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Medical Coverage Generally: DSHS Medical Programs

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Washington Medical Coverage:
State & Federal Medical Programs

State & Federal Medical Programs

 

Many low-income people can get their medical care covered by medical programs run by the Health Care Authority (HCA) in cooperation with the Department of Social and Health Services (DSHS). These programs are commonly referred to as "Medicaid", but technically they are not all part of the Medicaid program. Some are Medicaid, and therefore federally and state funded, and some are funded only by the state. The programs are similar in that they fund medical care; they have different names, each has slightly different financial and other eligibility requirements, and some of them fund different services.

Accessing DSHS Programs

You may apply for medical coverage and other benefits at the local Community Services Office (CSO) or online through the Washington Connection website. You need to fill out only one application for all of the assistance needed, including cash, food and medical assistance. Simpler, specialized applications are available for children's medical programs. For people who are hospitalized, hospital staff or companies they contract with can often assist with the application process. If you apply online, additional documents must be provided by mail.

Problem Solving

Any time an individual disagrees with a DSHS decision, including a decision about eligibility for one program versus another, or the availability of a particular service, the individual has the option to use both formal and informal avenues to resolve the disagreement. Informally, it is often useful to make a call to a supervisor to see if it is possible to resolve the problem. For medical programs, there is also a toll-free hotline. If that does not work, either because of inaction or because the supervisor or hotline staff says no, a formal appeal can be filed. This is called an administrative hearing. See the section on DSHS Hearings.

Medicare

Medicare is a medical insurance program not run by the state, but by the federal government. People who are on Social Security Disability and Retirement benefits (Title II) are eligible for Medicare. For more information, see section on Medicare.

 

 

Programs for Children and Families

Family Medical

Who is eligible?
Children and their parents or caretakers who are on WorkFirst/TANF or related to WorkFirst/TANF get categorically needy Medicaid. These families include:

• Families currently on WorkFirst/TANF (but immigrant families receiving State Family Assistance cash assistance are not eligible)
• Families who may not be on WorkFirst/TANF but meet family medical financial eligibility requirements for income and resources, which are higher than for the cash program
• Families who do not qualify for WorkFirst/TANF because of certain requirements that do not apply to Medicaid, such as teen parent living arrangements or work requirements (including those “in sanction”)
• Families who have left WorkFirst/TANF or Medicaid because of earnings may be eligible for transitional Medicaid for up to 12 months
• Families who leave WorkFirst/TANF or Medicaid because of increased child support are eligible for extended medical benefits for up to 4 months.
• Families who receive “diversion cash assistance.”

There is no time limit for Family Medical coverage.
There are no work requirements for Family Medical coverage.

What does the program cover?
Family Medical coverage provides Categorically Needy (CN) coverage, the broadest ranges of medical services DSHS provides. See WAC 182-501-0060(5), Healthcare coverage — Scope of covered categories of service. Family Medical recipients are usually required to be in a managed care plan called Healthy Options. People in managed care are required to have a primary provider who is the gatekeeper to other medical providers and the plan determines which providers will be covered under their plan. There are exemptions from Healthy Options for certain reasons, including need to continue with a treating provider, homelessness, children with special health care needs or in foster care, and people having private insurance coverage in addition to Medicaid.

 

Medical Coverage for Pregnant Women

Who is eligible?
Pregnant women at any point in their pregnancy can qualify for medical coverage. Pregnant women should apply for medical programs at the CSO office or online. The Department should first evaluate whether applicants qualify for Family Medical.

If pregnant applicants do not qualify for other coverage, they are eligible for medical coverage if they have income below 185% of the Federal Poverty Level (in 2011, this is $2,268/month for two people, the pregnant woman and her unborn fetus). There is no resource limit or immigration status requirement for pregnant women. Women are eligible for a 2-month postpartum extension of medical benefits, and family planning coverage beyond that time.

What does the program cover?
This program provides pregnant women with CN medical coverage. See WAC 182-501-0060(5), listing covered CN service categories.

Pregnant women receiving Medicaid are usually required to be in managed care (Healthy Options). See description under Family Medical.

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Children’s Healthcare Programs:  “Apple Health for Kids”

Who is eligible?
Newborns are automatically eligible for Apple Health for Kids if their mother received medical benefits at the time of the child's birth. The eligibility will last for 12 months. There are no income or resource limits.

