Program standard for income and resources

Revised date
Purpose statement

Below are the WACs for the income and resource standards, which are summarized in the Medical Income and Resource Standards Chart (pdf).

WAC 182-505-0100 Medical programs-- Monthly income standards based on the federal poverty level (FPL).

WAC 182-512-0010 Supplemental Security Income (SSI) standards; SSI-related categorically needy income level (CNIL); and countable resource standards.

WAC 182-517-0100 Medicare savings programs--Monthly income standards.

WAC 182-519-0050 Monthly income and countable resource standards for medically needy (MN).

WAC 182-519-0050 Monthly income and countable resource standards for medically needy (MN)

WAC 182-519-0050 Monthly income and countable resource standards for medically needy (MN).

Effective February 10, 2023

  1. Changes to the Medically Needy Income Level (MNIL) occur on January 1st of each calendar year when the Social Security Administration (SSA) issues a cost-of-living adjustment.
  2. Medically Needy (MN) standards for people who meet institutional status requirements are in WAC 182-513-1395. The standard for a client who lives in an alternate living facility is in WAC 182-513-1205.
  3. The resource standards for institutional programs are in WAC 182-513-1350. The institutional standard chart is found at Long Term Care Standards.
  4. Countable resource standards for the noninstitutional MN program are:
    1. One person $2,000.
    2. A legally married couple $3,000.
    3. For each additional family member add $50.
  5. People who do not meet institutional status requirements use the "effective" MNIL income standard to determine eligibility for the MN program. The "effective" MNIL is the one-person federal benefit rate (FBR) established by SSA each year, or the MNIL listed in the chart below, whichever amount is higher. The FBR is the supplemental security income (SSI) payment standard. For example, in 2023 the FBR is $914.
1 2 3 4 5 6 7 8 9 10
914 914 914 914 914 975 1125 1242 1358 1483

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.

WAC 182-505-0100 Monthly income standards for MAGI-based programs.

WAC 182-505-0100 Monthly income standards for MAGI -based programs.

Effective November 1, 2024.

  1. Each year, the federal government publishes new federal poverty level (FPL) income standards in the Federal Register found at https://aspe.hhs.gov/poverty-guidelines.
    1. The income standards for the following Washington apple health programs change on the first day of April every year based on the new FPL, except for subsections (2) and (3) of this section.
    2. The agency determines income eligibility by comparing countable income as determined of the person's medical assistance unit (MAU), under WAC 182-506-0010 and 182-506-0012, to the applicable income standard. Rules for determining countable income are in chapter 182-509 WAC.
  2. Parents and caretaker relatives under WAC 182-505-0240 must have countable income equal to or below the following standards:
    Medical Assistance Unit Size 1 2 3 4 5 6 7 8 9 10 11+
    Medical Assistance Unit Size $511 $658 $820 $972 $1,127 $1,284 $1,471 $1,631 $1,792 $1,951 $1,951
  3. Parents and caretaker relatives with earned income above the limits in subsection (2) of this section are the only people who may be eligible for the transitional medical program described in WAC 182-523-0100.
  4. Adults described in WAC 182-505-0250 who are not eligible under subsection (2) or (3) of this section must have countable income equal to or below 133 percent of the FPL.
  5. Pregnant people described in WAC 182-505-0115 must have countable income equal to or below 210 percent of the FPL.
  6. Children with countable income:
    1. Equal to or below 210 percent of the FPL as described in WAC 182-505-0210 (3)(a)(i) receive coverage at no cost.
    2. Greater than 210 percent but equal to or less than 312 percent as described in WAC 182-505-0210 receive premium-based coverage. Premium amounts are described in WAC 182-505-0225.

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.

WAC 182-512-0010 Supplemental security income (SSI) standards, SSI-related categorically needy income level (CNIL), and countable resource standards.

WAC 182-512-0010 Supplemental security income (SSI) standards, SSI-related categorically needy income level (CNIL), and countable resource standards.

Effective January 27, 2019

  1. The SSI payment standards, also known as the federal benefit rate (FBR), change each January 1st.
  2. See WAC 388-478-0055 for the amount of the state supplemental payments (SSP) for SSI recipients.
  3. See WAC 182-513-1205 for standards of clients living in an alternate living facility.
  4. The SSI-related CNIL standards are the same as the SSI payment standards for single persons and couples. Those paying out shelter costs have a higher standard than people who have supplied shelter.
  5. The countable resource standards for SSI and SSI-related CN medical programs are:
    1. One person $2,000
    2. A legally married couple $3,000

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.

WAC 182-517-0100 Federal medicare savings programs.

WAC 182-517-0100 Federal medicare savings programs.

Effective January 19, 2026

  1. Available programs. The medicaid agency offers eligible clients the following medicare savings programs (MSPs):
    1. The qualified medicare beneficiary (QMB) program;
    2. The specified low-income medicare beneficiary (SLMB) program;
    3. The qualified individual (QI-1) program; and
    4. The qualified disabled and working individuals (QDWI) program.
  2. Eligibility requirements.
    1. To be eligible for an MSP, a client must:
      1. Be entitled to medicare Part A; or
      2. Be eligible for and enrolled in the medicare Part D low-income subsidy (LIS) program through the social security administration (SSA); and
      3. Meet the general eligibility requirements under WAC 182-503-0505.
    2. To be eligible for QDWI, a client must be under age 65.
    3. Income limits.
      1. Income limits for all MSPs are found at www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/program-standard-income-and-resources.
      2. If a client's countable income is less than or equal to 110 percent of the federal poverty level (FPL), the client is income eligible for the QMB program.
      3. If a client's countable income is over 110 percent of the FPL, but does not exceed 120 percent of the FPL, the client is income eligible for the SLMB program.
      4. If a client's countable income is over 120 percent of the FPL, but does not exceed 138 percent of the FPL, the client is income eligible for the QI-1 program.
      5. If a client's countable income is over 138 percent of the FPL, but does not exceed 200 percent of the FPL, the client is income eligible for the QDWI program if the client is employed and meets disability requirements described in WAC 182-512-0050.
    4. The federal MSPs do not require a resource test.
  3. MSP income eligibility determinations.
    1. The agency has three methods for determining if a client is eligible for an MSP:
      1. The agency first determines if the client is eligible based on SSI-related methodologies under chapter 182-512 WAC. Under this method, the agency calculates the household's net countable income and compares the result to the one-person standard. However, if the spouse's income is deemed to the client, or if both spouses are applying, the household's net countable income is compared to the two-person standard.
      2. If the client is not eligible under the methodology described in (a)(i) of this subsection, the agency compares the same countable income, as determined under (a)(i) of this subsection, to the appropriate FPL standard based on family size. The number of individuals that count for family size include:
        1. The client;
        2. The client's spouse who lives with the client;
        3. The client's dependents who live with the client;
        4. The spouse's dependents who live with the spouse, if the spouse lives with the client; and
        5. Any unborn children of the client, or of the spouse if the spouse lives with the client.
      3. The third method for determining if a client is eligible for an MSP is the SSA LIS methodology. This is based on the client's application for the medicare Part D low-income subsidy program through the SSA, which the agency receives from SSA through the LIS data file. Under this methodology, the agency compares the LIS data file regarding income and household size to the current MSP standards.
    2. Under all eligibility determinations, the agency follows the rules for SSI-related people under chapter 182-512 WAC for determining
      1. Countable income;
      2. Availability of income;
      3. Allowable income deductions and exclusions; and
      4. Deemed income from and allocated income to a nonapplying spouse and dependents.
    3. The agency uses the eligibility determination that provides the client with the highest level of coverage.
      1. If the MSP applicant is eligible for QMB coverage under (a)(i) of this subsection, the agency approves the coverage.
      2. If the MSP applicant is not eligible for QMB coverage, the agency determines if the applicant is eligible under (a)(ii) of this subsection.
      3. If neither eligibility determination results in QMB coverage, the agency uses the same process to determine if the client is eligible under any other MSP.
    4. When calculating income under this section:
      1. The agency subtracts client participation from a long-term care client's countable income under WAC 182-513-1380, 182-515-1509, or 182-515-1514.
      2. The agency counts the annual Social Security cost-of-living increase beginning April 1st each year.
  4. Covered costs.
    1. The QMB program pays:
      1. Medicare Part A and Part B premiums using the start date in WAC 182-504-0025; and
      2. Medicare coinsurance, copayments, and deductibles for Part A, Part B, and Part C, subject to the limitations in WAC 182-502-0110.
    2. If the client is eligible for both SLMB and another medicaid program:
      1. The SLMB program pays the Part B premiums using the start date in WAC 182-504-0025; and
      2. The medicaid program pays medicare coinsurance, copayments, and deductibles for Part A, Part B, and Part C subject to the limitations in WAC 182-502-0110.
    3. If the client is only eligible for SLMB, the SLMB program covers medicare Part B premiums using the start date in WAC 182-504-0025.
    4. The QI-1 program pays medicare Part B premiums using the start date in WAC 182-504-0025 until the agency's federal funding allotment is spent. The agency resumes QI-1 benefit payments the beginning of the next calendar year.
    5. The QDWI program covers medicare Part A premiums using the start date in WAC 182-504-0025.
  5. MSP eligibility. Medicaid eligibility may affect MSP eligibility:
    1. QMB and SLMB clients may receive medicaid and still be eligible to receive QMB or SLMB benefits.
    2. QI-1 and QDWI clients who begin receiving medicaid are no longer eligible for QI-1 or QDWI benefits, but may be eligible for the state-funded medicare buy-in program under WAC 182-517-0300.
  6. Right to request administrative hearing. A person who disagrees with agency action under this section may request an administrative hearing under chapter 182-526 WAC.

