Allowable practitioners

Revised date

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

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

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

  • Acupuncturist
  • Dietician

Practitioners not allowable

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

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Managed care and long-term care

Revised date
Purpose statement

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

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

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

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

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

Consult the Overview - Long-term and Supports chart.

What are rehabilitative services or skilled nursing services?

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

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

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

What are long-term care services in a NF?

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

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

Who is enrolled in a Washington Apple Health (AH) managed care organization (MCO)?

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

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

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

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

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

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

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

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

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

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

How does a client change a Washington Apple Health managed care plan?

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

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

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

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

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

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

When are long-term care clients disenrolled from Washington Apple Health (AH) managed care organization (MCO) plan?

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

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

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

Public benefit specialist responsibilities

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

Short stays

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

See Short stay information for NF admissions not under AH MCO

30 days or more admissions

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

Example: Short Stay #1

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

Example: Short Stay #2

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

Example: Short Stay #3.

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

Example: 30 day or more admission #1

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

Example: 30 day or more admission #2

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

Nursing Facility Responsibilities

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

Provider Billing Guides:

Other managed care information: MCS admissions into a nursing facility

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

Other LTC insurance, Third party resources information

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

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Equitable estoppel

Revised date

WAC 182-526-0495 Equitable estoppel.

WAC 182-526-0495 Equitable estoppel.

Effective March 16, 2017

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

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

Clarifying information

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

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

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

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

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

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

Worker responsibilities

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

Guidelines for Establishment of Equitable Estoppel:

Element #1:

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

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

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

Element #2:

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

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

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

Element #3:

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

Factors which may be used as evidence of injury:

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

Element #4:

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

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

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

Element #5:

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

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Confidentiality information

Revised date
Purpose statement

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

Clarifying information

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

Worker responsibilities

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

Clarifying information

Disclosing information to parents with visitation rights or legal custody

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

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

Revised date

LTSS programs (HCS and DDA HCB Waivers)

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

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

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

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

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

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CMS guidance on Part D prescription drug expenses and spenddown

Revised date
Purpose statement

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

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

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

Note

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

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

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

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

Clarifying information

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

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

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

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

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Spousal impoverishment protections for the MAC and TSOA programs

Revised date
Purpose statement

This section describes the how spousal impoverishment protections apply to a married person who applies for MAC or TSOA.

WAC 182-513-1660 Medicaid Alternative Care (MAC) and Tailored Supports for Older Adults (TSOA) - Spousal Impoverishment

WAC 182-513-1660 Medicaid alternative care (MAC) and tailored supports for older adults (TSOA)—Spousal impoverishment.

Effective February 25, 2023

  1. The medicaid agency or the agency's designee determines financial eligibility for medicaid alternative care (MAC) or tailored supports for older adults (TSOA) using spousal impoverishment protections under this section, when an applicant or recipient:
    1. Is married to, or marries a person not in a medical institution; and
    2. Is ineligible for a noninstitutional categorically needy (CN) SSI-related program or the TSOA program due to:
      1. Spousal deeming rules under WAC 182-512-0920 for MAC;
      2. Exceeding the resource limit in WAC 182-512-0010 for MAC, or the limit under WAC 182-513-1640 for TSOA; or
      3. Both (b)(i) and (ii) of this subsection.
  2. When a resource test applies, the agency or the agency's designee determines countable resources using the SSI-related resource rules under chapter 182-512 WAC, except pension funds owned by the spousal impoverishment protections community (SIPC) spouse are not excluded as described under WAC 182-512-0550:
    1. Resource standards:
      1. For MAC, the resource standard is $2,000; or
      2. For TSOA, the resource standard is $53,100.
    2. Before determining countable resources used to establish eligibility for the applicant, the agency or the agency's designee allocates the state spousal resource standard to the SIPC spouse.
    3. The resources of the SIPC spouse are unavailable to the spousal impoverishment protections institutionalized (SIPI) spouse the month after eligibility for MAC or TSOA services is established.
  3. The SIPI spouse has until the end of the month of the first regularly scheduled eligibility review to transfer countable resources in excess of $2,000 (for MAC) or $53,100 (for TSOA) to the SIPC spouse.
  4. Income eligibility:
    1. For MAC:
      1. The agency or the agency's designee determines countable income using the SSI-related income rules under chapter 182-512 WAC, but uses only the applicant or recipient's income;
      2. If the applicant's or recipient's countable income is at or below the SSI categorically needy income level (CNIL), the applicant or recipient is considered a SIPI spouse and is income eligible for noninstitutional CN coverage and MAC services;
    2. For TSOA, see WAC 182-513-1635.
  5. Once a person no longer receives MAC services, eligibility is redetermined without using spousal impoverishment protections under WAC 182-504-0125.
  6. If the applicant's separate countable income is above the standards described in subsection (4) of this section, the applicant is not income eligible for MAC or TSOA services.
  7. The spousal impoverishment protections described in this section are time-limited for MAC clients and expire on September 30, 2027.
  8. Standards described in this chapter are located 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.