Children under age 19 may be eligible for Apple Health if they live in families with income of less than 300% of the federal poverty level (FPL) (or $4,633 per month for a family of three). To be eligible above 200% of FPL ($3,089 per month), children must not be covered by other insurance, and families must pay a monthly premium to DSHS. Income deductions and exclusions may apply. Even if income exceeds the above levels, families should be encouraged to apply. Eligibility for Apple Health does not require citizenship or immigrant status, but premiums may be higher for children with family income above 200% of FPL.

What does the program cover?

Children on Apple Health receive a broad scope of medical services. The general categories of CN service are listed in WAC 182-501-0060(5). Children receiving Apple Health are usually required to be in managed care (Healthy Options). See description under Family Medical. Foster children and children with special health care needs are exempted from Healthy Options upon request.

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Programs for People with Disabilities

People Who Are Likely To Meet SSI Aged, Blind or Disabled (ABD) Criteria (formerly Disability Lifeline Expedited)
May Get Medicaid

Who is eligible?
The Disability Lifeline financial assistance program ends October 31, 2011. Until then, people who qualified for Disability Lifeline and Medicaid received assistance through the Disability Lifeline Expedited program. The cash and Medicaid portion of this program still exists for those who the state determines are "likely to meet" the SSI aged, blind or disability criteria. As of November 2011, it will be known as ABD. Immigrant eligibility depends on immigration status and date of entry into the United States.

The decision whether to award ABD is made by a DSHS employee called the incapacity social worker (ISW) after the ISW has awarded Medical Care Services due to incapacity (see below). The ISW then reviews the medical evaluation done for the ABD application and determines whether the GA recipient is likely to meet SSI disability criteria. If so, they get ABD cash and Medicaid coverage.

Those who are considered unlikely to meet SSI disability criteria are instead awarded Medical Care Services (see below). Persons who are denied ABD may appeal the decision and should be encouraged to do so.

• A person must apply for SSI and follow through on that application to be eligible for ABD.
• A person is terminated from ABD when the SSI application is denied and either not pursued or all administrative appeals are exhausted.

 

What does the program cover?
ABD provides CN medical coverage, including:

• Physician services
• Prescriptions
• Hospital Care
• Vision care, mental health services, emergency dental (or greater if the person meets certain criteria), and other services which are “medically necessary”
• Retroactive coverage up to three months prior to application.

 

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People Who Are Incapacitated May Get Medical Care Services Coverage

Who is eligible?
People whom DSHS does not expect to qualify for SSI, but who meet the incapacity standards of the former Disability Lifeline program get Medical Care Services (MCS) coverage. Legal immigrants are eligible including those who are Permanently Residing Under Color Of Law (PRUCOL).

As of November 1, 2011 there is no longer a cash grant under this program; people will only be offered MCS and will be referred to county agencies for "Housing and Essential Needs," a noncash, non-entitlement program that replaced Disability Lifeline.

What does the program cover?
MCS covers a more limited range of services than CN.
It does not cover:

• Hospice care
• Indian health center services
• Non-institutional personal care services
• Retroactive coverage(coverage dates from the first of the month in which the application is approved)

See WAC 182-501-0060(5), listing MCS covered service categories.

 

ADATSA (Alcoholism and Drug Addiction Treatment and Support Act)

Who is eligible?
People on ADATSA because of an incapacity caused by drug or alcohol addiction get Medical Care Services (MCS). Legal immigrants are eligible including those who are residing here under color of law (PRUCOL).

What does the program cover?
See WAC 182-501-0060(5), listing MCS covered service categories, including substance abuse services.

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Programs For People On Or Related To Social Security

“Categorically Needy” SSI Recipients & Others

Who is eligible?
People who are getting SSI because they are disabled (according to Social Security’s definition), blind, or elderly (65 or older) and have limited income and resources are eligible for Medicaid. Immigrants who are eligible for SSI are eligible for this program. Some people with income over the SSI limit (such as disabled widows/widowers) qualify for Medicaid as “Categorically Needy” (CN).

What does the program cover?
This program provides CN medical coverage. See WAC 182-501-0060(5), listing CN covered service categories.

Coverage goes back to the date of application once it is approved. There are no co-payments or deductibles for this program. Some people on SSI also receive some Social Security, along with Medicare coverage. For these “dual eligibles,” most prescription drugs are available only through Medicare Part D, and they are required to pay small co payments.

 

Disabled And Elderly But Not On SSI (“Medically Needy”)

Who is eligible?
People not on SSI who are disabled (according to Social Security’s definition), blind, or 65 or older but who have income over SSI limits (or are not on SSI for another reason) may be eligible for Medicaid as well. Resource limit is $2,000 for an individual and $3,000 for a couple. Immigrants may be eligible for this program, depending on immigration status and date of entry into the United States.

