ACES codes

Revised date
Purpose statement

This section provides additional clarification regarding ACES coding for medical expenses for spenddown.

PR
  • Medicare Part A, Part B, Part C, or Part D
    • Premiums
    • Copayments
    • Coinsurance charges that are not covered under the Qualified Medicare Beneficiary (QMB) Medicare Savings Program (MSP)
    • Deductibles

Premiums. Individuals typically pay premiums for Part B and Part D plans and sometimes for Part C plans. The charges are allowed towards spenddown as follows:

  • Allow premiums that the individual is or has been responsible to pay.
  • If S03, S05 or S06 is being approved to cover Part B premiums, allow the first two months premiums in the current base period.
  • Allow any premiums paid by the individual within the 3-month retroactive period if an MSP is not approved to cover this period. S05 or S06 can and should be approved for the retroactive period if requested – remember to notify the HCA Medicare Buy-In unit that you need retroactive coverage for Part B premiums.
  • Otherwise allow premiums as the expense is incurred.

Copayments. Individuals typically pay copayments for prescriptions under Part D, which vary depending on the drug and the Part D plan. These charges are allowed towards spenddown when the individual is responsible to pay for it. Medicaid only covers prescription drug costs for Medicare individuals if the drug is not covered by Medicare under the Part D plan but is covered by Medicaid.

Coinsurance. Individuals typically pay coinsurance charges under Parts A and B, which are generally 20% of the Medicare allowed charge. These charges are allowed towards spenddown unless the individual is also eligible for S03 coverage.

Example

An individual is on spenddown without QMB. Dr. Jones bills an individual $425. The Medicare allowed amount is $370 for this charge. Medicare pays 80% or $296 towards the bill, and the individual is legally obligated to pay the remaining 20% coinsurance amount of $74. Dr. Jones is not allowed to bill the individual for the remaining $55 -- the difference between $425 and the $370 that Medicare allowed. $74 is what is applied towards spenddown. The Explanation of Benefits (EOB) will show the allowed charges and the amount the individual is responsible for.

Deductibles. Individuals pay a standard deductible under Parts A and B, which are listed on the Washington Apple Health Income and resource standards chart. This amount is also typically shown on the individual's EOB. Deductibles are allowed towards spenddown unless the individual is also eligible for S03 coverage.

CO
  • Private health insurance:
    • Copayments (not premiums)
    • Coinsurance charges
    • Deductibles

Example

An individual has Regence Health insurance. He pays $15 copayment for each doctor’s visit and has a $250 yearly deductible to meet before coverage begins. The $15 copayment would be coded “CO” in ACES. He brings you an insurance statement showing that he had a hospital visit in January and he is responsible for the first $250 of the bill. This would also be coded as “CO” in ACES.

Private health insurance premiums

Do not code private health insurance premiums as "CO". Private health insurance premiums are coded on the MEDX screen, which reduces the total spenddown amount.

MU
  • Certain expenses, such as:
    • Transportation to medical appointments or to pick up prescriptions.
    • Items prescribed by an allowable provider but not covered by Medicaid, such as hearing aids.
    • Prior unpaid charges that were denied by HCA as an uncovered expense.
    • Prescribed vitamins, supplements, or over-the-counter medications, such as prenatal vitamins
    • Orthodontic or chiropractic treatments
    • Laser eye surgery

It is not necessary to code the expenses of a nonapplying spouse or other household members as "MU" in order for ACES to treat their expenses as "uncovered". Code expenses for nonmembers the same as if the nonmember were applying for coverage based upon the expense type.

HO
  • Inpatient or outpatient services provided in a hospital setting. This includes emergency room visits, physician charges for services provided in the hospital, lab fees, x-rays etc.

Use initial date of service

Always code hospital expense with the date the individual first entered the hospital. When reviewing hospital statements, use the initial date of service and not the statement date.

MC
  • Any charges that are potentially payable by Medicaid, such as:
    • Doctor’s visits
    • Physical, speech or occupational therapy
    • Specialist appointments
    • Laboratory fees or X-rays
    • Mental health services, etc.

See Scope of care for more information about services covered under the MN program. For questions regarding coverage for specific expenses, call the HCA Medical Assistance Customer Service Center at 1-800-562-3022.

RX
  • Prescription pharmacy expenses for non-Medicare-eligible individuals.

Prescription drug name required

When entering an RX expense, it is a required field to enter the name of the prescription drug.

Enter each prescription separately – do not lump prescription drugs into one expense, even if paid for together.

Ensure the individual has provided a receipt showing payment and is not just providing a list of prescriptions they are waiting to fill.

Do not allow the following as prescription expenses:

  • Self-paid Medicare-covered drug. A Medicare eligible individual cannot choose to self-pay for a Medicare covered drug and then use the expense toward meeting a spenddown.
  • Prescription drug not on plan formulary. A prescription drug that is not on the individual’s Medicare Part D plan’s formulary cannot be allowed towards spenddown unless the individual has requested an exception from their plan and has received a written denial.
  • Prescribed items that are not pharmaceuticals.

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Free-form text for ACES letters

Revised date
Purpose statement

To describe the free-form text requirements for the Apple Health ACES Letters listed below.

Letter Letter title Freeform text requirement

0004-05

General Denial - No Information

List items that you asked for that were not provided.

0020-01

MN Spenddown

When approved, the letter will list all bills used to meet spenddown or applied towards the spenddown.

In the first mandatory freeform text section:

  • List all the bills you did not use and why you didn't use them.

0070-05

ETR Denial

State why the ETR was denied.

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DSHS and HCA forms, WACs, rule-making, and useful LTC links

Revised date

Forms

WACs and rulemaking

Aging and long-term supports

For more information on who does what LTSS program, see Overview - Long-term Services and Supports chart.

CSD/ESA contact numbers

Resources for LTSS staff

Medical assistance coverage

Medical assistance administrative hearing rules

Managed care, TPL, and long-term care insurance information

Nursing facility (NF) billing guides

Help desk and online services

Smarter track mailbox for internal ProviderOne manual updates

When to use MMIS Help

Situation: Client is discharged from a NF and cannot get a prescription filled because of the coding. We need to email MMIS Help when needing a manual fix in the system. This includes when we correct an incorrect date of death in ACES. Once the case is closed in ACES, any fix must be manually sent over to HCA to match ACES data.

Medicare buy-in issues

  • Field staff use Barcode tickler 102@MBU
  • For clients, contact the Medicaid Customer Service Center 800-562-3022

Federal Medicaid, Medicare, Social Security, and Railroad Retirement

Washington LawHelp, Ombudsman, RCS complaint line, SHIBA

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Who can apply for whom

Revised date
Purpose statement

To explain who can apply for Apple Health coverage and for whom.

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

Usually, individuals age 18 or younger apply for health coverage with their custodial parent(s) or guardian(s). But, they may be able to get health coverage on their own if they:

  • Live separately from their parents/guardians and are not claimed by them as a tax dependent;
  • Are homeless;
  • Are pregnant; or
  • Need birth control or sexually transmitted infection care.

If an individual age 18 or younger wishes to apply for Apple Health, he or she must call 855-WAFINDER (855-923-4633).

Who can apply when there is a custodial dispute of a dependent?

The primary custodial parent or guardian.

In cases where it is not clearly established who the custodial parent is, whether because the court orders establishes joint custody or there is no formal order, the custodial parent is the parent with whom the child spends the most nights.