Clarifying Information

Under Section 1924 of the Social Security Act, married people who receive coverage under an 1115 waiver demonstration project are considered to be an institutionalized spouse for the purposes of applying spousal impoverishment protections.  Spousal impoverishment protections do therefore apply to both MAC and TSOA clients if the spouse of the MAC/TSOA applicant doesn't reside in an institution.

For married TSOA applicants: the spousal impoverishment protections community (SIPC) spouse is allowed to have resources of $55,547 (effective 7/1/17) before any resources are counted towards the applicant’s $53,100 limit. The $53,100 standard does not change, however the state spousal resource standard ($55,547) may adjust every odd year in July. 

Combined resources must be at or below the state resource standard for a married couple plus $53,100 ($108,647 as 7/1/2017) for initial eligibility. Once eligibility is determined, the spouse receiving services has one year to transfer resources in their name over $53,100 to his or her spouse.

For TSOA income determinations, the name on check rule applies in that only the income of the TSOA applicant is counted, and not that of the community spouse. For TSOA, the community income rule (add both spouses income together and divide by two) isn’t permitted.

For married MAC applicants: for the most part MAC applicants will already be eligible for CN or ABP Medicaid.  However, in the following circumstances a second review of the person’s income and resources is required:

  • A married MAC applicant is not eligible for SSI-related CN Medicaid (for example, the person is active on S95 medically needy coverage, or pending spenddown on S99 due to the deemed income of their spouse.
  • SSI-related Medicaid is denied due to the couple being over the $3000 resource limit.

If the MAC applicant’s separate income is below the SSI-related CNIL and the couples joint resources are below the combined standard of $2000 for the applicant plus $55,547 for the community spouse, the applicant is eligible for SSI-related CN coverage (S02) as a spousal impoverishment protections institutional (SIPI) spouse. 

A person who is approved for SSI-related CN coverage as a SIPI spouse receives a 12 month certification regardless of whether they receive ongoing MAC services throughout the certification period. 

Note: For working clients who are potentially eligible for HWD, the same spousal impoverishment income protections apply.

Under current statute the spousal impoverishment protections are time-limited for MAC applicants and will end on December 31, 2018. This does not affect spousal impoverishment protections for TSOA applicants.

Worker Responsibilities

Use an ACES workaround to approve S02 or S08 coverage for SIPI MAC recipients, by coding the community spouse as a nonmember in the assistance unit. Code all resources over the $2000 resource limit on the spouse’s resource screens. Manually generate a notice to notify the applicant of the requirement to transfer all resources in excess of $2000 to their spouse prior to the first eligibility review.

Text to include with the letter: “We will review your case in (last day of review month). The amount of resources in your name must be $2,000 or less by the end of the review month. You can transfer any resources over $2,000 to your spouse. We will need proof of these transfers. See WAC 182-513-1660 for more information.”

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Tailored supports for older adults (TSOA) presumptive eligibility

Revised date
Purpose statement

This section describes how the presumptive eligibility process works.

WAC 182-513-1620 Tailored Supports for Older Adults (TSOA) - Presumptive Eligibility

WAC 182-513-1620 Tailored Supports for Older Adults (TSOA) - Presumptive Eligibility (PE).

