Public programs

Revised date

Overview

Medical expenses that are paid with public program funds (other than Medicaid) may be used to reduce a client's spenddown. They must be verified by the agency providing the services. HCA has negotiated individual agreements with the agencies identified below to recognize their programs as public programs for Medicaid purposes. This allows Medically Needy (MN) clients to use expenses paid on their behalf by the participating agency toward meeting their spenddown liability.

Public programs

The approved public programs in Washington are:

  1. Lifelong AIDS Alliance (Evergreen Insurance Program)
  2. Department of Health AIDS/HIV Early Intervention Program
  3. Kidney Centers in various communities to administer the Kidney Disease Program (KDP)
  4. Kitsap Mental Health Services
  5. Indian Health Service
  6. Behavioral Health Administrative Services Organizations

To qualify as a public program, the participating agencies must ensure that no federal funds are used to pay for these individual's expenses.

Public programs do not anticipate costs for medical expenses. They must submit verification to DSHS as medical expenses are incurred by the client and paid by the program. This verification may look different for each program depending upon the expenses that are being verified.

Expenses incurred by public programs prior to a Medicaid application

Public programs may pay spenddown expenses incurred by individuals during the three-month retroactive base period. Most public programs work with their clients to help them apply for Medicaid and to help cover the medical expenses while the Medicaid application is pending.

This enables clients to use expenses that are paid by the public program during the retroactive base period as qualifying expenses towards meeting spenddown liability in either the retroactive or current base period.

Indian Health Service

HCA has negotiated an agreement with the tribes to recognize tribal clinics as public programs. Tribal clinics may use Indian Health Service (IHS) funds to pay for medical expenses on behalf of their spenddown clients. The clinic must verify IHS is responsible for the cost of the medical expense before the expense can be applied toward spenddown.

Public programs - What do I need to do?

Accept verification of the expense amount submitted by the public program unless questionable. Allow the usual and customary charge from the provider toward the individual spenddown, even if the provider has reimbursement agreements with the public program that permit them to pay less for the service.

The Department of Health uses a form to verify prescription expenses paid on behalf of Early Intervention Program enrollees. Staff may use the expense listed, minus any third-party liability payments identified by the pharmacy, to reduce an individual's spenddown liability.

ACES no longer tracks public program expenses using the "PP" expense type. Staff need to enter the appropriate code based on the type of expense that has been paid by the public program and the date the expense was incurred.

Example: The HIV/AIDS Early Intervention program verifies it paid $150 in prescription expenses on April 3 and $30 transportation expenses to a medical appointment on April 7. Code the prescription expense as ‘RX’ (prescription expense) and code the transportation expense as ‘MU’ (not covered by Medicaid). ACES computes the effective date of eligibility based upon the combination of date of service and expense type entered.

Some public programs use their funding to purchase private health insurance on behalf of individuals. When a public program verifies payment of a health insurance premium on behalf of a spenddown individual, redetermine eligibility under the MN program using the expense as an income deduction and not a spenddown expense. Health Insurance premiums are coded on the MEDX screen in ACES and not entered as a spenddown expense in ACES online. Do not allow payments for Part C Medicare premiums on the MEDX screen.

In some cases, this results in clients becoming eligible for MN with no spenddown liability, and these cases are approved for 12 months. In other circumstances, the spenddown liability is simply reduced by the health insurance premium amount. Ensure a new letter is generated to let the client know what has changed.

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Requesting an administrative hearing

Revised date
Purpose statement

Fair Hearing WAC are found in chapter 182-526 WAC

Clarifying information

  1. Either the individual or their authorized representative may request a hearing. The request must be made within 90 days of the date of the decision, but if a hearing request is received after 90 days, the administrative law judge (ALJ) determines timeliness. All hearing requests must be forwarded to the Office of Administrative Hearings (OAH) for scheduling regardless of the date of the request. See RCW 74.09.741
  2. The request does not need to be in any particular form and can be made verbally or in writing.
  3. The request can be made to any responsible agency employee.
  4. The request should include the decision being appealed and why the individual is dissatisfied with the decision. However, any request indicating dissatisfaction with an agency decision should be treated as a hearing request.
  5. An individual may request a hearing several ways:
    1. Classic Washington Apple Health (Medicaid) decisions are made by the Department of Social and Health Services (DSHS) for clients who are over age 65, receiving Medicare, or receiving long-term services and supports. A request can be made:
      1. In writing to:
        1. Community Services Office (CSO) of record (address is on the top left of any letter sent);
        2. DSHS Customer Service Center, PO Box 11699, Tacoma WA 98411;
        3. Office of Administrative Hearings, PO Box 42488, Olympia WA 98504; or
        4. DSHS fax 888-338-7410.
      2. By phone:
        1. Home and Community Services (HCS) office (phone number is on the top right of any letter sent);
        2. DSHS Customer Service Contact Center at 877-501-2233; or
        3. Office of Administrative Hearings at 800-583-8271.
      3. In person at any HCS or CSO office.
    2. MAGI-based Washington Apple Health decisions are made through Washington Healthplanfinder for clients who are under age 19, under age 65 without Medicare, or pregnant/post-partum. A request can be made:
      1. In writing to:
        1. Health Care Authority, PO Box 45531, Olympia WA 98504;
        2. Washington Health Benefit Exchange (WAHBE) Appeals, PO Box 1757, Olympia WA 98507;
        3. Office of Administrative Hearings, PO Box 42488, Olympia WA 98504;
      2. By phone:
        1. Washington Healthplanfinder customer support at 855-923-4633;
        2. Health Care Authority at 800-562-3022; or
        3. Office of Administrative Hearings at 800-583-8271.
      3. By fax to 1-855-867-4467.
      4. By email to Ask MAGI.

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Working clients on long-term care services and supports

Revised date
Purpose statement

This section explains how to choose the correct program when a client is working and needs long-term services and supports (LTSS). 

Consult the Apple Health for Workers with Disabilities (HWD) section for complete information.

