Apr 1, 2021 — Health Insurance Plan) that covers the Categorically Categorically Needy (CN): The broadest, most free-or-low-cost/18-001P.pdf .
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1What is Washington Apple Health (Medicaid)? 2How to use this guide 2Scope of care 3Modi˜ed Adjusted Gross Income (MAGI) Programs 3Adults Adult Medical (N05) Family Medical (N01) Health Care Extension (N02) Pregnancy and Family Planning Pregnancy Medical (N03, N23) Medically Needy Pregnant Individuals (P99) Family Planning Extension (P05) Family Planning Only (P06) Apple Health for Kids Apple Health for Newborns (N10): Apple Health for Kids (N11, N31) Apple Health for Kids with Premiums (N13, N33) Apple Health for Medically Needy Kids (F99) Classic Medicaid Programs 6Breast and Cervical Cancer Treatment Program (BCCTP) (S30) Foster Care/Adoption Support/Former Foster Care (D01, D02, D26)Medical Care Services (A01, A05) Refugee (R02, R03) Non-Citizen Program 7Alien Emergency Medical (AEM) (K03, N21, N25, S07) State-funded long-term care services (L04, L24) Supplemental Security Income (SSI) Related Programs 8SSI Program (S01) SSI-Related Program (S02) SSI-Related MN Program (S95, S99) Apple Health for Workers with Disabilities (HWD) (S08) Medically Needy (MN) and Spenddown 9Medicare Savings Programs (MSP) 10Quali˜ed Medicare Bene˜ciary (QMB) (S03) Speci˜ed Low-Income Medicare Bene˜ciary (SLMB) (S05)Quali˜ed Individual (QI-1) (S06) Quali˜ed Disabled Working Individual (QDWI) (S04) Long-term services and supports (LTSS) and Hospice 11Covered servicesŠscope of service 11Scope of service categories Table: Bene˜t packages by program Other services 14Non-emergency Medical Transportation (brokered transport) Interpreter Services for Sign and Spoken LanguageWhere to apply for health care coverage 14MAGI Programs Classic Medicaid Programs Long-term Care Aged, Blind, Disabled Coverage Resources 15Apple Health Toll-free Customer Services (through the Health Care Authority) HCA Online Resources Scope of Care WACs De˜nitions 16Contents
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2Medicaid is the federally matched medical aid programs under Title XIX of the Social Security Act (and Title XXI of the Social Security Act for the Children™s Health Insurance Plan) that covers the Categorically Needy (CN) and Medically Needy (MN) programs. Washington Apple Health is an umbrella term or ﬁbrand nameﬂ for all Washington State medical assistance programs, including Medicaid. The brand name may be shortened to ﬁApple Health.ﬂ The Health Care Authority (HCA) administers most Washington Apple Health programs. (The Department of Social and Health Services administers the Classic Medicaid programs.) Medicaid expansion: Building on compassion The Patient Protection and A˚ordable Care Act (ACA), enacted by Congress in 2010, created an unrivaled opportunity for increasing health coverage. States had the option to expand eligibility for Medicaid and Washington State said yes. Before Medicaid expansion, coverage was essentially limited to low-income children, people with disabilities or devastating illnesses, and those whose incomes were far below the federal poverty level. Today, Apple Health covers adults with incomes up to 138 percent of the federal poverty level. In April 2021 that translated to about $17,775 for a single person or $36,570 for a family of four. For the ˜rst time, many low-income adults su˚ering from chronic conditions, such as diabetes, high blood pressure, asthma, and other diseases have better options than waiting until they are sick enough to go to the emergency room. People living on the edge ˜nancially don™t have to choose between going to the doctor and paying the electric bill. And people used to doing without are able to get regular doctor visits, including preventive care. More people served today The number of people eligible for Apple Health increased signi˜cantly with higher income limits. Others who had previously quali˜ed but not enrolled also obtained coverage. By 2021, over 680,000 enrollees were receiving Apple Health for Adults coverage. How to use this guide What is Washington Apple Health (Medicaid)? This guide gives an overview of eligibility requirements for Washington Apple Health. It doesn™t include every requirement or consider every situation that might arise. The explanation of Scope of Care on page 3 will be helpful in understanding the di˚erences between the programs. Also, refer to the De˜nitions on page 16 if you are not familiar with some of the terms used in this guide. Income levels, such as those based on Federal Poverty Level (FPL) and Cost of Living Adjustments (COLA), and speci˜c program standards change yearly, but in di˚erent months. Please understand that, while the information in this publication is current at the time of publication, some of these standards will change before the next annual update. For the most current information, go to the Health Care Authority website hca.wa.gov/apple-health .
