Medicare and long-term care

Revised date
Purpose statement

This section includes the link to Medicare programs and includes additional information relating to Medicare and long-term care programs. Long-term care programs are defined as residing in a medical institution 30 days or more or one of the HCS or DDA waiver programs.

Medicare programs

Apple Health Medicare Savings Programs has the WAC and clarifying on Medicare and Medicare Savings Programs (MSP).

Medicare Savings Program (MSP) Certification periods

Medicare information from the Washington State Office of the Insurance Commissioner (includes information on the different types of Medicare, Medicare supplement (called Medigap) plans in Washington and Medicare C Advantage Plans in Washington along with the SHIBA help line.

A client receiving both Medicare and Medicaid is called a full benefit dual eligible (FBDE).

Medicare Savings Programs reference guide - Desk aid describes the medical coverage groups and QMB, SLMB, QI-1 and state buy-in programs.

Railroad retirement

Railroad Retirement Medicare entitlement is NOT in SOLQ. The client can present a Red, White and Blue Medicare entitlement card or RRB approval or award letter that shows their or their dependent's Medicare coverage. RRB award letters do not provide entitlement dates for Part A and Part B. The RRB Red, White and Blue cards do provide Medicare entitlement dates.

The number for Railroad Retirement Medicare Benefits is: 1-877-772-5772. Railroad retirement field office locator.

Medicare buy-in unit

For Medicare Buy-in issues contact: 1-800-562-3022 Ext.1-6129. Business hours: Monday through Friday, 7:30 a.m. to 4:30 p.m. This phone number is strictly for Medicare premium payment questions only.

You can contact the Medicare Buy in unit on a case related question by using a barcode tickler to 102@MBU.

Medicare information specific to long-term care

Medicare payment for nursing facility cost of care:

  • Medicare pays the full cost of care for NF services for up to 20 days per benefit period and partial costs for the remainder of 100 days when the person meets Medicare requirements. The partial costs is called Medicare A coinsurance days.
  • If the FBDE enters the NF under Medicare coverage, the agency determines eligibility and participation the same as for any other institutional person on Medicaid. Do not code Medicare days in ACES (ME) as this will affect the NF award letter.
  • The FBDE does not pay participation toward Medicare days, but does pay participation toward Medicaid days. Participation is a post-eligibility requirement tied to institutional Medicaid programs, not the Medicare benefit.
  • Monitor resource eligibility when an FBDE is on full Medicare days. An FBDE on Medicare for the full 100 days who does pay participation may acquire excess resources. Medicare Coverage of Skilled Nursing Facility Care explains the NF Medicare benefit.

Reimbursement rates for full benefit dual eligibles (FBDE)

Purpose: This clarification is based on the Dear Nursing Home Administrator letter NH #2010-001 sent 3/26/2010.

For Medicaid clients enrolled in fee for service Medicare (not Medicare Advantage plans), Medicare will pay in full for up to the first twenty days of nursing facility care at the full Medicare rate. For the first day and up to eighty days thereafter (i.e. the hundred and first day), the amount paid by Medicare will be reduced by the client's coinsurance responsibility. The agency will pay up to the Medicaid rate for the coinsurance days. This is described in WAC 182-502-0110 (3) and 1902 of the Social Security Act

Reimbursement rates for Qualified Medicare Beneficiaries (QMB)

Those eligible for QMB are eligible for payment of Medicare cost sharing expenses.

A QMB only client may apply for a CN or MN program if Medicaid is needed beyond the Medicare days in the nursing facility.

QMB is medical coverage group S03 in ACES.

The agency will pay for Medicare coinsurance charges for QMB residents, up to the Medicaid nursing facility reimbursement rate. It will not be necessary for a QMB-only resident to apply for Medicaid services for payment of coinsurance expense during Medicare coinsurance days. QMB-only clients are not required to pay participation. They will not be issued a Medicaid award letter. An award letter is not required in order to bill the agency for Medicare copayment expenses. Providers should refer to the nursing home billing guide for instructions on how to bill for QMB-only claims.

Reimbursement rates for FBDE enrolled in Medicare Part C (Advantage) plans

For Medicaid clients enrolled in Medicare Part C plans, payment for Medicare days including coinsurance days may vary depending on the Medicare C plan. The agency will pay up to the Medicaid rate for coinsurance days.

Medicaid client participation during Medicare days including coinsurance days

Facilities may not collect participation from Medicaid clients during Medicare days, including Medicare coinsurance days. Client participation which is indicated on the nursing facility Medicaid award letter is only applicable for Medicaid days.

Client participation is not an eligibility factor for Medicare coverage. This includes cases where the Medicaid rate is higher than the Medicare coinsurance rate and DSHS is billed for the coinsurance up to the Medicaid rate. Clients or their representatives are responsible to report if their resources exceed Medicaid standards when clients are in Medicare status as they are not participating their monthly income toward the cost of care during Medicare days.

Note: The agency cannot use Medicaid funds to pay the recipient's coinsurance responsibility beyond the amount Medicaid would pay for the service and cannot allow nursing facilities to write off the unpaid amounts as bad debts on their Medicaid cost reports.

Nursing Home Providers may contact the nursing home claims processing unit at the Health Care Authority (HCA) with questions regarding the billing during Medicare days.

Noncontracted Medicaid nursing facilities

Some nursing facilities are contracted with Medicare, but not with Medicaid. Nursing facilities can file a Medicare coinsurance claim with HCA for QMB eligibles.

If the Medicare days end, the nursing facility cost would be considered private pay. If the person remains in a noncontracted Medicaid, the only program that can be considered is a S99. A private pay cost in a medical institution is an allowable spenddown expense.

If a client is on HCB Waiver and that is what is driving the S03/QMB eligibility, and enters a non-Medicaid contracted Medicare facility, a redetermination will be needed if the client is in the NF 30 days or more under the S99 program. This redetermination will likely cause the S03/QMB to close after the 10 day notice period.

Medicare premiums as a participation deduction

Only out-of-pocket Medicare premiums are an allowable participation reduction. If the Medicare premium is covered under a Medicare savings program (MSP) or state buy-in, it is not an allowable participation reduction. Consult the Allowable medical expenses in the Apple Health eligibility manual for complete information on medical expenses used as a participation reduction.

All FBDE individuals are automatically enrolled in the LIS/Extra help subsidy for Medicare D prescription drug coverage unless the individual has creditable coverage for prescriptions under another plan. If a LTC elects to have a nonbenchmark Medicare D plan, the out-of-pocket cost (difference in the premium minus the LIS subsidy) is an allowable medical expense deduction from participation. For new LTC clients that have these nonbenchmark premiums, the FSS should monitor when LIS subsidy begins for client and update the deduction in ACES. This can be monitored for when the PDP or MA-PD premium is deducted from SSA, by checking SOLQ and cross-match with SHIBA plan guides.

See What does Medicare prescription drug coverage (Part D) cost and cover? for more information about PDP plans.

See 2025 Medicare Advantage and Special Needs plans and prices by county for more information about MA-PD plans.

Any expense deducted from room and board (residential individuals in ALFs) is coded as an ETR. Signed ETRs are needed to deduct any expense from room and board. Do not request an ETR if there is available participation.

Medicare D-Prescription Drug Plan

Beginning January 1, 2006, Medicare assumed responsibility for the prescription drug coverage for over 6 million low-income Medicare beneficiaries who are also enrolled in Medicaid. These beneficiaries are referred to as full-benefit dual eligible (FBDE). They qualify for Medicare prescription drug coverage with no premiums. There are several Prescription Drug Plans (PDP) to choose from in Washington. Benchmark plans have no premium costs for Medicaid individuals. Benchmark plans are paid by Medicare under the low income subsidy (LIS) program. Medicare will provide prescription drugs for dual eligible individuals.

  • All FBDE transitioned from Medicaid drug coverage to Medicare drug coverage as of January 1, 2006.
  • FBDE receive their prescriptions through a Prescription Drug Plan (PDP) unless they receive prescriptions through a creditable coverage plan. If they do not enroll in a plan, they are automatically assigned a PDP. The assignment is random.
  • FBDE can change plans any time by contacting 1-800-Medicare. The new plan will be effective the first of the next month.
  • Medicaid will continue to cover some drugs not covered in Part D including over-the-counter medications that are specifically listed on the HCA website.
  • FBDE have copays under Medicare Part D that will vary.
  • FBDE on a benchmark Medicare D plan have their premiums paid by the low income subsidy (LIS) program through Medicare.
  • FBDE are entitled to premium-free Part D enrollment, however they may elect enrollment in an enhanced plan. Those who enroll in an enhanced plan are responsible for the portion of the premium attributable to the enhancement and that portion is an allowable deduction in the post-eligibility calculation.
  • FBDE residing in institutions (nursing homes and ICF-MRs) are exempt from Med D copays once they are residing in a facility for a full calendar month. A FBDE will have no Med D copays once they are deemed in a medical institution through the end of the calendar year. This group is called LIS 3.
  • FBDE eligible for a Home and Community Based Waiver are exempt from Med D copayments starting 1/1/2012. Starting 1/1/2012 a FBDE are deemed in the institutional group called LIS 3 through the end of the calendar year.

Example: FBDE is on Community First Choice (CFC) 2/1/2011, on 2/28/2011 the individual enters the NF. On 5/3/2011 the individual returns home on CFC. For this individual, the Medicare D co payments end on 4/30/2011 and will continue to have no copayments through 12/31/2011 (the end of the calendar year).

Note: Medicare D copayments ended for home and community based (HCB) waivers effective 1/1/2012 due to federal legislation. A pharmacy is required to accept at HCB Waiver award letter from ACES or a Planned Action Notice (PAN) from the social service authorization for new HCB Waiver openings until the interface between ProviderOne and Medicare identifies the HCB Waiver person as LIS 3 in the system.

Medicare D payment levels and what they mean

Health Care Authority (HCA) sends information to Centers for Medicare and Medicaid Services (CMS) regarding a FBDE status. CMS sends this information to the PDP.

Payment level 1: QMB, SLMB only

Payment level 2: FBDE individual not institutionalized

Payment level 3: Institutional group. Effective 1/1/2012 this will include HCB waiver eligibles authorized by DDA or HCS.

If the PDP indicates to the pharmacy that a person is still not showing up as a payment level 3, the individual must present an award letter or PAN showing institutional medical eligibility as "best available evidence" in order for the Medicare D copayments to be waived.

If the person in an institution or on a HCB Waiver still shows up as a payment level 2 even after the PDP has received an institutional award letter, the pharmacy or PDP should contact 1-800-Medicare.

Field staff or the individual can call 1-800-Medicare (1-800-633-4227) to report any issues around Medicare D or complaints about the PDP or a pharmacy not accepting an award letter or planned action notice. If a complaint is made to Medicare, a copy of the complaint will be forwarded to CMS. It also tracks the complaints to make the PDPs accountable for customer service.

For HCS individuals, refer the issue to the Regional Financial Program Manager to forward to CMS Region 10 contact if the pharmacy or PDP does not accept the Best Available Evidence (BAE) institutional award letter or PAN and a prescription is needed right away.

Include the individual's name, client ID, pharmacy and PDP if known. Indicate the type of BAE presented in order to get the individual's payment level changed to a 3.

The Medicare D benchmark plan is the maximum monthly premium that will be paid by CMS for persons qualifying for "Extra Help". If a person receiving the low-income subsidy (LIS) enrolls in a Medicare Part D plan which has a premium higher than the amount listed as a benchmark, the beneficiary is responsible for paying the difference in the premium.

All Medicaid individuals are automatically enrolled in the LIS/Extra help subsidy. If an LTC individual elects to have a nonbenchmark plan, the out-of-pocket cost (difference in the premium) is an allowable medical expense deduction from participation.

Medicare D Prescription Drug Plan for newly Medicaid eligible

Until a FBDE individual is auto enrolled in a Medicare D prescription drug plan, newly eligible Medicaid individuals get their prescription drugs through the Limited Income Net Program (LI-NET) powered by Humana.

Note: Medicare D premiums are paid by Medicare's low income subsidy (LIS) program not HCA. HCA sends information on all Medicaid recipients eligible to receive Medicare benefits to Medicare in order for Medicare to enroll these individuals in the low income subsidy program. Benchmark plan premiums are covered 100% by the Medicare LIS program. Individuals need to call 1-800-Medicare if they wish to switch to a benchmark plan. Individuals need to call their PDP plan to resolve issues with prescription drug coverage.

HCA does not enroll individuals in Medicare D plans, this is done by Medicare.

Creditable coverage and Medicare D

Not all Medicare eligible individuals have Medicare D. Individuals that have "creditable coverage" are not required to enroll into a Medicare D plan once they become Medicaid eligible.

What is creditable coverage?

Creditable Coverage Definition and Determination defined by CMS:

As defined in the regulation at 42 CFR §423.56(a), drug coverage is creditable if the actuarial value of the coverage equals or exceeds the actuarial value of standard Medicare prescription drug coverage. In general, this actuarial determination measures whether the expected amount of paid claims under the entity’s prescription drug coverage is at least as much as the expected amount of paid claims under the standard Medicare prescription drug benefit. See 70 CFR 4225

In other words, if an individual has a health insurance that includes comparable prescription drug coverage, they do not have to enroll into a Medicare D plan.

These plans are required to send a document to the individual indicating they provide comparable prescription drug coverage.

Refer individuals to the Washington State Office of Insurance Commissioner (SHIBA) if individuals have questions about switching insurance.

Do individuals have out-of-pocket prescription drug co payments associated with creditable coverage plans?

Yes. Creditable coverage plans may have co payment charges that are considered out-of-pocket costs to the individual. These out-of-pocket costs must be verified in order for the agency to reduce participation. Once the agency has verification of what the health insurance has paid toward the prescription drugs, the out-of-pocket co payment is an allowable deduction from participation.

What happens if the system automatically enrolls an individual with creditable coverage into a Medicare D prescription drug plan once they become eligible for Medicaid?

The individual or their representative will need to contact 1-800-Medicare and their creditable coverage insurance carrier to indicate they want to retain their creditable coverage health plan. There are times when Medicaid individuals are enrolled into a Medicare D PDP incorrectly when the individual has creditable coverage.

Clarification from Centers for Medicare and Medicaid Services (CMS) issued 12/2005 regarding Medicare D prescription drug costs and post eligibility.

Beginning January 1, 2006 individuals enrolled in Medicare will be able to receive prescription drugs through Medicare Part D. For the most part, coverage of prescription drugs will no longer be available under Medicaid. Many states have raised questions about how to treat pharmacy charges and Part D costs for institutionalized individuals.

Part D premiums

Full benefit dual eligibles (FBDEs) are entitled to premium-free Part D enrollment, however they may elect enrollment in an enhanced plan. Those who enroll in an enhanced plan are responsible for that portion of the premium attributable to the enhancement. When an institutionalized FBDE is enrolled in an enhanced plan the portion of the premium that remains the individual’s responsibility is an allowable deduction in the post-eligibility calculation.

Copays, deductibles and coverage gap

Full benefit dual eligibles (FBDEs) who are institutionalized and enrolled in a Part D plan or a Medicare Advantage-Prescription Drug plan (PDP or MA-PD) will not be responsible for the payment of deductibles or copays, nor will they be subject to a coverage gap in their Part D benefits (these rules do not apply to individuals eligible under a 1915 (c) waiver). Listed below are the various circumstances that may apply to institutionalized FBDEs:

  1. The plan will require no copays or deductibles and will apply no coverage gap.
  2. If the state identifies the individual as an institutionalized FBDE for past months on their monthly MMA file, the plan will reimburse the individual for any copays incurred during those months.
  3. If the state identifies the individual as an institutionalized FBDE for past months on their monthly MMA file, the plan will reimburse the individual for copays, deductibles and costs incurred during a coverage gap for those months.
  4. The plan will be responsible for drug charges with the effective date of the enrollment. The plan will not charge deductibles or copays, or apply a coverage gap to those enrolled as institutionalized FBDEs.

