Long-term care

Revised date
Purpose statement

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

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

Long-Term Care services include the following programs:

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

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

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

Effective February 20, 2017

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

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

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

Please report broken links or content problems.

Health care for pregnant individuals

Revised date
Purpose statement

Washington apple health -- Eligibility for pregnant individuals

WAC 182-505-0115 Washington apple health -- Eligibility for pregnancy and after-pregnancy coverage.

WAC 182-505-0115 Washington apple health -- Eligibility for pregnancy and after-pregnancy coverage.

Effective June 24, 2022.

  1. A pregnant person is eligible for Washington apple health pregnancy coverage if the person:
    1. Meets citizenship or immigration status under WAC 182-503-0535;
    2. Meets Social Security number requirements under WAC 182-503-0115;
    3. Meets Washington state residency requirements under WAC 182-503-0520 and 182-503-0525; and
    4. Has countable income at or below the limit described in:
      1. WAC 182-505-0100 to be eligible for categorically needy (CN) coverage; or
      2. WAC 182-505-0100 to be eligible for medically needy (MN) coverage. MN coverage begins when the pregnant person meets any required spenddown liability as described in WAC 182-519-0110.
  2. A noncitizen pregnant person who does not meet the requirements in subsection (1)(a) or (b) of this section is eligible for apple health pregnancy coverage if they meet countable income standards for CN or MN coverage as described in subsection (1)(d) of this section.
  3. The assignment of medical support rights as described in WAC 182-503-0540 does not apply to pregnant people.
  4. A person who was eligible for and covered under any CN or MN scope of coverage apple health program on the last day of pregnancy remains continuously eligible for after-pregnancy coverage for 12 months, beginning the month after their pregnancy ends. This includes people who meet an MN spenddown liability with expenses incurred no later than the date the pregnancy ends.
  5. Pregnancy coverage has CN scope of care for all people except those enrolled through the MN program who have MN scope of care. A person's after-pregnancy coverage has the same scope of coverage as their pregnancy coverage.
  6. A person who does not meet the requirements in subsection (4) of this section may qualify for after-pregnancy coverage if they:
    1. Apply for and meet all requirements of the apple health pregnancy coverage program other than pregnancy; and
    2. Apply any time during their 12-month postpartum period to receive ongoing medical coverage until the end of the 12th month after their pregnancy ends.

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

Pregnancy medical (N03, N23)

This program provides Categorically Needy (CN) coverage with countable income at or below 210% of the FPL without regard to citizenship or immigration status. Once enrolled in Apple Health for Pregnancy, the individual has continuous coverage regardless of any change in income through the end of the month after the pregnancy ends (e.g., pregnancy ends June 10, Apple Health for Pregnancy coverage continues through June 30th).

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

Effective November 2024

Household size Monthly income limit
1 NA
2 $3,662
3 $4,626
4 $5,590
5 $6,554
6 $7,518

Medically needy pregnant women (P99)

This program provides Medically Needy (MN) coverage to pregnant individuals with income above 210% of the FPL. Individuals who qualify for and enroll in Apple Health for Medically Needy Pregnant Women become eligible for MN coverage after incurring medical costs equal to the amount of the household income that is above the 210% FPL standard. For more explanation of MN benefits, see that section of this publication.

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

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

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

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

Family Planning Only (P06)

This program provides services for those with incomes at or below 260% FPL coverage for pre-pregnancy family planning services to prevent unintended pregnancies.

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

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

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

Effective March 28, 2025

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

To be eligible for family planning only services, as defined in WAC 182-532-001, a client must:

  1. Provide a valid Social Security number (SSN) or proof of application to receive an SSN, be exempt from the requirement to provide an SSN as provided in WAC 182-503-0515, or meet good cause criteria listed in WAC 182-503-0515(2);
  2. Be a Washington state resident, as described under WAC 182-503-0520;
  3. Have an income at or below two hundred sixty percent of the federal poverty level, as described under WAC 182-505-0100;
  4. Need family planning services; and
  5. Have been denied apple health coverage within the last 30 days, unless the applicant:
    1. Has made an informed choice to not apply for full-scope coverage as described in WAC 182-500-0035 and 182-501-0060, including family planning;
    2. Is age 18 or younger and seeking services in confidence;
    3. Is a domestic violence victim who is seeking services in confidence; or
    4. Has an income of 150 percent to 260 percent of the federal poverty level, as described in WAC 182-505-0100.
  6. A client is not eligible for family planning only medical if the client is:
    1. Pregnant;
    2. Sterilized;
    3. Covered under another apple health program that includes family planning services; or
    4. Covered by concurrent creditable coverage, as defined in RCW 48.66.020, unless they meet criteria in (1) (e) of this subsection.
  7. The agency does not limit the number of times a client may reapply for coverage.