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.

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Medicare and spenddown

Revised date
Purpose statement

This section provides information about what the department allows as medical expenses for individuals who have spenddown, are entitled to Medicare and who may qualify for a Medicare Savings Program (MSP).

To qualify for Medicaid, individuals who are entitled to Medicare must apply for and enroll in Medicare. See the Application for Medicare chapter for more information about this requirement.

Allowable expenses for the Medically Needy program must not be reimbursable by Medicare or other third-party coverage. Expenses must be the responsibility of the applicant/recipient. The amount left over after Medicare or other insurance pays is usually patient responsibility and usable against the spenddown liability. For more information about Medicare program coverage and allowable medical expenses please see the Allowable medical expenses chapter.

Individuals applying for medical benefits should be considered for all programs and if the individual is Medicare eligible the Medicare Savings Programs need to be considered. An individual can receive any of the MSPs while pending a spenddown. When an individual meets their spenddown amount the Medicaid case can open and be open concurrently to the QMB and SLMB programs. It is only QI-1 that cannot be open with an MSP. ACES will require the QI-1 case be closed and guide the user through the process.

In summary, the Medicare Savings Program has four levels of coverage, based on income, with the lowest income standard to qualify for QMB and the highest income standard to qualify for QDWI. QDWI has other eligibility criteria primarily that the individual has lost free Part A due to no-longer being considered disabled.

Qualified Medicare Beneficiary (QMB)

  • Pays Part A and Part B premiums
  • Pays deductibles
  • Pays copayments except for prescriptions

Specified Low-Income Medicare Beneficiary (SLMB)

  • Pays Part B premiums

Qualified Individual (QI-1)

  • Pays Part B premiums

Qualified Disabled Working Individual (QDWI)

  • Pays Part A premiums

Qualified Medicare Beneficiaries (QMB)

The QMB program is the only MSP that pays:

  • Medicare Part A and Part B premiums; and
  • Medicare Part A, Part B, and Part C coinsurance charges, deductibles, and copayments.

QMB does not pay for Part C or Part D premiums or for Part D prescription drug copayments. Very few medical expenses can be used to meet a spenddown liability when individuals have both QMB and Medicare because between these two programs they are already fully covered.

QMB recipients cannot be charged the customary 20% after Medicare. Balance billing of QMB recipients is not permitted by CMS.

Example

Joe brings you a current Explanation of Benefits (EOB) statement showing a recent 10-day hospital stay ($15,000) and what Medicare paid on the bill.

Medicare assigned $1,068 to Joe's Medicare deductible and charged him an additional $2670 for coinsurance.

Medicare paid $6,800 to the hospital. The hospital did an insurance adjustment for the remaining balance.

  • If Joe is eligible for QMB coverage, his charges of $1,068 and $2,670 will be paid by the QMB program and can't be used towards his spenddown liability.
  • If Joe isn't eligible for QMB coverage, these charges could be used towards meeting his spenddown liability.

Medicare premiums

Medicare premiums may only be allowed as an expense towards meeting spenddown when HCA (through the MSP programs, for Part A and Part B) or the federal government (through the Part D low-income subsidy) is not paying them. Allowable Medicare premiums are coded in ACES as a spenddown expense and aren't used as an income deduction on the MEDX screen. Enter the expense based on the date it is incurred by the individual.

Medicare Part A

HCA pays Part A premiums when the individual is eligible for the QMB (S03) program or the Qualified Disabled Working Individual (QDWI) (S04) program in ACES. HCA allows Part A premium expenses for spenddown only if:

  • The individual incurred the expense in the month of application and is not eligible for QMB until the first of the following month; or
  • The individual is eligible under an MSP that does not pay for Part A costs; or
  • The individual incurred the expenses in the three months prior to the application month and was not a QMB or QDWI recipient at that time.

Medicare Part B

HCA pays Part B premiums under the QMB (S03) program and Specified Low-Income Medicare Beneficiary (SLMB) (S05) program until the certification period ends. HCA does not allow Part B premiums as a spenddown medical expense for individuals who receive coverage under these programs.

HCA pays Part B premiums under the Qualified Individual (QI)-1 (S06) program (formerly known as the Expanded Specified Low-Income Medicare Beneficiary (ESLMB) program) as long as the individual is not eligible for CN or MN coverage and pays under the State Medicare Buy-In program when they are otherwise eligible for CN or MN coverage.

Note: When a QI-1 individual becomes MN or CN eligible, the QI-1 closes. If MN or CN coverage ends, the individual remains eligible for the rest of their original QI-1 certification. Be sure to reopen the S06 AU at the time you initiate the review on an MN program.

Medicare Part C

Part C premiums are paid by the individual; HCA no longer pays them. Part C is an option for Medicare individuals who choose to receive Medicare services through a Managed Care plan instead of through the original Medicare fee-for-service program. Part C coverage is also known as Medicare Advantage.

Some Part C plans also include a prescription drug benefit as part of their Part C coverage. An individual who receives prescription drug coverage under Part C doesn't have to enroll in a separate Part D plan. Since Part C premiums can't be paid by the department, do not refer Part C individuals to the Premium Payment program for assistance.

Part C premiums are an allowable medical expense for spenddown. Enter the expense into ACES as the expense is incurred. Part C premiums are not allowed as an income deduction so do not code Part C premiums as a medical deduction on the MEDX screen.