In the first three circumstances above, when post-eligibility is calculated, there should be no deductions for copays, deductibles or coverage gaps. This is because, if incurred, the individual is not ultimately responsible for these charges. In the last circumstance above, the individual will remain responsible for Part D covered drugs purchased prior to the effective date of the Part D enrollment. In this circumstance the cost of these drugs is an allowable deduction in the post-eligibility calculation.

Nonformulary Part D drugs

PDPs and MA-PDs are required to develop transition plans for institutionalized individuals. Plans may allow for limited coverage of drugs that are not part of the plan’s formulary. Each PDP/MA-PD’s transition plan may vary. Plans must issue a periodic (at least monthly) statement to the beneficiary explaining all benefits paid and denied. Part D drugs that are not covered by the plan may not be covered by Medicaid, and absent other drug coverage, these would remain the responsibility of the individual. These charges may be allowable deductions in the post-eligibility calculation. To determine whether or not prescription charges should be allowed in post-eligibility, apply the following rules:

  1. 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 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.
  2. If the drug charge appears on the statement as a denial, and an exception was requested and denied, allow the charge. At the state’s option, the deduction for these costs may be subject to reasonable limits.

This procedure will help ensure that legitimate costs for drugs not covered by the plan are correctly allowed in post-eligibility. By relying on the plan statements and exception notices, eligibility workers will not need to be concerned with knowing the plan’s formulary or nonformulary drugs covered under a transition plan or under the exception process. Applicants should be advised to maintain these documents for consideration in post-eligibility.

Non-Part D covered drugs

Certain drugs are not covered under Part D. State Medicaid programs have the option of covering these excluded drugs. If the institutionalized FBDE presents documentation that a purchased drug is excluded under Part D, and the State Medicaid program has not opted to cover the drug, absent other drug coverage, the drug may be an allowable deduction in the post-eligibility calculation. States may place reasonable limits on this deduction.

Projection and reconciliation

For states that opt to project medical expenses for post-eligibility, note that the projected figures must be reconciled at the end of the prospective period. Use the guidelines above to determine the beneficiary’s actual costs to determine the appropriate adjustment to the projected deductions.

Note: HCS Management Bulletin H06-015-Procedure dated March 7, 2006 includes several handout and Q and A regarding Medicare D.

What about Medicare insurance supplements, also called Medigap plans?

Medigap plans are private insurance supplements that provide additional coverage for certain Medicare copayments.

Medigap insurance premiums are an allowable post eligibility deduction from participation.

Medigap insurance is not allowed as an ETR from room and board. The reason for this is because individuals in medical institutions or on a HCB Waiver are eligible to receive a Medicare Savings Program (MSP) which provides the same copayment coverage as a Medigap plan. Do not allow Medigap insurance as a deduction from state-funded room and board.

Individuals can choose to cancel Medigap plans when going on institutional and HCB Waiver services and QMB. If the individual goes off Medicaid, they have 30 days per the Office of Insurance Commissioner to notify their Medigap plan that they want to be reinstated. Refer clients to their local SHIBA counselor if they have questions about cancelling and reinstating their Medigap plans.

Medicare C - Medicare Advantage plans

Medicare Advantage plans are another way to get original Medicare (Parts A and B).

Medicare pays a private insurance company you select to manage your care.

You pay:

  • Part A premiums (if any)
  • Part B premiums
  • The Medicare Advantage plan's premium (if any)
  • Any deductibles, copays, or coinsurance

For individuals on institutional Medicaid, the only out-of-pocket expense would be the Medicare Advantage plan premium if any.

Since institutional Medicaid individuals receive both Medicaid and QMB Medicare savings program, the deductible and copayments are covered (up to the state rate). Providers with a Medicaid contract are to accept payment at the state rate.

What do these plans cover?

All medically necessary care covered by original Medicare.

They could include prescription drug coverage (Medicare Part D)

They could include additional coverage for vision, hearing, dental, foot care.

For additional information on Medicare advantage plans including approved Medicare Advantage Plans in the State of Washington by county.

Medicare Savings Program (MSP) and long-term care: effective date

Note: The date eligibility is established for QMB/S03 is based on the financial worker having all the information needed in order to make a decision on the application. HCA has clarified that QMB needs to be open the first of the following month the action could have been taken by the FW.

QMB/S03 starts the first of the month following the date eligibility is established. If institutional eligibility is needed in order to open S03 because income is over the FPL, then the S03 opens the first of the month following the date all verification was received to establish eligibility. The date eligibility is established is the date that is indicated on the VERF screen. HCA has given a clarification that if verifications is received, but LTC does not start until the following month, that the FSS would indicate the date the verifications are received on the VERF screen. If verifications were received in a prior month than the LTC start date, this would cause the S03 to open in the same month as the LTC. Even though the LTC eligibility is driving S03 eligibility, this is correct.

S05/SLMB starts in the month the individual is income/resource eligible for the program. This includes a retro month.

S06/QI 1 starts in the month the individual is income/resource eligible for the program. This includes a retro month.

What is a retro month? A retro month is 3 months prior to the date the application was received.

What is a plug in? A plug in is needed when P1 does not pick up the eligibility from ACES. HCA indicates it is always needed for MSP or state buy in coverage in a retro month. To request a plug-in contact the Medicare buy-in unit using a barcode tickler to: 102@MBU

State buy-in. This is state funded and picks up the Medicare B premium in the 3rd month of Medicaid eligibility. State buy in is used when the individual is not eligible for a federally matched MSP program but is eligible for a Medicaid program. State buy-in is frequently used for the HWD program and spenddown as most of these individuals have income that exceeds the MSP income standards.

If we are opening an institutional program back several months and an individual was not eligible for the S03/QMB until the first of the month following the month we had all the necessary information to open S03, the state will still buy in the Medicare premium in the 3rd month of eligibility.

Active Medicaid client subsequently becomes eligible for Medicare. In this scenario, HCA has confirmed that the FSS would screen in the S03 in the month prior to the Medicare eligibility in order to start the MSP in the month the client becomes Medicare eligible.

Note: For more information, see allowable medical expenses

ACES-Medicare savings programs

LTCX screen coding and Medicare

  • OA-Medicare Part A premiums
  • OB-Medicare Part B premiums
  • OC-Medicare Part C premiums
  • OD-Medicare Part D premiums
  • OP-Medicare Part D copayments

Additional helpful links for Medicare issues

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HCS Home and Community based (HCB) waivers

Revised date
Purpose statement

This section is commonly referred as "The COPES chapter". It is used for the eligibility of the HCS HCB waiver programs. The medical coverage group is L22 and L21 for SSI recipients. The other HCS Waivers are New Freedom and the Residential Support Waiver (RSW). Some services use HCB Waiver rules for eligibility but are not considered HCB Waivers. These services are Hospice, Program of all-inclusive care for the elderly (PACE) and Roads to Community Living (RCL). This is described in the Overview of Home and Community Based (HCB) Waivers.

Purpose: This chapter describes the general and financial eligibility requirements for (HCB) services authorized by home and community services (HCS). These services are administered either in a home or residential (non medical institution) setting.

WAC 182-515-1505 Home and community based (HCB) waiver services authorized by home and community services (HCS).

WAC 182-515-1506 Home and community based (HCB) waiver services authorized by home and community services (HCS) general eligibility.

WAC 182-515-1507 Home and community based (HCB) waiver services authorized by home and community services (HCS) if a person is eligible for an SSI-related noninstitutional categorically needy (CN) medicaid program.

WAC 182-515-1508 Home and community based (HCB) waiver services authorized by home and community services (HCS) - Financial eligibility using SSI-related institutional rules.

WAC 182-515-1509 Home and community based (HCB) waiver services authorized by home and community services (HCS) - Client financial responsibility

WAC 182-515-1505 Home and community based (HCB) waiver services authorized by home and community services (HCS)

WAC 182-515-1505 Home and community based (HCB) waiver services authorized by home and community services (HCS).

Effective February 20, 2017

This chapter describes the general and financial eligibility requirements for categorically needy (CN) home and community based (HCB) waiver services authorized by home and community services (HCS). The definitions in WAC 182-513-1100 and chapter 182-500 WAC apply throughout this chapter.

  1. The HCS waivers are:
    1. Community options program entry system (COPES);
    2. New Freedom consumer-directed services (New Freedom); and
    3. Residential support waiver (RSW).
  2. WAC 182-515-1506 describes the general eligibility requirements for HCB waiver services authorized by HCS.
  3. WAC 182-515-1507 describes financial requirements for eligibility for HCB waiver services authorized by HCS when a person is eligible for a noninstitutional SSI-related categorically needy (CN) medicaid program.
  4. WAC 182-515-1508 describes the financial eligibility requirements for HCB waiver services authorized by HCS when a person is not eligible for SSI-related noninstitutional CN medicaid under WAC 182-515-1507.
  5. WAC 182-515-1509 describes the rules used to determine a person's responsibility for the cost of care and room and board for HCB waiver services if the person is eligible under WAC 182-515-1508.

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 182-515-1506 Home and community based (HCB) waiver services authorized by home and community services (HCS) general eligibility.

WAC 182-515-1506 Home and community based (HCB) waiver services authorized by home and community services (HCS) general eligibility.

Effective February 9, 2025

  1. To be eligible for home and community based (HCB) waiver services a person must:
    1. Meet the program and age requirements for the specific program:
      1. Community options program entry system (COPES), under WAC 388-106-0310;
      2. Residential support waiver (RSW), under WAC 388-106-0310; or
      3. New Freedom, under WAC 388-106-1410.
    2. Meet the disability criteria for the supplemental security income (SSI) program under WAC 182-512-0050;
    3. Require the level of care provided in a nursing facility under WAC 388-106-0355;
    4. Reside in a medical institution as defined in WAC 182-500-0050, or be likely to be placed in one within the next 30 days without HCB waiver services provided under one of the programs listed in (a) of this subsection;
    5. Attain institutional status under WAC 182-513-1320;
    6. Assessed for HCB waiver services, be approved for a plan of care, and receiving an HCB waiver service under (a) of this subsection;
    7. Be able to live at home with community support services and choose to remain at home, or live in a department-contracted alternate living facility under WAC 182-513-1100.
  2. A person is not eligible for home and community based (HCB) waiver services if the person:
    1. Is subject to a penalty period of ineligibility for the transfer of an asset under WAC 182-513-1363; or
    2. Has a home with equity in excess of the requirements under WAC 182-513-1350.
  3. See WAC 182-513-1315 for rules used to determine countable resources, income, and eligibility standards for long-term care (LTC) services.
  4. Current income and resource standards 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.

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 182-515-1507 Home and community based (HCB) waiver services authorized by home and community services (HCS) — Financial eligibility if a client is eligible for an SSI-related noninstitutional categorically needy (CN) medicaid program.

WAC 182-515-1507 Home and community based (HCB) waiver services authorized by home and community services (HCS) — Financial eligibility if a client is eligible for an SSI-related noninstitutional categorically needy (CN) medicaid program.

Effective February 25, 2023

  1. A client is financially eligible for home and community based (HCB) waiver services if the client:
    1. Is receiving coverage under one of the following categorically needy (CN) medicaid programs:
      1. SSI program under WAC 182-510-0001. This includes SSI clients under Section 1619(b) of the Social Security Act;
      2. SSI-related noninstitutional CN program under chapter 182-512 WAC; or
      3. Health care for workers with disabilities program (HWD) under chapter 182-511 WAC.
    2. Does not have a penalty period of ineligibility for the transfer of an asset under WAC 182-513-1363; and
    3. Does not own a home with equity in excess of the requirements under WAC 182-513-1350.
  2. A client eligible under this section does not pay toward the cost of care, but must pay room and board if living in an alternate living facility (ALF) under WAC 182-513-1100.
  3. A client eligible under this section who lives in a department-contracted ALF described under WAC 182-513-1100 :
    1. Keeps a personal needs allowance (PNA) under WAC 182-513-1105; and
    2. Pays towards room and board under WAC 182-513-1105.
  4. A client who is eligible under the HWD program must pay the HWD premium under WAC 182-511-1250, in addition to room and board, if residing in an ALF.
  5. Current resource, income, PNA, and room and board standards 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.

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 182-515-1508 Home and community based (HCB) waiver services authorized by home and community services (HCS) — Financial eligibility using SSI-related institutional rules.

WAC 182-515-1508 Home and community based (HCB) waiver services authorized by home and community services (HCS) — Financial eligibility using SSI-related institutional rules.

Effective February 25, 2023

  1. If a person is not eligible for a categorically needy (CN) program under WAC 182-515-1507, the agency determines eligibility for home and community based (HCB) waiver services authorized by home and community services (HCS) using institutional medicaid rules. This section explains how a person may qualify using institutional rules.
  2. A person must meet:
    1. General eligibility requirements under WAC 182-513-1315 and 182-515-1506;
    2. The resource requirements under WAC 182-513-1350;
    3. The following income requirements:
      1. Available income must be at or below the special income level (SIL), defined under WAC 182-513-1100;
      2. If available income is above the SIL, net available income is no greater than the effective one-person medically needy income level (MNIL). Net income is calculated by reducing available income by:
        1. Medically needy (MN) disregards found under WAC 182-513-1345;
        2. The average monthly nursing facility state rate;
        3. Health insurance premiums, other than medicare; and
        4. Outstanding medical bills, prorated monthly over a 12-month certification period, that meet the requirements of WAC 182-513-1350.
  3. The agency determines available income and income exclusions under WAC 182-513-1325, 182-513-1330, and 182-513-1340.
  4. A person eligible under this section is responsible to pay toward the cost of care and room and board, as described under WAC 182-515-1509.
  5. Current resource, income standards, and the average state nursing facility rate for long-term care 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.

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 182-515-1509 Home and community based (HCB) waiver services authorized by home and community services (HCS) – Client financial responsibility

WAC 182-515-1509 Home and community based (HCB) waiver services authorized by home and community services (HCS) – Client financial responsibility.