If it is claimed the child spends an equal number of nights with each parent, but for purposes of establishing Apple Health eligibility for that dependent, the agency accepts the application for the custodial parent or guardian that applied first.

This action does not prevent the other custodial parent or guardian from including that dependent on their application and counted towards their medical assistance unit.

For more information on determining a person's medical assistance unit see Household composition.

Who can apply for a deceased individual?

  1. Their spouse;
  2. The parent or caretaker relative as described in WAC 182-500-0020;
  3. A relative, either through blood, marriage, or adoption;
  4. The Executor, Administrator, or Personal Representative of the deceased's estate;
  5. A court appointed guardian who was appointed after the applicant or recipient's death; or
  6. Anyone legally authorized by the courts or by state law to act on behalf of the deceased or his or her estate.

Who cannot apply for a deceased individual?

  1. An Authorized Representative (AREP) who was designated while the applicant or recipient was living unless they are one of the following:
    • Their spouse;
    • The parent or caretaker relative as described in WAC 182-500-0020;
    • A relative, either through blood, marriage, or adoption;
    • The Executor, Administrator, or Personal Representative of the deceased's estate; or
    • Anyone legally authorized by the courts or by state law to act on the behalf of the deceased or his or her estate
  2. An individual or organization assigned guardianship or Power of attorney (POA) while the applicant or recipient was living.
    Guardianship and POA assigned while the individual is living ends after the applicant or recipient is deceased.

Note: This information does not apply to long-term care applications that were received prior to the applicant's death. ALTSA will continue to work with the applicant's designee to approve or deny the request.

Power of attorney defined:

A "power of attorney" (POA) is a legal document giving one person the legal power to act on behalf of someone else. A POA can grant someone a wide range of powers or a narrow range; it depends on what is written in the POA. The only way to know what powers are granted by a POA is to read the POA itself. A POA ends if:

  • The applicant or recipient dies;
  • The applicant or recipient becomes incompetent;
  • The person who granted the power revokes the POA;
  • The person who is given power by a POA terminates the POA; or
  • A court invalidates the POA.

Durable power of attorney defined:

A durable power of attorney (DPOA) is a power of attorney that stays in effect even if the person who signed it becomes incompetent or incapacitated. A DPOA can grant someone a wide range of powers or a narrow range; it depends on what is written in the DPOA. The only way to know what powers are granted by a DPOA is to read the POA itself.

Note: A person who is already legally incompetent cannot create a valid DPOA.

A DPOA ends if:

  • The applicant or recipient dies
  • The person who granted the power revokes the DPOA;
  • The person who is given power by a DPOA terminates the POA.
  • The person who is given power by a DPOA cannot be found; or
  • A court invalidates the DPOA.

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Tailored supports for older adults (TSOA)

Revised date
Purpose statement

To describe the Tailored Supports for Older Adults (TSOA) program and the eligibility requirements for a person to become eligible.

WAC 182-513-1610 Tailored Supports for Older Adults (TSOA) - Overview

WAC 182-513-1610 Tailored supports for older adults (TSOA) — Overview.

Effective July 1, 2017

  1. The tailored supports for older adults (TSOA) program is a federally funded program approved under section 1115 of the So­cial Security Act. It enables the medicaid agency and the agency's designees to deliver person-centered long-term services and supports (LTSS) to a person who:
    1. Meets nursing facility level of care described in WAC 388-106-0355; and
    2. Meets the functional requirements under WAC 388-106-1900 through 388-106-1990.
  2. For the purposes of TSOA, the applicant is the person receiv­ing care even though services may be authorized to the person provid­ing care. TSOA does not provide Washington apple health coverage.

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

WAC 182-513-1615 Tailored Supports for Older Adults (TSOA) - General Eligibility

WAC 182-513-1615 Tailored Supports for Older Adults (TSOA) - General Eligibility

Effective June 3, 2025

  1. The person receiving care must meet the financial eligibility criteria for tailored supports for older adults (TSOA).
  2. To be eligible for the TSOA program, the person receiving care must:
    1. Be age 55 or older;
    2. Be assessed as meeting nursing facility level of care under WAC 388-106-0355;
    3. Meet residency requirements under WAC 182-503-0520;
    4. Live at home and not in a residential or institutional setting;
    5. Have an eligible unpaid caregiver under WAC 388-106-1905, or meet the criteria under WAC 388-106-1910 if the person does not have an eligible unpaid caregiver;
    6. Meet citizenship or immigration status requirements under WAC 182-503-0535. To be eligible for TSOA, a person must be a:
      1. U.S. citizen under WAC 182-503-0535 (1)(c);
      2. U.S. national under WAC 182-503-0535 (1)(d);
      3. Qualifying American Indian born abroad under WAC 182-503-0535 (1)(f); or
      4. Qualified alien under WAC 182-503-0535 (1)(b) and have either met or is exempt from the five-year bar requirement for medicaid.
    7. Provide a valid Social Security number under WAC 182-503-0515;
    8. Have countable resources within specific program limits under WAC 182-513-1640; and
    9. Meet income requirements under WAC 182-513-1635.
  3. TSOA applicants who receive coverage under Washington apple health programs are not eligible for TSOA, unless they are enrolled in:
    1. Medically needy program under WAC 182-519-0100;
    2. Medicare savings programs under WAC 182-517-0300;
    3. Family planning program under WAC 182-505-0115;
    4. Family planning only programs under chapter 182-532 WAC; or
    5. The kidney disease program under chapter 182-540 WAC.
  4. A person who receives apple health coverage under a categorically needy (CN) or alternative benefit plan (ABP) program is not eligible for TSOA but may qualify for:
    1. Caregiver supports under medicaid alternative care (MAC) under WAC 182-513-1605; or
    2. Other long-term services and supports under chapter 182-513 or 182-515 WAC.
  5. The following rules do not apply to services provided under the TSOA benefit:
    1. Transfer of asset penalties under WAC 182-513-1363;
    2. Excess home equity under WAC 182-513-1350;
    3. Client financial responsibility under WAC 182-515-1509;
    4. Estate recovery under chapter 182-527 WAC;
    5. Disability requirements under WAC 182-512-0050;
    6. Assignment of rights and cooperation under WAC 182-503-0540

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 is a program funded under the Medicaid Transformation Project Demonstration and provides services to support unpaid caregivers in Washington State, and provides a small personal care benefit to people who don’t have an unpaid family caregiver to help them. It creates a new eligibility category and benefit package for people age 55 or older who are “at risk” of needing long-term services and supports in the future who don’t currently meet Medicaid financial eligibility criteria.

TSOA doesn’t provide health care coverage and is targeted towards people who aren’t currently eligible for medicaid. However, TSOA may be used for people who are currently only eligible for a limited scope program such as the Medicare Savings Programs, or who are only eligible for medically needy coverage.

Eligibility for TSOA is determined by reviewing the income and resources of the person (and their spouse) who receives care. The person must also be functionally eligible under WAC 388-106-1910. However, the services authorized are for the benefit of the caregiver, not the care receiver.

For example:

Joe is 85 years old and has dementia. He is being cared for by his 60 year old daughter Mary. Mary calls to apply for TSOA because Joe has started wandering and she wants to get a personal emergency response system set up to monitor Joe. She is also concerned that she doesn’t know the best way to care for Joe as his dementia worsens.

Joe is screened and meets nursing facility level of care. He meets TSOA financial eligibility criteria. Mary is approved to get a PERS unit for Joe and she is also registered to attend a local class that provides dementia education for caregivers. She is also authorized to receive respite care so someone is able to care for Joe while she attends the class.