All documents for LTSS are sent to:

ALTSA PO Box 45826 Olympia WA 98504-5826 or FAX 1-855-635-8305

Working clients on HWD and receiving Long-Term Services and Supports (LTSS)

  • HWD provides categorically needy (CN) scope of care . Those eligible may receive either Community First Choice (CFC) or Medicaid Personal Care (MPC).
  • HWD is included as an eligibility group in the Home and Community Based Services (HCBS) Waivers authorized by HCS or DDA.
  • HWD clients receiving CFC, MPC or an HCBS Waiver remain on the medical coverage group S08.
  • The functional approval for HCBS Waiver, CFC or MPC is made by the HCS or DDA social worker or case manager. The HCBS service is coded on the S08 in ACES.

What makes HWD (S08) better than using HCB Waiver rules (L22)?

  • No asset test for HWD.
  • No income test for HWD (income is verified for the premium calculation).
  • May have gross income over the special income level (SIL).
  • No client responsibility (participation) for the cost of care. There is a monthly HWD premium.
  • HWD clients in alternate living facilities (ALF) are responsible to pay the room and board standard to their provider and the HWD premium to the Office of Financial Recovery (OFR).
  • Earned income can be over the Social Security substantial gainful activity (SGA) limit. SGA is waived for the HWD program. SGA is a factor in determining disability for all the other SSI related Medicaid including HCB Waivers.

When is an HCBS Waiver program rules better than HWD?

  • The client's income is low enough where there is no, or less, client responsibility than the HWD premium.
  • The client is not interested in saving more in resources than the $2,000 amount allowed under the HCBS Waiver.

How is HWD like other SSI-related medical (CN)?

  • Same application form.
  • SSI-related rules when determining eligibility.
  • A non-grant medical assistance (NGMA) disability decision is needed if there is no current disability determination. A disability decision is needed for HWD clients 65 and over if there is no disability date indicated on the BENDEX, SDX or in the case record. Disability is an eligibility factor for HWD even if the client is age 65 or older.
  • Categorically Needy (CN) scope of care.

How is HWD different from other SSI-related medical (CN)?

  • No resource test.
  • No income standard - clients pay monthly premiums instead of a spenddown or client participation responsibility based on income.
  • Only designated HWD staff determine eligibility.
  • The client must be employed full or part-time (including self-employment) as described in WAC 182-511-1200 at initial application and in the month of renewal.
  • The substantial gainful activity (SGA) limit is not a factor for HWD. For all other SSI-related Medicaid programs, the SGA is an aspect of the disability criteria. Earnings can't equal or exceed the SGA amount. For HWD disability, this test does not apply. For an under age 65 client earning over the SGA standard, HWD is the only SSI-related program that should be considered if the client is not receiving a payment from SSA based on disability.
  • Resources accumulated in a separate account, designated by the client, that result from work activity during the client's enrollment in HWD are excluded per WAC 182-512-0550. If a client needs a redetermination to another program because they are no longer employed at renewal or are admitted into a nursing facility for 30 days or more, the accumulated resource is excluded. This account is coded as "Earnings Accumulated while Enrolled in HWD-Exempt MA (EH)" in ACES

Note: HWD covers short stays (29 days or less) in nursing homes. HWD does not cover medical institutionalization (Nursing Facility or Residential Habilitation Center (RHC) projected 30 days more. A redetermination under an L-track program is needed for HWD clients residing in a NF or RHC for 30 days or more.

Working Clients and HCBS Waiver programs (L22)

  • ACES supports the 65 and 1/2 earned income disregard in post eligibility for CN HCBS Waivers.
  • Expenses for self-employment are based on actual costs per SSI related rule in Chapter 182-512 WAC.
  • Impairment related work expenses (IRWE) are not allowed as a deduction in both initial and post eligibility for HCBS Waivers under the L22 program.

Working clients in a Medical Institution

  • Working clients in a medical institution don't receive the 65 and 1/2 earned income disregard in initial or post eligibility.
  • WAC 182-513-1380 (4) allows a post eligibility deduction for:
    • Mandatory taxes out of wages.
    • Department-approved training or rehabilitative program designed to prepare the client for a less restrictive placement. When determining this deduction employment expenses are not deducted. The employment must be approved by Division of Vocational Rehabilitation (DVR), HCS or DDA case manager.
  • The client's personal needs allowance (PNA), mandatory taxes, department approved wage deductions and guardianship fee deductions cannot exceed the MNIL.

Coding Department Approved Training or Rehabilitative Program Earnings for clients in Medical Institutions.

Clients with earnings in medical facilities must have their employment plan approved by HCS or DDA the social worker, case manager, or Division of Vocational Rehabilitation (DVR) to receive an allowance for the earnings. ACES is programmed to do the calculation correctly if the earnings are coded as Rehabilitation Income (RH).

Clients receiving services through DDA in an RHC, or ICF-ID are approved automatically through their care plan with DDA.

Clients receiving services in a Nursing Facility must have an approval with the HCS Social Worker to receive an allowance for the earnings. The Public Benefits Specialist will need to request an approval as part of the care plan from the HCS SW to code as RH in ACES.

HWD public benefit specialists (PBS)

HWD eligibility is done by specialists for both DDA and HCS. Current HWD specialists for the DDA LTC specialty team and HCS are found under clarifying information Apple Health for Workers with Disabilities.

DDA LTC specialty unit HWD public benefit specialists:

  • HWD barcode assignments are forwarded to the DDA LTC Specialty Unit via DMS under @HWD/017
  • DDA LTC specialty unit HWD Phone: 1-800-871-9275
  • To request an active HWD case from DDA LTC specialty unit, set a same day barcode tickler to @HWD for HCS 17 requesting the transfer. Indicate the HCS office that is requesting the transfer.
  • The financial record is requested from the DDA LTC HWD specialty unit when HCS services are opened
  • An application for HWD and HCS services goes to the HCS HWD regional specialist.
  • An application for HWD and no HCS services goes to the DDA LTC HWD specialty unit.