Effective May 29, 2021

  1. A person may be determined presumptively eligible for tailored supports for older adults (TSOA) services upon completion of a prescreening interview.
  2. The prescreening interview may be conducted by either:
    1. The area agency on aging (AAA); or
    2. By a home and community services intake case manager or social worker.
  3. To receive services under presumptive eligibility (PE), the person must meet:
    1. Nursing facility level of care under WAC 388-106-0355;
    2. TSOA income limits under WAC 182-513-1635; and
    3. TSOA resource limits under WAC 182-513-1640.
  4. The presumptive period begins on the date the determination is made and:
    1. Ends on the last day of the month following the month of the presumptive eligibility (PE) determination if a full TSOA application is not completed and submitted by that date; or
    2. Continues through the date the final TSOA eligibility determination is made if a full TSOA application is submitted before the last day of the month following the month of the PE determination.
  5. If the person applies and is not determined financially eligible for TSOA, there is no overpayment or liability on the part of the applicant for services received during the PE period.
  6. The medicaid agency or the agency's designee sends written notice as described in WAC 182-518-0010 when PE for TSOA is approved or denied.
  7. A person may receive services under presumptive eligibility only once within a twenty-four-month period.
  8. If the department of social and health services establishes a waitlist for TSOA services under WAC 388-106-1975, PE does not apply.

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

People who are interested in applying for TSOA or MAC may do so by contacting their local AAA or HCS office. A person may be found presumptively eligible and services may be approved for eligible people pending completion of the application process.

Both TSOA and MAC have a presumptive eligibility component that allows services to be authorized based on a quick prescreening of financial and functional eligibility criteria. The goals of both programs are to get services in place quickly to support the person and caregivers taking care of them. If the person is found presumptively eligible (PE) they can receive services for a period of up to about 60 days while the financial application is being processed and while DSHS confirms that the person meets the functional criteria for the programs.

As long as a financial application has been filed the PE period continues until the application is completed. 

If an application isn’t filed, the PE period will end at the end of the month after the month in which services were first authorized.

For example:

Mary is a caregiver to her father Joe. She talks with the local AAA office about getting some help with a bath bench for Joe. She asks about some possible training on how to safely lift him out of his bed in the morning and from his chair at night. Joe is found presumptively eligible for services under TSOA on 8/10 and is authorized to receive a bath bench.  Mary is scheduled for a local caregiver training class. Mary and Joe have until 9/30 to file an HCA 18-008 Application for TSOA if they wish to continue to receive services. If they don’t apply by that date, the TSOA services ends on 09/30.

Mary indicates she would also like respite services so she can get some shopping done for her family once a week.  She agrees to complete a TCARE Assessment and files the TSOA application form on 8/25.  Because Mary filed the application before the PE period ended, she can continue to receive services, including respite services, until a final decision is made on Joe’s application, even if the final decision takes longer than 09/30. 

If it is later determined that the person wasn’t eligible for services, there is no requirement to repay any of the services that were received during the PE period.  TSOA and MAC can’t be back-dated and won’t cover services provided before the date of the authorization. 

Worker Responsibilities

The PE process is determined and authorized by the AAA and HCS social services staff. Unlike Fast Track, financial staff don’t need to send a 07-104 communication to the authorizing case manager, approving PE.

For MAC: PE is only authorized for people who are currently eligible for CNP or ABP coverage, therefore the PE determination is only for the functional eligibility criteria. Staff should document the PE approval in the person’s case. If NFLOC is approved and MAC services are authorized, HCS will need to transfer the medicaid case into their HCS office to manage. 

For TSOA:  The PE determination may be for both functional and financial eligibility criteria. In most cases, the TSOA applicant will not be eligible for medicaid so the HCS financial worker doesn’t need to do anything at the time of the PE approval. Once a TSOA application is received and a case is screened into ACES, the worker should document that PE was authorized and send the case manager a 07-104 communication notifying them that the application was filed so that the PE authorization period can be extended until the application is processed. There is no requirement to open T02 coverage in months prior to the application month to cover the PE period. 