What are the financial eligibility criteria for TSOA?

The person who receives the care must be:

  • Age 55 or older and live in a home setting
  • A Washington State resident
  • Meet the citizenship and immigration eligibility for federally funded medicaid
  • Meet NFLOC
  • Provide a valid SSN or proof of application for an SSN
  • Meet income requirements under WAC 182-513-1635
  • Meet resource requirements under WAC 182-513-1640

A person may be authorized services under the TSOA program while also applying for medicaid. However, if the person is approved for medicaid, TSOA must be closed.

What LTSS financial rules don’t apply to TSOA services?

Certain provisions that apply to traditional long-term care services don’t apply to people who are eligible for TSOA. These include:

Recovery and TEFRA liens (Chapter 182-527 WAC)

Estate Recovery doesn’t apply to services paid by the TSOA program. Likewise the state can’t establish a TEFRA lien for the cost of services provided under this program.

Worker Responsibilities

The AAA worker will notify financial staff using the 14-443 communication form when a person has been approved for TSOA services. The form will include the date services are authorized which will be used to open the T02 coverage group in ACES.

HCS financial staff are responsible for ongoing case maintenance on TSOA clients, which includes processing food assistance requests if applicable.

Related links

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

Tailored supports for older adults (TSOA) presumptive eligibility

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Patient review and coordination

Revised date
Purpose statement

To explain the Patient Review and Coordination (PRC) program, which is intended to protect the health and safety of individuals, assure continuity of medical care, and prevent duplication of services.

WAC 182-501-0135 Patient review and coordination (PRC).

WAC 182-501-0135 Patient review and coordination (PRC).