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

Effective April 2023

Household size Monthly income limit
1 $3,159
2 $4,273
3 $5,386
4 $6,500
5 $7,614
6 $8,727

Find additional information about Family Planning Only.

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Health care for children

Revised date
Purpose statement

Apple health for kids

Apple Health for Kids coverage is free to children in households with income at or below 210% of the FPL and available for a monthly premium to children in households with income at or below 312% of the FPL.

WAC 182-505-0210 Eligibility for children.

WAC 182-505-0210 Eligibility for children.

Effective December 8, 2023.

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

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

April 1, 2021

Household size Monthly income limit
210% FPL
(No Cost)		 Monthly income limit
260% FPL
($20 Premium Child, $40 Maximum)		 Monthly income limit
312% FPL
($30 Premium/Child, $60 Maximum)
1 $2,254 $2,791 $3,349
2 $3,049 $3,775 $4,530
3 $3,843 $4,758 $5,710
4 $4,638 $5,742 $6,890
5 $5,432 $6,726 $8,071
6 $6,227 $7,709 $9,251

Apple health for newborns (N10):

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

Apple health for kids (N11, N31):

This program provides CN coverage to children under age 19 whose families have income at or below 210% of the FPL. Children who would have been eligible for Apple Health for Kids except for not meeting the immigration status requirements receive CN coverage under state-funded Apple Health for Kids.

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

This program provides CN coverage to children under age 19 whose families have income above 210% and at or below 312% of the FPL in exchange for the monthly premium. Children who would have been eligible for Apple Health for Kids with premiums except for not meeting the immigration status requirements receive CN coverage under state-funded Apple Health for Kids with Premiums in exchange for the monthly premium.

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

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

Effective January 23, 2021.

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

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

Apple health for medically needy kids (F99):

This program provides MN coverage to children under age 19 whose families have income above 312% of the FPL. Children who qualify and are enrolled in Apple Health for Medically Needy Kids become eligible for MN coverage after incurring medical costs equal to the amount of the household income that is above the 312% FPL standard. For an explanation of Medically Needy benefits, please see that section of this publication.

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Health care for adults

Revised date
Purpose statement

Adult medical (N05):

This program provides CN coverage to adults with countable income at or below 133% of the FPL who are between the ages of 19 up to 65, who are not incarcerated, and who are not entitled to Medicare.

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

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

Effective August 29, 2014.

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

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

Effective April 1, 2021

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

Family medical (N01):

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

WAC 182-505-0240 Parents and caretaker relatives.

WAC 182-505-0240 Parents and caretaker relatives.

Effective July 1, 2017.

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

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

Effective April 1, 2019

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

Health care extension (HCE) (N02):

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

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

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

Effective December 28, 2019

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

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

Please report broken links or content problems.

Standards - LTSS

Revised date
Purpose statement

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

Note:

Personal Needs Allowance (PNA) chart

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

Long-Term Care Resource Standards

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

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

Excess Home Equity Standards

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

Long-Term Care Income Standards

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

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

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

Medically Needy Income Level (MNIL)

Categorically Needy Income Level (CNIL)

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

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

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

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

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

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

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

Rate is updated annually on October 1st.

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

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

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

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

Special Income Level (SIL) 300 percent of the FBR

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

Clarifying Information

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

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Automated Client Eligibility (ACES) program codes

