first; the hospice service is added to the HCBS screen. It is important that services are coordinated between the Hospice provider and the DSHS agency providing services so there is no duplication of services.
For clients who elect hospice in a nursing facility, ACES is coded as hospice in a nursing facility on the institutional care screen under facilities and add the hospice service information in the HCBS screen. This will add the hospice indicator to the case; the case will trickle to a L31/L32.
Use the short stay screen for a hospice election in a NF when the client is already on Medicaid and the election and end of hospice service is under 30 days.
Use the short stay screen for a hospice election when a client is active on a medicaid program and is admitted into a hospice care center or hospice NF admission 30 days or less.

Example: Active client on L02 in nursing home elects Hospice on 10/2/2017 and dies or revokes hospice on 10/15/2017. This case does not need to be changed in order to issue a hospice award letter. Use the short stay screen to issue a hospice award letter from 10/2/2017 to 10/15/2017.

Example: Active CFC client on L52 elects hospice.
The client remains in the ALF under the CFC program. The hospice agency will bill the medicaid agency with hospice as a service. The CFC program remains the priority program. The hospice service should be updated in ACES on the institutional care screen.

Example: Active L22 COPES client elects hospice; the client resides in their own home.

The hospice service should be updated in ACES on the institutional care screen along with the COPES service. The COPES Waiver is the priority program and participation would go to the COPES provider.

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CMS guidance on Part D prescription drug expenses and spenddown

Revised date

March 6, 2024

Purpose statement

This is an overview of guidance given by CMS regarding Medicare D and spenddown expenses. The same guidance can be applied to reducing LTC participation by a Medicare D related expense.

When are prescription drugs for Medicare beneficiaries an allowable expense under spenddown?

For the purposes of Medicaid spenddown, incurred Part D pharmacy costs are treated in the same manner as any other costs incurred for medical care. All usual rules for determination of an applicant’s liability, insurance coverage and spenddown eligibility is applicable. Costs paid in whole or in part by a State Pharmaceutical Assistance Program (SPAP), or other public program of the state or a political subdivision of the state, which involves no federal funds may be counted as an incurred medical expense to establish eligibility for a Medicaid spenddown.

Note

If a State’s Medicaid program provides coverage of any of these costs, they are not allowable under spenddown.

Enrollment in Part D is voluntary, therefore not all Medicare beneficiaries will be enrolled in a Medicare Part D plan (PDP) or a Medicare Advantage plan (MA-PD). For those enrolled in a PDP or MA-PD, not all drugs will be covered. Each plan may have a different combination of deductibles, copays and coverage gaps. To determine if drug costs incurred by Medicare beneficiaries are allowable under spenddown, apply the following rules:

If the Medicare beneficiary was not enrolled in a PDP or MA-PD on the date of service, allow the prescription drug cost.
If the Medicare beneficiary was enrolled in a PDP or MA-PD on the date of service, the plan must issue a periodic (at least monthly) statement to the beneficiary explaining all benefits paid and denied, and amounts attributed to cost sharing. If the drug charge is identified on this statement as a beneficiary liability, i.e. part of a deductible, copay, or coverage gap, allow the expense under spenddown.
When a plan denies coverage of a prescription the beneficiary has the right to request an exception for coverage of the drug. The beneficiary is notified in writing of the decision. If the drug charge appears on the statement as a denial, and no exception was requested, do not allow the charge.
If the drug charge appears on the statement as a denial, and an exception was requested and denied, allow the charge.

These procedures will help ensure that legitimate part D cost sharing expenses are allowed under spenddown, as well as expenditures for drugs not covered by the PDP or MA-PD. By relying on the statements and exception notices, eligibility workers will not need to be concerned with knowing the cost sharing rules for each plan, the plan formularies or nonformulary drugs covered under a transition plan or under the exception process. Applicants should be advised to retain their statements and other related documentation for consideration under spenddown.

Clarifying information

If the Medicare beneficiary is not enrolled in a Part D plan (PDP or MA-PD) on the date of service allow the prescription drug cost toward spenddown. It doesn't matter why the beneficiary is not enrolled. The reverse would also be true if a Medicare beneficiary is enrolled in a PDP or MA-PD on the date of service, we would not allow the prescription drug cost, whether self-paid or not, because the drug is covered drug under the beneficiaries' Medicare Part D plan.

Enrollment in Medicare Part D is voluntary. A Medicaid individual could tell Medicare that they are "affirmatively declining Medicare Part D coverage" but this would not make them eligible for Medicaid to cover their prescription expenses. We could, however, apply the costs they incur for prescription drugs towards a spenddown liability upon confirmation from SSA that the individual had affirmatively declined coverage.

Since Medicare is primary payer for drugs covered under Part D and not Medicaid, there is no prescription drug coverage available to full benefit dual eligible individuals, including those not enrolled in a Part D plan—for (1) Covered Part D drugs; or (2) any cost-sharing obligations under Part D relating to covered Part D drugs. This means that if a CN or MN Medicaid individual with Medicare chooses to "affirmatively decline" Medicare Part D coverage, Medicaid will still not pay for any prescription drug costs that would have been covered under Medicare Part D or any Part D cost-sharing.

Disenrollment from a current Part D plan will not prevent Medicare reenrollment in the same or a different plan. To prevent reenrollment individuals must get their Medicare records documented with their statement that they are "declining prescription coverage under the national Medicare Part D prescription drug program".

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