Medicare Part D

The department doesn't pay Part D premiums. Individuals with income below certain standards may apply to the federal government for help paying Part D premiums. This is called the Low-Income Subsidy (LIS) program. Once the government determines individuals are eligible for the LIS, they remain eligible until the end of the calendar year.

Each year in January, individuals need to reapply for the LIS unless they are Medicaid individuals. Medicaid individuals are automatically "deemed" eligible for the LIS and remain eligible until the end of the calendar year in which they lose their Medicaid eligibility.

All States have a range of "benchmark" Part D plans. Benchmark plans are considered average Medicare plans. They have adequate health care coverage, and their premiums can be fully covered by the LIS. Other Part D plans have higher premiums than the benchmark plans. The premiums for these plans are higher than what the LIS covers. In these plans, the LIS pays a portion of the premium (up to the benchmark amount) and the individual pays the amount above the LIS limit if they want to remain with a specific Part D plan.

HCA does not allow Part D premiums as an allowable expense for spenddown unless they were:

  • Incurred prior to a period of eligibility for the LIS; or
  • The individual is paying the portion above the subsidy amount, in which case HCA allows only the amount the individual is actually paying.

When are a Medicare individual's prescription drug costs allowed for spenddown?

For the purposes of Medicaid spenddown, incurred Part D prescription costs are treated just like any other costs incurred for medical care. Apply all the usual rules for determining an individual's liability, insurance coverage and spenddown eligibility. Costs paid in whole or in part by a public program may be counted as incurred medical expenses to establish eligibility under a Medicaid spenddown.

Part D enrollment is voluntary, so not all Medicare individuals will be enrolled in a Medicare Part D plan (PDP) or a Medicare Part C Advantage Plan (MA-PD) when HCA first receives a medical application.

However, under WAC 182-503-0505, Part D enrollment is a condition of eligibility for Medicaid coverage. HCA notifies the federal government (CMS) when an individual becomes eligible for MN coverage. The individual is then automatically eligible for the LIS and enrolled in a Part D plan.

Limited eligibility period still provides extra help

Even if an individual is only eligible for MN coverage in one three-month base period a year, that certification provides extra help (through LIS) paying Part D premiums for the rest of that calendar year.

Enrollment in a PDP or MA-PD doesn't ensure that all drugs are covered. Each plan has a different combination of covered drugs, deductibles, copays, and coverage gaps.

Worker responsibilities

  • Always open QMB coverage whenever an individual is eligible, because HCA gets federal reimbursement for part of what it pays out for QMB individuals.
  • Carefully review medical expense for a QMB eligible individual before using any portion of the expense towards meeting spenddown liability.
  • To determine if drug costs incurred by Medicare individuals are allowable for spenddown, apply the following rules:
    • If the individual was not enrolled in a PDP or MA-PD on the date of service, allow the prescription drug cost. The reason the individual wasn't enrolled when the expense was incurred doesn't matter.
    • If the individual was enrolled in a Part D plan on the date of service and chose to self-pay for a covered prescription to try and meet spenddown liability, the expense can't be allowed because the drug was covered under their Part D plan.
    • If the individual 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 individual explaining all benefits paid and denied, and amounts attributed to cost-sharing. If the drug charge is identified on the statement as an individual's liability, such as part of a deductible, copay or coverage gap, allow the expense.
    • When a plan denies coverage of a prescription, the individual has the right to request an exception for coverage of the drug. The individual receives a written decision on any exception requested. 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 by the plan, allow the charge. Monthly plan statement.

Monthly plan statements

Ask for and review the monthly plan statements for questionable expenses before allowing the expenses towards meeting spenddown liability.

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ProviderOne services card and health plan card

Revised date
Purpose statement

To explain the ProviderOne services card mailed from the Health Care Authority and the health plan card mailed from an individual’s selected health or managed care plan.

ProviderOne services card

Each family member enrolled in Apple Health gets a ProviderOne Card. Your ProviderOne services card is activated while you are eligible for Apple Health. The card includes your name and client ProviderOne number which ends with a "WA" and stays with you for life when you are eligible and receive Apple Health. This number is needed to receive health-related medical services. You may also need to show a picture identification (ID) or provide other information to prevent unauthorized use of the card. Your providers will verify your eligibility for medical services based on client identification or ProviderOne number.

If you lose your ProviderOne services card:

  1. Call Apple Health Customer Service toll free at 1-800-562-3022 and follow the voice response prompts to ask for a new services card. 
  2. If you have access to the Washington Healthplanfinder app you can access a digital card.
  3. Request a card through the online client portal.
  4. Request a change online - Select the topic "Services Card"

You may still be able to receive medical services while waiting for a replacement care.
Your provider will need your name and your date of birth to verify your Apple Health enrollment.

Health plan card

The health plan you enroll in will also send you an ID card. This card may include:

  • Your name and date of birth
  • Client or Medicaid ID# (ends with WA)
  • Member ID#
  • Subscriber ID#
  • Group#
  • Primary care provider information

 You should have both your ProviderOne services card and your health plan ID card to:

  • Get health care services.
  • Make, cancel, or check appointments.
  • Order or pick up prescriptions.

Please call your health plan’s customer service number if any information on the card they send you is wrong, the card is lost, stolen, or needs to be replaced.

The toll free phone numbers for the five managed health care plans are:

  • Community Health Plan of Washington (CHPW) 1-800-440-1561
  • Coordinated Care of Washington (CCW) 1-877-644-4613
  • Molina Healthcare of Washington (MHW) 1-800-869-7165
  • UnitedHealthcare Community Plan of Washington (UHC) 1-877-542-8997
  • Wellpoint (WLP) 1-833-731-2167

For more information about the ProviderOne services card and health plan card, including replacement options, see the First Timers' Guide to Washington Apple Health (Medicaid).

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Health care for aged, blind, or disabled

Revised date
Purpose statement

To provider information on the Supplemental Security Income (SSI) program, SSI-related programs, and Apple Health for Workers with Disabilities (HWD).

SSI program (S01)

This program provides CN coverage to individuals receiving SSI cash benefits. SSI is for individuals who meet one of the following requirements:

  • Age 65 or older
  • Totally or partially blind
  • Have a medical condition that keeps you from working and is expected to last at least one year or result in death.

Eligibility for SSI is determined by the Social Security Administration and communicated to the states by the State Data Exchange (SDX).

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

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

Effective April 14, 2014.

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. The agency pays for a person's medical care outside of Washington according to WAC 182-501-0180.
  7. 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.
  8. 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.

SSI-related program (S02)

This program provides CN coverage to individuals who meet the SSI income and resource limits as well as one of the following requirements:

  • 65 years old or older (aged), or
  • Blind (as defined by the Social Security Administration and determined by DSHS), or
  • Disabled (as defined by the Social Security Administration and determined by DSHS).

WAC 182-512-0100 SSI-related medical -- Categorically needy (CN) medical eligibility.

WAC 182-512-0100 SSI-related medical -- Categorically needy (CN) medical eligibility.

Effective April 14, 2014.