Revised date
Program ACES Description Scope

SSI and SSI Related

SSI and SSI related also called Aged/Blind/Disabled category

Disability is determined by SSA or by NGMA referral to DDDS

 S01 SSI Recipients CNP

SSI and SSI Related

SSI and SSI related also called Aged/Blind/Disabled category

Disability is determined by SSA or by NGMA referral to DDDS

 S02 ABD Categorically Needy CNP

SSI and SSI Related

SSI and SSI related also called Aged/Blind/Disabled category

Disability is determined by SSA or by NGMA referral to DDDS

 S03 QMB Medicare Savings Program (MSP) Medicare premium and Medicare copays MSP

SSI and SSI Related

SSI and SSI related also called Aged/Blind/Disabled category

Disability is determined by SSA or by NGMA referral to DDDS

 S04 QDWI Medicare Savings Program MSP

SSI and SSI Related

SSI and SSI related also called Aged/Blind/Disabled category

Disability is determined by SSA or by NGMA referral to DDDS

 S05 SLMB Medicare Savings Program. Medicare Premium only MSP

SSI and SSI Related

SSI and SSI related also called Aged/Blind/Disabled category

Disability is determined by SSA or by NGMA referral to DDDS

 S06 QI-1 (SLMB) Medicare Savings Program MSP

SSI and SSI Related

SSI and SSI related also called Aged/Blind/Disabled category

Disability is determined by SSA or by NGMA referral to DDDS

 S07 Undocumented Alien - Emergency Related Service Only ERSO

SSI and SSI Related

SSI and SSI related also called Aged/Blind/Disabled category

Disability is determined by SSA or by NGMA referral to DDDS

 S95 Medically Needy no Spenddown MNP

SSI and SSI Related

SSI and SSI related also called Aged/Blind/Disabled category

Disability is determined by SSA or by NGMA referral to DDDS

 S99 Medically Needy with Spenddown MNP
Program ACES Description Scope

SSI Related living in an Alternative Living Facility (Non Medical Institution) Adult Family Home, boarding home or DDD Group Home

 G03 Non Institutional Medical in ALF CNP income under the SIL plus under state rate x 31 days + 38.84 CNP
SSI Related living in an Alternative Living Facility (Non Medical Institution) Adult Family Home, boarding home or DDD Group Home G95 Medically Needy Non Institutional in ALF no Spenddown MNP
SSI Related living in an Alternative Living Facility (Non Medical Institution) Adult Family Home, boarding home or DDD Group Home G99 Medically Needy Non Institutional in ALF with Spenddown MNP
Program ACES Description Scope
SSI Related Health Care for Workers w/disability S08 Health Care for Workers with Disability CNP Premium based program - Substantial Gainful Activity (SGA) not a factor in Disability determination. CNP
Program ACES Description Scope
Institutional
HCBS Waivers (HCS/DDD) and hospice		 L21 DDD/HCS Waiver on SSI CNP
SSI and SSI related L22 DDD/HCS Waiver - gross income under the SIL CNP
SSI and SSI related L24 Undocumented alien/noncitizens LTC - residential placement; must be preapproved by ADSA program manager; Emergency related service only (45 slots) ERSO - CNP
SSI and SSI related L31 PACE or Hospice on SSI (effective 10/1/2015) CNP
SSI and SSI related L32 PACE or Hospice - SSI related (effective 10/1/2015) CNP
SSI and SSI related L41 Roads to Community Living (RCL) on SSI (effective 10/1/2015) CNP
SSI and SSI related L99 Roads to Community Living - SSI related (effective 10/1/2015) CNP

Noninstitutional community first choice

Personal care services in the community

 L51 Community First Choice CFC on SSI (effective 10/1/2015) CNP

Noninstitutional community first choice

Personal care services in the community

 L52 Community First Choice - SSI-Related at home or in an ALF (effective 10/1/2015) CNP
Program ACES Description Scope

Institutional SSI - related

Residing in a medical institution 30 days or more

 L01 SSI recipient in a Medical Institution - Residing in a medical institution 30 days or more CNP

Institutional SSI - related

Residing in a medical institution 30 days or more

 L02 SSI related CNP in a medical institution income under the SIL CNP

Institutional SSI - related

Residing in a medical institution 30 days or more

 L04 Undocumented alien/non-citizen LTC must be preapproved by ADSA program manager. Emergency related service only (45 slots) ERSO - CNP

Institutional SSI - related

Residing in a medical institution 30 days or more

 L95 SSI related Medically Needy no Spenddown Income over the SIL; Income under the state rate MNP

Institutional SSI - related

Residing in a medical institution 30 days or more

 L99 SSI related Medically Needy with Spenddown; Income over the SIL; income over the state rate but under the private rate; locks into state NF rate MNP
Program ACES Description Scope
Institutional family/children TANF related income/resource rules K01 Categorically Needy family in medical institution CNP
Institutional family/children TANF related income/resource rules K03 Undocumented Alien family in medical institution - Emergency Related Service Only ERSO
Institutional family/children TANF related income/resource rules K95 Family LTC Medically Needy no Spenddown in Medical Institution MNP
Institutional family/children TANF related income/resource rules K99 Family LTC Medically Needy with Spenddown - in Medical Institution MNP
Pregnancy P02 Pregnant 185% of FPL & Postpartum Extension CNP
Pregnancy P04 Undocumented Alien Pregnant Woman CNP
Pregnancy P05 Family Planning Service Only Family planning
Pregnancy P06 Take Charge Family Planning Only  
Pregnancy P99 Medically Needy Pregnant Spenddown MNP
Refugee medical assistance R02 Transitional 4 month extension CNP
Refugee medical assistance R03 Refugee Categorically needy CNP
Program ACES Description Scope