Effective March 1, 2025

  1. A client eligible for home and community based (HCB) waiver services authorized by home and community services (HCS) under WAC 182-515-1508 must pay toward the cost of care and room and board under this section.
    1. Post-eligibility treatment of income, participation, and participate are all terms that refer to a client's responsibility towards cost of care.
    2. Room and board is a term that refers to a client's responsibility toward food and shelter in an alternate living facility (ALF).
  2. The agency determines how much a client must pay toward the cost of care for HCB waiver services authorized by HCS when living in their own home:
    1. A single client who lives in their own home (as defined in WAC 388-106-0010) keeps a personal needs allowance (PNA) of up to 300% of the federal benefit rate (FBR) for the supplemental security income (SSI) cash grant program and must pay the remaining available income toward cost of care after allowable deductions described in subsection (4) of this section. The Washington apple health income and resource standards chart identifies 300% of the FBR as the medical special income level (SIL).
    2. A married client who lives with the client's spouse in their own home (as defined in WAC 388-106-0010) keeps a PNA of up to the effective one-person medically needy income level (MNIL) and pays the remainder of the client's available income toward cost of care after allowable deductions under subsection (4) of this section.
    3. A married client who lives in their own home and apart from the client's spouse keeps a PNA of up to the SIL but must pay the remaining available income toward cost of care after allowable deductions under subsection (4) of this section.
    4. A married couple living in their own home where each client receives HCB waiver services is each allowed to keep a PNA of up to the SIL but must pay remaining available income toward cost of care after allowable deductions under subsection (4) of this section.
    5. A married couple living in their own home where each client receives HCB waiver services, one spouse authorized by the developmental disabilities administration (DDA) and the other authorized by HCS, is allowed the following:
      1. The client authorized by DDA pays toward the cost of care under WAC 182-515-1512 or 182-515-1514; and
      2. The client authorized by HCS retains the SIL and pays the remainder of the available income toward cost of care after allowable deductions under subsection (4) of this section.
  3. The agency determines how much a client must pay toward the cost of care for HCB waiver services authorized by HCS and room and board when living in a department contracted alternate living facility (ALF) defined under WAC 182-513-1100. A Client:
    1. Keeps a PNA of under WAC 182-513-1105;
    2. Pays room and board up to the room and board standard under WAC 182-513-1105; and
    3. Pays the remainder of available income toward the cost of care after allowable deductions under subsection (4) of this section.
  4. If income remains after the PNA and room and board liability under subsection (2) or (3) of this section, the remaining available income must be paid toward the cost of care after it is reduced by deductions in the following order:
    1. An earned income deduction of the first $65 plus one-half of the remaining earned income;
    2. Guardianship fees, conservatorship fees, and administrative costs including any attorney fees paid by the guardian or conservator only as allowed under chapter 388-79A WAC;
    3. Current or back child support garnished or withheld from the client's income according to a child support order in the month of the garnishment if it is for the current month. If the agency allows this as a deduction from income, the agency does not count it as the child's income when determining the family allocation amount in WAC 182-513-1385;
    4. A monthly maintenance-needs allowance for the community spouse as determined under WAC 182-513-1385. If the community spouse is also receiving long-term care services, the allocation is limited to an amount that brings the community spouse's income to the community spouse's PNA, as calculated under WAC 182-513-1385;
    5. A monthly maintenance-needs allowance for each dependent of the institutionalized client, or the client's spouse, as calculated under WAC 182-513-1385;
    6. Incurred medical expenses which have not been used to reduce excess resources. Allowable medical expenses are under WAC 182-513-1350.
  5. The total of the following deductions cannot exceed the special income level (SIL) defined under WAC 182-513-1100:
    1. The PNA allowed in subsection (2) or (3) of this section, including room and board;
    2. The earned income deduction in subsection (4)(a) of this section; and
    3. The guardianship fees, conservatorship fees, and administrative costs in subsection (4)(b) of this section.
  6. A client may have to pay third-party resources defined under WAC 182-513-1100 in addition to the room and board and participation.
  7. A client must pay the client's provider the sum of the room and board amount, and the cost of care after all allowable deductions, and any third-party resources defined under WAC 182-513-1100.
  8. A client on HCB waiver services does not pay more than the state rate for cost of care.
  9. When a client lives in multiple living arrangements in a month, the agency allows the highest PNA available based on all the living arrangements and services the client has received in a month.
  10. Standards described in this section 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.

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.

This section contains the following HCB Waiver services:

  1. Community options program (COPES)
  2. New Freedom consumer directed services (New Freedom)
  3. Program of all-inclusive care for the elderly (PACE)

Institutional standards used in determining initial and post eligibility (participation) in long term care change annually. Depending on the standard, these changes occur in January, April, July and August. See the Institutional standard chart for current standards used in long term care. This chart indicates the formula for the standard and when the standard last changed.

Personal needs allowance (PNA) for clothing, personal items and incidentals (CPI):

Personal needs allowance (PNA) for clothing, personal items and incidentals (CPI). Client's are allowed the highest personal needs allowance in a given month based on living arrangement, authorized service and marital status. If a client resided at home the first day of the month and went into a nursing home the same day, we would allow the in home PNA because they were residing in a home setting at least one moment during that given month. If a client went from a nursing home to an adult family home on HCB waiver services the first day of the month, we would allow the ALF PNA as it is the highest allowed. If that client were then discharged home from the ALF on the last day of the month, the benefit would be recalculated allowing the in home PNA

Medical Expenses used to reduce participation

To reduce participation, deduct medical expenses not already used to reduce excess resources as described in WAC 182-513-1350.

Income and Deduction changes in HCB Waivers. Method 3 effective 8/29/2014

WAC 182-504-0120 (12) Effective 8/29/2014 a change in income or deductions is effective the first of the month following the date the change was reported rather than the month the income or deduction changed (Method 1). Method 1 is used for clients residing in medical institutions. Method 3 is used for HCB Waivers.

When a change in income, or allowable expenses, changes the amount the client pays toward participation for a home and community-based waiver or service, we calculate the new participation amount effective the first of the month following the date the change was reported. The exception is if the change occurs due to the loss of an income source that is to last 2 months or longer and is reported timely.

Any change to an HCB Waiver client's income or post eligibility deductions that affect cost of care take effect in the ongoing month in ACES.

  • With the exception of loss of an income source or the lowering of income
    • The change takes effect the actual month of change.
    • We will make these historical changes in ACES.
    • To be considered a loss or reduction of income:
      • We must have a timely report of the change to income
      • We must have verification that this change is to last two months or longer;
      • Otherwise, it is a "change" in income that takes effect the following month.

What if a loss or lower of income is not reported timely?

  • Financial will not make historical adjustments in ACES.
  • Treat as an underpayment, or "client reimbursement".
  • Send the DSHS 07-104 in barcode to let the case manager know what the client's income or deduction actually was, and what we had in ACES. Indicate what the correct participation should have been for each month and that change was not reported timely.
  • The case manager/social worker will determine if the provider is to be paid more, if the client is owed any money or if there is a client overpayment.

Training information on Method 3 can be found on the financial program SharePoint under training, policy changes.

Note: Facility daily rates reported to financial by the social worker need to be made effective in the month the daily rate change occurred. Make these changes historical as it will affect the calculation in Provider One if there is a split participation month.

Overview of HCB Waivers

DDA home and community based (HCB) waivers

Additional clarification and worker responsibilities can be found in the Participation in a medical facility section.

See General eligibility for Long Term Care

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Redetermination overview

Revised date
Purpose statement

To define medical redetermination, describe when a medical redetermination is required, and to provide step by step directions through the process.

Definition: When eligibility ends for a CN Apple Health program during the certification period, federal law requires the agency (or its designee) to look at eligibility for other Apple Health programs before terminating CN coverage. Redetermination is completed at the point the agency considers eligibility for other Apple Health programs and documents in ACES that the reconsideration has been completed.

Without documentation of the redetermination process, the case will be found in error even if the correct action has been taken.

Note: CN coverage may end at the point of redetermination, even while waiting on a final disability determination, for example if the individual's income causes the CN medical (S02) to trickle to medically needy (MN) medical (S95/S99).

WAC 182-504-0125 Washington apple health -- Effect of reported changes.

WAC 182-504-0125 Washington apple health -- Effect of reported changes.

Effective October 1, 2017.

  1. If you report a change required under WAC 182-504-0105 during a certification period, you continue to be eligible for Washington apple health coverage until we decide if you can keep getting apple health coverage under your current apple health program or a different apple health program.
  2. If your apple health categorically needy (CN) coverage ends due to a reported change and you meet all the eligibility requirements for a different apple health CN program, we will approve your coverage under the new apple health CN program. If you are not eligible for coverage under any apple health CN program but you meet the eligibility requirements for either apple health alternative benefits plan (ABP) coverage or apple health medically needy (MN) coverage, we will approve your coverage under the program you are eligible for. If you are not eligible for coverage under any apple health CN program but you meet the eligibility requirements for both apple health ABP coverage and apple health MN coverage, we will approve the apple health ABP coverage unless you notify us that you prefer  apple health MN coverage.
  3. If your apple health coverage ends and you are not eligible for a different apple health program, we stop your apple health coverage after giving you advance and adequate notice unless the exception in subsection (4) of this section applies to you.
  4. If you claim to have a disability and that is the only basis for you to be potentially eligible for apple health coverage, then we refer you to the division of disability determination services (within the department of social and health services) for a disability determination. Pending the outcome of the disability determination, we also determine if you are eligible for apple health coverage under the SSI-related medical program described in chapter 182-512 WAC. If you have countable income in excess of the SSI-related categorically needy income level (CNIL), then we look to see if you can get coverage under apple health MN with spenddown as described in chapter 182-519 WAC pending the final outcome of the disability determination.
  5. If you are eligible for and receive coverage under the apple health parent and caretaker relative program described in WAC 182-505-0240, you may be eligible for the apple health medical extension program described in WAC 182-523-0100, if your coverage ends as a result of an increase in your earned income.
  6. Changes in income during a certification period do not affect eligibility for the following programs:
    1. Apple health for pregnant women;
    2. Apple health for children, except as specified in subsection (7) of this section;
    3. Apple health for SSI recipients;
    4. Apple health refugee program; and
    5. Apple health medical extension program.
  7. We redetermine eligibility for children receiving apple health for kids premium-based coverage described in WAC 182-505-0210 when the:
    1. Household's countable income decreases to a percentage of the federal poverty level (FPL) that would result in either a change in premium for apple health for kids with premiums or the children becoming eligible for apple health for kids (without premiums);
    2. Child becomes pregnant;
    3. Family size changes; or
    4. Child receives SSI.
  8. If you get SSI-related apple health CN coverage and report a change in work or earned income which results in a determination by the division of disability determination services that you no longer meet the definition of a disabled person as described in WAC 182-512-0050 due to work or earnings at the level of substantial gainful activity (SGA), we redetermine your eligibility for coverage under the health care for workers with disabilities (HWD) program. The HWD program is a premium-based program that waives the SGA work or earnings test, and you must approve the premium amount before we can authorize coverage under this program. For HWD program rules, see chapter 182-511 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.

Clarifying information

A medical redetermination is required for individuals who lose CN or ABP coverage during their certification period, which can be under any of the following medical groups:

  • Classic Apple Health (redetermination done by agency staff)
    • SSI terminations (S01, L01 or L21)
    • SSI-Related Medicaid (S02, G03)
    • Breast and Cervical Cancer (S30)
    • Institutional Medicaid (L02, K01, I01)
    • Hospice and Home and Community Waiver programs (L22)
  • MAGI-based Apple Health (redetermination for other MAGI-based programs automatically done by Washington Healthplanfinder)
    • Apple Health for Families/Caretaker Relatives (N01)
    • Apple Health for Newborns (N10)
    • Apple Health for Kids, with or without premiums (N11, N13, N31, N33)
    • Apple Health for Pregnant Women (N03, N23)
    • Apple Health for Adults (N05)

Note: Medical redetermination does not apply to individuals who lose eligibility during their certification period under the Apple Health Medical Care Services program (MCS).

A medical redetermination is not required in the following situations. The individual:

  • Dies;
  • Moves out of state;
  • Cannot be found (whereabouts unknown);
  • Is not federally qualified to receive Medicaid due to citizenship or immigration status; or
  • Asks the department to close medical coverage.

To complete the redetermination, the agency is required to review the individual's record for any indication that the individual may be eligible for another CN program, such as pregnancy or disability. The agency refers to this as "ex parte review", which is a required part of the redetermination process.

Worker responsibilities

Ex parte review and redetermination

For every redetermination for individuals who lose coverage under a CN medical coverage group, review available records of each individual within a terminated AU by checking:

  1. The electronic case record for the last review form, application or other documents;
  2. The notes in ACES or EJAS (if applicable); and
  3. SOLQ for a current SSI application or social security disability.

Instructions for common ex parte review scenarios

Below are instructions for handling common ex parte review findings.

No indication of disability or pregnancy

  1. Terminate the individual's CN coverage, and
  2. Document in ACES the actions taken and that the redetermination process has been completed.

Individual may be pregnant

  1. Refer the individual to Washington Healthplanfinder to apply for Apple Health for Pregnant Women;
  2. Set a 10-day tickler for follow-up;
  3. Terminate the individual's prior CN coverage only after the individual has been given 10 days to apply for Apple Health for Pregnant Women; and
  4. Document in ACES the actions taken and that the redetermination process has been completed

Individual claims to be disabled or there is an indication of disability in the record

  1. Screen in SSI-related medical (S02) coverage so that medical coverage can be continued while gathering the medical documentation needed to do a disability referral;
  2. Pend for verification of disability;
  3. Set a 20-day tickler for follow-up;
    1. If the individual does not respond within 20 days:
      1. Terminate the individual's prior CN coverage; and
      2. Send termination letter with Reason Code 552 and insert appropriate free-form text.
      3. Document in ACES the actions taken and that the redetermination process has been completed.
    2. If the individual responds within 20 days:
      1. Terminate the individual's prior CN coverage;
      2. Send termination letter with the appropriate Reason Code and insert appropriate free-form text;
      3. Finalize the pending S02 AU, including entering any new income;
        1. If there is income, the S02 may trickle to S99. If this happens, insert appropriate free-form text
      4. Set 4-month tickler for follow-up; and
      5. Add remarks behind the DEM2 screen explaining that the disability coding is a workaround to continue medical coverage under S02 while waiting for the NGMA determination due to redetermination.
      6. Document in ACES the actions taken and that the redetermination process has been completed.
      7. If the NGMA referral is returned indicating the individual is not disabled, remove the disability coding on the DEM2 screen to terminate the S02/S99 coverage.

Individual has pending SSI application

Follow instructions above for "Individual Claims to Be Disabled or There Is an Indication of Disability in the Record" except:

  1. Do not do a NGMA referral; and
  2. Notify the Division of Disability Determination Services (DDDS) that the agency has continued the individual's medical coverage and ask them to notify you when a decision is made on the individual's SSI application.

Individual may be eligible for Apple Health for Workers with Disabilities (HWD)

If the individual is over age 16 and working and is not otherwise eligible for S02 coverage (and meets disability requirements) send a referral to the specialized medical unit to consider eligibility for the Health Care for Workers with Disabilities (HWD) program. Allow the termination under the original program to proceed (allowing advance and adequate notice).

Note: If an individual is working and has monthly gross earnings at or above the Substantial Gainful Activity (SGA) level and does not receive Title 2 (SSDI, DAC, DWB), then HWD is the only Medicaid program that may provide coverage for them. An individual who is working at SGA is not eligible for S02/S95/S99 coverage, unless their Title 2 cash benefit continues. If their Title 2 has not ended, then HWD staff will explain their options to either enroll in HWD for CN coverage or meet their spenddown for MN coverage.

Set a barcode tickler to the HWD unit in DMS for @HWD in CSO 017 to contact the individual and determine if they wish to pursue HWD. Since HWD is a premium based program, CN coverage should not be authorized under this program until the individual has approved the premium requirement and amount.

For HCS individuals, set a barcode tickler to the HCS Regional HWD specialist to contact the individual and determine if they wish to pursue HWD.

Note: A working individual who is eligible under a Home and Community Based CN waiver program (L22 in ACES) whose income goes over the Special Income Limit (SIL) or who accumulates excess resources should always be referred to the HWD unit prior to terminating CN medical coverage. Both Home and Community Services (HCS) and the Division of Developmental Disabilities (DDD) have included the HWD program as an available coverage group in the CN waivers. An ADSA individual may transition from the L22 program to the S08 program and remain eligible for long-term care funding for waiver services.

System-generated alerts

The ACES system helps with the medical redetermination process by sending alerts when CN coverage ends for an individual or for all members in an assistance unit (AU), however staff should not rely solely on system generated alerts to determine when a medical redetermination is required.

The following alerts require the department to follow up, make a redetermination decision and document that decision in the narrative.

  • Alert 416 - Case closed in batch
  • Alert 322 - New MAU created for certain members of the closed AU
  • Alert 248 - SSI terminated, redetermine medical eligibility

When signed applications or review forms are not required

Signed application or eligibility review forms are NOT needed for:

  • Redeterminations of CN medical coverage for the same program (including MSP programs) with the same individuals in the assistance unit, either prior to the end of the certification period or within 30 days after the case closed. 
  • Changing to a medical program which has a more stringent eligibility requirement (such as changing from HWD, with no resource test to CN SSI-related, which does have a resource test). However, we do need to document in ACES that we asked the necessary questions for the more stringent requirements and what the answers to those questions were. 

Continuous eligibility

Redetermination does not apply to individuals who receive continuous eligibility, since their coverage continues through the end of their certification period. The following two programs provide continuous eligibility:

  1. Children terminated from any CN medical program are eligible through the end of their original 12-month certification period.
    1. Children whose coverage was approved under the family institutional medical program are eligible to receive one full year of coverage. When a child discharges from a medical facility and is no longer eligible for K01 coverage, open F06 for the balance of the certification period without requiring an application or review from the parents.
  2. Pregnant women terminated from any CN medical program are eligible for CN medical to continue through the end of the post partum period.