Once the TSOA application is approved or denied, send another 07-104 communication to the case manager to notify them of the final decision.

Note:  If the PE determination is made by AAA staff, the worker must select the correct AAA location in Barcode in order to send the 07-104 form to AAA staff responsible for the Medicaid Transformation Project, and not to AAA Medicaid Case Management staff.

Related Links

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

Tailored supports for older adults (TSOA)

 

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Hospice applications - clients eligible for categorically needy (CN) coverage

Revised date
Purpose statement

Clients who elect hospice in the community who are otherwise eligible for CN or ABP program are financially eligible to receive hospice services at home.

If a client is in a nursing facility or hospice care center:

  • For the Aged/Blind/Disabled group, use the hospice institutional rules if in the institution 30 days or more.
  • For a MAGI coverage group, the client remains on the MAGI program. 

Hospice applications - eligibility for CN coverage

An 18-005 application is used for clients to apply for non-MAGI hospice coverage in a nursing facility, hospital, or hospice care center. The same application is used for noninstitutional aged, blind, or disabled coverage.

The financial worker will process applications following non-MAGI rules. If a client elects hospice outside of a nursing facility, hospital, or hospice care center, the L32 program is not used if client is eligible for CN under a noninstitutional CN coverage group, such as S01 or S02.

Note: The N05 coverage group also provides hospice care for those who meet program requirements. An 18-001 application is submitted to WA Health Plan Finder for MAGI coverage. 

If a client elects hospice when residing in a medical facility/care center and is expected to remain there 30 days or more, the L31 coverage group is used for clients who receive SSI cash. For clients who do not receive SSI cash, but are SSI-related based on aged, blind, or disabled requirements, the L32 coverage group is used. This group uses the institutional rules and the 300% Federal Benefit Rate (FBR) income standard when determining eligibility for CN coverage.

The hospice election needs to be updated in ACES when the client is active on a noninstitutional CN program. Code the hospice provider number on the Institutional Care screen in ACES, under the Home and Community Based Services section, and indicate MA (Health Care Authority) as the approval source. ACES uses the provider number to issue copies of the award letter to the hospice agency and ensure that the provider also receives copies of any pending letters sent to the client. This helps them assist the client in gathering any missing verifications.

Follow necessary Equal Access (EA) procedures. This is formerly known as Necessary Supplemental Accommodation (NSA).

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Filing an application

Revised date
Purpose statement

To explain the rules and procedures on who can apply for Washington Apple Health (Medicaid) coverage, how to apply, and the minimum amount of information that must be provided to start the application process.

WAC 182-503-0010 Washington apple health -- Who may apply.

WAC 182-503-0010 Washington apple health -- Who may apply.

Effective January 16, 2020.

  1. You may apply for Washington apple health for yourself.
  2. You may apply for apple health for another person if you are:
    1. A legal guardian;
    2. An authorized representative (as described in WAC 182-503-0130);
    3. A parent or caretaker relative of a child age eighteen or younger;
    4. A tax filer applying for a tax dependent;
    5. A spouse; or
    6. A person applying for someone who is unable to apply on their own due to a medical condition and who is in need of long-term care services.
  3. If you reside in an institution of mental diseases (as defined in WAC 182-500-0050(1)) or a public institution (as defined in WAC 182-500-0050(4)), including a Washington state department of corrections facility, city, tribal, or county jail, or secure community transition facility or total confinement facility (as defined in RCW 71.09.020), you, your representative, or the facility may apply for you to get the apple health coverage for which you are determined eligible.
  4. You are automatically enrolled in apple health and do not need to submit an application if you are a:
    1. Supplemental security income (SSI) recipient;
    2. Person deemed to be an SSI recipient under 1619(b) of the SSA;
    3. Newborn as described in WAC 182-505-0210; or
    4. Child in foster care placement as described in WAC 182-505-0211.
  5. You are the primary applicant on an application if you complete and sign the application on behalf of your household.
  6. If you are an SSI recipient, then you, your authorized representative as defined in WAC 182-500-0010, or another person applying on your behalf as described in subsection (2) of this section, must turn in a signed application to apply for long-term care services as described in WAC 182-513-1315.