  1. Washington apple health (WAH) categorically needy (CN) coverage is available for an SSI-related person who meets the criteria in WAC 182-512-0050, SSI-related medical—General information.
  2. To be eligible for SSI-related WAH CN medical programs, a person must also have:
    1. Countable income and resources at or below the SSI-related WAH CN medical monthly standard (refer to WAC 182-512-0010) or be eligible for an SSI cash grant but choose not to receive it; or
    2. Countable resources at or below the SSI resource standard and income above the SSI-related WAH CN medical monthly standard, but the countable income falls below that standard after applying special income disregards as described in WAC 182-512-0880; or
    3. Met requirements for long-term care (LTC) WAH CN income and resource requirements that are found in chapters 182-513 and 182-515 WAC if wanting LTC or waiver services.
  3. An ineligible spouse of an SSI recipient is not eligible for noninstitutional SSI-related WAH CN health care coverage. If an ineligible spouse of an SSI recipient has dependent children in the home, eligibility may be determined for health care coverage under the WAH medically needy program or for a modified adjusted gross income-based program.

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 January 1, 2023

Household size Monthly income limit Resource limit
1 $914 $2,000
2 $1,371 $3,000

SSI-related MN program (S95, S99)

This program provides MN coverage to individuals with income above the SSI income and resource limits. Individuals who qualify and enroll in the Apple Health SSI-related MN program become eligible for MN coverage after incurring medical costs equal to the amount of the household income that is above the SSI income standard. For an explanation of Medically Needy benefits, please see that section of this publication.

WAC 182-512-0150 SSI-related medical -- Medically needy (MN) medical eligibility.

WAC 182-512-0150 SSI-related medical -- Medically needy (MN) medical eligibility.

Effective June 26, 2022.

  1. Washington apple health (WAH) medically needy (MN) health care coverage is available for any of the following:
    1. A person who is SSI-related and not eligible for WAH categorically needy (CN) medical coverage because the person has countable income that is above the WAH CN income level (CNIL) (or for long-term care (LTC) recipients, above the special income limit (SIL)):
      1. The person's countable income is at or below WAH MN standards, leaving no spenddown requirement; or
      2. The person's countable income is above WAH MN standards requiring the person to spenddown their excess income (see subsection (4) of this section). See WAC 182-512-0500 through 182-512-0800 for rules on determining countable income, and WAC 182-519-0050 for program standards or chapter 182-513 WAC for institutional standards.
    2. An SSI-related ineligible spouse of an SSI recipient;
    3. A person who meets SSI program criteria but is not eligible for the SSI cash grant due to immigration status or sponsor deeming. See WAC 182-503-0535 for limits on eligibility for aliens;
    4. A person who meets the WAH MN LTC services requirements of chapter 182-513 WAC;
    5. A person who lives in an alternate living facility and meets the requirements of WAC 182-513-1205; or
    6. A person who meets resource requirements as described in chapter 182-512 WAC, elects and is certified for hospice services per chapter 182-551 WAC.
  2. A person whose countable resources are above the SSI resource standards is not eligible for WAH MN noninstitutional health care coverage. See WAC 182-512-0200 through 182-512-0550 to determine countable resources.
  3. A person who qualifies for services under WAH long-term care programs has different criteria and may spend down excess resources to become eligible for WAH LTC institutional or waiver health care coverage. Refer to WAC 182-513-1315 and 182-513-1395.
  4. A person with income over the effective WAH MN income limit (MNIL) described in WAC 182-519-0050 may become eligible for WAH MN coverage when the person has incurred medical expenses that are equal to the excess income. This is the process of meeting spenddown. Refer to chapter 182-519 WAC for spenddown information.
  5. A person may be eligible for health care coverage for any or all of the three months immediately prior to the month of application, if the person has:
    1. Met all eligibility requirements for the months being considered; and
    2. Received medical services covered by medicaid during that time.
  6. A person who is eligible for WAH MN without a spenddown is certified for up to 12 months. For a person who must meet a spenddown, refer to WAC 182-519-0110. For a person who is eligible for a WAH long-term care MN program, refer to WAC 182-513-1395 and 182-513-1315.
  7. A person must reapply for each certification period. There is no continuous eligibility for WAH MN.

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 January 1, 2023

Household size Monthly income limit
1 $914
2 $914
3 $914
4 $914
5 $914
6 $975

Apple health for workers with disabilities (HWD) (S08)

This program provides CN coverage to people with disabilities and with earned income who purchase health care coverage based on a sliding income scale.

HWD has no asset test, age or income limit.

WAC 182-511-1000 Health care for workers with disabilities (HWD) -- Program description.

WAC 182-511-1000 Health care for workers with disabilities (HWD) -- Program description.

Effective January 1, 2020

This section describes the apple health for workers with disabilities (HWD) program.

  1. The HWD program provides categorically needy (CN) scope of care as described in WAC 182-501-0060.
  2. The HWD program also provides long-term services and supports described in chapters 182-513 and 182-515 WAC for a client who meets the functional requirements for those programs, are approved for those services, and choose to enroll in HWD.
  3. The medicaid agency approves HWD coverage for twelve months effective the first of the month in which a person applies and meets program requirements. See WAC 182-511-1100 for retroactive coverage for months before the month of application.
  4. A person who is eligible for another medicaid program may choose not to participate in the HWD program.
  5. A person is not eligible for HWD coverage for a month in which the person received benefits under the medically needy (MN) program.

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.

To be eligible, an individual must meet federal disability requirements, and be employed (including self-employment) full or part time. To receive HWD benefits, enrollees pay a monthly premium determined as a percentage of their income. The premium will never exceed 7.5 percent of total income. American Indians and Alaska Natives are exempt from paying premiums for HWD.

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Long-term care

Revised date
Purpose statement

LTC programs are tailored to fit individual needs and situations. Home and Community Based (HCB) Services, such as COPES and DDA waivers, enable people to continue living in their homes with assistance to meet their physical, medical, and social needs. When these needs cannot be met at home, care in a residential or nursing facility is available.

Different income standards are used to determine eligibility for Categorically Needy (CN) or Medically Needy (MN) LTC services coverage. A person must meet both the financial eligibility rules and be found eligible for the LTC services based on a comprehensive assessment to be eligible for most LTC programs. Contact a local Home and Community Services Office for more information.

Long-Term Care services include the following programs:

  • Community Options Program Entry System (COPES) (L21, L22)
  • New Freedom (L21, L22)
  • Developmental Disabilities Administration (DDA) Waivers (L21, L22)
  • Program of all-inclusive care for the elderly (PACE) (L21, L22)
  • Hospice (L31, L32, L95, L99)
  • Family LTC (K01, K95, K99)
  • Nursing Facility LTC (L01, L02, L95, L99)

WAC 182-513-1315 General eligibility requirements for long-term care (LTC) programs.

WAC 182-513-1315 General eligibility requirements for long-term care (LTC) programs.

Effective February 20, 2017

This section lists the sections in this chapter that describe how the agency determines a person's eligibility for long-term care services. These sections are:

  1. WAC 182-513-1316 General eligibility requirements for long-term care (LTC) programs.
  2. WAC 182-513-1317 Income and resource criteria for an institutionalized person.
  3. WAC 182-513-1318 Income and resource criteria for home and community based (HCB) waiver programs and hospice.
  4. WAC 182-513-1319 State-funded programs for noncitizens who are not eligible for a federally funded program.

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.

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Health care for pregnant individuals

Revised date
Purpose statement

Washington apple health eligibility for pregnant individuals

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.

Pregnancy medical (N03, N23)

This program provides Categorically Needy (CN) coverage with countable income at or below 215% of the FPL without regard to citizenship or immigration status. Once enrolled in Apple Health for Pregnancy, the individual has continuous coverage regardless of any change in income through the end of the month after the pregnancy ends (e.g., pregnancy ends June 10, Apple Health for Pregnancy coverage continues through June 30th).