Worker Responsibilities for HWD receiving HCS or DDA services

  • A preliminary HWD premium can be determined using trial eligibility on a pending or active S08 AU. Indicate a HWD start date on the pending AU to get a projected HWD premium, and then delete the HWD start date if you are not ready to process the case.
  • HWD receiving HCBS Waiver services are subject to transfer of asset, annuity declaration and excess home equity provisions that are specific to institutional programs (L22). MPC or CFC services are not subject to the transfer of asset provisions. An HWD client with a transfer penalty can't get HCBS Waiver services.
  • The medical coverage group S08 must be used for HWD clients for the premium bill to go out to the client from OFR. (HCBS Waiver, CFC or MPC service information is indicated on the Institutional Care screen under the HCBS service field).
  • HWD specialists inform the client and the client case manager/social worker when a tickler is received from OFR regarding overdue premiums. It is important for the client and/or their representative to pay the HWD premium to OFR timely. There are penalties described in the HWD chapter when premium payments are overdue. This penalty could result in no HWD coverage for 4 months which could affect the client's eligibility for continued services. Follow NSA/equal access provisions to notify the case manager if client is behind on their premiums.
  • When a Non-grant medical assistance (NGMA) is needed for HWD, make sure the following language is added to the NGMA cover sheet to DDDS: Disability determination is needed for Health Care for Workers with Disabilities (HWD). SGA is waived for this program. A NGMA is also needed for an HWD applicant that is 65 or older and there is no disability indicated on the BENDEX, SDX or established by a NGMA in the case record.
  • If an HWD client's job ends and HWD continues to be the preferable program, it is continued through the certification period if the premium continues to be paid unless the HWD client is on an HCBS Waiver service and there would be no participation with that program. Always consider the program that is most beneficial for the client. per HWD rule, the change is effective the first of the following month.
  • Premium adjustments based on income changes occurs on the first of the following month.
  • Code the appropriate LTSS service and service start date on the Institutional Care screen based on the HCS 14-443 or the DDA 15-345
  • For people applying for HCS services who are employed follow management bulletin H19-071 Apple Health for Workers with Disabilities for detailed instructions on referring a case to the regional HCS HWD specialist.

What should staff do if a client reports employment or wants to be employed?

For HCS Staff:

  • Notify the HWD PBS in your region if the client is not an SSI and may benefit from HWD. Clients on SSI report their wages to the Social Security Administration for the determination of Medicaid. If the client is on food benefits, wages must be reported to PBS staff.
  • Notify the Employment Specialist in your Region when a HCS client starts employment or wants to be employed:
  • Send or give the client information on the HWD program: HCA 22-333 Apple Health for Workers with Disabilities.

Applicants:

  • When a request is received, via an application for HWD, the Financial Applications Customer Service Specialist or the Public Benefit Specialist based on regional processes will make the initial contact and document the following in narrative:
    • Is the client physically working or not? This does not include collecting sick leave and other employment based benefits.
    • If speaking with the client, verbally request verification of earnings, if current electronic information is not found in TALX.
    • Forward the application to the appropriate regional HWD PBS.
  • The HWD PBS will review the application within 5-days of receipt. If discovered that it will be more beneficial for the applicant to receive HCBS Waiver services, the HWD PBS will communicate to the HCS PBS based on regional processes for assigning new applications and the PBS will process the HCBS Waiver application. The PBS will also communicate vice versa to the HWD Specialist.

Recipients:

  1. The current PBS will request verification of earnings by sending the Employment Verification (Form No. 14-252). You can attach this form to an ACES letter.
  2. Send an email correspondence to your Regional HWD Specialist. Do not forward in DMS.
  3. The HWD Specialist will be responsible for closing and opening HWD cases, the HWD specialist will redetermine eligibility for the appropriate medical program.
  4. If there is any overpayment for HCBS Waiver or Basic Food (SNAP), the PBS for the assigned alphabet will process it.

DDA Public Benefit Specialist (PBS) staff:

Process for a client currently receiving DDA services who is working and their income and/or resources are over the current program limit(s); when a change is reported by the client, a CRM via 15-345, or the LTC PBS discovers the change:

  1. The current medical program remains active to allow the client to provide verification or take corrective action to remain income and resource eligible.
  2. The LTC PBS will contact the client or authorized representative (AREP) and request additional information by phone and/or mailing a Request for Information letter (023-02) to include specified mandatory text based on the Long-Term Care & Specialty programs Unit's process and procedures.
    1. Income: The LTC PBS will review and verify the current and anticipated ongoing income, and budgeting method; to include if the client's income has reduced, is temporary, or if the client plans to reduce their work hours.
    2. Resource: The LTC PBS will review, and address excess resource; to include if the client plans to spenddown or convert to an excludable resource.
  3. After the LTC PBS reviews and verifies all changes they will determine if an HWD referral is required.

If the client's income and/or resources are, and will continue, to exceed the program limit, and if the client/AREP prefers to maintain their current income and/or resources with the understanding that they will have to pay a monthly premium for medical benefits:

  • The LTC PBS will document in the narrative, set a communication (COMM) tickle to @HWD notifying the HWD Specialists of the request for HWD consideration, and notify the client via mail of the HWD; referral.
  • Current medical program will remain active during the HWD referral process;
  • Once HWD eligibility has been determined, the HWD specialist will terminate the current medical program.

Process for a working client who has just been determined functionally eligible for DDA services and their income is over the CN limit or SIL:

  • The LTSS PBS will start application process to include completing an interview, and requesting required verification that is needed to determine financial eligibility. One verification is received, and the LTSS PBS determines an HWD referral is needed; the LTSS PBS will document in the narrative, and notify the HWD specialists for HWD.

Only an HWD specialist will determine financial eligibility if a client is changing from HWD to another medical program.

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Medicaid Alternative Care (MAC)

Revised date
Purpose statement

To describe the Medicaid Alternative Care program and the eligibility requirements for a person to become eligible.