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

Medical applications of parents with joint custody of a minor dependent child

Only one household may receive health care coverage for a child, but for modified adjusted gross income (MAGI) coverage, the child may be listed on more than one application in more than one assistance unit (MAU). The household that cares for the child the majority of time receives coverage for that child and that coverage follows the child within the state. When two households have joint custody of a child, the child may obtain health care services while staying at either home in Washington.

Applications by others

Individuals may apply on behalf of an individual if they have one of the following relationships to the applicant:

  1. A legal guardian;
  2. An authorized representative;
  3. A parent or caretaker relative of a child less than nineteen years of age;
  4. A tax filer applying for a tax dependent less than nineteen years of age; or
  5. A spouse.

Note: While others can apply for benefits on behalf of individuals, HIPAA restrictions prevent us from discussing the individual's health information with the person making the application unless the representative has power of attorney for the individual or the individual has signed an Authorization for release of information.

Authorized representative

An authorized representative can be any adult who has sufficient knowledge of the individual's circumstances to act on the individual's behalf. In general, the individual chooses who will be their authorized representative. For more information, see Authorized representatives.

Authorized representatives are not authorized to apply on behalf of deceased individuals.

Applications while in a public institution

Prior to release from a public institution, individuals may apply for Apple Health coverage. See the Incarceration overview page for more information.

WAC 182-503-0005 Washington apple health -- How to apply.

WAC 182-503-0005 Washington apple health -- How to apply.

Effective June 4, 2023

  1. You may apply for Washington apple health at any time.
  2. For apple health programs for children, pregnant people, parents and caretaker relatives, and adults age 64 and under without medicare, (including people who have a disability or are blind), you may apply:
    1. Online via the Washington Healthplanfinder at www.wahealthplanfinder.org;
    2. By calling the Washington Healthplanfinder customer support center and completing an application by telephone;
    3. By completing the application for health care coverage (HCA 18-001P), and mailing or faxing to Washington Healthplanfinder; or 
    4. At a department of social and health services (DSHS) community services office (CSO).
  3. ​If you seek apple health coverage and are age 65 or older, have a disability, are blind, need assistance with medicare costs, or seek coverage of long-term services and supports, you may apply:
    1. Online via Washington Connection at www.WashingtonConnection.org;
    2. By completing the application for aged, blind, disabled/long-term care coverage (HCA 18-005) and mailing or faxing it to DSHS;
    3. By calling the DSHS customer service contact center and completing an application by telephone;
    4. In person at a local DSHS CSO or home and community services (HCS) office; or
    5. As specified in subsection (2) of this section, if you are a child, pregnant, a parent or caretaker relative, or an adult age 64 and under without medicare.
  4. You may receive help filing an application.
    1. For households containing people described in subsection (2) of this section:
      1. Call the Washington Healthplanfinder customer support center number listed on the application for health care coverage form (HCA 18-001P); or 
      2. Contact a navigator, health care authority volunteer assistor, or broker.
    2. For people described in subsection (3) of this section who are not applying with a household containing people described in subsection (2) of this section:
      1. Call or visit a local DSHS CSO or HCS office; or 
      2. Call the DSHS community services customer service contact center number listed on the medicaid application form. 
  5. To apply for tailored supports for older adults (TSOA), see WAC 182-513-1625.
  6. You must apply directly with the service provider for the following programs:
    1. The breast and cervical cancer treatment program under WAC 182-505-0120;
    2. The family planning only programs under chapter 182-532 WAC; and
    3. The kidney disease program under chapter 182-540 WAC.
  7. For the confidential pregnant minor program under WAC 182-505-0117 and for minors living independently, you must complete a separate application directly with us (the medicaid agency). More information on how to give us an application may be found at the agency's web site:  www.hca.wa.gov/free-or-low-cost-health-care (search for "teen").
  8. As the primary applicant or head of household, you may start an application for apple health by providing your:
    1. Full name;
    2. Date of birth; 
    3. Physical address, and mailing addresses (if different); and
    4. Signature.
  9. To complete an application for apple health, you must also give us all of the other information requested on the application.
  10. You may have an authorized representative apply on your behalf as described in WAC 182-503-0130.
  11. We help you with your application or renewal for apple health in a manner that is accessible to you. We provide equal access (EA) services as described in WAC 182-503-0120 if you:
    1. ​Ask for EA services, you apply for or receive long-term services and supports, or we determine that you would benefit from EA services; or
    2. Have limited-English proficiency as described in WAC 182-503-0110. 