Note: A pregnant woman who applies for retroactive medical coverage and is found eligible for CN medical in any month of the retroactive period also remains continuously eligible for CN through the end of the post partum period.

SSI redetermination

When an individual loses eligibility for Supplemental Security Income (SSI) cash assistance, the department must redetermine their eligibility for Medicaid. The State Data Exchange (SDX) interfaces with ACES and provides us with information regarding the termination or suspension of SSI cash assistance. (The ACES automated redetermination process does not apply to any individual where the SDX medical eligibility code shows as A, C, G, N, or Y on the SDX1 screen. These individuals are considered SSI cash recipients and remain eligible under the S01 medical coverage group).

When the medical eligibility code is 'R' (Referred to State), the ACES system takes the following steps, depending on whether the SSI is in nonpay status or is in suspended status.

Suspended Status

ACES checks the SDX to determine the individual's payment status code. If the code is a payment suspense code (S01, S04, S05, S06, S07, S08, S09 or S10) ACES waits and does not generate the 22-05 Redetermination letter and Alert 248 - SSI Terminated, Redetermine Medical Eligibility for 60 days. Social Security uses the suspense codes when updating an individual's address, changing a payee or budgeting fluctuating income and in many cases the SSI cash starts again within a short period of time.

If the individual's status changes again from suspended status to nonpay status at any time during the 60 day wait period, the 22-05 Redetermination letter is generated, along with the 248 Alert.

If the individual's status changes from suspended back to a pay status, then all tracking is stopped and no 22-05 Redetermination letter is sent. ACES automatically removes the SSI closure information from the bottom of the UNER screen when this happens.

After 60 days, if the status on the SDX has not changed, ACES generates the 248 Alert and 22-05 Redetermination letter to the individual.

Nonpay status

When the SSI closes for an individual who is not in a suspended status with Social Security Administration, ACES populates the bottom of the UNER screen with the SSI closure date and generates the 22-05 Redetermination letter and Alert 248.

Both suspended and terminated individuals have 60 days from the review is sent to return the form. At the end of 60 days, if the S01 AU is still active, ACES will check for 'Y' (Yes) in the ELIG RVW RCVD field on the MISC screen to indicate the review has been received. A barcode to ACES interface automatically populates this field if an eligibility review form is received in the Document Management System (DMS).

If there is a 'Y' on the MISC screen, Alert 251-SSI TERM'D 60 DAYS AGO, COMPLETE MED REDETERMINATION generates and the AU remains active until the review is initiated in the system.

If there is not a 'Y' on the MISC screen, the S01, L01 or L21 AU's will automatically close with reason code 235 - Review Not Complete and ACES generates the correct termination letter allowing advance notice. At this point, the redetermination process is complete. The ACES tracking process automatically stops if an SDX record is sent indicating the individual has started receiving SSI again.

Note: When SSI closes, a redetermination of the individual's disability status is also required, in addition to reviewing income and resource criteria. If SSI closed because the individual began receiving Title II Social Security Disability benefits, a new disability determination is not required. However, a referral needs to be made to DDDS to determine the disability review date if the individual is under the age of 65.

Disability review date

If SSI closed for some other reason, a new referral to DDDS for a disability determination may need to be made, unless you are able to contact the local SSA field office for the disability review date, or 'diary' date which is the term used by SSA. DDDS does not keep information about the disability review date once it sends the disability decision to the SSA field office, but SSA staff do have access to the information. Unfortunately, the diary date information is not available through any of the department interfaces with SSA, so if you are unable to obtain the diary date, or if it is time for the individual's disability status to be reviewed, a new DDDS referral for NGMA needs to be initiated. Follow directions under the Ex-Parte review process by screening in an S02. Then set the end date 4 months out to allow time for the disability decision to come back. Set a barcode tickler to review the case again at that time if no disability decision was received within that time frame.

Note: When approving the S02 (or S95/S99) coverage group, remember to change the Approval Source code on the DEM2 screen from "SI" to "SA" if the individual starts receiving Title II benefits.

If the individual receives long-term care services under a Home and Community Waiver (HCBS) program (COPES or DDD waiver), it is important to coordinate closely with the social worker or case manager during this process to ensure Apple Health coverage is not closed for these vulnerable individuals. If the individual has an Equal Access representative, guardian or designated authorized representative, ensure copies of all letters are sent to them so they can respond on behalf of the individual. See WAC 182-503-0120 for more information on Equal Access Services.

If the individual receives services through HCS or DDD, attach a copy of the latest individual CARE assessment to the NGMA referral packet (or ensure DDDS receives a copy if an electronic NGMA referral is initiated through barcode).

SSI-Related Special Income Disregards discusses the ACES redetermination process for individuals who lose eligibility under the SSI program but who remain eligible for CN Medicaid due to the SSI-related special income disregards: Pickle, Disabled Adult Child or the Disabled Widow(er) provisions.

Redetermination for Individuals Who Might Be Eligible for Apple Health.

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Medical assistance definitions

Revised date
Purpose statement

Provide links to the WAC with the definitions of words and phrases that are used in the rules for medical assistance and other health care programs.

WAC 182-500-0005 Definitions.

WAC 182-500-0005 Definitions.

Effective August 29, 2016

Chapter 182-500 WAC contains definitions of words and phrases used in rules for medical assistance and other health care programs. When a term is not defined in this chapter, other agency or agency's designee WAC, or state or federal law, the medical definitions found in the Taber's Cyclopedic Medical Dictionary will apply. For general terms not defined in this chapter, other agency or agency's designee WAC, or state or federal law, the definitions in Webster's New World Dictionary apply. If a definition in this chapter conflicts with a definition in another chapter of Title 182 WAC, the definition in the specific WAC prevails.

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.

182-500-0010 Medical assistance definitions -- A.
182-500-0015 Medical assistance definitions -- B.
182-500-0020 Medical assistance definitions -- C.
182-500-0025 Medical assistance definitions -- D.
182-500-0030 Medical assistance definitions -- E.
182-500-0035 Medical assistance definitions -- F.
182-500-0040 Medical assistance definitions -- G.
182-500-0045 Medical assistance definitions -- H.
182-500-0050 Medical assistance definitions -- I.
182-500-0065 Medical assistance definitions -- L.
182-500-0070 Medical assistance definitions -- M.
182-500-0075 Medical assistance definitions -- N.
182-500-0080 Medical assistance definitions -- O.
182-500-0085 Medical assistance definitions -- P.
182-500-0090 Medical assistance definitions -- Q.
182-500-0095 Medical assistance definitions -- R.
182-500-0100 Medical assistance definitions -- S.
182-500-0105 Medical assistance definitions -- T.
182-500-0110 Medical assistance definitions -- U.
182-500-0120 Medical assistance definitions -- W.

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Tailored supports for older adults (TSOA) - applications, rights, and responsibilities

Revised date
Purpose statement

This section describes the application process for a TSOA applicant and explains a person’s rights and responsibilities.

WAC 182-513-1625 Tailored Supports for Older Adults (TSOA) - Applications.

WAC 182-513-1625 Tailored Supports for Older Adults (TSOA) — Applications.

Effective October 9, 2023

  1. Applications for tailored supports for older adults (TSOA) are submitted:
    1. Online at Washington Connection at www.washingtonconnection.org;
    2. By sending a completed HCA 18-005 application for TSOA form to P.O. Box 45826, Olympia, WA 98605;
    3. By faxing a completed HCA 18-005 application for TSOA form to 1-855-635-8305;
    4. By contacting your local area agency on aging (AAA) office at 1-855-567-0252; or
    5. By contacting your local home and community services (HCS) office. To find your local HCS office, see https://www.dshs.wa.gov/ALTSA/resources.
  2. Help filing an application:
    1. The Medicaid agency or the agency's designee provides help with the application or renewal process in a manner that is accessible to people with disabilities, limitations, or other impairments as described in WAC 182-503-0120 and to those who are limited-English proficient as described in WAC 182-503-0110;
    2. For help filing an application:
      1. Contact a local AAA office;
      2. Contact a local HCS office;
      3. Have an authorized representative apply on the person's behalf.
  3. The following people can apply for the TSOA program:
    1. The applicant (the person receiving care);
    2. The applicant's spouse;
    3. The applicant's caregiver (person providing in-home caregiver services);
    4. A legal guardian; or
    5. An authorized representative, as defined in WAC 182-500-0010.
  4. A phone interview is required to establish TSOA financial eligibility, but may be waived if the applicant is unable to comply:
    1. Due to the applicant's medical condition; and
    2. Because the applicant does not have another person that is able to conduct the interview on the applicant's behalf.
  5. The agency or the agency's designee processes TSOA applications using the same timelines under WAC 182-503-0060.
  6. TSOA begins on the date the person is determined presumptively eligible for TSOA under WAC 182-513-1620; or on the date all eligibility requirements are established if not found presumptively eligible.
  7. When the person withdraws an application for TSOA, or is determined ineligible for TSOA services, the agency or the agency's designee denies the application under WAC 182-503-0080.

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 application for TSOA may be submitted in several ways, either in person, by mail, by fax or online. In addition, a person may contact a Home and Community Services office by calling their local intake line, or by contacting an Area Agency on Aging (AAA) office at 1-855-567-0252.

Many people need help applying for services or Medicaid. Often there are family members or friends, or staff members of a hospital or nursing home or other agency, who are able to help. Help is also available from your local AAA and from DSHS staff, especially for people who have physical or mental impairments that make it hard to get through the application process on their own.

In order to determine if a person meets the financial eligibility criteria for the TSOA program, a person is required to have an interview. The interview may be conducted with the applicant, their spouse, authorized representative, guardian, or caregiver. If a person isn’t able to complete the interview due to the person’s medical condition, and no-one else is available to do the interview on their behalf, this requirement may be waived.

TSOA applications follow the same standard of promptness as regular medicaid applications and must be processed within 45 days, unless good cause applies.

How to request a long-term care (LTC) assessment

Call and schedule an assessment through the DSHS Central intake lines. Social Service central intake lines are divided by Regions in the State of Washington. This is used to request a social service assessment for home and community services (in-home care, care in a residential facility, nursing facility coverage).

Region 1 North

HCS-Adams, Chelan, Douglas, Ferry, Grant, Lincoln, Okanagan, Pend Oreille, Spokane, Stevens, and Whitman counties:
Phone: 1-866-323-9409

Region 1 South

HCS-Asotin, Benton, Columbia, Franklin, Garfield, Kittitas, Klickitat, Walla Walla, and Yakima counties. Contact the local Home and Community Service (HCS) office based on county.

Region 2 North

HCS – Island, San Juan, Skagit, Snohomish, and Whatcom, counties:
Phone: 1-800-780-7094
Fax: 425-339-4859

Region 2 South

HCS - King County:
Phone: 206-341-7750
Fax: 206-373-6855

Region 3

HCS- Clallam, Clark, Cowlitz, Grays Harbor, Jefferson, Kitsap, Lewis, Mason, Pacific, Pierce, Thurston, and Wahkiakum Counties:
Phone: 1-800-786-3799 or 360-664-9138
Fax: 360-586-0499

WAC 182-513-1630 Tailored Supports for Older Adults (TSOA) - Rights and Responsibilities

WAC 182-513-1630 Tailored Supports for Older Adults (TSOA) — Rights and Responsibilities.

Effective July 1, 2017

  1. A person applying for or receiving tailored supports for older adults (TSOA) has the right to:
    1. Have TSOA rights and responsibilities explained and provided in writing;
    2. Be treated politely and fairly without regard to race, color, political beliefs, national origin, religion, age, gender (including gender identity and sex stereotyping), sexual orientation, disability, honorably discharged veteran or military status, or birthplace;
    3. Get help with the TSOA application if requested;
    4. Have an application processed promptly and no later than the timelines described in WAC 182-503-0060;
    5. Have at least ten calendar days to give the medicaid agency or the agency's designee information needed to determine eligibility and be given more time if asked for;
    6. Have personal information kept confidential. The agency or the agency's designee may share information with other state and federal agencies for purposes of eligibility and enrollment in other Washington apple health programs;
    7. Get written notice, in most cases, at least ten calendar days before the agency or its designee denies, terminates, or changes eligibility for TSOA;
    8. Ask for an appeal if the person disagrees with the agency or the agency's designee's decision. A person can also ask a department supervisor or administrator to review the decision or action without affecting the right to a fair hearing.
    9. Ask for and get interpreter or translator services at no cost and without delay.
    10. Ask for voter registration assistance;
    11. Refuse to speak to an investigator if the person's case is audited. If the person does not want to let the investigator enter their home, there is no requirement to do so and the person may ask the investigator to come back at another time. Such a request will not affect a person's eligibility for TSOA; and
    12. Get equal access services under WAC 182-503-0120 if eligible.
  2. An applicant or recipient of TSOA is responsible to:
    1. Report changes in household or family circumstances as required under WAC 182-513-1650;
    2. Provide the agency or the agency's designee with any information or proof needed to determine eligibility. If the person has trouble getting proof, the agency or the agency's designee helps get the proof needed or contacts other persons or agencies for it;
    3. Provide a valid Social Security number or immigration document number in order to verify identity, citizenship, immigration status, date of birth, and whether the person has other health care coverage. This information is not shared with the department of homeland security;
    4. Complete renewals when requested; and
    5. Cooperate with quality assurance when requested.

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

TSOA doesn’t provide health care coverage, therefore, many of the requirements under Apple Health don’t apply to TSOA applicants and recipients. However, the same client rights do apply, including hearing rights full TSOA determinations.

Related links

Tailored supports for older adults (TSOA) - applications, rights, and responsibilities

Tailored supports for older adults (TSOA)

Please report broken links or content problems.

Medicaid Personal Care

Revised date
Purpose statement

To explain a Medicaid program called Medicaid Personal Care (MPC) for individuals eligible for a noninstitutional CN program and meeting the functional criteria for personal care services.

WAC 182-513-1225 Medicaid Personal Care (MPC)

WAC 182-513-1225 Medicaid Personal Care (MPC)

Effective February 25, 2023

  1. Medicaid personal care (MPC) is a state-plan benefit available to a client who is determined:
    1. Functionally eligible for MPC services under WAC 388-106-0200 through 388-106-0235; and
    2. Financially eligible for a noninstitutional categorically needy (CN) or alternative benefits plan (ABP) Washington apple health (medicaid) program.
  2. MPC services may be provided to a client residing at home, in a department-contracted adult family home (AFH), or in a licensed assisted living facility that is contracted with the department to provide adult residential care services.
  3. A client who resides in an alternate living facility (ALF) listed in subsection (2) of this section:
    1. Keeps a personal needs allowance (PNA) under WAC 182-513-1105; and
    2. Pays room and board up to the room and board standard under WAC 182-513-1105, unless CN eligibility is determined using rules under WAC 182-513-1205.
  4. A client who receives MPC services under the health care for workers with disabilities (HWD) program under chapter 182-511 WAC must pay the HWD premium in addition to room and board under WAC 182-513-1105, if residing in an ALF.
  5. A client may have to pay third-party resources as defined under WAC 182-513-1100 in addition to room and board.
  6. Current PNA and room and board standards 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.

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.

What is Medicaid Personal Care (MPC)

A Medicaid program that is allowed under Washington State’s Medicaid State Plan, that provides assistance with activities of daily living to individuals who are eligible for noninstitutional categorically needy (CN) or Alternative Benefit Plan (ABP) medical programs.

Functional eligibility for this program is based on Chapter 388-106 WAC.

MPC services are available in the individual’s own home, adult family homes (AFH), assisted living or DDA group home for clients that do not meet NFLOC, but meet functional eligibility for MPC.

MPC is authorized by Home and Community Services (HCS) and Developmental Disabilities (DDA) administrations.

A CARE assessment is done by a case manager, nurse or social service specialist from DDA, HCS or Area Agency on Aging (AAA).

Individuals must meet the functional criteria based on the social service assessment and financial eligibility based on eligibility for a noninstitutional CN or ABP Medicaid program.