WAC 182-513-1600 Medicaid Alternative Care (MAC) - Overview

WAC 182-513-1600 Medicaid Alternative Care (MAC)

Effective July 1, 2017

Medicaid alternative care (MAC) is a Washington apple health benefit authorized under section 1115 of the Social Security Act. It enables the medicaid agency and the agency's designees to deliver an array of person-centered long-term services and supports (LTSS) to unpaid caregivers caring for a medicaid-eligible person who meets nursing facility level of care under WAC 388-106-0355.

  1. For services included with the MAC benefit package, see WAC 388-106-1900 through 388-106-1990.
  2. For financial eligibility for MAC services, see WAC 182-513-1605.

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 182-513-1605 Medicaid alternative care (MAC) - Eligibility.

WAC 182-513-1605 Medicaid alternative care (MAC) — Eligibility.

Effective July 1, 2017

  1. The person receiving care must meet the financial eligibility criteria for medicaid alternative care (MAC).
  2. To be eligible for MAC services, 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, and choose to receive services under the MAC program instead of other long-term services and supports;
    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;
    6. Meet citizenship and immigration status requirements under WAC 182-503-0535 (2)(a) or (b); and
    7. Be eligible for either:
      1. A noninstitutional medicaid program, which provides categorically needy (CN) or alternative benefit plan (ABP) scope of care under WAC 182-501-0060; or
      2. An SSI-related CN program by using spousal impoverishment protections institutionalized (SIPI) spouse rules under WAC 182-513-1660.
  3. An applicant whose eligibility is limited to one or more of the following programs is not eligible for MAC:
    1. The medically needy program under WAC 182-519-0100;
    2. The medicare savings programs under WAC 182-517-0300;
    3. The family planning program under WAC 182-505-0115;
    4. The family planning only programs under chapter 182-532;
    5. The medical care services (MCS) program under WAC 182-508-0005;
    6. The alien emergency medical (AEM) program under WAC 182-507-0110 through 182-507-0120;
    7. The state funded long-term care for noncitizens program under WAC 182-507-0125;
    8. The kidney disease program under chapter 182-540 WAC; or
    9. The tailored supports for older adults (TSOA) program under WAC 182-513-1610.
  4. The following rules do not apply to services provided under the MAC benefit:
    1. Transfer of asset penalties under WAC 182-513-1363;
    2. Excess home equity under WAC 182-513-1350; and
    3. Estate recovery under chapter 182-527 WAC.

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

Clarifying Information

MAC creates a new optional choice for people who are eligible for CN or ABP Medicaid but not currently accessing Medicaid-funded LTSS and provides services to unpaid caregivers designed to assist them in providing quality care to family members while also improving their own well-being. MAC offer services to support the needs of the person who is providing care to a family member so they are able to continue to provide care.

People who choose services under the MAC benefit must make a choice between receiving MAC services or traditional LTSS services (such as the COPES waiver or Community First Choice (CFC)).  A person who chooses to receive CFC may not also receive support services for an unpaid family member.  

What are the financial eligibility criteria for MAC?

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
  • Eligible for CN or ABP Medicaid coverage
  • Eligible for SSI-related CN Medicaid if spousal impoverishment protections are applied. 

If a person wants to apply for MAC services and the person is not already eligible for Medicaid, they must submit an HCA 18-005 Application for Aged, Blind, Disabled/Long-term care, or may apply for MAGI coverage by applying through the Washington Healthplanfinder.  A person may be authorized services under the Tailored Supports for Older Adults (TSOA) program while the Medicaid application is being processed. 

What are the functional eligibility criteria for MAC?

  • The person receiving care must meet nursing facility level of care (NFLOC) and doesn't need to have a disability determination.
  • The person providing care must be age 18 or older and meet the criteria under WAC 388-106-1905 WAC.

A person may be prescreened for MAC services by either Home and Community Services or by the Area Agency on Aging (AAA) office.  However all services are authorized at the AAA.

How do spousal impoverishment protections work for a MAC applicant?

Spousal impoverishment protections apply to a MAC applicant who meets the following criteria:

  • The applicant is married and the spouse doesn't live in an institution;
  • The applicant isn’t otherwise eligible for noninstitutional SSI-related CN Medicaid because of:
    • income deemed available to them from a nonapplying spouse; or
    • resources over the $3000 couple limit;
  • The applicant’s separate net income is below the SSI federal benefit rate.

For more information see Clarifying Information under WAC 182-513-1660.

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

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

Recovery and TEFRA liens (Chapter 182-527 WAC)

Estate Recovery doesn't apply to services paid by the MAC 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 client has been approved for MAC services. 

Financial staff are responsible for ongoing case maintenance on MAC clients.  If the case is managed by the CSO, the HCS financial worker will transfer the case into HCS to case manage and update the case to show the MAC approval and start date.  This includes processing food assistance requests if applicable.   

Note:  HCS staff don’t manage MAGI or Breast and Cervical Cancer cases.  

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500 Series reason codes

Revised date
Purpose statement

500 Series Reason Code Protocols

Go to the Reason Code Link chart to link directly to a specific reason code or scroll through the list below.

For ACES procedures go to ACES Letters in the ACES User Manual.

Reason code Reason code description WAC references
- Classic Medicaid		 Free form text
- Classic Medicaid		 WAC references
- MAGI-Based Medicaid		 Free form text
- MAGI-Based Medicaid

520

Change in Federal law

There has been a change in the Federal law that regulates this program.

None

None required

 182-518-0005 None required

525

No Eligibility Review Form - We haven't received your eligibility review or renewal form.

HPF

You have not completed your renewal for Washington Apple Health

388-434-0005

388-434-0010

388-492-0090

388-492-0110

388-492-0100

388-400-0070

None required

182-504-0035

None required

528

Eligibility Review Form incomplete

The eligibility review or renewal form we received wasn't complete.

HPF

The renewal form that you sent to us was not complete.