Effective November 23, 2024

  1. Patient review and coordination (PRC) is a health and safety program that coordinates care and ensures clients enrolled in PRC use services appropriately and in accordance with agency rules and policies.
    1. PRC applies to medical assistance fee-for-service and managed care clients organization (MCO) enrollees.
    2. PRC is authorized under federal medicaid law by 42 U.S.C. 1396n (a)(2) and 42 CFR 431.54.
  2. Definitions. Definitions found in chapter 182-500 WAC and WAC 182-526-0010 apply to this section. The following definitions apply to this section:
    "Appropriate use" - Use of healthcare services that are safe and effective for a client's healthcare needs.
    "Assigned provider" - An agency-enrolled healthcare provider or one participating with an agency-contracted managed care organization (MCO) who agrees to be assigned as a primary provider and coordinator of services for an FFS client or MCO enrollee in the PRC program. Assigned providers can include a primary care provider (PCP), a pharmacy, a prescriber of controlled substances, and a hospital for nonemergency services.
    "At-risk" - A term used to describe one or more of the following:
    1. A client with a medical history of:
      1. Seeking and obtaining healthcare services at a frequency or amount that is not medically necessary;
      2. Potential life-threatening events or life-threatening conditions that required or may require medical intervention.
    2. Behaviors or practices that could jeopardize a client's medical treatment or health including, but not limited to:
      1. Indications of forging or altering prescriptions;
      2. Referrals from medical personnel, social services personnel, or MCO personnel about inappropriate behaviors or practices that place the client at risk;
      3. Noncompliance with medical or drug and alcohol treatment;
      4. Paying cash for medical services that result in a controlled substance prescription or paying cash for controlled substances;
      5. Arrests for diverting controlled substance prescriptions;
      6. Positive urine drug screen for illicit street drugs or nonprescribed controlled substances;
      7. Negative urine drug screen for prescribed controlled substances; or
      8. Unauthorized use of a client's services card for an unauthorized purpose.
        "Care management"- Services provided to MCO enrollees with multiple health, behavioral, and social needs to improve care coordination, client education, and client self-management skills.
        "Client" - See WAC 182-500-0020.
        "Conflicting" - Drugs or health care services that are incompatible or unsuitable for use together because of undesirable chemical or physiological effects.
        "Contraindicated" - A medical treatment, procedure, or medication that is inadvisable or not recommended or warranted.
        "Duplicative" - Applies to the use of the same or similar drugs and health care services without due medical justification. Example: A client receives health care services from two or more providers for the same or similar condition(s) in an overlapping time frame, or the client receives two or more similarly acting drugs in an overlapping time frame, which could result in a harmful drug interaction or an adverse reaction.
        "Emergency department information exchange (EDIE)" - An internet-delivered service that enables health care providers to better identify and treat high users of the emergency department and special needs patients. When patients enter the emergency room, EDIE can proactively alert health care providers through different venues such as fax, phone, email, or integration with a facility's current electronic medical records.
        "Emergency medical condition" - See WAC 182-500-0030.
        "Emergency services" - See 42 C.F.R. 438.114.
        "Fee-for-service" or "FFS" - See WAC 182-500-0035.
        "Just cause" - A legitimate reason to justify the action taken including but not limited to, protecting the health and safety of the client.
      9. "Managed care organization (MCO) enrollee" - A medical assistance client enrolled in, and receiving health care services from, an agency-contracted managed care organization (MCO).
        "Prescriber of controlled substances" - Any of the following health care professionals who, within their scope of professional practice, are licensed to prescribe and administer controlled substances (see chapter 69.50 RCW, Uniform Controlled Substance Act) for a legitimate medical purpose:
        (a) A physician under chapter 18.71 RCW;
        (b) A physician assistant under chapter 18.71A RCW;
        (c) An osteopathic physician under chapter 18.57 RCW;
        (d) An advanced registered nurse practitioner under chapter 18.79 RCW.
        "Primary care provider" or "PCP" - A person licensed or certified under Title 18 RCW including, but not limited to, a physician, an advanced registered nurse practitioner (ARNP), or a physician assistant (PA) who supervises, coordinates, and provides health care services to a client, initiates referrals for specialty and ancillary care, and maintains the client's continuity of care.
  3. Clients selected for PRC review. The agency or agency's designee selects a client for PRC review when either or both of the following occur:
    1. An agency or MCO claims utilization review report indicates the client has not used health care services appropriately; or
    2. Medical providers, social service agencies, or other concerned parties have provided direct referrals to the agency or MCO.
  4. Clients not selected for PRC review. Clients are not reviewed or placed into the PRC program when they :
    1. Are in foster care;
    2. Are covered under state-only funded programs;
    3. Do not have medicaid as the primary payor; or
    4. Are covered under the alien emergency medical (AEM) program according to WAC 182-507-0115.
  5. Prior authorization. When an FFS client is selected for PRC review the prior authorization process as defined in WAC 182-500-0085 may be required:
    1. Before or during a PRC review; or
    2. When the FFS client is currently in the PRC program.
  6. Review for placement in the PRC program. When the agency or MCO selects a client for PRC review, the agency or MCO staff, with clinical oversight, reviews either the client's medical history or billing history, or both, to determine if the client has used health care services at a frequency or amount that is not medically necessary (42 CFR 431.54(e)).
  7. Usage guidelines for PRC placement. Agency or MCO staff use the following usage guidelines to determine PRC placement. A client may be reviewed for placement in the PRC program when the review shows the usage is not medically necessary and either the client's medical history or billing history, or both, documents any of the following:
    1. Any two or more of the following conditions occurred in a period of 90 consecutive calendar days in the previous 12 months. The client:
      1. Received services from four or more different providers, including physicians, ARNPs, and PAs not located in the same clinic or practice;
      2. Had prescriptions filled by four or more different pharmacies;
      3. Received 10 or more prescriptions;
      4. Had prescriptions written by four or more different prescribers not located in the same clinic or practice;
      5. Received similar services in the same day not located in the same clinic or practice; or
      6. Had 10 or more office visits;
    2. Any one of the following occurred within a period of 90 consecutive calendar days in the previous 12 months. The client:
      1. Made two or more emergency department visits;
      2. Exhibits "at-risk" usage patterns;
      3. Made repeated and documented efforts to seek health care services that are not medically necessary; or
      4. Was counseled at least once by a health care provider, or an agency or MCO staff member with clinical oversight, about the appropriate use of health care services;
    3. The client received prescriptions for controlled substances from two or more different prescribers not located in the same clinic or practice in any one month within the 90-day review period; or .
    4. The client has either a medical history or billing history, or both, that demonstrates a pattern of the following at any time in the previous 12 months:
      1. Using health care services in a manner that is duplicative, excessive, or contraindicated;
      2. Seeking conflicting health care services, drugs, or supplies that are not within acceptable medical practice;
  8. PRC review results. As a result of the PRC review, the agency or MCO staff may take any of the following steps:
    1. Determine that no action is needed and close the client's file;
    2. Send the client and, if applicable, the client's authorized representative a one-time only written notice of concern with information on specific findings and notice of potential placement in the PRC program; or
    3. Determine that the usage guidelines for PRC placement establish that the client has used health care services at an amount or frequency that is not medically necessary, in which case one or more of the following actions take place:
      1. The MCO:
        1. Refers the MCO enrollee:
          1. For education on appropriate use of health care services; or
          2. To other support services or agencies; or
        2. Places the MCO enrollee into the PRC program for an initial placement period of no less than 24 months. For MCO enrollees younger than 18 years of age, the MCO must get agency approval before placing the MCO enrollee into the PRC program; or
      2. The agency places the FFS client into the PRC program for an initial placement period of no less than 24 months.
  9. Initial placement in the PRC program.
    1. When an FFS client is initially placed in the PRC program, the agency places the FFS client for no less than 24 months with a primary care provider (PCP) for care coordination and a pharmacy for all medication prescriptions and one or more of the following types of health care providers:
      1. Prescriber of all controlled substances if different than PCP;
      2. Hospital for nonemergency services unless referred by the assigned PCP or a specialist. An FFS client may receive covered emergency services from any hospital; or
      3. Another qualified provider type, as determined by agency program staff on a case-by-case basis; or
      4. Additional pharmacies on a case-by-case basis.
    2. Based on a medical necessity determination, the agency may make an exception to PRC rules when in the best interest of the client. See WAC 182-501-0165 and 182-501-0160.
    3. When an MCO enrollee is initially placed in the PRC program, the MCO restricts the MCO enrollee for no less than 24 months with a primary care provider (PCP) for care coordination and a primary pharmacy for all medication prescriptions and one or more of the following types of health care providers:
      1. Prescriber of controlled substances if different than PCP;
      2. Hospital for nonemergency services unless referred by the assigned PCP or a specialist. An MCO enrollee may receive covered emergency services from any hospital;
      3. Another qualified provider type, as determined by MCO program staff on a case-by-case basis; or
      4. Additional pharmacies on a case-by-case basis.
  10. MCO enrollees changing MCOs. MCO enrollees:
    1. Remain in the same MCO for no less than 12 months for initial placement and whenever the enrollee changes MCOs, unless:
      1. The MCO enrollee moves to a residence outside the MCO's service area and the MCO is not available in the new location;
      2. The MCO enrollee's assigned PCP no longer participates with the MCO and is available in another MCO, and the MCO enrollee wishes to remain with the current provider;
      3. The MCO enrollee is in a voluntary enrollment program or a voluntary enrollment county.
      4. The MCO enrollee is in the address confidentiality program (ACP), indicated by P.O. Box 257, Olympia, WA 98507; or
      5. The MCO enrollee is an American Indian/Alaska native.
    2. Placed in the PRC program must remain in the PRC program for no less than 24 months regardless of whether the MCO enrollee changes MCOs or becomes an FFS client.
  11. Notifying the client about placement in the PRC program. When the client is initially placed in the PRC program, the agency or the MCO sends the client and, if applicable, the client's authorized representative, a written notice that:
    1. Informs the client of the reason for the PRC program placement;
    2. Informs the client of the providers the client has been assigned to;
    3. Directs the client to respond to the agency or MCO to take the following actions if applicable:
      1. Change assigned providers, subject to agency or MCO approval;
      2. Submit additional health care information, justifying the client's use of health care services; or
      3. Request assistance, if needed, from agency or MCO program staff; and
    4. Informs the client of administrative hearing or appeal rights (see subsection (16) of this section).
  12. Selection and role of assigned provider. A client has a limited choice of providers.
    1. The following providers are not available:
      1. A provider who is being reviewed by the agency or licensing authority regarding quality of care;
      2. A provider who has been suspended or disqualified from participating as an agency-enrolled or MCO-contracted provider; or
      3. A provider whose business license is suspended or revoked by the licensing authority.
    2. For a client placed in the PRC program, the assigned:
      1. Provider(s) must be located in the client's local geographic area, in the client's selected MCO, and be reasonably accessible to the client.
        1. PCP supervises and coordinates health care services for the client, including continuity of care and referrals to specialists when necessary.
          (A) The PCP:
          (I) Provides the plan of care for clients that have documented use of the emergency department for a reason that is not deemed to be an emergency medical condition;
          (II) Files the plan of care with each emergency department that the client is using or with the emergency department information exchange;
          (III)Makes referrals to behavioral health treatment for clients who are using the emergency department for behavioral health treatment issues.
        2. (B) The assigned PCP must be one of the following:
          (I) A physician;
          (II) An advanced registered nurse practitioner (ARNP); or
          (III) A licensed physician assistant (PA)
          (iii) Prescriber of controlled substances prescribes all controlled substances for the client;
          (iv) Pharmacy fills all prescriptions for the client; and
          (v) Hospital provides all hospital nonemergency services.
    3. A client placed in the PRC program must remain with the assigned provider for 12 months after the assignments are made, unless:
      1. The client moves to a residence outside the provider's geographic area;
      2. The provider moves out of the client's local geographic area and is no longer reasonably accessible to the client;
      3. The provider refuses to continue to serve the client;
      4. The client did not select the provider. The client may request to change an assigned provider once within 30 calendar days of the assignment;
      5. The MCO enrollee's assigned PCP no longer participates with the MCO. In this case, the MCO enrollee may select a new provider from the list of available providers in the MCO network or follow the assigned provider to the new MCO; or
      6. The client is in the address confidentiality program (ACP), indicated by P.O. Box 257, Olympia, WA 98507.
    4. When an assigned prescribing provider no longer contracts with the agency or the MCO:
      1. All prescriptions from the provider are invalid 30 calendar days following the date the contract ends;
      2. The client must choose or be assigned another provider according to the requirements in this section.
  13. PRC placement.
    1. The initial PRC placement is no less than 24 consecutive months.
    2. The second period of PRC placement is no less than an additional 36 consecutive months.
    3. Each subsequent PRC placement is no less than 72 consecutive months.
  14. Agency or MCO review of a PRC placement period. The agency or MCO reviews a client's use of health care services before the end of each PRC placement period described in subsection (13) of this section using the guidelines in subsection (7) of this section.
    1. The agency or MCO assigns the next PRC placement if the usage guidelines for PRC placement in subsection (7) of this section apply to the client.
    2. When the agency or MCO assigns a subsequent PRC placement, the agency or MCO sends the client and, if applicable, the client's authorized representative, a written notice informing the client:
      1. Of the reason for the subsequent PRC program placement;
      2. Of the length of the subsequent PRC placement;
      3. That the current providers assigned to the client continue to be assigned to the client during the subsequent PRC placement;
      4. That all PRC program rules continue to apply;
      5. Of administrative hearing or appeal rights (see subsection (16) of this section); and
      6. Of the rules that support the decision.
    3. The agency or MCO may remove a client from PRC placement if the client:
      1. Successfully completes a treatment program that is provided by a substance use disorder (SUD) service provider certified by the agency under chapter 182-538D WAC;
      2. Submits documentation of completion of the approved treatment program to the agency; and
      3. Maintains appropriate use of health care services within the usage guidelines described in subsection (7) of this section for six consecutive months after the date the treatment ends; or
      4. Successfully stabilizes due to the usage of treatment medications including, but not limited to, Buprenorphine.
    4. The agency or MCO determines the appropriate placement for a client who has been placed back into the program.
    5. A client remains placed in the PRC program regardless of change in eligibility program type or change in address.
  15. Client financial responsibility. A client placed in the PRC program may be billed by a provider and held financially responsible for nonemergency health care services obtained from a nonpharmacy provider when the provider is not an assigned or appropriately referred provider as described in subsection (12) of this section. See WAC 182-502-0160.
  16. Right to administrative hearing or appeal.
    1. An FFS client who disagrees with an agency decision regarding placement or continued placement in the PRC program has the right to an administrative hearing regarding placement. An FFS client must request an administrative hearing from the agency within 90 days of the written notice of placement or continued placement to exercise this right.
    2. An MCO enrollee who disagrees with an MCO decision regarding placement or continued placement in the PRC program has a right to appeal this decision in the same manner as an adverse benefit determination under chapter 182-538 WAC.
    3. The agency conducts an administrative hearing according to chapter 182-526 WAC.
    4. A client who requests an administrative hearing or appeal within 10 calendar days from the date of the written notice of an initial PRC placement will not be placed in the PRC program until ordered by an administrative law judge (ALJ) or review judge.
    5. A client who requests an administrative hearing or appeal more than 10 calendar days from the date of the written notice of initial PRC placement will remain placed in the PRC program until a final administrative order is entered that orders the client's removal from the program.
    6. A client who requests an administrative hearing or appeal in all other cases and who has already been assigned providers will remain placed in the PRC program unless a final administrative order is entered that orders the client's removal from the program.
    7. An ALJ may rule the client be placed in the PRC program prior to the date the record is closed and before the date the initial order is issued based on a showing of just cause.