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

Clarifying information

Application forms

Application through Washington Healthplanfinder (18-001)

Application for aged, blind, disabled/long-term care coverage (18-005)

Program-specific application forms

Application for Medicare Savings Program (MSP)

Application for the Tailored Supports for Older Adults (TSOA) program

Application for pregnant teen health care coverage (under age 19)

K01 application process

Opportunity to apply

CSOs must make application forms readily available and provide a form to anyone requesting one. An individual cannot be refused an application form for any reason. For MAGI-based applications done via Washington Healthplanfinder, CSOs provide computers in their lobbies for applicants to apply for health care coverage in Washington Healthplanfinder. Additionally, CSOs may offer assistance in applying in Washington Healthplanfinder when an individual is also applying for SNAP (food assistance).

Starting an application

An individual has filed a partial application when a signed application is received with at least the name and date of birth of the head of household or primary applicant and the physical/mailing address. Once submitted, the individual will have at least 15 days to complete the application and submit verification, if needed.

Where to apply

MAGI-based coverage

Applying for Apple Health through Washington Healthplanfinder is best for individuals who are:

  1. Adults under age 65 who are ineligible for Medicare;
  2. Adults who are parents or caretaker relatives of minor children;
  3. Pregnant; or
  4. Under age 19.

Washington Healthplanfinder applications can be completed:

  1. Online at wahealthplanfinder.org;
  2. By phone with the Washington Healthplanfinder Customer Support Center at 1-855-WAFINDER (1-855-923-4633);
  3. Through a navigator;
  4. By submitting a paper Health Care Coverage application (18-001P) by fax to 1-855-867-4467; or
  5. By submitting a paper Health Care Coverage application (18-001P) by mail to:
    Washington Healthplanfinder
    PO Box 946
    ​Olympia, WA 98504

Navigators are available around the state. Navigators are a network of people, usually in clinics and hospitals, who can help individuals find and apply for coverage. The Washington Healthplanfinder Navigator Search can be found at Applications for long term services and supports (LTSS).

Individuals not eligible via Washington Healthplanfinder but who appear to qualify for non-MAGI coverage receive an application form by mail to apply for non-MAGI based coverage.

Non-MAGI-based Classic Apple Health coverage

DSHS processes applications for individuals who are age 65 or over, eligible for Medicare, are blind or disabled, need a disability determination, or are in need of long-term services and supports. DSHS has two areas that process applications: Economic Services Administration (ESA) and the Aging and Long-Term Support Administration (ALTSA).

DSHS Community Services Office (CSO)

DSHS CSOs process applications for individuals who are 65 or over, eligible for Medicare, are blind or disabled, or need a disability determination. Applications for non-MAGI Apple Health can be completed:

  1. Online at WashingtonConnection.org;
  2. By submitting a paper Application for aged, blind, disabled/long-term services and supports (18-005) by fax to 1-888-338-7410;
  3. By calling the DSHS Customer Service Contact Center at 1-877-501-2233 to complete an application over the telephone with a telephonic signature; or
  4. By submitting a paper Application for aged, blind, disabled/long-term services and supports (18-005) by mail to:
    DSHS
    Community Services Division – Customer Service Center
    PO Box 11699
    Tacoma, WA 98411-6699

Find a local CSO.

ALTSA Home and Community Services (HCS)

ALTSA’s HCS processes applications for individuals not eligible for MAGI-based coverage and who are in need of care in their own home, a community residential care facility (adult family home or assisted living facility) or nursing facility. More information on the HCS application process can be found in the Medicaid and Long-Term Care Services for Adults publication (22-619).