The only exception is the Alien Emergent Medical (AEM) Modified Adjusted Gross Income (MAGI) medical program under N21 and N25. AEM programs do not cover Medicaid Personal Care (MPC) services.

MPC individuals pay room and board if living in a adult family home, adult residential center (ARC) or DDA group home.

What is room and board

Throughout the manual both terms, room and board and board and room are used to describe a living arrangement in which an individual purchases food, shelter, and household maintenance requirements from one vendor. In other words, room and board is considered "rent".

There is also a term used by ALTSA and DDA called the room and board rate. This rate is based on the FBR minus the HCS/COPES Waiver PNA in an ALF.

Most MPC individuals pay the ALTSA standard room and board rate for their rent.

The exception is individuals receiving medical under the G03 program. This is because the standard that is used to make them eligible for a CN program has been raised based on having to pay all of their countable income minus the PNA to the provider. This rate for the purpose of the G03 program is called the individual's total responsibility.

What is Classic Medicaid

Classic Medicaid are programs for individuals that are aged, blind or disabled (ABD).

The ABD classic medical programs are also called SSI-related programs. In order to receive one of these medical programs, you must be age 65 or over, or considered disabled or blind by Social Security criteria. All individuals age 65 or over or on Medicare must be considered for a Classic program unless they do not meet citizenship requirements for federal Medicaid.

Classic Medicaid included the institutional group (ABD individuals living in a medical institution 30 days or more) and Home and Community Based (HCB) Waiver programs. (L track).

What is the basic difference between "institutional" and "noninstitutional"

Institutional Medicaid has different income standards and rules for initial eligibility and higher resource standards for a couple when only one needs institutional services.

Institutional also has a 2nd eligibility component called "post-eligibility treatment of income". This 2nd eligibility computation determines the amount the individual must pay toward their cost of care to the medical institution or to the HCB Waiver provider. This is called "participation".

Noninstitutional Medicaid does not have a "post eligibility" component, therefore individuals living in the community on noninstitutional Medicaid do not "participate" toward the cost of their personal care.

MPC individuals do not pay "participation" but they are responsible to pay room and board (their rent) when living in an alternate living facility.

Classic Programs that do not fall into the aged/blind/disabled group:

  • Foster care medical authorized and maintained by the Health Care Authority. Some foster care children may be disabled, but disability is not a requirement for this program that can be authorized up to age 26. (D01, D02, D26)
  • Institutional children (K01, K95, K99) This program uses Modified Adjusted Gross Income (MAGI) income methodology to determine initial eligibility but the eligibility is not done by the Health Benefit Exchange. The eligibility is determined by the Health Care Authority and is primarily used for children's mental health facilities (CLIP) and children needing hospitalization that are not eligible for medical under a N track MAGI program.

Consult the medical program chart desk tool under the MPC column to determine what classic medical programs can authorize MPC.

What is Modified Adjusted Gross Income (MAGI) Medicaid

MAGI Medicaid eligibility is determined by the Health Benefit Exchange.

These programs show up as "N" track in ACES and are for children, pregnant woman, and adults under age 65. In order to be considered for medical under MAGI methodology, you can't be on Medicare.

It is possible for a disabled individual not on Medicare to qualify under MAGI by the Health Benefit Exchange.

Once an individual is eligible to receive Medicare, the case is redetermined from the MAGI program to a ABD Classic Medicaid program.

Individuals receiving MAGI programs under "N" track in ACES with the exception of AEM N21 and N25 are eligible to receive MPC if functionally eligible.

What is Medical Care Services (MCS)

MCS is a state funded medical program used for legally admitted non citizens that do not qualify for a Classic or MAGI Medicaid program because they are in their 5 year bar for federal Medicaid.

MCS covers nursing home and HCS has a state funded residential program for individuals eligible to receive MCS.

MCS does not cover MPC or HCB Waiver.

Agency responsibilities

CSD, HCS, and DDA LTC specialty unit Financial staff determines eligibility for classic medical assistance programs.

The Health Benefit Exchange (HBE) determines eligibility for MAGI-based medical.

The Medical Care Services ​(MCS) program includes a chart to indicate which specific agency is responsible to determine financial eligibility for each medical program.

DDA, HCS, or AAA case manager responsible for placement and case management services, determines functional eligibility, initiates the payment to the provider via ProviderOne and determines the amount the individual must pay to the facility for their cost of care and notifies the individual.

The assigned case manager/social service specialist indicates what services are authorized with the start date, the state daily rate, the current address and any other pertinent information needed to process the case such as if a payee or power of attorney is involved in the case.

The financial worker is responsible to determine the financial eligibility for Classic Medicaid. Changes need to be reported back and forth between the financial worker and assigned case manager/social service specialist.

HCS social service specialists use the DSHS 14-443 Financial/Social Service communication form in barcode.

DDA case managers use the DSHS 15-345 DDA Communication in barcode.

Worker responsibilities

HCS financial staff

All Classic Medicaid receiving MPC services through HCS

Indicate M for MPC service in ACES under the HCB type field. Indicate the start date of the service and the approving agency under the approval source. Indicate the payment authorization date. For MPC the start date of the service and the payment authorization date is the same date.

If the individual is living in an alternate living facility, the facility section must be completed. A provider number is not needed for an alternate living facility, but the entry date, level of care, payment authorization date and state rate are needed.

DDA and HCS financial staff responsibilities

If MPC services end, indicate the service end date on the HCBS field in the month services ended.

If in an ALF/residential setting indicate the end date under the facility line.

If the individual is not eligible for a noninstitutional Classic CN program, notify the agency authorizing MPC services that the individual is not financially eligible for MPC. The individual may be considered for a CN institutional Waiver program such as COPES.

See ​​HCS Home and Community based (HCB) waivers or ​DDA Home and Community Based (HCB) waivers for rules describing waiver services authorized by each agency.

An individual going from MPC to waiver must qualify under the rules for the waiver program including transfer of asset and excess home equity rules, income and resource rules that apply to waiver/institutional programs.

Social service specialists and case managers must consult financial service staff prior to switching a MPC case to a waiver case to make sure the individual is eligible under waiver rules.

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TSOA certification periods, change of circumstances, and renewals

Revised date

WAC 182-513-1645 Tailored Supports for Older Adults (TSOA) - Certification Periods.

WAC 182-513-1645 Tailored supports for older adults (TSOA) — Certification periods.

Effective July 1, 2017

  1. A certification period is the period of time a person is determined eligible for the tailored supports for older adults (TSOA) program. It begins on the first day of the month that the medicaid agency or the agency's designee determines the person is eligible for TSOA services, and continues through the last day of the month of the certification period.
  2. TSOA is certified for twelve months of continuous coverage regardless of a change in circumstances, unless the person:
    1. Moves out-of-state;
    2. Meets institutional status under WAC 182-513-1320;
    3. Becomes eligible for a categorically needy or alternate benefit plan Washington apple health program; or
    4. Dies.
  3. Financial eligibility for the TSOA program may not be approved prior to the date of a presumptive or full eligibility determination.

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 182-513-1650 Tailored Supports for Older Adults (TSOA) - Changes of Circumstances Requirements.

WAC 182-513-1650 Tailored Supports for Older Adults (TSOA) — Changes of Circumstances Requirements.

Effective July 1, 2017

  1. Changes in tailored supports for older adults (TSOA) household and family circumstances described in subsection (2) of this section must be reported to the medicaid agency or the agency's designee within thirty days of the date of the change.
  2. The following changes must be reported:
    1. A change in residential or mailing address, including if the TSOA recipient moves out-of-state;
    2. When a person admits to an institution, as defined in WAC 182-500-0050, and is likely to reside there for thirty days or longer; or
    3. The person dies.
  3. Effective date is the date of the changes.
    1. When TSOA terminates because the recipient dies, the effective date is the date of death.
    2. When TSOA terminates because of one of the following reasons, the effective date is the first day of the month following the advance notice period described in subsection (4) of this section. The TSOA recipient:
      1. Is admitted to an institution as defined in WAC 182-503-0050, and is expected to reside there for thirty days or longer;
      2. Is approved for coverage under a home and community-based waiver program;
      3. No longer meets nursing facility level of care under WAC 388-106-0355; or
      4. Becomes eligible for categorically need (CN) or alternative benefits plan (ABP) apple health coverage. The recipient may continue to receive authorized services through the medical alternative care (MAC) program under WAC 182-513-1600. The person may also apply for other long-term services and supports available under chapters 182-513 and 182-515 WAC.
  4. The advance notice period:
    1. Begins on the day the letter about the change is mailed; and
    2. Is determined according to the rules in WAC 182-518-0025.
  5. When the law or regulation is the effective date of the change.

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

Medicaid Alternative Care (MAC) change of circumstance

MAC recipients must report changes following the requirements under Chapter 182-504 WAC since all MAC recipients are eligible for Washington Apple Health coverage. 

MAC recipients may freely transition between the MAC program and long-term services and supports through the Community First Choice (CFC) program without filing a new financial application.  This could be because the care receiver’s needs can no longer be met under the MAC program or because the client chooses to access services that are only available under CFC. A person who needs services under a Home and Community based waiver would need to complete an Apple Health application (HCA 18-005 Application for Aged, Blind, Disabled/LTC form).

TSOA changes of circumstances  

TSOA recipients must report changes within 30 days of the date of the change; however, once a person is determined eligible for TSOA, they remain continuously eligible throughout the 12 month certification unless one of the following changes happens:

  • The person no longer meets NFLOC
  • The person is no longer a WA state resident
  • The person moves into an institution (nursing facility)
  • The person becomes eligible for CN or ABP Medicaid
  • The person passes away. 

There is no requirement to report changes in income or resources for a TSOA recipient.

Like MAC, TSOA recipients may transition to other LTSS services that they may be eligible for.  However most TSOA recipients don’t qualify for Apple Health coverage because they are spending down their resources to qualify, or their income is too high.  Also, although some TSOA recipients may qualify for Apple Health coverage, either under a medically needy program or a program with limited scope such as a Medicare Savings Program, these programs don’t provide CFC or HCB waiver services.  In both scenarios, a care receiver receiving TSOA services who needs to access Community First Choice or HCB waiver services must complete an Apple Health application to determine if they meet eligibility criteria for traditional long-term services and supports.  

Equally, existing clients who receive traditional LTSS may also choose to stop receiving those services and receive MAC or TSOA services instead.  Since there are many factors that may influence a person’s  decision, staff must take time to explain the options available and any consequences of making that decision, such as, the loss of Apple Health coverage if someone were to choose TSOA services.

Worker Responsibilities

Staff will follow HCS Equal Access guidelines and provide advance and adequate notice prior to terminating a MAC or TSOA case, unless the person has passed away. If a person moves to an institutional or residential setting, the T02 AU will need to be closed in ACES. If the client requests institutional medicaid coverage and is approved, the case will be historically closed in ACES, but there is no overpayment established for TSOA services provided through the advance notice period. If the client does not apply for medicaid coverage for an institutional stay, T02 can be reopened for the remainder of the T02 financial certification period; the client cannot receive TSOA services while in the institutional or residential setting. It is the responsibility of the AAA MTD Case Manager to confirm that services are not authorized during the admission.

Example: A client is active on T02 and an SSI-related spenddown S99 (met or unmet). The client admits to a nursing facility and is admitted for 40 days. The client chooses to not apply for an institutional medicaid (L02). They plan on private paying for the nursing facility stay and use the bill to meet their spenddown liability. The T02 be reopened when the client discharges home if the discharge is within the clients original T02 financial certification period; the client should not receive a TSOA service while admitted to an institution.

WAC 182-513-1655 Tailored Supports for Older Adults (TSOA) - Renewals.

WAC 182-513-1655 Tailored supports for older adults (TSOA) — Renewals.

Effective July 1, 2017

  1. A person who receives tailored supports for older adults (TSOA) services must complete a renewal of all eligibility factors for the program at least every twelve months.
  2. Forty-five days prior to the end of the certification period, notice is sent with the HCA 18-008 application for TSOA form. Complete the TSOA renewal in any of the following ways:
    1. Complete the TSOA application form, sign it, and mail it to P.O. Box 45826, Olympia, WA 98605 by the due date on the letter;
    2. Complete the TSOA application form, sign it, and fax it to 1-855-635-8305 by the due date on the letter;
    3. Renew online at Washington connection at https://www.washingtonconnection.org by the due date on the letter; or
    4. Call your local home and community services office at the telephone number on the letter by the due date on the letter.
  3. During the renewal process, the medicaid agency or the agency's designee reviews all eligibility factors to determine ongoing eligibility for TSOA, and may request additional verification of eligibility factors under WAC 182-503-0050 if unable to verify information through existing data sources. If additional information is needed, the agency or the agency's designee sends written notice under WAC 182-518-0015.
  4. If the agency or the agency's designee is unable to complete the renewal or determine eligibility for TSOA beyond the certification period, prior to ending eligibility for TSOA, the agency or the agency's designee sends a written termination notice as described in WAC 182-518-0025.
  5. A person who is terminated from TSOA for failure to renew has thirty days from the termination date to submit a completed renewal. If still eligible, TSOA is reopened without a break in eligibility.
  6. Equal access services as described in WAC 182-503-0120 are provided for anyone who needs help meeting the requirements of this section.
  7. Anyone who disagrees with an action regarding TSOA eligibility may ask for a 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.

Clarifying Information

TSOA Renewals must be completed once every 12 months and may be completed by phone, online, or on paper.  At the time of renewal, the person must still be receiving services under the TSOA program.

MAC renewals are based upon the certification period of the program the person is eligible under.

Follow HCS equal access policies to contact the person to complete the renewal.

Worker Responsibilities

Renewal notices are generated 45 days prior to the end of the certification period. When the renewal is received, review all eligibility factors and confirm with the AAA case manager whether the person is still receiving TSOA or MAC services. 

If this is the first renewal, verify whether resources over the standard have been transferred to the community spouse. 

For MAC clients who are only eligible for S02 coverage as a SIPI spouse under WAC 182-513-1660, verify MAC services are still being received.  If not, terminate S02 coverage and redetermine the person’s eligibility under medically needy coverage if eligible.

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Income special disregards

Revised date

WAC 182-512-0880 SSI-related medical -- Special income disregards.

WAC 182-512-0880 SSI-related medical -- Special income disregards.

Effective April 14, 2014.

Portions of a person's income the agency otherwise counts are disregarded when determining eligibility for Washington apple health (WAH) SSI-related medical programs.