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

  1. The agency may receive an administrative hearing request from the individual regarding assignment to PRC. Call HCA at 800-351-6827 or Office of Administrative Hearings at 800-583-8271 regarding PRC administrative hearing requests.
  2. The agency issues the notice to the individual when the individual is assigned to PRC when the medical review indicates the individual overuses medical services or uses medical services inappropriately or unnecessarily as determined by the agency's review of the individual:
    1. Medical records and other documents which indicate the individual's use of medical services meets the criteria in WAC 182-501-0135 (6); and
    2. Diagnoses, the history of services provided or other medical information supplied by the health care provider or managed care plan.
  3. When an individual has been enrolled in more than one managed care plan during the review period, the agency obtains and evaluates the individual's medical records and other documents from all agency-contracted managed care plan(s) in which the individual is or has been enrolled during the review period.
  4. When HCA designates a PCP, pharmacy, hospital or other providers for the individual, HCA inputs the assigned providers into the ProviderOne billing system. Providers have access to this information when they swipe the ProviderOne Services Card or through the benefit inquiry which identifies the individual as an individual in the patient review and coordination program.

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Incarceration overview

Revised date

Background: 

Prior to July, 2017, Washington Apple Health (Medicaid) was closed when a person receiving coverage became incarcerated. Following the passage of SSB 6430 Medicaid Suspension, the Health Care Authority (HCA) was directed to suspend, not terminate Medicaid coverage for individuals in a correctional setting. The bill also directed HCA to accept applications from justice involved (JI) individuals in these settings during their incarceration period. While a JI individual’s Medicaid is suspended, the scope of coverage is limited to inpatient hospitalizations lasting longer than 24 hours.

To be eligible for Apple Health, the JI individual must meet program requirements, including income. For individuals in Department of Corrections (DOC) facilities (state prisons), the facility will complete a Medicaid application. For individuals in a city/county jail, the facility may allow individuals to apply depending upon its available resources (staffing, etc.).

HCA receives a daily interface from DOC and the statewide Jail Booking and Reporting System (JBRS) to facilitate the suspension of Medicaid coverage for the incarcerated. Suspended coverage means the individual is eligible for Medicaid, but all claims payment and managed care assignment is suspended while the individual is in custody. For claims payment, suspension means only inpatient claims can be paid. Once an individual is released, full scope Medicaid coverage is reinstated. Justice involved individuals with Medicaid coverage will simultaneously show both a Medicaid and a jail suspension coverage group in ProviderOne. This means the individual is incarcerated and only has coverage for inpatient hospitalization.

DSHS continues to process applications for 1290 related individuals as well as other ‘Classic’ SSI-related cases (aged, or disabled and entitled to Medicare). An individual who is not age 65 or older, or not eligible for SSI or Medicare, should apply for Apple Health through Healthplanfinder (HPF). There are organizations with staff helping people apply throughout the state, but the level of services to support this varies depending upon local area resources.

Applications for the Justice-Involved Individual

Applications for Medicaid generally fall into two groups: individuals currently incarcerated and applications for an inpatient hospitalization. Depending on whether the applicant is related MAGI or non-MAGI, the applications go to either DSHS or Healthplanfinder (HPF). Clients who are 65 years of age or older, or receive SSI or Medicare need to apply through DSHS. Others need to apply for MAGI-based coverage in HPF. 

In some instances applications are processed prior to the date of release. In the past this was possible due to a signed Memorandum of Understating (MOU) between the Medicaid agency and the facility. The MOU defines roles and responsibilities of the facility and HCA. The MOU also defines the timeline for when applications can be submitted prior to release. Now that the agency has the capability to suspend Medicaid coverage for those incarcerated in a city, county, or state correctional facility the need for MOUs is diminished.  Facilities can now submit an application for Apple Health while the individual is incarcerated. For those who are eligible, coverage is suspended based on incarceration data received nightly. When the individual is released from custody, suspension is lifted automatically and full scope coverage is reinstated. 

Medicaid Eligibility while Incarcerated - Suspension

The federal rule for Apple Health does not prohibit having an individual open/active on Apple Health while residing in a correctional facility, but it does prohibit HCA from receiving federal match while the individual is incarcerated. Under current policy, an incarcerated individual can retain their Apple Health eligibility indefinitely, however, their scope of coverage will change. When an individual is incarcerated HCA suspends full scope coverage and limits it to inpatient hospitalization only.  While incarcerated the agency also suspends any payments to managed care organizations, behavioral health organizations, and any other Medicaid-related service authorizations. 

Apple Health coverage for inmates of a public institution (i.e. jail or prison) that are admitted for an inpatient hospitalization or to a chemical dependency treatment facility

Inmates of public institutions, such as a prison or jail, may be Apple Health eligible if they are categorically relatable and income/resource eligible for an Apple Health program. There is no need to have an inpatient event to be program relatable. Individuals can be determined Medicaid eligible at any time and the system will suspend coverage overnight if incarcerated. 