DCFS/JRA Medical

Foster Care

 D01 SSI Recipient FC/AS/JRA Categorically Needy CNP
FC/AS/JRA Categorically Needy D02 CN CNP
Title IV-E Federal Foster Care - Under 26 D26 CN CNP
Family related medical assistance F01 TANF cash and Medicaid (ended 9/30/2013) CNP
Family related medical assistance F02 Transitional Medicaid CNP
Family related medical assistance F03 Post TANF child/spousal support (4 months max - ended 12/31/2013) CNP
Family related medical assistance F04 TANF related CNP
Family related medical assistance F05 Newborn CNP
Family related medical assistance F06 Categorically needy medical children (effective 1/1/2009, this may be CNP Medicaid children or CNP State funded children) CNP
Family related medical assistance F07 Children's health insurance program CNP
Family related medical assistance F08 Undocumented alien children (this coverage group ended 12/31/2008 and is merged with the F06 group) CNP
Family related medical assistance F09 Undocumented alien - Emergency related service only ERSO
Family related medical assistance F10 Interim Categorically needy (2 months max - ended 12/31/2014) CNP
Family related medical assistance F99 Medically needy children spenddown MNP
Program ACES Description Scope
MAGI Family Related MA N01 MAGI Parent/Caretaker Medicaid; Adult CNP
MAGI Family Related MA N02 12 Month Transitional MAGI Parent/Caretaker Medicaid; Adult CNP
MAGI Family Related MA N03 MAGI Pregnancy CNP
MAGI Family Related MA N04 After Pregnancy CNP/ABP
MAGI Family Related MA N05 MAGI Adult Medicaid; Income =<133% (Medicaid Expansion) ABP
MAGI Family Related MA N07 After pregnancy; not Medicaid eligible during pregnancy CNP
MAGI Family Related MA N10 MAGI Newborn Medical Birth to One Year CNP
MAGI Family Related MA N11 MAGI Children's Medicaid/Age Under 19 CNP
MAGI Family Related MA N13 MAGI Children's Health Insurance Program (CHIP) Children Under 19; Premium Payment Program CNP
MAGI Family Related MA N20 MAGI Adult Medical 19 - 64; Income = < 138% Apple Health Expansion AHE - State funded
MAGI Family Related MA N21 MAGI Parents/Caretaker; Emergency Only; AEM ERSO
MAGI Family Related MA N23 MAGI Pregnancy; Not Lawfully Present CNP
MAGI Family Related MA N24 After pregnancy; not lawfully present CNP
MAGI Family Related MA N25 MAGI Adult Medicaid; Noncitizen - Income =<133% (Medicaid Expansion) AEM ERSO
MAGI Family Related MA N27 After pregnancy; not lawfully present; not Medicaid eligible during pregnancy CNP
MAGI Family Related MA N31 MAGI Children's Medical; Under 19; Noncitizen State funded CNP
MAGI Family Related MA N33 MAGI Children's Health Insurance Program (CHIP): Under 19; Premium Payment Program, Noncitizen State funded CNP
ADATSA State program drug & alcohol TX program W01 ADATSA Medical state funded (ended 12/31/2013) State funded
ADATSA State program drug & alcohol TX program W02 ADATSA Medical state funded (ended 12/31/2013) State funded
ADATSA State program drug & alcohol TX program W03 Detox medical state funded (ended 12/31/2013) State funded
Program ACES Description Scope
Medical care services and ABD cash with CN Medicaid G01 MCS Medical care services (ended 8/31/2014) State funded
Medical care services and ABD cash with CN Medicaid A01 State funded Medical Care Services and ABD Cash Aged/Blind/Disabled State funded
Medical care services and ABD cash with CN Medicaid A05 Medical Care Services non citizen (under 65, incapacitated) State funded
Medical care services and ABD cash with CN Medicaid A24 Medical Care Services non citizen SFA for survivors of certain crimes State funded
Medical care services and ABD cash with CN Medicaid G02