  1. The agency disregards cost of living adjustments (COLAs) to Social Security benefits and provides categorically needy (CN) SSI-related medicaid benefits under the Pickle Amendment criteria of 42 C.F.R. 435.135(1)(a) to a person who:
    1. Is currently receiving Title II Social Security benefits;
    2. Was eligible for and received SSI or State Supplement payments (SSP) but became ineligible for those payments after April, 1977; and
    3. Would still be eligible for SSI or SSP payments if the amount of Social Security COLA increases paid under section 215(i) of the Social Security Act were deducted from his or her current Title II Social Security benefits.
    4. To satisfy this provision, a person must have been eligible for and received SSI or SSP payments and in the same month was entitled to, but did not necessarily receive, a Title II Social Security benefit for at least one month since April 1977. This includes a person who receives a Title II Social Security benefit payment the month after the last SSI or SSP payment is made due to the fact that Social Security is paid the month after entitlement begins.
    5. For purposes of this section, the agency also disregards COLAs received by a person, his or her financially responsible spouse, and other financially responsible family members, such as a parent.
  2. In determining SSI-related CN-WAH coverage, the agency disregards:
    1. Widow(er)'s benefits for a person who:
      1. Was entitled to SSA title II (widow/widower's) benefits in December 1983;
      2. Was at least fifty years old, but not yet sixty at that time;
      3. Received title II benefits and SSI in January 1984;
      4. Would continue to be eligible for SSI/SSP payments if the title II benefits were disregarded; and
      5. Filed an application for medicaid with the state by July 1, 1988.
    2. Widow, Widower or Surviving Divorced Spouse (title II) benefits for a person who:
      1. Received SSI/SSP benefits the month prior to receipt of title II benefits;
      2. Would continue to be eligible for SSI/SSP benefits if the title II benefits or the COLA(s) to those benefits were disregarded; and
      3. Is not eligible for medicare Part A. This person is considered an SSI recipient until becoming entitled to medicare Part A.
  3. A disabled adult child (DAC) who is ineligible for SSI/SSP solely due to receipt of either Social Security benefits as a disabled adult child of a person with a Social Security account or due to receipt of a COLA to the DAC benefits, may be income eligible for WAH categorically needy (CN) health care coverage if disregarding the SSA DAC benefits and COLA brings countable income below the CN standards, and the person:
    1. Is eighteen years of age or older;
    2. Remains related to the SSI program through disability or blindness;
    3. Lost SSI eligibility on or after July 1, 1988, due solely to the receipt of DAC benefits from SSA or a COLA to those benefits; and
    4. Meets the other WAH SSI-related CN medical requirements.
  4. A person is eligible for WAH CN coverage if:
    1. In August 1972, the person received:
      1. Old age assistance (OAA);
      2. Aid to blind (AB);
      3. Aid to families with dependent children (AFDC); or
      4. Aid to the permanently and totally disabled (APTD).
    2. The person was entitled to or received retirement, survivors, and disability insurance (RSDI) benefits; or
    3. The person was ineligible for OAA, AB, AFDC, SSI, or APTD solely because of the twenty percent increase in Social Security benefits under P.L. 92-336.
  5. Persons who stop receiving an SSI cash payment due to earnings, but still meet all of the other SSI eligibility rules and have income below the higher limit established by the Social Security Act's Section 1619(b) are eligible for continued WAH CN medicaid.
  6. TANF income methodology is used to determine countable income for children and pregnant women applying for WAH medically needy (MN) coverage unless the SSI methodology would be more beneficial to the person. When using the TANF income methodologies, deduct:
    1. A fifty percent earned income disregard described in WAC 388-450-0170;
    2. Actual child care and dependent care expenses related to employment; and
    3. Child support actually paid.

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

SSI-Related Special Income Disregards

When SSI cash assistance closes because the individual begins to receive Title II Social Security Income, ACES does several automated checks to determine if the individual would continue to qualify for CN Apple Health due to one or more of the special income disregards below:

  • Use the Application/Benefit field on the bottom of the UNER screen is used to identify the reason and date an individual was terminated from SSI.
    Note: ACES automatically populates the "Ever Received SSI?" field with a "Y" (Yes) and adds the SSI closure date when an SDX record is received showing the individual is no longer in pay status for SSI. Do not change this designation.
  • SSI closure codes are available to help identify individuals who are eligible for an SSI-related special income disregard. These codes are:
    • H - Receipt of DAC Benefits, or a COLA to DAC benefits
    • I - Receipt of Widows Benefits (Group 1)
    • J - Receipt of or COLA to Widow/Widowers/Surviving Spouse Benefits (Group 2)
    • K - SSI terminated for any other reason and the individual received Title II benefits at the time of termination or by the time ACES rechecks for Title II benefits 60 days after termination. (Pickle disregard)
    • T - SSI terminated for any other reason and the individual did NOT receive Title II benefits at the time of termination or within 60 days of the termination.
    • U - Unable to determine the reason for the SSI termination. This is a system generated code and must be updated to the correct value at the next review or application.
    • C - Old code prior to October 2009.
  • When ACES identifies that SSI closed because of a cost of living increase (COLA), Disabled Adult Child (DAC) benefit, or widow(er) income, it updates the reason code to the bottom of the UNER screen.
  • If ACES is unable to determine the reason for the SSI closure, you need to manually update the closure codes with the correct information while completing the eligibility review required for the redetermination process. See Worker Responsibilities.

Cost of Living Adjustment (COLA) and the Pickle Disregard

The Pickle disregard applies to individuals who lose SSI eligibility due to their beginning to receive Title II Social Security benefits or a Cost of Living Adjustment (COLA) to the Title II benefits. An individual must have been entitled to both SSI and the Title II benefits within the same month for the Pickle disregard to apply. This does not mean that the individual must have received an SSI check and a Title II check in the same month. An individual who loses SSI in one month and receives Title II income in the following month meets the criteria for the Pickle disregard. Individuals who become ineligible for SSI/SSP because of a COLA may be eligible for CN Apple Health through the disregard of COLA. The COLA disregard is allowed only for CN Apple Health. The disregard does not apply to other Apple Health programs.

Disabled Adult Child (DAC) Disregard

The DAC disregard applies to individuals who lose eligibility for SSI because they begin to receive DAC benefits or a COLA to DAC benefits. The DAC disregard is only allowed for CN Apple Health. To receive DAC income, an individual must have been found disabled prior to their twenty-second birthday. Requirements to receive the DAC disregard include:

  • Individual is 18 years of age or older.
  • Individual meets the aged, blind or disabled criteria.
  • Individual has an SSI closure date that is 7/1/88 or later.
  • Net countable income after applying the disregard is below the categorically needy income level (CNIL).
  • Individual meets all other SSI-related CN eligibility requirements.

Widow(er) Group 1 Disregard - Additional Reduction Factor

The widow(er) Group 1 disregard applies to a small group of individuals who meet specific age criteria. When Social Security changed how it calculates Title II benefits for widow(er)s in 1983, SSI ended for some in this group because of an increase in their Title II benefit. These individuals were grandfathered into continued CN eligibility.

Widow(er) Group 2 Disregard - Early Medicare

The widow(er) Group 2 disregard applies to individuals who lose SSI eligibility because of their having to apply for Title II widow(er) benefits or a COLA to those benefits. The disregard protects CN eligibility for these individuals until they are entitled to receive Medicare. Individuals who meet these criteria automatically meet the criteria for the Pickle disregard if they have income from another Title II source.

Worker Responsibilities

Special Income Disregards

Note: If the bottom of the UNER screen does not show any SSI closure information, review the SDX or SOLQ for SSI information. If an individual received SSI in another state and it ended before the individual moved to Washington, SDX records are not available. If the SSI information is questionable or not available, ask the individual for verification.

  • Use the following codes to identify which special income disregard applies:
    • H - Receipt of DAC Benefits, or a COLA to DAC benefits
    • I - Receipt of Widows Benefits (Group 1)
    • J - Receipt of or COLA to Widow/Widowers/Surviving Spouse Benefits (Group 2)
    • K - SSI terminated for any other reason and the individual received Title II benefits at the time of termination or by the time ACES rechecks for Title II benefits 60 days after termination. (Pickle disregard)
    • T - SSI terminated for any other reason and individual did NOT receive Title II benefits at the time of termination or within 60 days of the termination.
    • U - Unable to determine the reason for the SSI termination. This is a system generated code and must be updated to the correct value at the next review or application.
    • C - Old code prior to October 2009.

Cost of Living Adjustment (COLA) and the Pickle Disregard

When ACES receives an SDX record showing SSI income has terminated, there may or may not already be Title II income in the record. The BENDEX interface, which updates the Title II Social Security income, may be received after the original SDX record.

  • If there is Title II income type "SD" or "SS" already coded in ACES, then ACES automatically updates the SSI closure information in the Application/Benefit field on the UNER screen and enters the "K" Pickle indicator code.
  • If there is no Title II income in the record, ACES updates the status code to a "U" Unknown and waits for the BENDEX record to come in. ACES will check the record again in 60 days to see if Title II income was added to the case record.
  • At the time of the 60 day check, if no Title II income was added, or if the existing income has been removed, ACES automatically changes the Application/Benefit Status field to a "T" Terminated and applies no disregards.
  • If another source of Title II income is added to the case prior to the 60 day check, then ACES changes the "U" or "K" code to "H" if the income type that was added is "SC" or to a "J" if the income type that was added is "SW" or "SB".
  1. When the individual provides the eligibility review sent at the time of SSI closure, screen in an S02 medical AU and process, allowing the S01 AU to close. Review the coding on the bottom of the UNER screen to determine if the correct disregards are being applied.

    If the individual is eligible only for the Pickle disregard, then just the COLAs received since SSI was terminated will be excluded in the CN income calculation. You can determine if the disregard was applied by reviewing the MAFI screen. If the Pickle disregard is allowed, ACES indicates this by displaying a "P" in the Disregard Applied field.

    For ACES to apply the Pickle disregard, the following criteria must be met:

    • The individual must receive Title II income either in the same month as they received SSI or in the month immediately after they stopped receiving SSI. In ACES, this means there must be unearned income type SD, SS, SC, SW or SB in an amount greater than zero.
    • The SSI closure date is after 04/30/1977.
    • Individual meets the aged, blind, or disabled criteria.
    • The Application/Benefit status field on the UNER is coded with an "H", "I", "J", or "K".
    • Net countable income after applying the disregard is below the SSI Categorically Needy Income Level.
    • The individual meets all other SSI-related CN medical requirements.

    Note: Individuals may not be CN eligible under Pickle criteria at the time of the SSI closure, but may become eligible for the disregard in subsequent years depending on income. Always review MN spenddown cases for the correct coding before establishing a spenddown liability.

  2. If the disregard makes the individual eligible for CN and the individual:
    • Is receiving CN, continue the certification. Make a note to allow the disregard at the next review.
    • Is receiving MN, change the balance of the certification period to CN. Do not recompute spenddown for the period before the change.
    • Is pending spenddown (in "M" status), recalculate eligibility for the period after the change using the disregard. The period before the change remains the same.
  3. If coded correctly, ACES calculates whether the individual is given the Pickle Disregard and is eligible for CN Apple Health. To calculate it manually, follow these steps:
    • Determine the individual's total income.
    • Determine the month and year the SSI benefits stopped. Use this date to select the Pickle multiplier found in ACES in the parameters.
    • To get to the parameters, go to ACES mainframe.
      • From WMEN screen choose option "F" (parameters).
      • Then choose option "A" (eligibility parameters).
      • From that screen, choose option "O" (CA-MA Tables 3 Inquiry).
      • Then choose the most recent benefit year you are interested in. Current eligibility uses the most recent multiplier.
    • Multiply the current SSA benefit by the multiplier you selected to determine the COLA disregarded amount. Round to the nearest dollar.
    • Subtract the COLA disregard and other income exemptions and disregards from the individual's total income.
    • Add any income allocated from a spouse or parents.
    • Compare the result to the SSI CNIL.
      • If income is below the CNIL, authorize CN.
      • Do not allow the COLA disregard for programs other than CN.

    Example: Laura received SSA and SSI beginning in 1988, but was terminated from SSI after the most recent COLA. In redetermining her eligibility for health care coverage, the worker notes that her income is above the CNIL after the $20 disregard, but she is eligible for the Pickle (COLA) disregards. After checking the ACES parameters table, using the multiplier for the current year (which effectively disregards the yearly COLAs Laura received), her income is below the CNIL and she is eligible for a CN Apple Health (S02) instead of MN with spenddown (S99).

Disabled Adult Child (DAC)

When ACES receives an SDX record where the Medical Eligibility code is "D" and there is Title II income type "SC", ACES automatically updates the SSI closure information on the UNER screen and enters the "H" code. When the individual returns the eligibility review sent at the time of the SSI closure, screen in an S02 medical AU and process, allowing the S01 AU to close.

  1. Review the coding on the bottom of the UNER screen to determine if the correct disregards are being applied. If the individual is eligible for the disregard, the entire amount of the DAC income is excluded in the CN income calculation. You can determine if the disregard was applied by reviewing the MAFI screen. If DAC income was disregarded, ACES will indicate this by displaying a "D" in the Disregard Applied field. If both the DAC and the Pickle disregards are applied, ACES indicates this by displaying an "E" in that field.

    For ACES to apply the DAC disregard, the following criteria must be met:

    • Individual has unearned income type "SC" in an amount greater than zero.
    • Individual is 18 years of age or older.
    • Individual meets the aged, blind, or disabled criteria.
    • Individual has an SSI closure date that is equal to or later than 7/1/88.
    • The Application/Benefit status field on the UNER screen is coded with an "H".
    • Net countable income after applying the disregard is below the SSI categorically needy income level.
    • Individual meets all other SSI-related CN medical requirements.
  2. To verify receipt of DAC benefits, use either:
    • An SDX record that shows this Medicaid Eligibility code and message: D - DISABLED ADULT CHILD: CONT SSI MED; or
    • An SSA inquiry, BDX record or award letter that shows the individual has a BIC code (the 2-letter/number suffix to the Social Security claim number) beginning with a C.

    Note: An individual receiving DAC benefits, who marries anyone other than another DAC or Title II beneficiary will lose their DAC designation and benefits.

  3. To determine manually if the individual receiving DAC benefits would be CN income eligible but for receiving DAC benefits or a COLA to those benefits:
    • Determine the individual's total income;
    • Subtract any appropriate deductions, such as exclusions under federal statute;
    • Determine and subtract the COLA increase on SSA income other than DAC;
    • Subtract the total DAC amount;
    • Compare the results to the CNIL.
      • If income is below the CNIL, authorize CN Apple Health. Continue the DAC disregard as long as the individual is CN eligible with the disregard and continues to meet all other program requirements.
      • If income is above the CNIL, the individual is NOT eligible for the DAC disregard. Determine eligibility for other Apple Health coverage.
  4. Review eligibility for the DAC income disregard:
    • At application and renewal for Apple Health coverage;
    • When you receive an SDX record that shows the Medicaid Eligibility code and message: D - DISABLED ADULT CHILD: CONT SSI MED;
    • At each MN certification

Widow/Widower's Benefit (DWB)

Group 1

If the individual is eligible for the disregard, the entire amount of the widow(er) income is excluded in the CN income calculation. You can determine whether the disregard was applied by reviewing the MAFI screen. If widow(er)s income was disregarded, ACES will indicate this by displaying a "W" in the Disregard Applied field. If both the widow(er) Group 1 and the Pickle disregard are applied, ACES displays an "X" on the MAFI screen.

Note: SSA no longer sends information about these individuals on the SDX records, so automatic updates do not happen for this group. SSA sends a letter to these individuals, which tells them to contact the CSO when their SSI terminates. These individuals receive SSA benefits under the SSN of the deceased spouse, not their own.

For ACES to apply the Widow(er) Group 1 disregard, the following criteria must be met:

  • Individual has unearned income type "SW" in an amount greater than zero.
  • Individual's date of birth is after December 31, 1923 and before January 1, 1934.
  • Individual meets the aged, blind or disabled criteria.
  • Individual has an SSI closure date on the UNER screen that is in January 1984.
  • The Application/Benefit status field on the UNER screen is coded with an "I".
  • Net countable income after applying the disregard is below the categorically needy income level.
  • The individual meets all other SSI-related CN medical requirements.
  1. Use the SSA letter to verify SSA terminated the individual's SSI because the individual began to receive Title II Social Security.
  2. Use an SSA inquiry, SDX screen or the BENDEX screen to verify the benefits as DWB and the amount. Widow/er benefits or Surviving Divorced Spouse benefits are listed as source code SB or SW on the UNER help screen in ACES.
  3. Find the source code SB and SW on the help screen and compare the BIC code for the individual with all possible BICs for these source codes. If the individual's BIC is the same as one of the SB or SW source codes, the individual is eligible for this disregard.
  4. To determine if the individual receiving DWB benefits would be CN income eligible except for the DWB benefits or COLA to these benefits, determine the individual's total countable income;
  • Subtract other income exemptions and disregards from the total income;
  • Subtract the COLA increase on SSA income other than DWB the individual has received from the date SSI ended (using the Pickle multiplier in ACES);
  • Subtract the total DWB amount;
    • If the remaining income is below the CNIL, authorize CN;
    • Continue the DWB disregard as long as the individual is CN eligible with the disregard, and continues to meet the requirements described in this section;
    • If the remaining income is above the CNIL, the individual is not eligible for the DWB disregard. Determine eligibility for other Apple Health coverage. Do not allow the DWB disregard for programs other than CN.