Applications for individuals in a correctional facility or public institution

Prior to release from a public institution, individuals may apply for public assistance and/or Medicaid. The CSO needs to accept these applications.

  1. Expedited medical assistance for people with mental disorders before release from public institutions.
    The enactment of House Bill 1290 in 2005 requires the department to perform expedited eligibility determinations and provide timely access to medical assistance for individuals with mental disorders being released from confinement. The goal is to provide eligible people with a medical assistance identification card on the date they are released, whenever possible. MAGI-related individuals will most likely apply for Apple Health with the assistance of an IPA or corrections staff. Individuals entitled to Medicare must apply through Washington Connections or use the paper application HCA 18-005.
  2. Chemical dependency treatment
    Individuals may apply for a determination of financial eligibility to allow the institution to arrange for chemical dependency assessment and treatment placement. Accept applications from individuals whose situation is described above and determine eligibility or notify the individual of necessary verification and follow-up.
  3. Program options for inmates
    The Department of Corrections (DOC) and county and city jails have a variety of programs that may be used in placing offenders outside public institutions. The Program options for the justice involved matrix is intended to clarify how placement in a correctional program affects a person's eligibility for public assistance or Apple Health benefits. 

SSI/SSDI suspended by SSA for JI Individuals

Title XVI clients (SSI)

The Social Security Administration stops an SSI cash benefit, if an individual is incarcerated for more than 30 days, and reduces it to $30 if an individual goes into a medical facility for more than 30 days. SSA suspends eligibility for the cash benefit, if the stay continues for up to 12 months. It terminates eligibility for the benefit after 12 months. If an individual discharges while still in suspense, Medicaid can be reinstated. SSA will need to do a ‘technical review’ of their living arrangement, income, and resources; a new disability determination is not needed. The individual must go to SSA in person, however, to get the cash benefit reinstated.

SSI terminated prior to discharge. If SSI is terminated while the individual is at the state hospital, then SSA will require a new SSI application and a new disability determination, with the exception of concurrently entitled clients detailed below (i.e., Title XVI and Title II). SSA will accept a new application up to 90 days in advance of an individual’s release date. 

Title II clients (SSDI)

Individuals who are admitted to the state hospital or prison after conviction of a crime will have their Title II benefits suspended.

SSDI suspended due to IMD stay

An individual continues to have disability status even if the diary date has passed while they were in the hospital or jail. For Medicaid purposes, SSI related Medicaid can be approved without a new disability decision. There is no ‘technical review’ for a Title II claim as it is not considered a needs-based payment. For someone who was receiving Title II, but has not yet turned 65 or become eligible for Medicare, an application through Healthplanfinder (HPF) should be made first, to see if the person will income eligible for MAGI coverage.

For both SSI and SSDI clients, the individual must be discharged/released from the incarceration setting or hospital before a suspended benefit can be put back into payment status.

Medicare – When Title II closes, Medicare entitlement often continues. However the Part B benefit usually closes for nonpayment of premiums. 

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

Revised date
Purpose statement

The program of all-inclusive care for the elderly (PACE) provides long-term services and supports (LTSS), medical, mental health and chemical dependency treatment through a department-contracted managed care plan using a personalized plan of care for each enrollee.

WAC 182-513-1200 and WAC 182-513-1230 describes the eligibility for PACE.

WAC 182-513-1200 Long-term services and supports authorized under Washington Apple Health programs

WAC 182-513-1200 Long-term services and supports authorized under Washington Apple Health programs

Effective February 20, 2017

  1. Long-term services and supports (LTSS) programs available to people eligible for noninstitutional Washington apple health coverage who meet the functional requirements.
    1. Noninstitutional apple health coverage in an alternate living facility (ALF) under WAC 182-513-1205.
    2. Community first choice (CFC) under WAC 182-513-1210.
    3. Medicaid personal care (MPC) under WAC 182-513-1225.
    4. For people who do not meet institutional status under WAC 182-513-1320, skilled nursing or rehabilitation is available under the CN, medically needy (MN) or alternative benefits plan (ABP) scope of care if enrolled into a managed care plan.
  2. Non-HCB waiver LTSS programs that use institutional rules under WAC 182-513-1315 and 182-513-1380 or HCB waiver rules under chapter 182-515 WAC, depending on the person's living arrangement:
    1. Program of all-inclusive care for the elderly (PACE) under WAC 182-513-1230.
    2. Roads to community living (RCL) under WAC 182-513-1235.
    3. Hospice under WAC 182-513-1240.

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

Eligibility for PACE is based on institutional or home and community-based (HCB) waiver rules; the rules depends on the setting a person resides. If in a medical facility, institutional rules are used for financial eligibility. If in the home or community, waiver rules are used for financial eligibility.

WAC 182-513-1230 Program of all-inclusive care for the elderly (PACE)

WAC 182-513-1230 Program of all-inclusive care for the elderly (PACE).

Effective February 20, 2017

  1. The program of all-inclusive care for the elderly (PACE) provides long-term services and supports (LTSS), medical, mental health, and chemical dependency treatment through a department-contracted managed care plan using a personalized plan of care for each enrollee.
  2. Program rules governing functional eligibility for PACE are listed under WAC 388-106-0700, 388-106-0705, 388-106-0710, and 388-106-0715.
  3. A person is financially eligible for PACE if the person:
    1. Is age:
      1. Fifty-five or older and disabled under WAC 182-512-0050; or
      2. Sixty-five or older;
    2. Meets nursing facility level of care under WAC 388-106-0355;
    3. Lives in a designated PACE service area;
    4. Meets financial eligibility requirements under this section; and
    5. Agrees to receive services exclusively through the PACE provider and the PACE provider's network of contracted providers.
  4. Although PACE is not a home and community based (HCB) waiver program, financial eligibility is determined using the HCB waiver rules under WAC 182-515-1505 when a person is living at home or in an alternate living facility (ALF), with the following exceptions:
    1. PACE enrollees are not subject to the transfer of asset rules under WAC 182-513-1363; and
    2. PACE enrollees may reside in a medical institution thirty days or longer and still remain eligible for PACE services. The eligibility rules for institutional coverage are under WAC 182-513-1315 and 182-513-1380.
  5. A person may have to pay third-party resources as defined under WAC 182-513-1100 in addition to the room and board and participation.

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

PACE is a voluntary program that provides long-term care and acute medical services to older and disabled clients. The client can be enrolled in PACE in their own home, a residential setting, or in a medical institution. Enrollment is effective the first day of the month and disenrollment is effective the last day of the month. Clients are eligible for PACE services on the first of the month following the date the client is financially and functionally eligible.

There are a few exceptions to regular institutional rules. A person must be 55 years of age or older for PACE and there are no transfer of asset penalties. Modified Adjusted Gross Income (MAGI) clients are also eligible to be enrolled in PACE.

Clients receiving PACE in a medical institution are required to pay towards their PACE services under institutional post-eligibility rules (WAC 182-513-1380). A client in the community pays for their PACE services using the rules for Home and Community Services (HCS) HCB waiver post-eligibility rules (WAC 182-515-1509). If the client receives PACE under a MAGI Medicaid program, they do not pay participation.

PACE is "all inclusive;" a person should not have out-of-pocket medical expenses (e.g., health insurance, copayments, etc.). When a PACE enrollee reports medical expenses, they cannot be allowed as deductions. The client is not required to pay the expense, the expenses are covered by PACE.