Individuals eligible under a categorically needy (CN) or alternative benefits plan (ABP) MAGI-based program can receive long-term services and supports (LTSS) if determined functionally eligible by an ALTSA social worker or case manager. A separate application is not needed for active MAGI based individuals for Medicaid personal care (MPC), Community First Choice (CFC) or nursing facility services. If LTSS is needed, contact the HCS intake for an assessment. The intake phone numbers for a social service assessment is located under applications for LTC: Applications for long term services and supports (LTSS)

Applications for services through HCS can be completed:

  1. Online at WashingtonConnection.org;
  2. By submitting a paper application for aged, blind, disabled/long-term care coverage (18-005) by fax to 1-855-635-8305; or
  3. By submitting a paper application for aged, blind, disabled/long-term care coverage (18-005) by mail to:
    DSHS
    Home and Community Services – Long Term Care Services
    PO Box 45826
    Olympia, WA 98504-5826

Find a local HCS office.

Pending applications

When an individual submits an application and more information is needed to determine eligibility, they will receive a letter in the mail (unless they are receiving electronic notices through Washington Healthplanfinder). This letter will tell them what information is needed, when to submit it, and how to submit it. See the General verification chapter for more information.

Example: Jenny, age 35, has a pending application for SNAP (Basic Food) and ABD cash. At her intake interview, she requests health care coverage. She reports she is not aged or blind, but may have a disability. The CSO worker offers assistance to apply in Washington Healthplanfinder, which Jenny accepts. The worker inputs the application data into Washington Healthplanfinder and Jenny is approved for Apple Health for Adults.

Example: Maria, age 66, has a pending application for SNAP (Basic Food). At her telephone intake interview, the worker lets her know she may be eligible for non-MAGI (Classic) Apple Health. She decides to apply for coverage as well. The worker can complete an interactive interview and follow procedures to capture a telephonic signature when appropriate.

Handling multiple applications from the same household (Classic Medicaid only)

  1. Additional applications received before we determine eligibility on the first application:
    1. Do not deny the additional application(s);
    2. Review the application(s) for impact on eligibility and whether the household is applying for any additional programs that were not selected on the first application;
    3. If the household is not applying for additional programs, document in the case that additional application(s) were received, the date(s) the additional application(s) were received, and that the agency is still considering eligibility under the original application date;
    4. If the household is applying for additional programs, treat the application as a new application for the additional programs only and continue to consider any requests for programs which are still pending under the original application date;
    5. Document in ACES to explain any additional information used to determine eligibility; and
    6. Do not extend the Timeliness period for the original application
      1. Note: If the additional application is received before we determine eligibility on the first application but a worker does not act on the additional application until after the first application has been approved or denied, follow procedures under (2) below.
  2. Additional applications received after we determine eligibility on the first application:
    1. If we denied the first application, treat this as an initial application.
      1. Exception: If we are still within the original 30 day reconsideration period under WAC 182-503-0080 and there has not been a change of circumstances that would warrant a new request for information, then do not treat this as an initial application. Instead, treat this as a reconsideration. See Denials.
    2. If we approved the first application, review the additional application(s) to determine if household circumstances have changed. Take appropriate actions on any changes reported.
    3. If neither (a) nor (b) applies, the additional application should be denied as a duplicate application as follows:
      1. Use reason code 587;
      2. Send out the required denial letter (if not system generated); and
      3. Add text to explain that the application is being denied because the person(s) on the application is already receiving the Apple Health coverage.

Please note: Reuse AUs! When denying additional applications as described in (b)(iii) above, avoid creating a new AU if an old AU is available.

Name, address, and signature requirements

  1. Name and address
    If we receive an application without a name or address to contact the individual, we make any reasonable effort we can to contact the individual to find out who the individual is and where they can be reached. If contact cannot be made, no further action needs to be taken.
  2. Applications marked “homeless”
    If we receive a paper application that includes a name and signature, but is marked "homeless" and/or does not indicate a mailing address, make a reasonable attempt to locate an address or phone number for the individual. This can be done by searching the electronic case record, case narrative, ACES remarks, or past Washington Healthplanfinder applications to see if there’s a recent address reported. If no address is provided and no contact can be made, no further action needs to be taken.
  3. Signatures
    1. The individual/authorized representative must sign the application.
    2. A minor child may sign the application if there is no adult in the household.
    3. A mark is an acceptable signature if another person witnesses the making of the mark and signs the application.
    4. Online applications are considered signed electronically when transmitted.
    5. Telephonic signatures are accepted through Washington Healthplanfinder’s customer support center.
    6. See matrix below for signature requirements and date of application.