To determine the individual's family size, include the number of unborn children with the number of household members (e.g., an individual living alone and pregnant with twins is considered a three-person household).

Effective April 1, 2026

Household size Monthly income limit
1 $2,860
2 $3,879
3 $4,896
4 $5,913
5 $6,932
6 $7,949

Medically needy pregnant women (P99)

This program provides Medically Needy (MN) coverage to pregnant individuals with income above 215% of the FPL. Individuals who qualify for and enroll in Apple Health for Medically Needy Pregnant Women become eligible for MN coverage after incurring medical costs equal to the amount of the household income that is above the 215% FPL standard. For more explanation of MN benefits, see that section of this publication.

After-Pregnancy Coverage (N04/N24/N07/N27)

After- Pregnancy Coverage (APC) provides CN coverage to individuals any time in the 12 months after their pregnancy ends.

APC begins regardless of how the pregnancy ends. Individuals on an Apple Health program while pregnant will automatically receive 12 months of postpartum coverage. APC begins the month after the pregnancy ends and is continuous coverage regardless of a change in income or household composition.

Individuals who were not on an Apple Health program during the time of their pregnancy may apply for APC and receive postpartum coverage, as long as it is within twelve months after the month in which the pregnancy ends.

Family Planning Only (P06)

This program provides services for those with incomes at or below 265% FPL coverage for pre-pregnancy family planning services to prevent unintended pregnancies.

Individuals access Family Planning Only services through local family planning clinics that participate in the program.

WAC 182-532-510 Family Planning only program - Client eligibility

WAC 182-532-510 Family planning only program—Client eligibility

Effective October 6, 2025

For the purposes of this section, "full-scope coverage" means coverage under either the categorically needy (CN) program, the broadest, most comprehensive scope of health care services covered or the alternative benefits plan (ABP), the same scope of care as CN, applicable to the apple health for adults program.

  1. To be eligible for family planning only services, as defined in WAC 182-532-001, a client must:
    1. Provide a valid Social Security number (SSN) or proof of application to receive an SSN, be exempt from the requirement to provide an SSN as provided in WAC 182-503-0515, or meet good cause criteria listed in WAC 182-503-0515(2);
    2. Be a Washington state resident, as described under WAC 182-503-0520;
    3. Have an income at or below two hundred sixty percent of the federal poverty level, as described under WAC 182-505-0100;
    4. Need family planning services; and
    5. Have been denied apple health coverage within the last 30 days, unless the applicant:
      1. Has made an informed choice to not apply for full-scope coverage as described in WAC 182-500-0035 and 182-501-0060, including family planning;
      2. Is age 26 or younger and seeking services in confidence;
      3. Is a domestic violence victim who is seeking services in confidence; or
      4. Has an income of 150 percent to 260 percent of the federal poverty level, as described in WAC 182-505-0100.
  2. A client is not eligible for family planning only medical if the client is:
    1. Pregnant;
    2. Sterilized;
    3. Covered under another apple health program that includes family planning services; or
    4. Covered by concurrent creditable coverage, as defined in RCW 48.66.020, unless they meet criteria in (1) (e) (ii) or (iii) of this section.
  3. The agency does not limit the number of times a client may reapply for coverage.

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 April 1, 2026

Household size Monthly income limit
1 $3,525
2 $4,781
3 $6,034
4 $7,288
5 $8,544
6 $9,797

Find additional information about Family Planning Only.

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Health care for children

Revised date
Purpose statement

Apple health for kids

Apple Health for Kids coverage is free to children in households with income at or below 215% of the FPL and available for a monthly premium to children in households with income at or below 317% of the FPL.

WAC 182-505-0210 Eligibility for children.

WAC 182-505-0210 Eligibility for children.

Effective June 9, 2025

  1. General eligibility. For purposes of this section, a child must:
    1. Be a Washington state resident under WAC 182-503-0520 and 182-503-0525;
    2. Provide a Social Security number under WAC 182-503-0515, unless exempt; and
    3. Meet program-specific requirements.
  2. Deemed eligibility groups. A child is automatically eligible for coverage without an application if the child meets the program-specific requirements in (a) through (c) of this subsection.
    1. Newborn coverage. A child younger than age one is eligible for categorically needy (CN) coverage if the birth parent was eligible for Washington apple health on the date of delivery:
      1. Including a retroactive eligibility determination; or
      2. By meeting a medically needy (MN) spenddown liability with expenses incurred by the date of the newborn's birth:
    2. Washington apple health for supplemental security income (SSI) recipients. A child who is eligible for SSI is automatically eligible for CN coverage under WAC 182-510-0001.
    3. Foster care coverage. A child age 20 and younger is eligible for CN coverage under WAC 182-505-0211 when the child is in foster care or receives subsidized adoption services. For children who age out of the foster care program, see WAC 182-505-0211(3).
  3. Continuous eligibility for children under age six. A child is eligible for Washington apple health continuous eligibility for children under age six when they:
    1. Have household income at or below 210 percent of the federal poverty level at the time of application; or
    2. On or after January 8, 2025, have household income greater than 210 percent but equal to or less than 312 percent of the federal poverty level at the time of application; or
    3. Received coverage under subsection (5) of this section and are no longer eligible for deemed coverage under subsection (5) (b) or (c) of this section.
  4. MAGI-based eligibility groups. A child age 18 or younger is eligible for CN coverage based on modified adjusted gross income (MAGI):
    1. At no cost when the child's countable income does not exceed the standard in WAC 182-505-0100 (6)(a);
    2. With payment of a premium when the child's countable income does not exceed the standard in WAC 182-505-0100 (6)(b), and the child meets additional eligibility criteria in WAC 182-505-0215;
    3. Under chapter 182-514 WAC, if the child needs long-term care services because the child resides or is expected to reside in an institution, as defined in WAC 182-500-0050, for 30 days or longer. An institutionalized child is eligible for coverage under the medically needy (MN) program if income exceeds the CN income standard for a person in an institution (special income level);
    4. Under WAC 182-505-0117, if a child is pregnant;
    5. When the child has household income at or below 215 percent of the federal poverty level at the time of application and is eligible for Washington apple health continuous eligibility for children under age six.
  5. Non-MAGI-based children's programs. The agency determines eligibility for the:
    1. MN program according to WAC 182-519-0100. A child age 18 or younger is eligible if the child:
      1. Is not eligible for MAGI-based coverage under subsection (3) of this section;
      2. Meets citizenship or immigration requirements under WAC 182-503-0535 (2)(a), (b), (c), or (d); and
      3. Meets any spenddown liability required under WAC 182-519-0110.
    2. SSI-related program. A child age 18 or younger is eligible for CN or MN SSI-related coverage if the child meets:
      1. SSI-related eligibility under chapter 182-512 WAC;
      2. Citizenship or immigration requirements under WAC 182-503-0535 (2)(a), (b), (c), or (d); and
      3. Any MN spenddown liability under WAC 182-519-0110.
    3. SSI-related long-term care program.
      1. A child age 18 or younger is eligible for home and community based (HCB) waiver programs under chapter 182-515 WAC if the child meets:
        1. SSI-related eligibility under chapter 182-512 WAC;
        2. Citizenship or immigration requirements under WAC 182-503-0535 (2)(a), (b), (c), or (d); and
        3. Program-specific age and functional requirements under chapters 388-106 and 388-845 WAC.
      2. A child age 18 or younger who resides or is expected to reside in a medical institution as defined in WAC 182-500-0050 is eligible for institutional medical under chapter 182-513 WAC if the child meets:
        1. Citizenship or immigration requirements under WAC 182-503-0535 (2)(a), (b), (c), or (d);
        2. Blindness or disability criteria under WAC 182-512-0050; and
        3. Nursing facility level of care under chapter 388-106 WAC.
  6. Alien emergency medical program. A child age 20 or younger who does not meet the eligibility requirements for a program described under subsections (2) through (5) of this section is eligible for the alien emergency medical (AEM) program if the child meets:
    1. The eligibility requirements of WAC 182-507-0110; and
    2. MN spenddown liability, if any, under WAC 182-519-0110.
  7. Other provisions.
    1. A child residing in an institution for mental disease (IMD) as defined in WAC 182-500-0050 is not eligible for inpatient hospital services, unless the child is unconditionally discharged from the IMD before receiving the services.
    2. A child incarcerated in a public institution as defined in WAC 182-500-0050 is only eligible for inpatient hospital services.