Worker Responsibilities

ACES requires a PACE Provider ID and the Provider ID can be located in ACES Provider Search. The financial worker will enter the Provider ID along with the HCBS indicator (A) for PACE. The indicator will drive eligibility for L31 and L32 programs. Since the PACE Provider has its ID entered, the PACE provider receives all LTC-related letters.

Financial will be notified by the end of the month prior to PACE enrollment date. ACES does not allow future start dates, so financial will process the program change or approval on the first business day of the month that PACE services are authorized.

Note: The L31 & L32 coverage groups are used for both hospice as a program and PACE. This is because both hospice as a program and PACE both use the same HCB waiver rules for eligibility. ACES determines which program (hospice or PACE) a client is on based on the service indicator and facility coded on the ACES institutional services screen. A PACE recipient cannot receive hospice as a service because they receive all care through the PACE provider.

HCS Financial staff are not responsible for ongoing maintenance of a MAGI PACE client unless client is no longer eligible for their MAGI Medicaid program. HCS Financial will redetermine the appropriate Medicaid program for ongoing coverage if the client is financially eligible.

When a PACE client disenrolls from PACE, the HCS Financial staff will receive a Financial / Social Services Communication form (DSHS 14-443) indicating the client’s disenrollment. Disenrollment from PACE is effective the last day of the month. The client should be redetermined for other Medicaid programs and the financial staff should coordinate with social services to determine if other HCS services will be authorized in the ongoing months.

Related Links

Social Service WACs:

388-106-0700 What services may I receive under PACE?

388-106-0705 Am I eligible for PACE services?

388-106-0710 How do I pay for PACE services?

388-106-0715 How do I end my enrollment in the PACE program?

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Non-Grant Medical Assistance (NGMA) hearings

Revised date

Clarifying information

The Office of Administrative Hearings schedules the following hearing types as HCA Hearings and sends a notice of the hearing to the DSHS Administrative Hearing Coordinator (AHC):

  • Non-Grant Medical Assistance decisions made by Division of Disability Determination Services (DDDS).
  • Medical Assistance decisions made by the Health Care Authority regarding:
    • Medical equipment and services, or
    • Managed care eligibility or services, or
    • Restricted use of medical care, or
    • Coordination of Benefits (TPL) issues.

Representation may be from the department, agency, or office that made the decision (e.g. issue related to denial of a medical service or choice of a managed care plan).

In most situations, the AHC acts as the agency representative and the other office or agency provides witnesses to testify regarding the Department or agency decision that is being contested.

AHC responsibilities

There are several offices within the (HCA) that make decisions which are subject to administrative hearings. It is important to contact the appropriate office as soon as a notice of hearing is received to coordinate representation.

  1. Medical assistance hearings:
    1. For hearings involving medical services, equipment, transportation, managed care enrollment, and Patient Review and Coordination (PRC) program contact the HCA's Office of Hearings and Appeals at: MS 445531, 360-725-1254 or 800-351-6827.
      1. The HCA staff may act as the agency's representative for these cases, coordinate testimony of medical consultants, help obtain additional medical information, and arrange medical examinations, if necessary.
      2. The HCA Appeals Administrator will coordinate review and implementation of hearing decisions as required by HCA.
      3. The DSHS AHC acts as liaison between HCA staff and the Appellant and their representative if required. For example, if the Appellant requests an in-person hearing and it is scheduled at the local CSO, the DSHS AHC may assist the ALJ and the Appellant during the hearing because HCA staff participates in the hearing telephonically from Olympia, WA.
  2. For insurance issues, contact HCA's Revenue, Recovery and Premium Payment Section or HCA's Coordination of Benefits Section, as appropriate:
    1. COB Health Units: 800-562-3022 ext # 16134
    2. COB Casualty Unit: 800-562-3022 ext # 15462
    3. RRPS Premium Payment: 800-562-3022 ext # 15473
  3. For eligibility and policy issues, when clarification is required, contact Eligibility Policy and Innovative Customer Supports (EPICS) inbox at: HCA AH Eligibility Policy or MS 45534.
  4. For hearings involving CHIP (N13), After Pregnancy Coverage (N04/N24/N07/N27), BCCTP (S30) or other cases assigned to CSO 76 contact Ariane Takano 360-725-1795 MS 45531 or contact 800-351-6827.
  5. Non-grant medical assistance (NGMA) hearings: The AHC acts as the agency representative, and a Division of Disability Determination Services (DDDS) employee provides testimony to support the decision. Individuals have up to 90 days to request a hearing on a NGMA decision. As soon as the hearing request is received:
    1. Initiate reconsideration of the original decision by completing in hard copy a DSHS 14-144, Transmittal Summary, and check the box for Administrative Hearing Review. The reconsideration is a required step in the DDDS process prior to hearing. Request continuances as appropriate to allow sufficient time for the reconsideration.
    2. Forward the DSHS 14-144 and the DDDS original decision packet in hard copy to the appropriate DDDS office. Attach any new medical documentation and release of information authorizations, if appropriate. (Do not use the automated Barcode referral process for administrative hearing reviews.)
    3. Notify DDDS of the scheduled date and time of the hearing.
    4. Coordinate requested continuances from either the appellant or DDDS with the local OAH office. Continuances are often necessary in these cases to obtain additional medical information. It is important that the AHC keep all parties informed of the status of the case prior to the hearing.
    5. Notify the appellant if the original DDDS decision is reversed in the DDDS review process.
    6. If the original denial is affirmed in the DDDS review process, consult with the DDDS hearing supervisor who will assign someone to testify in support of the denial.

Note: A hearing request is not always needed for the Dept. to review a NGMA decision. Individuals may ask for a review within 30 days of the initial denial if medical evidence exists that was not used to make the original decision. Please follow the above steps and note on the referral that it is a reconsideration of denial.

DDDS hearings contact:
Michael Magill
Hearings manager
360-664-7394
MS 45550

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Change of circumstance

Revised date
Purpose statement

A person who is eligible for Medically Needy (MN) coverage with a spenddown liability is required to report changes in their circumstances following rules in WAC 182-504-0105. Whether the person has already met their spenddown liability or is still in pending status, we are required to consider the effect of the change on the individual's eligibility.

Worker responsibilities

The following are some common examples of changes in circumstance and some guidance on the action needed by the worker.

The only eligible individual dies or becomes ineligible before the end of the base period

In this situation you will need to shorten the base period and recalculate the spenddown amount, whether the spenddown has been met or not.

Example

Dennis, an SSI-related individual, elected a 6-month base period and had a total spenddown liability of $738 ($123 per month). Sadly, Dennis passes away in month four of the base period. The worker should close the case. If Dennis was still in pending status and had not met spenddown, recalculate the spenddown based on a 4-month base period and send an amended letter showing the new amount to be $492. Note: There may be outstanding medical bills that can be applied to the spenddown even after Dennis' death.

The head of household/primary applicant passes away

When the HOH of a MAGI passes away, go to Healthplanfinder to report a change and remove the Primary Applicant (PA). This will close the deceased’s MAU as of the date of death.

If there are other active individuals receiving WAH under the deceased PA, those AUs will also close, but with advance and adequate notice.

When there is a surviving spouse and other dependents who are receiving WAH and there is enough information to redetermine eligibility, start a new application with the surviving spouse as the HOH and include the other dependents. Submit the application. Send them a general correspondence letter with the following text:

"Please accept our condolences for your loss. Based on the information we had on your household’s previous application, we have opened coverage with you as the head of household on a new application. If any of the information has changed or is incorrect, please create or log in to your Healthplanfinder account at www.wahealthplanfinder.org to correct the information. You may also call the Health Benefit Exchange call center at 1-855-923-4633 to report the change and update your application."