We need you to complete the form before we can determine your eligibility.

388-492-0110

388-492-0100

388-400-0070

388-434-0005

388-492-0090

You must return the completed form to us by 00/00/00 in order for your benefits to continue.

182-504-0035

None required
529

Termination/Denial due to nonpayment of premium

Health coverage stopped for the children listed above because you are three months behind in premium payments. Washington Apple Health with premiums coverage can't start again until the premiums are paid.

     182-505-0225 None required

531

Voluntary withdrawal for excess resources

You withdrew your request for assistance because you have too many resources to get assistance right now.

388-513-1350

388-406-0050

None required

    
532

State-funded LTC - Program Full

The state-funded long-term care services program is subject to caseload limits. The program is currently full. We aren’t enrolling new members at this time. See WAC rule (Washington Administrative Code):

     182-507-0125 None required

534

Family Medical To 12-month medical extension

Your cash benefits will stop because of earnings. Medical benefits for your family will continue under the Medical Extension Benefit program. You will get a separate letter to tell you about this program. See WAC rule (Washington Administrative Code):

Not applicable

Not applicable

    

535

Error in initial eligibility - Removed continuous tracking for child - For administrative use only

None

Specify the reason for termination and a WAC related to that reason.

    
538

TSOA Closure

You can’t receive services under this program when you are eligible for certain Medicaid programs. See WAC rule (Washington Administrative Code):

     182-513-1615 None required

542

We got your change report form. Some information is still missing. We sent you a letter telling you what you need to give to us. We did not get it.

388-418-0011

Specify what is missing.

    

544

Your bank didn't honor your premium payment.

None

None required

    

550

Voluntary withdrawal

You withdrew your request for assistance. See WAC rule (Washington Administrative Code):

HPF

You withdrew your request for Washington Apple Health

388-406-0050

388-492-0020

None required

 

182-503-0080

None required

551

Whereabouts unknown

We don’t know where you are. See WAC rule (Washington Administrative Code):

388-458-0030

388-492-0020

None required

182-518-0005

182-503-0520

182-503-0525

182-504-0105

  

552

Failed to provide verification

You did not give us the information we needed.

HPF

You didn't give us the information we asked for.

182-503-0050

388-400-0070

388-472-0005

388-490-0005

388-458-0020

388-492-0020

On 00/00/00, I asked you to provide some information by 00/00/00. I still need:

List of items

182-503-0050

__________???
554

RCL Error in Initial Eligibility

You didn’t meet Medicaid eligibility on the day of your discharge from a medical institution. See WAC rule (Washington Administrative Code):

     182-513-1235 Describe the reason the client was not initially eligible for Medicaid.

555

Application opened in error - For administrative use only

None

None required

    

557

AU requests closure

You asked us to stop your assistance.

HPF

You asked us to stop your Washington Apple Health coverage

None

 

None required

 

182-503-0080

None required

558

Failed to cooperate in securing other income and resources

You have income or resources that you could use but you haven’t made a reasonable effort to get them. If there is a good reason why you have not done this, please tell us. See WAC rule (Washington Administrative Code):

388-400-0070

388-458-0020

388-472-0005

388-490-0005

388-492-0020

You told us that you have (type of income/resource). To become eligible, you must try to make it available by __ (specify what they must do to make income or resource available).

 182-503-0050  

559

Client already received assistance in another AU for this benefit month

Although you can belong to more than one assistance unit, you can only get benefits from one at a time.

388-400-0005

388-400-0010

388-400-0025

388-400-0030

388-400-0040

388-400-0045

388-400-0060

388-400-0070

You are already getting medical assistance.

    

561

AU screened in error - System generated only

None

None required

    

562

Due to your child(ren)'s immigration status they do not qualify for Medicaid. The Children's Health Program is now full and your child(ren) are on a waiting list. When an opening occurs, you will be contacted to review family circumstances. See WAC rule (Washington Administrative Code)

  

Specify which children.

 182-505-0210  

564

Noncooperation with TPL process

You did not cooperate in obtaining another source of coverage for your medical care. See WAC rule (Washington Administrative Code):

  

You told us that you could get help with medical from (specify TPL source).

    

566

Refused to cooperate with application process

You refused to cooperate in the application process. Based on the information we have, we are unable to determine your eligibility. See WAC rule (Washington Administrative Code):

HPF

You have not cooperated with the application process. Based on the information we have, we are unable to determine your eligibility.

388-400-0070

388-406-0025

388-406-0035

388-406-0050

388-406-0060

388-452-0005

388-492-0020

388-406-0050

You did not __ . If you need help, let me know and I will try to assist you.

182-503-0080

  

572

User voided application - For administrative use only

None

None required

    

577

Missed application deadline - For administrative use only

None

None required

    

587

Already eligible for program in different AU - For administrative use only

388-408-0035

388-412-0005

The following persons aren't eligible for medical assistance for [MM/YYYY] because they already received medical assistance in another household:

list name of ineligible persons

NOTE: You may need to manually create a denial or termination letter or add text to the ACES system-generated letter.

    

588

Ineligible ESLMB already receiving MA

You are not eligible for the ESLMB program because you are receiving Medicaid benefits. See WAC rule (Washington Administrative Code):

You are not eligible for the Qualified Individual (QI-1) Program because you are receiving Medicaid Benefits. You are eligible for the State-funded Buy-In Program. We will pay for your Medicare Part A premiums, if you have any, as well as your Part B premiums, coinsurance, and deductibles.

  

None required

 182-517-0300  

589

Based on your current medical information, you are no longer disabled under Social Security rules. See WAC rule (Washington Administrative Code):

388-511-1105

None required

    

590

You have a penalty period because you gave away a non exempt asset or sold it for less than fair market value.

You, your representative or guardian, or with your consent, the facility where you live, may request an undue hardship waiver if you can show that without LTC services you will be deprived of housing, food, clothing or medical care and that your health or life will be endangered.