ABD cash plus either:

  • ABD-X Presumptive SSI Federally funded CN Medicaid (ended 12/31/2013)
  • ABD-A Federally funded CNP - AGED (ended 8/31/2014)
  • ABD-D Federally funded CNP - NGMA disability determination (ended 8/31/2014)
 CNP
Program ACES Description Scope
Mental health institutional I01 Inpatient psychiatric (mental health - ended 12/31/2013) CNP
Breast and Cervical Cancer Program S30 Breast and Cervical Cancer (Health Department Approval) CNP
Program ACES Description Scope
Take Charge P06 Family Planning (Take Charge) Family Planning
Psychiatric inpatient M99 Psychiatric indigent inpatient spenddown (MI prior to 7/2003)
Mental health ONLY (ended 12/31/2013)		 Inpatient psychiatric hospital only
Tailored supports for older adults (TSOA)
HCS maintains TSOA cases		 T02 TSOA - No medical benefits and no Medicaid services card issued
Pre- Medicaid benefit for the caregiver of a person 55 or older to support the caregiver. For those not eligible for a CN or ABP Medicaid program and not needing or eligible for other LTSS services because of resources. Must meet NFLOC.		 No medical benefits
Program ACES Description Scope
Apple Health Eligibility S20 Classic Adult Medical 65+; Income = < 138% Apple Health Expansion AHE - State Funded

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

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WAC 182-531-1710 Alcohol and substance misuse counseling.

WAC 182-531-1710 Alcohol and substance misuse counseling.

Revised February 23, 2025

  1. The medicaid agency covers alcohol and substance misuse counseling through screening, brief intervention, and referral to treatment (SBIRT) services when delivered by, or under the supervision of, a qualified licensed physician or other qualified licensed health care professional within the scope of their practice.
  2. SBIRT is a comprehensive, evidence-based public health practice designed to identify, reduce and prevent problematic use, abuse, and dependence on alcohol and illicit drugs. SBIRT can be used to identify people who are at risk for or have some level of substance use disorder which can lead to illness, injury, or other long-term morbidity or mortality. SBIRT services are provided in a wide variety of medical and community health care settings such as primary care centers, hospital emergency rooms, trauma centers, and dental offices.
  3. The following health care professionals are eligible to become qualified SBIRT providers to deliver SBIRT services or supervise qualified staff to deliver SBIRT services:
    1. Advanced registered nurse practitioners, in accordance with chapters 18.79 RCW and 246-840 WAC;
    2. Substance use disorder professionals (SUDP), in accordance with chapters 18.205 RCW and 246-811 WAC;
    3. Licensed practical nurses, in accordance with chapters 18.79 RCW and 246-840 WAC;
    4. Mental health counselors, in accordance with chapters 18.225 RCW and 246-809 WAC;
    5. Marriage and family therapists, in accordance with chapters 18.225 RCW and 246-809 WAC;
    6. Independent and advanced social workers, in accordance with chapters 18.225 RCW and 246-809 WAC;
    7. Physicians, in accordance with chapters 18.71 RCW and 246-919 WAC;
    8. Physician assistants, in accordance with chapters 18.71A RCW and 246-918 WAC;
    9. Psychologists, in accordance with chapters 18.83 RCW and 246-924 WAC;
    10. Registered nurses, in accordance with chapters 18.79 RCW and 246-840 WAC;
    11. Dentists, in accordance with chapters 18.260 RCW and 246-817 WAC; 
    12. Dental hygienists, in accordance with chapters 18.29 RCW and 246-815 WAC; and
    13. Certified behavioral health support specialists, in accordance with chapters 18.227 RCW and 246-821 WAC.
  4. To become a qualified SBIRT provider, eligible licensed health care professionals must:
    1. Complete agency-approved SBIRT training and mail or fax the SBIRT training certificate or other proof of this training completion to the agency; or
    2. Have an addiction specialist certification and mail or fax proof of this certification to the agency.
  5. The agency pays for SBIRT as follows:
    1. Screenings, which are included in the reimbursement for the evaluation and management code billed;
    2. Brief interventions, limited to four sessions per client, per provider, per calendar year; and
    3. When billed by one of the following qualified SBIRT health care professionals:
      1. Advanced registered nurse practitioners;
      2. Mental health counselors;
      3. Marriage and family therapists;
      4. Independent and advanced social workers;
      5. Physicians;
      6. Psychologists;
      7. Dentists; and
      8. Dental hygienists.
  6. The agency evaluates a request for additional sessions in excess of the limitations or restrictions according to WAC 182-501-0169.
  7. To be paid for providing alcohol and substance misuse counseling through SBIRT, providers must bill the agency using the agency's published billing instructions.