Group 2

When ACES receives an SDX record where the medical eligibility code is "W" and there is Title II income type "SW" or "SB", ACES automatically updates the SSI closure information on the UNER screen and enters the "J" code.

The widow(er) Group 2 disregard applies to individuals who lose SSI eligibility because of their having to apply for Title II widow(er) benefits or a COLA to those benefits. The disregard protects CN eligibility for these individuals until they are entitled to receive Medicare. Individuals who meet these criteria automatically meet the criteria for the Pickle disregard, if they have income from another Title II source.

  • Widow/er benefits and Surviving Divorced Spouse benefits recipients have an SS claim number other than their own SSN and have BIC codes as listed on the ACES help screen in UNER (source codes SW, SB). These individuals' most common BIC codes (the letters at the end of the SS claim number) begin with D, E or W.
  • Ineligibility for SSI due to reasons such as excess resources, other income, etc., does not qualify the individual for this income protection. Widow/er benefit disregards are only for those meeting the requirements in WAC.
  • SSA sends a letter to the individual that tells them to contact the CSO when their SSI terminates.

If the individual returns the eligibility review sent at the time of the SSI closure, screen in an S02 and process and allow the S01 AU to close.

If the individual is eligible for the disregard, the entire amount of the widow(er) income is excluded in the CN income calculation. You will be able to determine if the disregard was applied by reviewing the MAFI screen. If widow(er) income was disregarded, ACES will indicate this by displaying an "S" in the Disregard Applied field. If both widow(er) and the Pickle disregard are applied, ACES displays an "R" on the MAFI screen.

For ACES to apply the Widow(er) Group 2 disregard, the following criteria must be met:

  • Individual has unearned income type "SW" or "SB" in an amount greater than zero.
  • Individual is currently at least 50, but not yet 65.
  • Individual meets the blind or disabled criteria.
  • Individual has an SSI closure date on the UNER screen that is January 1, 1991 or later.
  • Individual is not eligible for Medicare Part A.
  • The Application/Benefit status field on the UNER screen is coded with a "J".
  • Net countable income after applying the disregard is below the categorically needy income level.
  • The individual meets all other SSI-related CN Apple Health requirements.

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Citizen and immigration status definitions

Revised date
Purpose statement

To explain basic definitions of various citizen and immigrant statuses relevant for determining eligibility for Apple Health programs.

WAC 182-503-0535 Washington apple health -- Citizenship and immigration status.

WAC 182-503-0535 Washington apple health -- Citizenship and immigration status.

Effective February 7, 2025

  1. Definitions.
    1. Nonqualified alien means someone who is lawfully present in the United States (U.S.) but who is not a qualified alien, a U.S. citizen, a U.S. national, or a qualifying American Indian born abroad.
    2. Qualified alien means someone who is lawfully present in the United States and who is one or more of the following:
      1. A person lawfully admitted for permanent residence (LPR).
      2. An abused spouse or child, a parent of an abused child, or a child of an abused spouse who no longer resides with the person who committed the abuse, and who has one of the following:
        1. A pending or approved I-130 petition or application to immigrate as an immediate relative of a U.S. citizen or as the spouse of an unmarried LPR younger than 21 years of age.
        2. Proof of a pending application for suspension of deportation or cancellation of removal under the Violence Against Women Act (VAWA).
        3. A notice of prima facie approval of a pending self-petition under VAWA. An abused spouse's petition covers his or her child if the child is younger than 21 years of age. In that case, the child retains qualified alien status even after he or she turns 21 years of age.
      3. A person who has been granted parole into the U.S. for one year or more, under the Immigration and Nationality Act (INA) Section 212 (d)(5), including public interest parolees.
      4. A member of a Hmong or Highland Laotian tribe that rendered military assistance to the U.S. between August 5, 1964, and May 7, 1975, including the spouse, unremarried widow or widower, and unmarried dependent child of the tribal member.
      5. A person who was admitted into the U.S. as a conditional entrant under INA Section 203 (a)(7) before April 1, 1980.
      6. A person admitted to the U.S. as a refugee under INA Section 207.
      7. A person who has been granted asylum under INA Section 208.
      8. A person granted withholding of deportation or removal under INA Section 243(h) or 241 (b)(3).
      9. A Cuban or Haitian national who was paroled into the U.S. or given other special status.
      10. An Amerasian child of a U.S. citizen under 8 C.F.R. Section 204.4(a).
      11. A person from Iraq or Afghanistan who has been granted one of the following:
        1. Special immigrant status under INA Section 101 (a) (27);
        2. Special immigrant conditional permanent resident; or
        3. Parole under Section 602 (b) (1) of the Afghan Allies Protection Act of 2009 or Section 1059(a) of the National Defense Authorization Act of 2006.
      12. An Afghan granted humanitarian parole between July 31, 2021, and September 30, 2023, their spouse or child, or a parent or guardian of an unaccompanied minor who is granted parole after September 30, 2022, under Section 2502 of the Extending Government Funding and Delivering Emergency Assistance Act of 2021.
      13. A citizen or national of Ukraine (or a person who last habitually resided in Ukraine) who, under section 401 of the Additional Ukrainian Supplemental Appropriations Act, 2022 (AUSAA) and the Ukraine Security Supplemental Appropriations Act, 2024 (USSAA), is evaluated as a qualified alien until the end of their parole term when:
        1. Granted parole into the United States between February 24, 2022, and September 30, 2024; or
        2. Granted parole into the United States after September 30, 2024, and is:
          1. The spouse or child of a person described in (b)(xiii)(A) of this subsection; or
          2. The parent or guardian of a person described in (b)(xiii)(A) of this subsection who is an unaccompanied minor.
      14. A person who has been certified or approved as a victim of trafficking by the federal office of refugee resettlement, or who is:
        1. The spouse or child of a trafficking victim of any age; or
        2. The parent or minor sibling of a trafficking victim who is younger than 21 years of age. 
      15. A person from the Federated States of Micronesia, the Republic of Palau, or the Republic of the Marshall Islands living in the United States in accordance with the Compacts of Free Association. 
    3. U.S. citizen means someone who is a United States citizen under federal law.
    4. U.S. national means someone who is a United States national under federal law.
    5. Undocumented person means someone who is not lawfully present in the U.S.
    6. Qualifying American Indian born abroad means someone who:
      1. Was born in Canada and has at least 50 percent American Indian blood, regardless of tribal membership; or
      2. Was born outside of the United States and is a member of a federally recognized tribe or an Alaska Native enrolled by the Secretary of the Interior under the Alaska Native Claims Settlement Act.
  2. Eligibility.
    1. A U.S. citizen, U.S. national or qualifying American Indian born abroad may be eligible for:
      1. Apple health for adults;
      2. Apple health for kids;
      3. Apple health for pregnant women; or
      4. Classic medicaid.
    2. A qualified alien who meets or is exempt from the five-year bar may be eligible for:
      1. Apple health for adults;
      2. Apple health for kids;
      3. Apple health for pregnant women; or
      4. Classic medicaid.
    3. A qualified alien who neither meets nor is exempt from the five-year bar may be eligible for:
      1. Alien medical programs;
      2. Apple health for kids;
      3. Apple health for pregnant women; or
      4. Medical care services.
    4. A nonqualified alien may be eligible for:
      1. Alien medical programs;
      2. Apple health for kids;
      3. Apple health for pregnant women; or
      4. Medical care services.
    5. An undocumented person may be eligible for:
      1. Alien medical programs;
      2. State-only funded apple health for kids; 
      3. State-only funded apple health for pregnant women; or
      4. State-only funded apple health expansion.
  3. The five-year bar.
    1. A qualified alien meets the five-year bar if he or she:
      1. Continuously resided in the U.S. for five years or more from the date he or she became a qualified alien; or
      2. Entered the U.S. before August 22, 1996, and:
        1. Became a qualified alien before August 22, 1996; or
        2. Became a qualified alien on or after August 22, 1996, and has continuously resided in the U.S. between the date of entry into the U.S. and the date he or she became a qualified alien.
    2. A qualified alien is exempt from the five-year bar if he or she is:
      1. A qualified alien as defined in subsections (1)(b)(vi) through (xv) of this section;
      2. An LPR, parolee, or abused person, who is also an armed services member or veteran, or a family member of an armed services member or veteran, as described below:
        1. An active-duty member of the U.S. military, other than active-duty for training;
        2. An honorably discharged U.S. veteran;
        3. A veteran of the military forces of the Philippines who served before July 1, 1946, as described in Title 38 U.S.C. Section 107; or
        4. The spouse, unremarried widow or widower, or unmarried dependent child of an honorably discharged U.S. veteran or active-duty member of the U.S. military.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

Clarifying information

A person's citizenship or immigration status must be determined as part of the eligibility determination for health care coverage under Apple Health (which includes both Classic Medicaid program and MAGI-based Medicaid programs). Everyone falls into one of the following four citizenship/immigration status groups for purposes of determining Apple Health eligibility:

  • Lawfully Present Qualified Immigrant;
  • Lawfully Present Nonqualified Immigrant;
  • Not Lawfully Present (Undocumented) Immigrant; or
  • Citizen or U.S. National.

Lawfully present

A lawfully present immigrant refers to any noncitizen or immigrant presently permitted to remain in the United States. Lawfully present means that USCIS has actively granted these immigrants permission to remain in the U.S. and has issued documentation of their lawfully present status that is currently valid. A lawfully present immigrant must still meet state residency requirements in WAC 182-503-0520 in order to qualify for health care coverage.

For a list of typical citizenship/immigration documents see the:

Qualified immigrant/nonqualified immigrant terms

Qualified immigrant and nonqualified immigrant are terms used in federal immigration law and do not by themselves indicate whether an immigrant is eligible for Apple Health coverage benefits. Both qualified immigrants and nonqualified immigrants may be eligible for health care coverage.

Note: If there is uncertainty about whether a particular individual has met the conditions for citizenship or immigration status, legal assistance is available at the Northwest Immigrant Rights Project in Western Washington at 206-587-4009 or in Eastern Washington at 509-854-2100.

Qualified immigrants

A qualified immigrant who is exempt from, or who has met, the 5-year bar is potentially eligible for federally-funded Apple Health (Medicaid) programs.
A qualified immigrant who is not exempt or has not yet met the 5-year bar is potentially eligible for state-funded Apple Health programs if they are a child, pregnant, or they have a qualifying medical emergency under the Alien Emergency Medical (AEM) program as described under WAC 182-507-0110.

Immigrants included in the qualified immigrant category can be found at Citizenship and Immigration Status Guide.

5-year bar

Federal law requires many qualified immigrants to wait five years before becoming eligible for Apple Health (Medicaid). This 5-year waiting period is commonly referred to as the 5-year bar. Unless exempt, the 5-year waiting period usually begins when the person receives their qualifying immigration status, not when they entered the U.S.

Note: The five-year bar does not apply to individuals that have obtained a qualified immigration status within the last 5 years, if they entered the U.S. prior to August 8, 1996, and have continuously lived in the U.S. since August 22, 1996.

Note: The category code on the I-551 Permanent Resident Card (green card) indicates how an LPR entered the U.S. If an individual entered the U.S. under a status that is exempt from the 5-year bar.

For more information on the 5-year bar see the Citizenship and Immigration Status Guide.

The following immigrant categories are exempt from the 5-year bar:

Refugee

An immigrant outside their own country of origin who is unable or unwilling to return to their country of origin because of persecution or on account of race, religion, nationality, membership in a particular social group, or political opinion as defined in sec. 101 (a)(42) of the INA, who are admitted under section 207 of the INA.

Asylee

A non-citizen in the U.S. or at a port of entry found to be unable or unwilling to return to their country or nationality, or to seek protection of that country because of persecution or well-founded fear of persecution.

Withholding of removal

Non-citizens in removal proceedings are granted withholding of removal when they can establish that it is more likely than not that their life or freedom would be threatened on account of race, religion, nationality, membership in a particular social group, or political opinion if returned to their native country. Only a judge can grant withholding of removal.

Amerasian

Amerasians who were born to U.S. citizen armed services member in Korea, Vietnam, Laos, Kambuchea, or Thailand, after December 31, 1950, but before October 22, 1982, who were admitted to the U.S. as immigrants pursuant to Section 584 of the Foreign Operation, Export Financing, and Related Programs Appropriations Act.

Hmong or Highland Laotian tribe members

Hmong (or Highland Laotian) tribe members born before May 8, 1975, whose tribe assisted the U.S. military during Vietnam era (August 5, 1964 to May 7, 1975) are “qualified immigrants” and potentially eligible for Apple Health (Medicaid) without having to meet the 5-year bar. The tribe member's spouse and unmarried dependent children under age 19 automatically qualify.

If the applicant does not have USCIS documentation of this status, he or she may submit the following statement under penalty of perjury: I was a Hmong (or Highland Laotian) tribe member when the tribe assisted the U.S. military during Vietnam era (August 5,1964 to May 7, 1975).

Cuban/Haitian entrants

Individuals approved for the Haitian Family Reunification Parole (HFRP) program will enter the U.S. as Cuban/Haitian entrants under 501(e) of the Refugee Education Assistance Act of 1980 and are "qualified immigrants" who are exempt from the 5-year bar.

Cuban/Haitian entrants include:

  • Cuban and Haitian nationals who have current or expired parole;
  • Cuban and Haitian nationals who are in pending removal proceedings;
  • Cuban and Haitian nationals who have a pending application for asylum; or
  • Have an I-94 stamped Cuban/Haitian Entrant pending.

Cuban/Haitian entrants who apply for asylum are exempt from the 5-year bar while their application is pending. Asylum applicants of other nationalities are non-qualified immigrants.

Cuban/Haitian entrants who are in removal proceedings remain exempt from the 5-year bar until a final, non-appealable, and legally enforceable order of removal, deportation, or exclusion has been issued. If a Cuban/Haitian Entrant is in removal proceedings, or is suspected of being in removal proceedings, or indicates a previous order is under appeal, call the Executive Office of Immigration Review (EOIR) at 1-800-898-7180 to confirm their current status.

Victims of human trafficking

Per the Victims of Trafficking and Violence Protection Act of 2000, the U.S. Department of Health and Human Services (HHS) is the sole federal agency authorized to certify foreign adult victims of human trafficking. Victims of trafficking will be issued a certification letter from the Office on Trafficking in Persons (OTIP). If you have questions about the validity of an OTIP certification letter, call 1-866-401-5510. Derivative T-statuses (family members of the primary victim) do not receive a certification letter.

Iraqi or Afghan special immigrants

Immigrants from Iraq or Afghanistan who were granted Special Immigrant Status under section 101(a)(27) of the INA; or Special Immigrant Conditional Permanent Residence; or Paroled under section 602(b)(1) of the Afghan Allies Protection Act or section 1059(a) of the National Defense Authorization Act of 2006 are qualified immigrants and are eligible for federally-funded Washington Apple Health. Their eligibility period starts from their date of entry into the United States or, if occurred after the U.S. entry, the date Special Immigrant Status was granted. .

Afghans granted humanitarian parole

Under the Consolidated Appropriations Act of 2023, Afghans granted humanitarian parole between July 31, 2021, and September 30, 2023 and their spouses and children, and the parents and guardians of unaccompanied minors who are granted parole after September 30, 2022, are evaluated as qualified immigrants until March 31, 2023, or the end or their parole term, whichever is later.

Ukrainians granted humanitarian parole

Ukrainians (and non-Ukrainians who last habitually resided in Ukraine) granted humanitarian parole between February 24, 2022, and September 30, 2023 and their spouses and children, and the parents and guardians of unaccompanied minors who are granted parole after September 30, 2022, under Section 401 of the Additional Ukrainian Supplemental Appropriations Act of 2022 are evaluated as qualified immigrants.