The request must be:

  • In writing
  • State the basis for requesting the undue hardship waiver
  • Be signed by the requestor and include the requestor's name, address and telephone number and
  • Be made within 90 days of the date of denial or termination of LTC services.

388-513-1363

388-513-1364

388-513-1365

388-513-1367

Explain the amount of the transfer used to determine the penalty or penalties periods. Indicate the dates the penalty period starts and ends.

    

596

Failure to pursue Medicaid

You aren't eligible for ABD cash or Housing and Essential Needs (HEN) Referral because you failed to pursue Medicaid.

388-400-0060

388-400-0070

(Social Service Specialist provides mandatory free form text via 14-118)

    

599

Other - For user generation only

None

None required

(If used for ABD or HEN Referral denial or termination, Social Service Specialist provides mandatory free form text via 14-118)

    

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Post-eligibility index

Revised date
Purpose statement

This section describes the process that is used to determine participation. This is also called the post-eligibility treatment of income (PETI). PETI only applies to institutional long term care services and Home and Community Based (HCB) Waivers.

Participation in a Medical Facility

Determining a client's financial participation in the cost of care for long-term care (LTC) services

WAC 182-513-1380. This section describes the post-eligibility treatment of income (PETI) process for determining participation for individuals residing in a medical institution such as a nursing home or DDA RHC.

Participation for HCB Waivers

How does the department determine how much of my income I must pay towards the cost of my care if I am only eligible for home and community based (HCB) services under WAC 182-515-1508?

HCS HCB Waiver. WAC 182-515-1509. This section describes the post-eligibility treatment of income (PETI) process for determining participation for individuals receiving a HCB Waiver authorized by HCS.

How does the department determine how much of my income I must pay towards the cost of my DDA waiver services if I am not eligible for Medicaid under a categorically needy program (CN) listed in WAC 182-515-1512

DDA HCB Waiver WAC 182-515-1514.This section describes the post-eligibility treatment of income (PETI) process for determining participation for individuals receiving a HCB Waiver authorized by DDA.

Additional participation references and links

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Apple Health Kidney Disease Program (KDP)

Revised date

What is the Kidney Disease Program?

The Kidney Disease Program (KDP) is a state-funded program that helps low-income, eligible clients with treatment costs for end-stage renal disease.

Client eligibility is determined by each contracted kidney center. Eligibility is based on the program's residential and medical criteria in addition to income and asset standards.

Contracted kidney centers require clients to apply for medical programs that provide medical coverage such as Medicaid, Medicare, supplemental insurance, or employer sponsored insurance.

Program manuals

Program information

Income and resource standards

For program questions, please email the Kidney Disease Program.

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Medicare Part D staff handout

Revised date
Purpose statement

This section has the text of the Prescription Drug Coverage handouts used by HCS staff.

If you receive Medicaid and Become Eligible for Medicare-Recipient

Once you become eligible for Medicare, you no longer use your Med ID card to pay for most of your prescription drugs. You will now get most of your prescription drugs through Medicare Part D and the Prescription Drug Plan (PDP) you enroll in.

It is important that you enroll in a PDP so that the plan will be effective the month you become eligible for Medicare.

Getting enrolled in a Prescription Drug Plan (PDP)

The Centers for Medicare and Medicaid Services (CMS) sends you an enrollment packet “Welcome to Medicare” before you become eligible for Medicare. The explanation for how to enroll in a PDP is in this packet.

A PDP is insurance that covers both brand name and generic prescription drugs at participating pharmacies in your area. There are many different types of plans to choose from that vary in cost, coverage, and yearly deductibles.

Be sure to ask about the premium and copays when comparing plans. Not all PDP premiums are fully paid for by Medicare. If you choose a PDP that is not fully paid for by Medicare, you may have to pay a portion of your plan’s premium and higher copays.

If you do not enroll in a PDP, CMS automatically enrolls you in a premium free plan. You may have a period of time that you can’t get prescriptions unless you enroll in a plan through the emergency system, WellPoint.

Emergency prescription drug coverage

If you are not enrolled in a PDP and need prescriptions right away, most major pharmacies can enroll you through a national emergency system called WellPoint. Bring your Medicare card and Medicaid coupon to the pharmacy to get your prescriptions. You will be enrolled into the WellCare plan. WellCare will be your PDP. If WellCare doesn’t work for you, you can change plans.

Changing Plans

You can change plans at any time. If you change plans, the new plan takes effect the next month after the month you enroll. If you do change plans, you need to let Medicare staff know. Call 1-800-Medicare (1-800-633-4227) or TRS 711 through Washington Relay and let them know. You also need to tell a representative from your new plan that you are changing plans and which plan CMS had selected for you.

Resources that can help you pick a plan

  • Below are resources that can help you decide which plan is best for you.
    The Washington State Office of the Insurance Commissioner’s Statewide Health Insurance Benefits Advisors (SHIBA) HelpLine can help you understand your options. Call them at 1-800-562-6900.
  • Visit the federal Medicare website at www.medicare.gov. The site has several tools to help you understand, compare, and choose a plan. You can also talk with Medicare staff by calling 1-800-Medicare (1-800-633-4227) or TRS: 711 through Washington Relay.
  • Your local Senior Information and Assistance Office (I&A). To find your local I&A office, visit the AAA website and click on “local AAAs” or look for the Area Agency on Aging office in the yellow pages of your telephone book under “Senior Services”.

Frequently Asked Questions

Can I Keep My Medicaid Drug Coverage?

No. Once you are eligible for Medicare, Medicaid will not continue the drug coverage it currently provides.

What if I have prescription drug coverage from another type of insurance (employer, union or retirement plan)?

If your other insurance plan is not as good as the Medicare prescription drug coverage, talk to your insurance carrier about your options. You may not be able to join a Medicare PDP without dropping your current health coverage (doctor and hospital). If you drop your current insurance, you may not be able to get it back.