What does the program cover?
See WAC 182-501-0060(5), listing MN covered service categories.
For those on Medicare (“dual eligibles”), most prescription drugs are available only through Medicare Part D, and they are required to pay small co-payments.

Spenddowns
The state may require a person to pay some of their medical costs, called a “spenddown” amount. A spend down amount is an amount of medical bills a person must incur before DSHS will authorize coverage and pay for covered expenses.
The spenddown amount is based on income. The amount by which countable income exceeds a certain level ($674 in 2011 for one person, called the Medically Needy Income Level or MNIL) will be the spend down amount. There is a publication called "Medicaid for Adults 65 and Older or Disabled Who Don't Get SSI" that has a more complete explanation of how a spenddown is calculated.

 

Medicare

Generally
Medicare is the federal health insurance program for people who are 65 or over or disabled according to Social Security’s definition. It is run by the Social Security Administration. People apply at the Social Security office. Decisions about Medicare eligibility and about coverage for specific services can be appealed. Appeals should be filed with the Social Security Administration.

Who is eligible?
Coverage begins at age 65, or two years after an individual becomes eligible for Social Security Disability Insurance (SSDI) benefits. There are no financial eligibility requirements.

What does Medicare cover?

• Hospital Insurance—Part A: covers some of the cost of hospital and related care, home health care, hospice care and care in a skilled nursing facility following a hospital stay
• Medical Insurance—Part B: covers some of the cost of physician visits, outpatient hospital services, and other services. Medicare preventive health care or care received outside of the United States. In addition, Medicare requires recipients to pay premiums, deductibles, and co-payments. These premiums may be deducted from the recipient’s monthly benefits check. For those who qualify, Medicaid will cover these premiums and many of the costs not paid by Medicare. See Medicare Buy-in Programs, below.
• Prescription drugs –Part D: provides some coverage for prescription drugs starting January 2006. Enrollees must select a Prescription Drug Plan available in the region; each plan has its own drug formulary. “Dual eligibles” and others with limited income qualify for “extra help” – a Part D subsidy from the federal government. Additional information may be found at the federal government's Medicare web site.

 

Medicare Buy-in Programs

Who is eligible and what do these programs cover?
These Medicaid programs pay Medicare premiums and cost-sharing for very low-income individuals. Qualified Medicare Beneficiary (QMB): An individual with income at or below 100% Federal Poverty Level (in 2011: $908 + $20 disregard for one person, $1,226 + $20 disregard for two people) can get DSHS funding for their Medicare deductibles, co-payments, Part B premiums, Medicare Part C premiums for Part A and B of their Medicare coverage. They automatically get Medicare Part D without a premium and lower co payments. The resource limit is $6,680 for an individual and $10,020 for a couple in 2011.

Special Low-Income Medicare Beneficiary (SLMB): An individual with income between 100% the Federal Poverty level and 120% of the Federal Poverty Level ($1,089 +$20 disregard for one person, $1,471 + $20 disregard for two people) can get funding for their Part B Premiums. They automatically get Medicare Part D without a premium and lower co payments. The resource limit is $6,680 for an individual and $10,020 for a couple.

Expanded Special Low-Income Medicare Beneficiary (ESLMB, or “QI-1”); and Qualified Disabled Working Individual (QDWI) are for those with income between 120% and 200% FPL. QI-1 clients have income below 135% FPL and qualify for Medicare Part D zero premium and lower co-payments.  These programs are described here.

 

Long Term Care

Who is eligible?
People who qualify medically to receive the level of care in a nursing home can get Medicaid under “Institutional” and “waiver” Medicaid programs. These programs have more liberal income and resource rules than regular Medicaid, particularly for married people.

These recipients also get CN Medicaid to cover their other medical expenses, except clients on the small “Medically Needy waiver” programs get access to Medically Needy benefits instead. Clients in the waiver programs can receive services at home or in community-based facilities. Clients receiving CN Medicaid apart from a long term care program (such as clients receiving SSI) can get “Medicaid Personal Care” services instead; the level of care standard is less stringent for this program. Eligibility for nursing home and COPES programs are described in frequently revised pamphlets posted on the on the Aging / Elder Law page of the Washington Law Help web site.