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3Scope of care describes which medical and health care services a particular Apple Health program covers. There are four categories of scope of care: Ł Categorically Needy (CN): The broadest, most comprehensive scope of health care services covered. Ł Alternative Bene˜ts Plan (ABP): The same scope of care as CN, with the addition of habilitative services, applicable to the Apple Health for Adults program. Ł Medically Needy (MN): This scope of care covers slightly fewer health care services than Categorically Needy. Medically Needy coverage is available to individuals who qualify for disability- based Apple Health, Apple Health for Long- Term Care, or Apple Health for Kids or Pregnant Individuals, except that their income and/or resources are above the applicable Apple Health program limits. Ł Medical Care Services (MCS): This scope of care covers fewer health care services than Medically Needy. MCS is a state-funded medical program available to adults who are not eligible for Apple Health programs with CN, ABP, or MN scope of care and meet the eligibility criteria for either the Aged, Blind or DisabledŒcash or the Housing Essential Needs (HEN) program. Adults Adult Medical (N05): This program provides ABP coverage to adults with countable income at or below 133 percent of the FPL who are ages 19 up to 65, who are not incarcerated, and who are not entitled to Medicare. 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. Health Care Extension (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 bene˜ts. Scope of care Modi˜ed Adjusted Gross Income (MAGI) Programs E˚ective April 1, 2021 Household Size Monthly Income Limit 1$1,4282$1,9313$2,4344$2,9385$3,4416$3,944E˚ective April 1, 2021 Household Size Monthly Income Limit 1$5112$6583$8204$9725$1,1276$1,284
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4Pregnancy and Family Planning Pregnancy Medical (N03, N23): This program provides CN coverage to pregnant individuals with countable income at or below 193 percent of the FPL without regard to citizenship or immigration status. Once enrolled in Apple Health for Pregnant Individuals, the individual is covered regardless of any change in income through the end of the month after the 60th day after the pregnancy end date (e.g., pregnancy ends June 10, health care coverage continues through August 31). Individuals receive this post-partum coverage regardless of how the pregnancy ends. Individuals who apply for Pregnancy Medical after the baby™s birth may not receive postpartum coverage, but they may qualify for help paying costs related to the baby™s birth if they submit the application within three months after the month in which the child was born. To determine the pregnant 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). Medically Needy Pregnant Individuals (P99): This program provides MN coverage to pregnant individuals with income above 193 percent of the FPL. Individuals who qualify are eligible for MN coverage after incurring medical costs equal to the amount of the household income that is above the 193 percent FPL standard. Family Planning Extension (P05): This program provides family planning services only for 10 months after Pregnancy Medical ends. Individuals receive the Family Planning Extension automatically, regardless of how the pregnancy ends. Family Planning Only (P06): This program provides both men and women coverage for pre-pregnancy family planning services to help participants take charge of their lives and prevent unintended pregnancies. Family Planning Only: Ł Annual examination. Ł Family planning education and risk reduction counseling. Ł FDA-approved contraceptive methods including: birth control pills, IUDs, and emergency contraception. Ł Over the counter contraceptive products, such as condoms, and contraceptive creams and foams. Ł Sterilization procedures. Clients access Family Planning Only services through local family planning clinics that participate in the program. Find additional information at hca.wa.gov/family- planning.E˚ective April 1, 2021 Household Size Monthly Income Limit 1N/A2$2,8023$3,5324$4,2635$4,9936$5,723
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6Breast and Cervical Cancer Treatment Program (BCCTP) (S30): This federally-funded program provides health care coverage for individuals diagnosed with breast or cervical cancer or a related pre-cancerous condition. Eligibility is determined by the Breast, Cervical, and Colon Health Program (BCCHP) in the Washington State Department of Health (DOH). DOH is responsible for screening and eligibility, while HCA administers enrollment and provider payment. Coverage continues through the full course of treatment as certi˜ed by the BCCHP. An individual is eligible if they meets all of the following criteria: Ł Screened for breast or cervical cancer under the BCCHP. Ł Requires treatment for either breast or cervical cancer or for a related pre-cancerous condition. Ł Is under age 65.Ł Is not covered for another CN (Categorically Needy) Apple Health program. Ł Has no insurance or has insurance that is not creditable coverage. Ł Meets residency requirements. Ł Meets social security number requirements. Ł Meets citizenship or immigration status requirements. Ł Meets income limits set by the BCCHP. For further information, go to the DOH website: doh.wa.gov/YouandYourFamily/IllnessandDisease/ Cancer/BreastCervicalandColonHealth.aspx 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 from the age of 18 up to 26 who age out of foster care in Washington State. Medical Care Services (A01, A05): This state-funded program provides limited health care coverage to adults who are not eligible for Apple Health programs with CN, ABP, or MN scope of care and meet the eligibility criteria for either the Aged, Blind or DisabledŒcash or the Housing Essential Needs (HEN) program. 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 percent 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 eight 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. Classic Medicaid Programs