You do not need to enroll in a Medicare PDP if your other insurance plan provides benefits equal to or better than the Medicare PDP. Your insurance provider should tell you if your current insurance plan is equal to or better than the Medicare PDP. To keep your current insurance plan, you need to decline or disenroll in any Medicare PDP. You need to talk with Medicare staff to do this. Call 1-800-Medicare (1-800-633-4227) or TRS: 711 through Washington Relay to decline or disenroll in the Medicare PDP.

What if I move to or live in a nursing home?

If you move to a nursing home, you still have a choice of what PDP you want to use. You can also switch plans at any time. If you want help deciding which plan is best for you, use the resources listed above. You might also want to talk with staff at the nursing home and ask them for their suggestions.

What if I pay part of my income for the cost of my long-term care (participation)?

If you are enrolled in a PDP where you have to pay part or all of your copays and premium, it is considered a medical expense and may be used to reduce your participation.

Report the amount you pay for copays and premiums to your local Home and Community Services (HCS) financial worker. If you don’t remember who your financial worker is, call your local HCS Office. The financial worker will need to see receipts for the amount you report.

If you get food assistance, copays and other medical expenses that exceed $35.00 per month may be used to give you more food benefits. Report the amount you pay to your financial worker and provide receipts for the amount you report.

Prescription Drug Coverage If you are new to receiving Medicaid and are eligible for Medicare-Applicants

If you already receive Medicare or are eligible for it, you will get most of your prescription drugs through Medicare Part D and the Prescription Drug Plan (PDP) you enroll in. You need to enroll in a PDP if you haven’t done so (see below). Medicaid does not pay for most of your prescription drugs.

If you need to enroll in Medicare, contact your local Social Security Office. To find the nearest office, look in the “Federal Government” pages of your phone book or on the web at www.socialsecurity.gov.

Getting enrolled in a Prescription Drug Plan (PDP)

A PDP is insurance that covers both brand name and generic prescription drugs at participating pharmacies in your area. There are many different types of plans to choose from that vary in cost, coverage, and yearly deductibles.

Be sure to ask about the premium and copays when comparing plans. Not all PDP premiums are fully paid for by Medicare. If you choose a PDP that is not fully paid for by Medicare, you may have to pay a portion of your plan’s premium and higher copays.

If you are not enrolled in a PDP, the Centers for Medicare and Medicaid Services (CMS) automatically enrolls you in a premium free plan shortly after you are authorized for Medicaid. You have 20 days to change PDPs if the plan CMS enrolls you in does not work for you. You may have a period of time that you can’t get prescriptions unless you enroll in a plan through the emergency system, LI Net program operated by Humana.

If you are already enrolled in a PDP and are paying some or all of the premium, it may be time to find and switch to a premium-free plan since you are now receiving Medicaid. This is your choice.

If you do not enroll in a premium-free plan, CMS will enroll you in a premium-free plan shortly after you are authorized to receive Medicaid. You will have 20 days to change plans if the plan CMS enrolls you in does not work for you or if you want to keep the plan you have.

Emergency prescription drug coverage

If you are not enrolled in a PDP and need prescriptions right away, most major pharmacies can enroll you through a national emergency system called LI Net program operated by Humana. Bring your Medicare card and Medicaid service card to the pharmacy to get your prescriptions. You will be enrolled into the Medicaid D prescription drug plan. LI Net will be your PDP. If LI Net doesn’t work for you, you can change plans.

Changing Plans

You can change plans at any time. If you change plans, the new plan takes effect the next month after the month you enroll. If you do change plans, you need to let Medicare staff know. Call 1-800-Medicare (1-800-633-4227) or TRS: 711 through Washington Relay and let them know. You also need to tell a representative from your new plan that you are changing plans and which plan CMS had selected for you.

Resources that can help you pick a plan

Below are resources that can help you decide which plan is best for you.

  • The Washington State Office of the Insurance Commissioner’s Statewide Health Insurance Benefits Advisors (SHIBA) HelpLine can help you understand your options. Call them at 1-800-562-6900.
  • Visit the federal Medicare website at www.medicare.gov. The site has several tools to help you understand, compare, and choose a plan. You can also talk with Medicare staff by calling 1-800-Medicare (1-800-633-4227) or TRS: 711 through Washington Relay.
  • Your local Senior Information and Assistance Office (I&A). To find your local I&A office, visit the AAA website and click on “local AAAs” or look for the Area Agency on Aging office in the yellow pages of your telephone book under “Senior Services”.

Frequently Asked Questions

What if I have prescription drug coverage from another type of insurance (employer, union or retirement plan)?

If your other insurance plan is not as good as the Medicare prescription drug coverage, talk to your insurance carrier about your options. You may not be able to join a Medicare PDP without dropping your current health coverage (doctor and hospital). If you drop your current insurance, you may not be able to get it back.

You do not need to enroll in a Medicare PDP if your other insurance plan provides benefits equal to or better than the Medicare PDP. Your insurance provider should tell you if your current insurance plan is equal to or better than the Medicare PDP. To keep your current insurance plan, decline or disenroll in any Medicare PDP. Call and talk with Medicare staff by calling 1-800-Medicare (1-800-633-4227) or TRS: 711 through Washington Relay to decline or disenroll in the Medicare PDP.

What if I pay part of my income for the cost of my long-term care (participation)?

If you are enrolled in a PDP where you have to pay part or all of your copays and premium, it is considered a medical expense and may be used to reduce your participation.

Report the amount you pay for copays and premiums to your local Home and Community Services (HCS) financial worker. If you don’t remember who your financial worker is, call your local HCS Office. The financial worker will need to see receipts for the amount you report.

If you get food assistance, copays and other medical expenses that exceed $35.00 per month may be used to give you more food benefits. Report the amount you pay to your financial worker and provide receipts for the amount you report.

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Foster Care, Relative Placement, Adoption Support, Juvenile Rehabilitation, Unaccompanied Minor Program

Revised date
Purpose statement

To give instructions and contact information when working with children enrolled in Foster Care, Adoption Support, Juvenile Rehabilitation, and Unaccompanied Refugee Minor programs. Children in these programs will be active on D01/D02 medical coverage groups.