Citizens of the Republic of the Marshall Islands, the Republic of Palau and the Federated States of Micronesia

Citizens of Marshall Islands, Micronesia or Palau may have a birth certificate, current or expired I94 arrival or departure record, current or expired passport or other document verifying they are citizens of one of these countries. These individuals have special rights under Compacts of Free Association and are lawfully allowed to enter, reside and work in the U.S., but are not U.S. nationals. They are considered lawfully present qualified immigrants exempt from the 5-year bar unless they have some other immigration status.

Armed Service Members or Veterans

Lawful Permanent Residents, parolees, or battered immigrants who are also an armed services member or veteran, or a family member of a veteran as described below:

  • On active duty in the US military, other than active duty for training;
  • An honorably discharged US veteran;
  • A Veteran of the military of the Philippines who served prior to July 1, 1946;
  • The spouse, an un-remarried widow or widower; or Unmarried dependent child of a veteran or active-duty service member.

Nonqualified immigrants

Nonqualified immigrants have temporary permission to stay in the U.S. and potentially qualify for Apple Health for children, pregnancy, or Alien Emergency Medical (AEM) as described under WAC 182-507-0110.

Some lawfully present nonqualified aliens have temporary status or pending applications and consequently their status may expire when their document is expired or when a final denial of their application is issued.

Immigrants included in the non-qualified category can be found at the Citizenship and Immigration Status Guide.

Deferred Action Childhood Arrival (DACA or "Dream Act"), is technically considered a non-qualified status; however, they are not eligible for federally-funded Washington Apple Health. DACA persons may be eligible for state-funded health care coverage, including Apple Health for children, pregnancy, or Alien Emergency Medical (AEM).

Undocumented individuals

Undocumented individuals are individuals who are not lawfully present. This includes both individuals who entered the U.S. without document inspection and individuals whose lawful presence status has expired.

An individual whose lawful presence has expired may be in the process of pursuing an extension or change of status. Without evidence of actively pursuing an extension or change of status, an individual whose lawful presence status has expired will be considered an undocumented individual.

Citizens/U.S. nationals/qualifying American Indians born abroad

U.S. citizens

U.S. citizens include the following:

  • Individuals born in the U.S; or its territories - Guam, Puerto Rico, the U.S. Virgin Islands; and residents of the Northern Mariana Islands who chose to become U.S. citizens.
  • Individuals who have become naturalized U.S. citizens.
  • *Certain individuals born abroad to at least one U.S. citizen.

U.S. nationals

Individuals born in America Samoa or Swain Island and residents of the Mariana Islands who did not choose to become U.S. citizens.

American Indians/Alaska Natives

The term American Indian refers to members of federally recognized (and in some cases, state-recognized) tribes in the U.S. The term Alaska Native refers to members of Alaska Native Villages and of Alaska Native Corporations under the Alaska Native Corporation Settlement Act.

American Indians and Alaska Natives born outside the United States are eligible for federal benefits to the same extent as American Indians and Alaska Natives born in the U.S. if they are:

Note: Noncitizen American Indians have the same eligibility for health care coverage as U.S. Citizens, but citizen documentation requirements do not apply. Instead they will need to provide tribal verification.

Example: A member of a federally recognized tribe (e.g., Pueblo) who is a Mexican citizen gives birth to a child outside of the U.S. The child qualifies as a member of the tribe but is not a citizen. That child is potentially eligible for Washington Apple Health as long as the child can establish that he or she is a member of the federal tribe.

Qualifying American Indians born abroad

  • Individuals born in Canada who have at least fifty percent American blood, regardless of tribal membership; or
  • Individuals born outside of the United States who are:
    • Members of a federally recognized tribe; or
    • Alaska Natives enrolled by the Secretary of the Interior under the Alaska Native Claims Settlement Act.

Qualifying American Indians born abroad have the same eligibility requirements as U.S. citizens; however, citizenship and identity requirements do not apply. They will need to provide the following verification as appropriate:

  • Canadian birth certificate;
  • Tribal affiliation; and/or
  • Blood quantum

The Child Citizenship Act of 2000

For children born outside the U.S. to acquire citizenship under the Child Citizenship Act of 2000, they must meet all the conditions in WAC 182-503-0530 on or after February 27, 2001. The Act applies to children related to the citizen parent by birth or adoption only - stepchildren are not included unless also adopted. Citizenship for these children can depend on:

  • Which parent is a U.S. citizen;
  • How long the citizen parent resided in the U.S.; and
  • Whether the parents were married at the time.

Once a child becomes a citizen under the Act, subsequent changes in the parents' marital status, such as separation or divorce, have no bearing on the child's citizenship. Nor does it matter whether the parent in question became a U.S. citizen after entering the U.S.

If a child is 18 years or older when the parent becomes a citizen, child citizenship laws do not apply, and he/she must independently apply for naturalization.

For individuals who automatically become citizens under terms of the Child Citizenship Act of 2000 or previous legislation, USCIS issues no documentation unless requested. Individuals themselves may not be aware that they or their children are already citizens.

If unable to verify, refer individual to an immigration attorney at:

  • Northwest Justice Project at 206-464-1519 or 888-201-1012
  • Northwest Immigrant Rights Project - Seattle - 206-587-4009 or 800-445-5771
  • Northwest Immigrant Rights Project - Tacoma - 253-383-0519 or 877-814-6444
  • Northwest Immigrant Rights Project - Granger - 509-854-2100 or 888-756-3641; or
  • Northwest Immigrant Rights Project - Wenatchee - 509-570-0054 or 866-271-2084

Reasonable opportunity period

Individuals otherwise eligible for Apple Health are conditionally approved and granted a reasonable opportunity period (ROP) of up to 90 days to obtain and provide verification of their citizenship or immigration status. The ROP may extend beyond 90 days if the individual requests additional time, and they are making a good faith effort to obtain the necessary documentation.

Examples of good faith effort includes:

  • Up-to-date documents showing immigration status is pending with DHS/United States Citizenship and Immigration Services (USCIS).
  • Other verification that reasonably verifies that a good faith effort is being made.

When the individual's citizenship or immigration status has not been verified by the end of the ROP, coverage may end.

Immigration documentation

Expired documents versus expired immigration status.

Many immigration documents have expiration dates; however, an expired immigration document does not necessarily mean the immigration status has expired. For instance, qualified immigration status does not expire even if the immigration documents expire, with the following exceptions:

  • Lawful Permanent Residents with Conditions (2-year Conditional Residents): Conditional residents receive a 2-year LPR card, often based on a recent marriage to a U.S. citizen. At the end of the 2 years, they must either file a joint petition to remove the condition or a request for a waiver of the joint filing requirement (for instance, on grounds of divorce and /or domestic violence). Clients with this expired status must provide proof of a pending petition to remove the condition or of an application to waive the joint filing requirement.
  • Parolees: Their status expires after the expiration date. Parolees usually have an I-94 arrival/departure record stamped with an entry and expiration date. Some may have their expiration date stamped "waived" or "indefinite".

On the other hand, nonqualified immigration status (including those in the U.S. on nonimmigrant visas) typically expires when their immigration documents expire.

Additional information regarding specific document types and status

Form I-797

Notice of Action may or may not have an expiration date. It is used to notify the individual that a fee was paid, an application was accepted, the case is pending, a step in the process is completed, or status is approved. Individuals with I-797s are undocumented unless it verifies that status has been approved.

Example: An example that a step in the process has been completed but status has not been approved is the Notice of Approval for Immigrant Petition for Relative. This is the initial step in the family-related immigrant application process. It solely establishes relationship. It does not establish status. If this is the only document provided, the individual is considered undocumented for purposes of benefits eligibility.

Example: An example that status is approved is the Approval Notice of an I-360 Self-Petition under the Violence Against Women Act (VAWA). In most cases a VAWA self-petitioner will first receive a Prima Facie notice, indicating that the petitioner has submitted evidence sufficient to establish a case. Both notices verify that the individual is a qualified immigrant and their status does not expire.

Order from Immigration Judge

An order is issued because the immigrant is or has been in removal proceedings. The Judge provides a decision notifying the individual whether the individual can remain in the country. The order does not have an expiration date.

Example: An example of a status granted by an Order from Immigration Judge are Granted Withholding of Deportation which is a qualified immigrant category and Order of Supervision which is a nonqualified immigrant category.

Form I-589

Application for Asylum (nonqualified immigrant) does not have an expiration date; however, USCIS is required to provide a decision within 180 days. Despite this requirement, some asylum applicants may not receive a decision within the 180 day deadline. If the document is more than 180 days old, staff will need to check USCIS website (see below) to determine if it is still pending a decision. If still pending a decision, the asylum applicant retains their nonqualified status.

Note: If an applicant for Asylum is a national of Cuba or Haiti, they are Cuban/Haitian Entrants eligible for benefits to the same extent as refugees while their application is pending.

Form I-912

In cases with expired immigration documents, individuals should apply with USCIS for renewal and submit the Form I-912 (Request for Fee Waiver) at the same time. Individuals seeking or receiving public assistance, including Apple Health, are eligible for Fee Waivers with their application. Fee Waiver Guidance can be found at USCIS - Fee Waiver Guidance.

  • If USCIS denies the fee waiver request, they will notify the individual with a notice of rejection and an explanation why the fee waiver request was denied. In these cases, copy the notice of rejection into the individual’s file and offer help paying for the documents. If USCIS approves the fee waiver request, the individual will also be notified.
  • Staff can check the current case status of pending USCIS documents by entering the receipt number on the document at the USCIS website.

Note: If you are uncertain about someone’s eligibility for benefits after reviewing this clarifying page, please contact your area representative.

For a list of typical citizenship/immigration documents see the:

  • National Immigration Law Center (NILC) Guide in Appendix II; or
  • Documents Typically Used by Lawfully Present Immigrants.

Worker responsibilities

Note: If a person's naturalized citizenship or immigration status does not federally verify during the initial application process, their naturalized citizenship or immigration status must be verified using the Systematic Alien Verification for Entitlements (SAVE) system, with the following exceptions:

  • Client attest to not having an immigration status
  • American Indians/Alaska natives (See American Indians/Alaska Natives entry below for required documentation)
  • Qualified American Indians Born Abroad (See Qualified American Indians Born Abroad entry below for required documentation)

Grant individuals a reasonable opportunity period when they meet all other eligibility criteria and have an unverified citizenship or immigration status. During this time, they receive Apple Health benefits while proof of their status is obtained and verified.

Classic Medicaid (in Washington Connection) Modified Adjusted Gross Income (MAGI) - Based Medicaid (in Healthplanfinder)
Applicants who have been granted DACA status should be coded CL in the INS Stat field on the ALAS screen Applicants who have been granted DACA status should be described as Not Lawfully Present in Washington Healthplanfinder.

For all Apple Health applications, make sure you match names, dates of birth, and immigration document expiration dates with what is on the application.

ACES procedures

Recording citizenship / alien status

See Client Demographic 2 (DEM2) Screen

Completion of the (ALAS) Screen for Noncitizens

See Aliens, Students, and Medically Indigent (ALAS) Screen

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Third Party Liability

Revised date
Purpose statement

This category applies to all individuals receiving medical assistance benefits. Federal law requires that Apple Health be the payer of last resort for the cost of medical care.

WAC 182-503-0540 Assignment of rights and cooperation.

WAC 182-503-0540 Assignment of rights and cooperation.

Effective January 27, 2019.

  1. When you become eligible for any of the agency's health care programs, you assign certain rights to the state of Washington. You assign all rights to any type of coverage or payment for health care that comes from:
    1. A court order;
    2. An administrative agency order; or
    3. Any third-party benefits or payment obligations for medical care which are the result of subrogation or contract (see WAC 182-501-0100).
  2. When you sign the application you assign the rights described in subsection (1) of this section to the state for:
    1. Yourself; and
    2. Any eligible person for whom you can legally make such assignment.
  3. You must cooperate with us in identifying, using or collecting third-party benefits. If you do not cooperate, your health care coverage may end unless you can show good reason not to cooperate with us. Examples of good reason include, but are not limited to:
    1. Your reasonable belief that cooperating with us would result in serious physical or emotional harm to you, a child in your care, or a child related to you; and
    2. Your being incapacitated without the ability to cooperate with us.
  4. Your WAH coverage will not end due solely to the noncooperation of any third party.
  5. You will have to pay for your health care services if you:
    1. Received and kept the third-party payment for those services; or
    2. Refused to give to the provider of care your legal signature on insurance forms.
  6. The state is limited to the recovery of its own costs for health care costs paid on behalf of a recipient of health care coverage. The legal term which describes the method by which the state acquires the rights of a person for whom the state has paid costs is called subrogation.

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

When another party (a third party) has been identified as responsible for payment of a health care expense, Apple Health does not pay the health care claim until after the third party has paid. When Apple Health has paid a claim for a health care expense prior to third party payment, the Health Care Authority or Managed Care Organization is entitled to collect third party benefits.

The limit of the recoupment from the settlement, judgment or awards of monies is the amount of the health care expense paid by the Health Care Authority or Managed Care Organization. The method of determining what portion of a settlement represents past medical expenses is left to the state, the parties, and/or the court. Refer all such questions or challenges to Health Care Authority at 1-800-562-3022.

Assignment of rights is effective for all periods of eligibility certification, including any retroactive period of eligibility.

Worker responsibilities

  1. Other Insurance: If an individual has other insurance, or indicates there is a pending lawsuit or casualty settlement, send TPL information to Health Care Authority's COB unit using tickler type: TPLI to @TPL pool, Site 102 in DMS. The tickler must include the following information:
    1. How the information was reported
    2. Where the information is located with the date
    3. What kind of TPL information was reported

      Example: Report via document Subject: MAP in ECR 9/15/09Details: Individual reported new insurance

      Example: Report via Phone or Interview Subject: See ACES narrative 9/20/09Details: Individual reports end of insurance

      The Medical Coverage Information form (HCA 14-194) can also be used to report insurance and casualty information, but does NOT need to be completed to report the presence of Medicare.

  2. Completion of HCA 14-194
    1. Ensure that the individual's name and ACES client ID number is prefilled on the form before sending it to the individual for completion.
    2. Write "For Information Only" on top of the HCA 14-194 form and send to DMS when the only medical resource is:
      1. Accident case with potential liability (auto, medical malpractice, homeowners);
      2. Labor and Industries coverage of an injury;
      3. Crime Victim and Victim Assistance involvement; or
      4. Products liability potential coverage.
    3. No referral to COB/TPL is necessary when the only medical resource is:
      1. Coordinated Children Services;
      2. Indian Health
      3. Veterans coverage (other than active duty military coverage or Champus);
      4. Life Insurance
      5. Automobile Insurance (unless related to a current injury);
      6. Homeowner's or Rental Insurance (unless related to a current injury);
      7. Medicare (use TPL procedures in ACES for Medicare only); or
      8. Enrollment in a HMO/HIO under an Agency Medicaid contract.

        Note: Coordination of Benefits (COB) automatically receives a copy of the HCA 14-194 form through the DMS System in a "to do" box when the individual completes and returns this form.

  3. Payment of private health insurance: The Health Care Authority offers a Premium payment program for people who have been determined eligible for Apple Health, and have private health insurance (including individual policies, COBRA policies, and employer-sponsored plans). The Premium Payment Program handles applications for reimbursement of cost effective private health insurance premiums except for Medicare + Choice (managed care). All applicants for the premium payment program must first have been approved for free Apple Health coverage.
    1. How to apply
      1. Download an application form (HCA 13-705) for the HCA Premium Payment Program.
      2. Mail the completed form to:
        Premium Payment Program
        P O Box 45518
        Olympia WA 98599-5518

        or send by fax to: 877-893-3810

        Questions? Contact a Premium Payment Program specialist at 800-562-3022, ext. 15473

Note: An applicant diagnosed with HIV or AIDS who is not eligible for Apple Health may be eligible for assistance through the Department of Health (DOH). The DOH HIV Client Services Program funds a contract to assist persons who have HIV and/or AIDS with ongoing medical insurance premiums, or to acquire insurance. For more information about this program contact the Early Intervention Program (EIP) at DOH at 1-877-376-9316 or visit the EHIP website.

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