If there is not enough information to redetermine eligibility, start an application, submit it, and request the needed information from the individual.

If there is no surviving spouse or the surviving spouse was not receiving WAH, those closed from MAGI will automatically receive a letter telling them to reapply.

The household reports an increase in income

If the individual reports an increase in income, we need to recalculate the spenddown amount for the remaining months in the base period.

If the individual has not met spenddown and is still in pending status, the worker needs to send a new letter to the individual indicating that their spenddown liability has increased.

If the individual has already met spenddown and the MN coverage is active, the worker needs to:

  • Terminate the MN coverage (with advance and adequate notice),
  • Recalculate the new spenddown liability for the remaining months in the base period, and
  • Send an amended spenddown letter, showing the additional amount of spenddown liability the household needs to incur.

When calculating the additional spenddown liability amount, the individual must be given a credit for the remaining months in the base period. The example below shows how to calculate the amount of the credit. Enter the credit amount as a paid expense type 'MU' in ACES and document that this is a workaround to give the individual the benefit of the credit. When the individual reapplies for MN coverage, the credit will be applied to the individual's new spenddown.

Example

Norma receives social security disability of $720 per month. Her spenddown liability is $156 ($26 per month) based on a 6-month base period from February through July.

She met her spenddown on March 10 and is active on MN medical. On May 5, she reports that she started receiving a small pension in the amount of $115 per month. Terminate medical coverage effective the end of May.

Recalculate the spenddown liability for the months of June and July. Since Norma had already met her spenddown for a 6-month period, and she has only received coverage for a 4-month period, we need to allow her a credit towards the new increased liability based on the number of months left until the end of the original base period. In this example, her spenddown amount was $26 per month so she receives a 'credit' of $104. ($26 x 4 months). Code the $104 as a paid expense type 'MU' in ACES online, and the credit will be applied to the individual's next base period.

The household reports a decrease in income

If the individual reports a decrease in income that brings their income below the CN income standard:

  • Close the medically needy assistance unit,
  • Screen the individual for the categorically needy (CN) program,
  • Recalculate the spenddown liability for the months prior to the approval for CN medical by shortening the base period, and
  • Send an amended spenddown letter to reflect the new liability amount for this prior period.

Example

Josie, a pregnant woman has income over 193% FPL at the time of her application for pregnancy medical. Her baby is due in July. In April, she reports and verifies she is no longer working and her income is now below the CN standard. The worker would approve Josie for CN medical (Apple Health for Pregnant Women) effective April 1 (the first of the month in which she reported her change and was found CN eligible). She is now continuously eligible for CN coverage through the birth and the 2 months post partum period.

The worker would also recalculate the spenddown amount for the prior months and send an amended letter to advise her of the lower amount. If she incurred medical expenses through March that were more than the recalculated spenddown amount, she would qualify for MN coverage and the agency would cover her medical expenses for the time period after she met her recalculated spenddown and before she became eligible for CN coverage.

The household reports a change in household composition

When the household reports a change in household composition (someone moves into or out of the home), the worker needs to recalculate the spenddown for the balance of the base period and giving 10 days advance and adequate notice if this is an adverse action.

Example: someone moves out of the household

Katie, an SSI-related individual, applies for medical coverage in December. She is married and has a 17 year old daughter Lucy. Her spenddown liability is $300 for a 6-month base period.

In February, Lucy moves out of the home. With Lucy no longer living in the home, Katie's spenddown amount will increase because she loses the child allowance.

If Katie has not yet met spenddown, the worker should recalculate the spenddown amount for March, April and May without the child allowance and send an amended spenddown letter for the new total liability amount.

If Katie has already met spenddown, the worker should terminate MN coverage (giving advance and adequate notice of the adverse action) and generate a new letter showing the increase in additional spenddown liability.

Example: Someone moves into the household, causing household to qualify for CN coverage

Ken is 68 years old and lives alone. He has monthly income of $857 Social Security disability and has a spenddown of $978 with a base period from June through November. In July, he reports that his new wife Valerie moved into his home. Valerie has no income and has a current disability determination. She is applying for medical coverage for herself also.

Recalculate medical eligibility for her and Ken. Based upon their reported income, you determine this household is now CN eligible.

If Ken has already met spenddown, close his MN coverage and screen in a CN medical program for both, effective the first of the month in which he reported the change and in which Valerie applied for medical coverage for herself.

If Ken had not already met spenddown, authorize the CN coverage effective the first of the month in which he reported the change. Recalculate the spenddown liability for the months prior to the CN approval and generate an amended MN spenddown letter showing the reduced liability amount.

Example: Same as previous, except Valerie does not apply for coverage and Ken does not qualify for CN coverage

The facts are the same as the example above, except that Valerie is not applying for medical coverage for herself or is not SSI-related. The worker would still need to redetermine the effect of the change on Ken's medical coverage. Since Valerie is a nonapplying spouse, the worker would reduce Ken's countable income by allocating income to her.

If Ken has not already met spenddown, recalculate eligibility for the months of July through November. With the spousal allocation, he would be eligible for MN without spenddown. The worker would:

  • Certify S95 coverage for Ken through the balance of the base period,
  • Recalculate the spenddown liability for June by shortening the base period to the month of June only, and
  • Send an amended spenddown liability for this month.

Ken will need to meet the new spenddown amount before June coverage could be approved.

Nonapplying spouse applies for medical coverage after applying spouse receives MN coverage

In many cases involving a married couple, individuals have to choose who will receive health care coverage because of the effects of income deeming. Couples may choose the same person for each base period or may alternate who gets coverage. However; there are some situations when MN coverage has already been certified for one spouse and the other spouse has a medical emergency where they also need coverage during the same base period. The following example explains the steps and calculations needed to determine eligibility for the new applying spouse.

Example

Jim and Carla are a married SSI-related couple. They have a 6-month base period from January through June. They both have income and the spenddown liability when both of them apply is too high for them to meet. However, when only one applies for coverage, their spenddown liability is reduced to $100 per month ($600 for six months). They opt to apply for MN coverage for Jim since he has a chronic ongoing health condition and he has no other coverage.

They present medical expenses to the agency in January, and they meet his spenddown liability of $600 on January 10.

On March 18, Jim calls his case worker and tells him that Carla was admitted to the hospital on March 3 and they need to apply for medical for her also. She was in the hospital for 4 days, and they now have a bill for $45,000 which they cannot pay.

The worker would do the following:

  • Terminate MN coverage for Jim effective March 31.
  • Screen in a new S02 AU with both Jim and Carla as applicants with a request date of March 1.
  • Shorten the base period to match the original S99 certification through the end of June.
  • Recalculate the spenddown liability for the period March through June (4 months) and send them a new letter showing the increased spenddown amount which includes both Jim and Carla's income.
  • Since Jim has already paid for his share of the 4 full months remaining in his base period, credit them $400 towards the new higher spenddown liability (4 months x the original $100 per month liability).
  • Code the $400 as a paid 'MU' expense in ACES so that it is credited towards the new spenddown amount.
  • Use the $45,000 hospital bill incurred on March 3 to meet the spenddown for both.

They will be responsible for the spenddown amount, but the agency will be able to pay on the balance of the bill for them.

For more information on income deeming and allocation, see SSI-Related - Income - Allocation and Deeming.

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