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 388-79A-015 Procedure for allowing guardianship fees and related costs from client participation before June 1, 2018.

WAC 388-79A-015 Procedure for allowing guardianship fees and related costs from client participation before June 1, 2018.

Revised June 1, 2018

  1. This section describes the procedure for allowing guardianship fees and related costs from client participation when:
    1. A court order was entered before June 1, 2018; and
    2. The client under guardianship was receiving medicaid-funded long-term care before June 1, 2018.
  2. The medicaid agency or the agency's designee, after receiving the court order, adjusts the client's current participation to reflect the amounts, as allowed under WAC 182-513-1380, 183-515-1509, or 183-515-1514.
  3. A client's participation cannot be prospectively or retrospectively reduced to pay guardianship fees and related costs incurred:
    1. Before the client's long-term care medicaid eligibility effective date;
    2. During any time when the client was not eligible for or did not receive long-term care services; or
    3. After the client has died.
  4. The fees and costs allowed by the court at the final accounting must not exceed the amounts advanced and paid to the guardian from the client's participation if:
    1. The court, at a prior accounting, allowed the guardian to receive guardianship fees and related costs from the client's participation in advance of services rendered by the guardian; and
    2. The client dies before the next accounting.

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 388-79A-010 Maximum guardianship fees and related costs before June 1, 2018.

WAC 388-79A-010 Maximum guardianship fees and related costs before June 1, 2018

Revised June 1, 2018

  1. This section sets the maximum guardianship fees and related costs when:
    1. The court order was entered before June 1, 2018; and
    2. The client under guardianship was receiving medicaid-funded long-term care before June 1, 2018.
  2. For court orders entered before June 1, 2018, where the order establishes or continues a legal guardianship for a client:
    1. Guardianship fees must not exceed $175 per month;
    2. Costs directly related to establishing a guardianship for a client must not exceed $700; and
    3. Costs to maintain the guardianship must not exceed $600 during any three-year period.

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.

Other programs

Revised date

Breast and Cervical Cancer Treatment Program (BCCTP) for Women (S30):

This federally-funded program provides health care coverage for women diagnosed with breast or cervical cancer or a related precancerous condition. Eligibility is determined by the Department of Health's (DOH) Breast, Cervical, and Colon Health Program (BCCHP). DOH is responsible for screening and eligibility, while HCA administers enrollment and provider payment. Coverage continues through the full course of treatment as certified by the BCCHP.

A woman is eligible if she meets all of the following criteria:

  • Screened for breast or cervical cancer under BCCHP
  • Requires treatment for either breast or cervical cancer or for a related precancerous condition
  • Is under age 65
  • Is not covered for another CN (Categorically Needy) Apple Health program
  • Has no insurance or has insurance that is not creditable coverage
  • Meets residency requirements
  • Meets social security number requirements
  • Meets citizenship or immigration status requirements
  • Meets income limits set by the BCCHP.

For further information, see the Department of Health website.

Foster Care/Adoption Support/Former Foster Care (D01, D02, D26):

This program provides CN coverage to children receiving foster care or adoption support services. This program also provides CN coverage to individuals up to age 26 who turn 18 or age out of foster care in Washington State.

Medical Care Services (A01):

This state-funded program provides limited health care coverage to adults meeting incapacity requirements who are not eligible for Apple Health programs with CN, MN or ABP scope of care and who meet the income and resource standards for this program. Individuals over age 65 who are qualified immigrants within their 5-year bar and nonqualified immigrants are eligible for MCS if they meet income and resource requirements.

Refugee (R02, R03):

The Refugee Medical Assistance program (RMA) provides CN coverage to refugees who are not eligible for Apple Health programs with CN or ABP scope of care and who meet the income and resource standards for this program. RMA is a 100% federally funded program for persons granted asylum in the U.S. as refugees or asylees. Individuals enrolled in RMA are covered from the date they entered the U.S.

Eligibility for refugees/asylees that have been in the United States for more than twelve months is determined the same as for U.S. citizens.

Immigrants from Iraq and Afghanistan who were granted Special Immigrant status under Section 101(a)(27) of the Immigration and Nationality Act (INA) are eligible for Medicaid and Refugee Medical Assistance (RMA) the same as refugees.

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