WAC 182-505-0211 Washington apple health -- Foster Care.

WAC 182-505-0211 Washington apple health -- Foster Care.

Effective January 1, 2023.

  1. A client under the age of 18 is eligible for Washington apple health foster care coverage when they:
    1. Are in foster care as determined by the department of children, youth, and families (DCYF) under the legal responsibility of the state, or a federally recognized tribe located within the state; and
    2. Meet Washington residency requirements as described in WAC 182-503-0520 or 182-503-0525.
  2. A client age 20 or younger is eligible for coverage when the client meets:
    1. Washington residency requirements as described in WAC 182-503-0520 or 182-503-0525;
    2. Citizenship or immigration status requirements as described in WAC 182-503-0535;
    3. Social Security number requirements as described in WAC 182-503-0515; and
    4. One of the following requirements:
      1. Is in foster care, or is eligible for continued foster care services as determined by the children's administration, under the legal responsibility of the state, or a federally recognized tribe located within the state; or
      2. Receives subsidized adoption services through the children's administration; or
      3. Is enrolled in the unaccompanied refugee minor (URM) program as authorized by the office of refugee and immigrant assistance (ORIA); or
      4. Is living in a community facility (as defined in WAC 110-700-005) operated or contracted by DCYF's juvenile rehabilitation.
  3. A client age 18 or older but under age 26 is eligible for Washington Apple Health coverage when a client:
    1. Was in foster care under the legal responsibility of any state or a federally recognized tribe located within any state.
      1. On the client's 18th birthday; or
      2. At such higher age as to when the state or tribe extends foster care coverage; and
    2. Meets residency, Social Security number, and citizenship requirements as described in subsection (2) of this section.
  4. A client described in subsections (1) through (3) of this section is not eligible for full-scope coverage if the client is confined to a public institution as defined in WAC 182-500-0050, except:
    1. If the client is under age 21;
    2. Resides in an institution for mental disease (IMD); and
    3. Meets the institutional status requirements in WAC 182-513-1320, 182-514-0250, or 182-514-0260.

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

The Foster Care and Adoption Support (FCAS) is responsible for the following cases:

  1. Foster Care (D01/D02): These are children who are placed in a licensed foster care or relative's home by the Children's Administration (CA) or a federally recognized Tribe. The foster care parent receives a monthly payment from CA and the child is eligible for Apple Health.
    1. CA sends an alert to the FCAS to inform them a child has entered foster care. FCAS works the alert and opens a D01 (foster care child receiving SSI) or D02 (foster care) case for the child.
    2. D01/D02 foster care cases:
      1. Are assigned to CSO 076
      2. Display in ACES with asterisks in the address field and AREP screen. The asterisks have been added to insure address confidentiality for the foster care family and child.
      3. Require special coding in the DEM1 living arrangement and DEM1 REL code fields.
    3. When the CSO/CSC and FCAS have a shared D01/D02 case, only the FCAS can finalize or update the case. The CSO can "add a program" to a D01/D02 case, but will not be able to finalize the case. CSO/CSC staff will need to coordinate with the FCAS @ 800-562-3022 ext. 15480 to have them complete case actions. FAX number is 360-725-1158.

      Note: CSO staff should not change the living arrangement or REL code on the foster care child's DEM1 screen or close out a foster care assistance unit. To make any change to a D01/D02 case contact the FCAS @ 800-562-3022 ext. 15480.
       

  2. Former Foster Care Medical Program (D26): The Affordable Care Act expanded Medicaid eligibility for individuals who were in foster care and receiving Medicaid on their 18th birthday to age 26. These individuals have their D02 medical coverage automatically spout to D26 the first of the month following their 18th birthday. They remain eligible for health care coverage under the D26 program until their 26th birthday regardless of changes in income, household composition, or marital status, as long as they remain a Washington resident.
  3. Adoption Support (D01/D02): Is a payment received by an adoptive parent who cares for children who have been placed by Washington State or another state. These children are categorically eligible for Apple Health as long as they are receiving an adoption support payment. Children in adoption support may be eligible up to age 21.
    1. Adoption Support cases are approved by the Children's Administration (DSHS). CA communicates adoption support enrollment to the FCAS. The FCAS opens D01 or D02 medical program.
    2. D01/D02 adoption support cases are:
      1. Assigned to CSO 076
      2. Display in ACES with asterisks in the address field and AREP screen.
      3. Require special coding in the DEM1 living arrangement and the REL code fields.
    3. Changes to adoption support case and any case associated with adoption support can only be made by FCAS.

      Note: A child placed with adoptive parents will often be assigned a new Client Identification (CL ID) number. The assignment of a new CL ID number will help ensure confidentiality.
       

  4. Juvenile Rehabilitation (D01/D02): Children who reside in a Juvenile Rehabilitation Administration (JRA) group home are eligible for Apple Health through the month in which they are paroled.
    1. JRA notifies the FCAS that a child has been placed in a group home. The FCAS opens a D01 or D02 medical case for the child.
    2. JRA cases are:
      1. Assigned to CSO 076
      2. Display in ACES with asterisks in the address field and AREP screen.
      3. Require special coding in the DEM1 living arrangement and REL code fields.
    3. CSO/CSC may see JRA cases in ACES when the child has recently been released from the group home. To add a child back to their family assistance unit or to open new coverage for the child the CSO/CSC must contact FCAS @ 360-725-1519.
  5. Unaccompanied Refugee Minor (URM) Program: The Department of State and the Office of Refugee Immigration Assistance (ORIA) work together to identify minor children who need foster care placement and approve them for resettlement in this country. Children are placed in culturally sensitive foster homes and are eligible for Apple Health. When a child has been placed in the URM Program, the ORIA program manager notifies the FCAS to open Apple Health coverage under D02 program. Children in the URM program remain eligible for Apple Health coverage up to age 21 as long as URM payments are being made.

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