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.

April 1, 2026

Household size Monthly income limit
215% FPL
(No Cost)		 Monthly income limit
265% FPL
($20 Premium Child, $40 Maximum)		 Monthly income limit
317% FPL
($30 Premium Child, $60 Maximum)
1 $2,860 $3,525 $4,216
2 $3,879 $3,879 $5,719
3 $4,896 $4,896 $7,218
4 $5,913 $5,913 $8,718
5 $6,932 $6,932 $10,220
6 $6,932 $7,949 $11,719

Apple health for newborns (N10):

This program provides 12 months of CN coverage if the mother was enrolled in an Apple Health program when the child was born. There is no resource or income limit for this program.

Apple health for kids (N11, N31):

This program provides CN coverage to children under age 19 whose families have income at or below 215% of the FPL. Children who would have been eligible for Apple Health for Kids except for not meeting the immigration status requirements receive CN coverage under state-funded Apple Health for Kids.

Apple health for kids with premiums (N13, N33):

This program provides CN coverage to children under age 19 whose families have income above 265% and at or below 317% of the FPL in exchange for the monthly premium. Children who would have been eligible for Apple Health for Kids with premiums except for not meeting the immigration status requirements receive CN coverage under state-funded Apple Health for Kids with Premiums in exchange for the monthly premium.

WAC 182-505-0215 Children's Washington apple health with premiums.

WAC 182-505-0215 Children's Washington apple health with premiums.

Effective January 23, 2021.

  1. A child is eligible for Washington apple health with premiums if the child:
    1. Meets the requirements in WAC 182-505-0210(1);
    2. Has countable income below the standard in WAC 182-505-0100 (6)(b); and
    3. Pays the required premium under WAC 182-505-0225, unless the child is exempt under WAC 182-505-0225 (2)(c).
  2. A child is not eligible for Washington apple health with premiums if the child:
    1. Is eligible for no-cost Washington apple health;
    2. Has creditable health insurance coverage as defined in WAC 182-500-0020.
  3. A child with creditable health insurance coverage may be eligible for Washington apple health with premiums if the child is eligible for either:
    1. Public employees benefits board (PEBB) health insurance coverage based on a family member's employment with a Washington state agency, or a Washington state university, community college, or technical college; or
    2. School employees benefits board (SEBB) health insurance coverage based on a family member's employment with a Washington school district, charter school, or educational service district; and
    3. Meets the requirements in WAC 182-505-0210 (1).

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.

Apple health for medically needy kids (F99):

This program provides MN coverage to children under age 19 whose families have income above 317% of the FPL. Children who qualify and are enrolled in Apple Health for Medically Needy Kids become eligible for MN coverage after incurring medical costs equal to the amount of the household income that is above the 317% FPL standard. For an explanation of Medically Needy benefits, please see that section of this publication.

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Health care for adults

Revised date
Purpose statement

To understand the programs associated with health care for adults.

Adult medical (N05)

This program provides CN coverage to adults with countable income at or below 138% of the FPL who are between the ages of 19 up to 65, who are not incarcerated, and who are not entitled to Medicare.

WAC 182-505-0250 Washington apple health -- MAGI-based adult medical.

WAC 182-505-0250 Washington apple health -- MAGI-based adult medical.

Effective August 29, 2014.

  1. Effective on or after January 1, 2014, a person is eligible for Washington apple health (WAH) modified adjusted gross income (MAGI)-based adult coverage when he or she meets the following requirements:
    1. Is age nineteen or older and under the age of sixty-five;
    2. Is not entitled to, or enrolled in, medicare benefits under Part A or B of Title XVIII of the Social Security Act;
    3. Is not otherwise eligible for and enrolled in mandatory coverage under one of the following programs:
      1. WAH SSI-related categorically needy (CN);
      2. WAH foster care program; or
      3. WAH adoption support program;
    4. Meets citizenship and immigration status requirements described in WAC 182-503-0535;
    5. Meets general eligibility requirements described in WAC 182-503-0505; and
    6. Has net countable income that is at or below one hundred thirty-three percent of the federal poverty level for a household of the applicable size.
  2. Parents or caretaker relatives of an eligible dependent child as described in WAC 182-503-0565 are first considered for WAH for families as described in WAC 182-505-0240. A person whose countable income exceeds the standard to qualify for family coverage is considered for coverage under this section.
  3. Persons who are eligible under this section are eligible for WAH alternative benefit plan as defined in WAC 182-500-0010 coverage. A person described in this section is not eligible for medically needy WAH.
  4. Other coverage options for adults not eligible under this section are described in WAC 182-508-0001.

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 April 1, 2021

Household size Monthly income limit
1 $1,428
2 $1,931
3 $2,434
4 $2,938
5 $3,441
6 $3,944

Family medical (N01)

This program provides CN coverage to adults with countable income at or below the applicable Medicaid standard and who have dependent children living in their home who are under the age of 18.

WAC 182-505-0240 Parents and caretaker relatives.

WAC 182-505-0240 Parents and caretaker relatives.

Effective July 1, 2017.

  1. A person is eligible for Washington apple health categorically needy (CN) coverage when the person:
    1. Is a parent or caretaker relative of a dependent child who meets the criteria described in WAC 182-503-0565(2);
    2. Meets citizenship and immigration status requirements described in WAC 182-503-0535;
    3. Meets general eligibility requirements described in WAC 182-503-0505; and
    4. Has countable income below the standard in WAC 182-505-0100 (2).
  2. To be eligible for coverage as a caretaker relative, a person must be related to a dependent child who meets the criteria described in WAC 182-503-0565(2).
  3. A person must cooperate with the state of Washington in the identification, use and collection of medical support from responsible third parties as described in WAC 182-503-0540.
  4. A person who does not cooperate with the requirements in subsection (3) of this section is not eligible for coverage.

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 April 1, 2026

Household size Monthly income limit
1 $511
2 $658
3 $820
4 $972
5 $1,127
6 $1,284

Health care extension (HCE) (N02)

This program provides CN coverage to individuals who lost eligibility for Family Medical because of an increase in their earned income after they received Family Medical coverage for at least 3 of the last 6 months. These individuals are eligible for up to 12 months extended CN medical benefits (Medical Extension).

WAC 182-523-0100 Washington apple health--Medical extension

WAC 182-523-0100 Washington apple health--Medical extension.