Transfer of asset restrictions
In one respect, eligibility for long term care is more restrictive than eligibility for regular Medicaid programs. Clients may be made ineligible for giving away assets. “Transfer of assets” provisions are described in the COPES and Nursing Home “Questions and Answers” pamphlets. While these transfer of assets provisions do not apply to the Medicaid Personal Care program, clients should be cautious. A client who gives away an asset before applying for or while on Medicaid Personal Care may need nursing home care or COPES at some point in the future. A penalty period (period of disqualification) for nursing home care or COPES may be imposed at the time the client needs to go into a nursing home or needs COPES because of an earlier transfer of assets. Clients should seek the advice of a knowledgeable lawyer.

Broad coverage, flexible programs
SSI-related (aged/blind/disabled) Medicaid recipients may receive personal care services paid by Medicaid long term care programs. Personal care services can include assistance with bathing, dressing, ambulation, toileting, and other “personal care” tasks, as well as with necessary daily living activities such as meal preparation, housekeeping, laundry and shopping. Washington’s programs cover long term care in community based facilities (“assisted living,” boarding homes, adult family homes), or in the client’s own home. Nursing home care is also covered for eligible persons. There are two kinds of programs that provide assistance in the home or in a community-based setting: waiver programs and non-waiver programs.

• Medicaid Personal Care (MPC): Clients receiving CN Medicaid apart from a long term care program (primarily clients receiving SSI) can get personal care services under the MPC program.   The level of care standard is less stringent for this program. MPC is open to anyone who qualifies financially and who is assessed to need personal care services including seniors, younger,  people with physical disabilities, people with mental illness, and people with intellectual disabilities, or people with combinations of disabilities.
  
  
• COPES Waiver: This program is intended to prevent people who need help from having to go to nursing homes. Clients with incomes higher than SSI who are eligible for admission to a nursing home because of the amount of care they need may get personal care services through the COPES program and stay out of the nursing home. COPES is called a “waiver” program because some of the financial eligibility rules for Medicaid are “waived” and some rules that would ordinarily prohibit payment for other services are “waived” if paying for those services would prevent the client from having to go to a nursing home. COPES eligibility requires a somewhat greater need for personal care services than the MPC program requires. 
  
  
• Medically Needy In-Home waiver (MNIW): Eligibility for MNIW is the same as for COPES except for the gross income limit. MNIW is intended to allow someone over the COPES income limit to receive in-home personal care services. The MNIW waiver is capped, at 200 clients, but as of late 2011, there were only 63 enrollees.
  
  
• Medically Needy Residential Waiver (MNRW): Eligibility for MNRW is the same as for COPES except for the gross income limit. MNRW is intended to allow someone over the COPES income limit to receive community-based residential care services such as Adult Family Home or Assisted Living. The MNRW waiver is capped at 982, but as of late 2011, there were only 611 enrollees.
  
  
• DDD Waivers: These waivers are administered by the DSHS Division of Developmental Disabilities (DDD.)These waivers are intended, like COPES, to keep clients out of institutions. In this case, instead of preventing admission to nursing homes, these waivers prevent admission to institutions for persons with intellectual disabilities such as Fircrest, Rainier School, or Lakeland Village. Like the COPES waiver, some of the financial eligibility rules for Medicaid are “waived” and some rules that would ordinarily prohibit payment for other services are “waived” if paying for those services would prevent the client from having to go to an institution. Unlike the COPES waiver, these waivers are capped. This means that eligible persons may not be placed on a DDD waiver because there are no waiver slots for them. Persons with intellectual disabilities, however, who meet MPC financial eligibility criteria and need help with personal care are eligible for the MPC program. And, persons with intellectual disabilities who meet COPES financial eligibility criteria and need help with personal care to avoid nursing home admission are eligible for COPES.

 

Most clients must “participate” in the cost of the care.  Calculations for those costs are described in the COPES and Nursing Home “Questions and Answers” pamphlets.
 
These LTC program recipients also get CN Medicaid to cover their other medical expenses, except clients on the small “Medically Needy Residential Waiver” and “Medically Needy In-Home Waiver” programs get access to Medically Needy benefits instead. . Eligibility for nursing home and COPES programs are described in frequently revised pamphlets posted on the on the Aging / Elder Law page of the Washington Law Help web site.

Assessments: The CARE Tool
The state uses the CARE assessment tool to assess and determine the number of hours in-home personal care services or the rate paid to a residential provider, such as an Adult Family Home or Assisted Living Facility. This tool is used for the MPC program and the COPES, MNIW, MNRW, and DDD waivers. The hours and monthly rates awarded have been reduced in various ways as the result of budget cuts. Changes to the CARE tool and the state’s process for determining the number of service hours have been subjects of litigation.  

Washington State Medical Coverage: Other Programs

Problem Solving

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