Application received

Online

In person, mailed, emailed, faxed, dropped off, scanned, or over the phone

Application signed?

Yes. Always signed when submitted

May or may not be signed. Does not need to be signed in order to be accepted. Must be signed, however, to be processed

Date of application

Date received or next business day if received after business hours

If signed, date received or next business day if received after business hours. If not signed, see "Action to Take".

Action to take

Only applicant needs to sign in two parent households

If not signed, or taken over the phone, have the individual sign or mail back for signature. The date we receive the signature is the date of application.

Note: When an interactive interview over the phone or in-person is used to complete an application for benefits, a signature must be obtained. This does not apply to applications completed by using the DSHS telephonic signature process.

Additional situations requiring an application or eligibility review
Signed application or eligibility review forms (which may be signed telephonically) are needed for:

  • When an individual is terminated from SSI and we must redetermine eligibility under a different program.
  • Adding someone new to an assistance unit who has either not previously applied, or whose previous DSHS coverage ended more than 30 days earlier.
  • Medically Needy (MN) coverage, and whenever establishing a new base period. If the application/review is completed by phone using the DSHS application telephonic signature process, the Interactive Interview Declaration (IID) must be printed out and sent to the individual for review.
  • When an individual applies for long-term services and supports (LTSS), such as COPES, nursing home care, or a DDA waiver, and is expected to receive the LTC service for longer than 30 days. This includes SSI recipients.

Other programs

Family Planning Only is a program that provides individuals coverage for family planning services.

Find more information on the Family Planning Only page.

Alien Emergency Medical (AEM) applications are processed by either HCA or DSHS. See the AEM presentation for more information.

Breast and Cervical Cancer Treatment Program (BCCTP) provides health care coverage for an individual diagnosed with breast or cervical cancer or a related precancerous condition. Find more information at the Department of Health’s BCCTP page.

The Apple Health Kidney Disease Program (KDP) is a state-funded program that helps low-income, eligible individuals with treatment costs for end-stage renal disease. Eligibility is determined by each contracted kidney center. More information can be found on the KDP page.

Pregnant minors under 19 who need confidential health care coverage can apply using the Application for Pregnant Teen (14-430) form. The form can be submitted by mail or fax to:

Medical Eligibility Determination Services (MEDS)

PO Box 45531
Olympia, WA 98504-5531
Fax 360-725-1898

Homeless teens applying on their own will need assistance with their Washington Healthplanfinder application. See the Homeless Teen Process form for more information.

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

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

Effective August 8, 2021

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

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

Worker responsibilities (Non-Classic Medicaid only)

Date stamping the application

  1. Date stamp the application, the same day we get the application, even if the application is sent to the wrong office; or
  2. The next business day if we received the application outside of normal business hours.

Shared case processing / transfers

CSO and Foster Care and Adoption Support (FCAS) may need to coordinate actions on shared cases involving foster and adopted children or foster alumni receiving D01, D02, or D26 medical programs. To contact the FCAS call 1-800-562-3022, extension 15480; or email at FCAS@hca.wa.gov.

CSO and MEDS staff must coordinate actions taken on shared cases. If the CSO needs a shared case transferred, email Medstransfer@hca.wa.gov. For MEDS, if there is a shared case, contact the CSO before making any change. If MEDS staff are unable to reach the CSO to take action on a shared case, they will contact the CSO supervisor of record for action.

How to contact MEDS:

By Mail:
MEDS
PO Box or Mail Stop 45531
Olympia, Washington 98504-5531

Phone: General Information: 800-562-3022

FAX: 855-867-4467

Email: Case transfers Medstransfer@hca.wa.gov

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