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Institutional coverage for individuals eligible under a MAGI based program:
With the exception of N21 and N25 (both AEM), all MAGI based N-track programs determined by the Health Benefit Exchange (HBE) provide nursing facility coverage or Medicaid Personal Care (MPC) coverage if functionally eligible.
Individuals on MAGI based N-track programs do not pay participation toward the cost of care.
For individuals needing services in a medical institution such as a hospital, nursing facility or Children's Long-term Inpatient Program (CLIP) and are not eligible for a MAGI based program determined by HBE (N track) because income is over the standard, there is an institutional medical program called MAGI-based long term care program. In ACES this program is under the K-track.
This program uses MAGI income and resource methodology.
The eligibility for this program is determined by staff at the Health Care Authority (HCA).
Eligibility for this program is described below.
Effective February 25, 2023.
This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.
Effective February 29, 2016.
This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.
Effective February 29, 2016.
Applicants for and recipients of the modified adjusted gross income (MAGI)-based long-term care program are exempt from the transfer-of-asset evaluation under WAC 182-513-1363, and there is no resource test.
This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.
Effective July 1, 2017
This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.
Effective February 29, 2016.
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.
The person must meet institutional status by residing in an institution for 30 days or longer. For the agency to use institutional rules in a hospital setting, the person must have been in the medical facility continuously for 30 days. If a person discharges from hospital to a nursing home with no break, the hospital days count towards the 30 day limit. A person admitted to a nursing facility must meet nursing facility level of care.
Apply online at the Washington Healthplanfinder website. On the Additional Screening Questions page, answer yes to question that asks if anyone in the household needs long-term care and indicate that you or the applicant is residing in a hospital or other medical facility setting.
For hospitals assisting a patient with an application:
If free Apple Health coverage is not approved, send a follow-up email to K01App@hca.wa.gov and provide the following information:
Note: By submitting the online application HCA can ensure that coverage is looked at for all household members and enables HCA to open continued coverage for the child at discharge. If the child is eligible for free Apple Health coverage in the Washington Healthplanfinder, no additional information is needed.
If facilities receive a paper application (18-001), these should be imaged and emailed to K01App@hca.wa.gov.
US citizens, US nationals, and noncitizens who are lawfully admitted for permanent residence who have met the 5-year bar can be eligible. Children under the age of 19 may be eligible without regard to citizenship. Non citizen children are not eligible for coverage under the medically needy (MN) program, only the categorically needy (CN) program.
Adults may qualify under the Alien Emergency Medical (AEM) K03 program if they meet the requirements under the acute and emergent criteria for inpatient hospitalization.
Please refer to Clarifying Information under the AEM chapter on Apple Health Alien Medical programs for instructions on how to process applications.
Once the person has met the 30-day requirement, only the income of the institutionalized person is counted. For adults, this means the income of their spouse is not included in the eligibility determination. For children, the income of their parents is not included in the eligibility determination but do count any income they get in their own name, including social security income or other MAGI-based income received by the child.
This is dependent upon the age of the individual person. See below:
Medically needy (MN) coverage is available for children and adults through the age of 21. There is no MN coverage for adults over the age of 21 (unless the person is already in treatment in an inpatient psychiatric facility in which case, they remain eligible until they discharge or turn 22, whichever occurs first).
There is no asset test.
K01 can be used for an adult if they meet the following criteria, and the person is not eligible for MAGI based N-track medical through the HBE:
Adults between the age of 21 and 65 are not eligible for Medicaid if they are admitted to a long-term psychiatric treatment program at Western or Eastern State hospital. Children and adults under the age of 21 can qualify for Medicaid coverage for inpatient psychiatric treatment. If the person is in treatment and turns 21 at the facility, they can stay open on Medicaid until they discharge or until they turn 22 whichever happens first. (Adults age 65 and older may also qualify for Medicaid under the SSI-related long-term care program).
K01 is categorically needy (CN) medical coverage and is initially approved with a 12-month certification. Children under the age of 19 remain continuously eligible for the full 12 months even if they discharge from the facility. Noninstitutional MAGI- based health care coverage should be opened for any remaining months of the certification period. Adults aged 19 or older will have eligibility redetermined when they leave the facility.
If a child discharges from a medical facility and has already been approved under the K01 program, HCA will change this to a children’s medical program at discharge without the requirement to submit a review. They will get the balance of their certification under the CN medical program. If the review is due after their discharge and the family is over income for a noninstitutional medical program, the family may choose to have a medically spenddown case or enroll the child into a qualified health plan through the Health Benefit Exchange if eligible.
If a required renewal is due and the individual fails to follow through with the process, the case will be closed.
Those eligible under MAGI-based long-term care don't pay toward the cost of care.
The person may be subject to Estate Recovery provisions for long-term care services received.
If a child is eligible under the premium based Apple Health for Kids program, the Agency redetermines eligibility under K01 so that the family doesn't pay a premium for that child and the child can receive a year of CN coverage.
For MAGI-based programs determined by the HBE, (N-track programs in ACES), no institutional award letter is issued.
For nursing facilities and hospitals, these are paid as a claim through Provider One.
For MAGI-based programs through the K-track program, an institutional award letter will be issued by HCA.
Managed Care and Long-term Care: scroll to: Nursing Home Admissions under a modified adjust gross income (MAGI) medical group.