Effective December 28, 2019

  1. A parent or caretaker relative who was eligible for and who received coverage under Washington apple health for parents and caretaker relatives, described in WAC 182-505-0240, in any three of the last six months is eligible, along with all dependent children living in the household, for twelve months' extended health care coverage if the person becomes ineligible for coverage due to increased earnings or hours of employment.
  2. A person remains eligible for apple health medical extension unless:
    1. The person:
      1. Moves out of state;
      2. Dies; or
      3. Leaves the household.
    2. The family:
      1. Moves out of state;
      2. Loses contact with the agency or its designee or the whereabouts of the family are unknown; or
      3. No longer includes an eligible dependent child as defined in WAC 182-503-0565(2).
  3. When a person or family is determined ineligible for apple health coverage under subsection (2)(a)(i) through (iii) or (b)(i) or (ii) of this section during the medical extension period, the agency or its designee redetermines eligibility for the remaining household members as described in WAC 182-504-0125 and sends written notice as described in chapter 182-518 WAC before apple health medical extension is terminated.

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.

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Standards - LTSS

Revised date
Purpose statement

This chart includes standards for LTSS income and resource eligibility. The personal needs allowance (PNA) chart defines the amount of money a client is allowed to keep for their personal use.

Note:

Personal Needs Allowance (PNA) chart

Program standard for income and resources (WAC references and historical standards charts)

Long-Term Care Resource Standards

Resource standards WAC 182-513-1350 Defining the resource standard and determining resource eligibility for long-term care (LTC) services.

Standards can be found on the Program standard for income and resources page.

Excess Home Equity Standards

Excess home equity limits. Applies to institutional Medicaid programs per WAC 182-513-1350. These limits may change on January 1 based on the consumer price index-Urban (CPIU).

Long-Term Care Income Standards

Income standards Used to determine income and resource eligibility in long-term care. Standards can be found on the Program standard for income and resources page.

Medicaid special income level (SIL) 300% of the FBR. May change annually on January 1 based on consumer price index. Maximum gross income level for institutional Medicaid.

Federal Benefit Rate (FBR) The FBR is the maximum dollar amount paid to an aged, blind, or disabled person who receives Social Security Disability benefits under SSI

Medically Needy Income Level (MNIL)

Categorically Needy Income Level (CNIL)

Federal Poverty Level (FPL) may change annually on April 1

CS Maintenance Needs Allowance Maximum 150% of the 2-person FPL may change annually on July 1.

CS Maintenance Needs Allowance Maximum may change annually on January 1 based on the consumer price index. (with excess shelter costs)

Excess shelter cost standard may change annually on July 1. 30% of 150% of the 2-person

Utility standard for determining excess shelter costs for a community spouse. Food Assistance Utility Standard (SUA) for a 4-person household. May change annually on 10/1.

Nursing Facility average state rate. Used to determine income eligibility for HCS HCB Waivers when gross income is over the Medicaid SIL

Nursing Facility average state rate. This is used to determine eligibility for HCB Waivers authorized by HCS when the gross income is over the Medicaid SIL. This is described in WAC 182-515-1508.

Rate is updated annually on October 1st.

Standards can be found on the Program standard for income and resources page.

Nursing facility private rate standard. Used to determine period of ineligibility due to asset transfers

Reference WAC 182-513-1363 Transfer of an asset. This rate may change annually on October 1. It is calculated using the reported date from Medicaid cost reports and determined by ALTSA. This standard is used to determine a period of ineligibility due to a resource transfer.

Standards can be found on the Program standard for income and resources page.

Special Income Level (SIL) 300 percent of the FBR

  1. The agency compares an individual's available income to the SIL to determine whether a client is eligible for LTC services under the CN program.
  2. The SIL is equal to 300% of the annually adjusted SSI Federal Benefit Rate (FBR).
  3. The agency does not allow income disregards when determining eligibility for CN institutional services. It reduces an individual's gross income only by the exclusions allowed by federal statute as described in WAC 182-513-1340.

Clarifying Information

  1. Special Income Level (SIL): The agency compares a person's nonexcluded income to the SIL to determine whether a person is eligible for LTC services under the institutional CN program.
    1. The SIL is equal to 300% of the annually adjusted SSI Federal Benefit Rate (FBR).
    2. The agency does not allow income disregards when determining eligibility for CN services. It reduces a person's gross income only by the exclusions allowed by federal statute as described in WAC 182-513-1340.
    3. All income disregards under section 1612(b) of the Social Security Act aren't allowed before doing the SIL comparison. Examples are the $20 disregard and 65 ½ earned income deduction and Impairment Related Work Expenses (IRWE).
    4. The SIL is the maximum amount allowed by law as the CN income standard for institutional Medicaid.
  2. Disabled Adult Children (DAC), Pickle/COLA, Widowers, SSI individuals and SSI individuals because of 1619(b) status. How does the SIL affect their eligibility for HCBS Waiver programs?
    1. Clients who are on SSI, or are considered eligible for SSI by Social Security Administration 1619(b) or Deemed eligible for SSI (Protected DAC, Widowers, Pickle/COLA ) have countable income under the SSI Standard. These clients may have gross income above the SIL.
    2. For an SSI client who has 1619(b) status with Social Security Administration, it is possible that a 1619(b) status individual can have gross income over the SIL because of their earnings. A 1619(b) client is treated just like an SSI client. Their eligibility is maintained by the Social Security Administration and they do not need to submit eligibility reviews to the agency for Medicaid eligibility. The SDX gives information on clients having 1619(b) status and to continue the CN Medicaid eligibility.
  3. Not all clients receiving DAC are deemed SSI clients. If their SSI was lost due to receipt of DAC and their non-DAC countable income is under the SSI standard, they are deemed eligible "protected DAC". If their SSI was not lost due to receipt of DAC income, or if their other income exceeds the SSI standard, they are not deemed eligible for SSI.
  4. These clients do need to meet specific eligibility criteria for LTSS such as Transfer of asset penalties under WAC 182-513-1363 and excess home equity under WAC 182-513-1350.

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Automated Client Eligibility (ACES) program codes

Revised date

Codes on this page:

A01-A24 | D01-D26 | F99 | G01-G99 | K01-K99 | L01-L99 | M99 | N01-N33 | P06-P99 | R02-R03 | S01-S99 | T02

Scope legend: CNP = Categorically Needy Program MNP = Medically Needy Program ERSO = Emergency Related Services Only (AEM) MSP = Medicare Savings ABP = Alternative Benefit Plan

A01-A24

ACES Program Description Scope
A01 Medical care services and ABD cash with CN Medicaid State funded Medical Care Services and ABD Cash Aged/Blind/Disabled State funded
A05 Medical care services and ABD cash with CN Medicaid Medical Care Services non citizen (under 65, incapacitated) State funded
A24 Medical care services and ABD cash with CN Medicaid Medical Care Services non citizen SFA for survivors of certain crimes State funded

D01-D26

ACES Program Description Scope
D01 Foster Care SSI Recipient Foster Care or Adoption Support or Juvenile Rehabilitation CNP
D02 Foster Care Foster Care or Adoption Support or Juvenile Rehabilitation CNP
D26 Federal Foster Care Former Foster Care expansion to age 26 years CNP

F99

ACES Program Description Scope
F99 Family related medical assistance Medically needy children spenddown MNP

G01-G99

ACES Program Description Scope
G01 Medical care services and ABD cash with CN Medicaid MCS Medical care services (ended 8/31/2014) State funded
G02 Medical care services and ABD cash with CN Medicaid

ABD cash plus either:

  • ABD-X Presumptive SSI Federally funded CN Medicaid (ended 12/31/2013)
  • ABD-A Federally funded CNP - AGED (ended 8/31/2014)
  • ABD-D Federally funded CNP - NGMA disability determination (ended 8/31/2014)
 CNP
G03 SSI Related living in an Alternative Living Facility (Non Medical Institution) Adult Family Home, boarding home or DDD Group Home Non Institutional Medical in ALF CNP income under the SIL plus under state rate x 31 days + 38.84 CNP
G95 SSI Related living in an Alternative Living Facility (Non Medical Institution) Adult Family Home, boarding home or DDD Group Home Medically Needy Non Institutional in ALF no Spenddown MNP
G99 SSI Related living in an Alternative Living Facility (Non Medical Institution) Adult Family Home, boarding home or DDD Group Home Medically Needy Non Institutional in ALF with Spenddown MNP

K01-K99

ACES Program Description Scope
K01 Institutional family/children Categorically Needy family in medical institution CNP
K03 Institutional family/children Undocumented Alien family in medical institution - Emergency Related Service Only ERSO
K95 Institutional family/children Family LTC Medically Needy no Spenddown in Medical Institution MNP
K99 Institutional family/children Family LTC Medically Needy with Spenddown - in Medical Institution MNP

L01-L99

ACES Program Description Scope
L01

Institutional SSI - related

Residing in a medical institution 30 days or more

 SSI recipient in a Medical Institution - Residing in a medical institution 30 days or more CNP
L02

Institutional SSI - related

Residing in a medical institution 30 days or more

 SSI related CNP in a medical institution income under the SIL CNP
L04

Institutional SSI - related

Residing in a medical institution 30 days or more

 Undocumented alien/non-citizen LTC must be preapproved by ADSA program manager. Emergency related service only (45 slots) ERSO - CNP
L21 Institutional
HCBS Waivers (HCS/DDD) and hospice		 DDD/HCS Waiver on SSI CNP
L22 SSI and SSI related DDD/HCS Waiver - gross income under the SIL CNP
L24 SSI and SSI related Undocumented alien/noncitizens LTC - residential placement; must be preapproved by ADSA program manager; Emergency related service only (45 slots) ERSO - CNP
L31 SSI and SSI related PACE or Hospice on SSI (effective 10/1/2015) CNP
L32 SSI and SSI related PACE or Hospice - SSI related (effective 10/1/2015) CNP
L41 SSI and SSI related Roads to Community Living (RCL) on SSI (effective 10/1/2015) CNP
L51

Noninstitutional community first choice

Personal care services in the community

 Community First Choice CFC on SSI (effective 10/1/2015) CNP
L52

Noninstitutional community first choice

Personal care services in the community

 Community First Choice - SSI-Related at home or in an ALF (effective 10/1/2015) CNP
L95

Institutional SSI - related

Residing in a medical institution 30 days or more

 SSI related Medically Needy no Spenddown Income over the SIL; Income under the state rate MNP
L99 SSI and SSI related Roads to Community Living - SSI related (effective 10/1/2015) CNP
L99

Institutional SSI - related

Residing in a medical institution 30 days or more

 SSI related Medically Needy with Spenddown; Income over the SIL; income over the state rate but under the private rate; locks into state NF rate MNP

M99

ACES Program Description Scope
M99 Psychiatric inpatient Psychiatric indigent inpatient spenddown (MI prior to 7/2003)
Mental health ONLY (ended 12/31/2013)		 Inpatient psychiatric hospital only

N01-N33

ACES Program Description Scope
N01 Modified Adjusted Gross Income (MAGI) MAGI Parent/Caretaker Medicaid; Adult CNP
N02 Modified Adjusted Gross Income (MAGI) 12 Month Transitional MAGI Parent/Caretaker Medicaid; Adult CNP
N03 Modified Adjusted Gross Income (MAGI) MAGI Pregnancy CNP
N04 Modified Adjusted Gross Income (MAGI) After Pregnancy ABP
N05 Modified Adjusted Gross Income (MAGI) MAGI Adult Medicaid; Income =<133% (Medicaid Expansion) ABP
N07 Modified Adjusted Gross Income (MAGI) After pregnancy; not Medicaid eligible during pregnancy CNP
N08 Modified Adjusted Gross Income (MAGI) After pregnancy state funded; eligible during pregnancy, > 193% and = < 210% FPL  
N10 Modified Adjusted Gross Income (MAGI) MAGI Newborn Medical Birth to One Year CNP
N11 Modified Adjusted Gross Income (MAGI) MAGI Children's Medicaid/Age Under 19 CNP
N13 Modified Adjusted Gross Income (MAGI) MAGI Children's Health Insurance Program (CHIP) Children Under 19; Premium Payment Program CNP
N20 Modified Adjusted Gross Income (MAGI) MAGI Adult Medical 19 - 64; Income = < 138% Apple Health Expansion AHE - State funded
N21 Modified Adjusted Gross Income (MAGI) MAGI Parents/Caretaker; Alien Emergency Related Service Only ERSO
N23 Modified Adjusted Gross Income (MAGI) MAGI Pregnancy; Not Lawfully Present CNP
N24 Modified Adjusted Gross Income (MAGI) After pregnancy; not lawfully present CNP
N25 Modified Adjusted Gross Income (MAGI) MAGI Adult - Alien Emergency Related Service Only ERSO
N27 Modified Adjusted Gross Income (MAGI) After pregnancy; not lawfully present; not Medicaid eligible during pregnancy CNP
N31 Modified Adjusted Gross Income (MAGI) MAGI Children's Medical; Under 19; Noncitizen State funded CNP
N33 Modified Adjusted Gross Income (MAGI) MAGI Children's Health Insurance Program (CHIP): Under 19; Premium Payment Program, Noncitizen State funded CNP

P06-P99

ACES Program Description Scope
P06 Family Planning Only Family Planning Only  
P99 Pregnancy Medically Needy Pregnant Spenddown MNP

R02-R03

ACES Program Description Scope
R02 Refugee medical assistance Transitional 4 month extension CNP
R03 Refugee medical assistance Refugee Categorically needy CNP

S01-S99

ACES Program Description Scope
S01

SSI and SSI Related

 SSI Recipients CNP
S02

SSI and SSI Related

 ABD Categorically Needy CNP
S03

SSI and SSI Related

 QMB Medicare Savings Program (MSP) Medicare premium and Medicare copays MSP
S04

SSI and SSI Related

 QDWI Medicare Savings Program MSP
S05

SSI and SSI Related

 SLMB Medicare Savings Program. Medicare Premium only MSP
S06

SSI and SSI Related

 QI-1 (SLMB) Medicare Savings Program MSP
S07

SSI and SSI Related

 Undocumented Alien - Emergency Related Service Only ERSO
S08 SSI Related Health Care for Workers w/disability Health Care for Workers with Disability CNP Premium based program - Substantial Gainful Activity (SGA) not a factor in Disability determination. CNP
S20 Apple Health Eligibility Classic Adult Medical 65+; Income = < 138% Apple Health Expansion AHE - State Funded
S30 Breast and Cervical Cancer Program Breast and Cervical Cancer (Health Department Approval) CNP
S95

SSI and SSI Related

 Medically Needy no Spenddown MNP
S99

SSI and SSI Related

 Medically Needy with Spenddown MNP

T02

ACES Program Description Scope
T02 Tailored supports for older adults (TSOA)
HCS maintains TSOA cases		 TSOA - No medical benefits and no Medicaid services card issued
Pre- Medicaid benefit for the caregiver of a person 55 or older to support the caregiver. For those not eligible for a CN or ABP Medicaid program and not needing or eligible for other LTSS services because of resources. Must meet NFLOC.		 No medical benefits

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