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7Non-Citizen Programs Alien Emergency Medical (AEM) (K03, N21, N25, S07): This program covers health care services to treat qualifying emergency medical conditions. To be eligible for AEM, an individual must: Ł Be categorically relatable to a an Apple Health program but not eligible for the an Apple Health program solely due to immigration status requirements (which program an individual is related to determines whether they follow the MAGI or Classic Medicaid eligibility rules and application processing); and Ł Have a qualifying emergency medical condition as described in WAC 182-507-0115, or 182-507-0120, that is approved by HCA™s medical consultant team. Ł Income and resource limits are the same as for the program to which the AEM applications are categorically relatable. Below is a summary of the 3 WACs that cover the Alien Emergency Medical Programs: Ł 182-507-0110: Alien Medical Programs: This explains the eligibility requirements for the program. Ł 182-507-0115: Alien Emergency Medical (AEM): The qualifying services must be provided in a hospital setting (inpatient, outpatient surgery, emergency room) that includes evaluation and management visits by a physician and be needed to treat the emergency medical condition. Certi˜cation is limited to the dates on which the qualifying services were provided. Ł 182-507-0120: Alien Medical for Dialysis and Cancer Treatment: The qualifying services must be needed to treat the qualifying condition of cancer, acute renal failure, or end stage renal disease, or be anti-rejection medication. These services do not need to be provided in a hospital setting. State-funded long-term care services (L04, L24) Ł This program provides in-home, residential, or nursing facility care for a limited number of individuals who are not eligible for an Apple Health due to immigration status who need long-term care services. Ł 182-507-0125: State-funded long-term care services Œ The applicant must meet all other eligibility factors for placement including receiving an assessment that the person meets nursing facility level of care, and receive prior authorization by the Aging & Long-Term Support Administration (ALTSA). This program is subject to caseload limits.
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8Supplemental Security Income (SSI) Related Programs SSI Program (S01): This program provides CN coverage to individuals receiving SSI (Supplemental Security Income) cash bene˜ts. SSI-Related Program (S02): This program provides CN coverage to individuals who meet the SSI income and resource limits and at least one of the following requirements: Ł 65 years old or older (aged). Ł Blind (as de˜ned by the Social Security Administration and determined by DSHS). Ł Disabled (as de˜ned by the Social Security Administration and determined by Disability Determination Services (DDS)). SSI-Related MN Program (S95, S99): This program provides MN coverage to individuals with income above the SSI income limits. Individuals who qualify and enroll in the Apple Health SSI- Related MN Program become eligible for MN coverage after incurring medical costs equal to the amount of the household income that is above the SSI income standard. Apple Health for Workers with Disabilities (HWD) (S08): This program provides CN coverage to adults with disabilities (aged 16 through 64) with earned income who purchase health care coverage based on a sliding income scale. HWD has no asset test and no upper income limit. To be eligible, an individual must meet federal disability requirements, be employed (including self- employment) full or part time, and pay the monthly premium. To receive HWD bene˜ts, enrollees pay a monthly premium determined as a percentage of their income. The premium will never exceed 7.5 percent of total income and may be less. American Indians and Alaska Natives are exempt from paying premiums for HWD. Also, while enrolled in HWD, a person may put earnings into a separate and designated account that will not be counted when determining eligibility for another program. E˚ective January 1, 2021 Household Size Monthly Income Limit Resource Limit1$794$2,0002$1,191$3,000E˚ective January 1, 2021 Household Size Monthly Income Limit 1$7942$7943$7944$7945$8586$975
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9Medically Needy (F99, G95, G99, K95, K99, L95, L99, P99, S95, S99): The Medically Needy (MN) program is a federal and state-funded Apple Health program for individuals who are aged, blind, disabled, pregnant, or a child with income above the applicable CN limits. MN provides slightly less health care coverage than CN and requires greater ˜nancial participation by the individual. Spenddown An individual with income above the limits for the applicable CN program may enroll in the MN program. An enrollee is given a base period, typically three or six months, to spend down excess incomeŠ in other words, to incur ˜nancial obligations for medical expenses equal to his or her spenddown amount. (Spenddown is the amount of the individual™s income minus the income limit for his/her particular program.) The enrollee is responsible for paying these medical expenses. The enrollee receives MN health care coverage for the selected base period once the spenddown is met. Medically Needy (MN) and Spenddown Example: Martha is 67 years of age and applies for Apple Health for MN coverage in April. Her monthly Social Security benefit is $1,207. After disregarding $20 from her Social Security benefit, which leaves $1,187, she is over the SSI monthly income limit of $794 by $393.Martha is found eligible for the MN spenddown program for the aged. She selects a six- month spenddown base period. Her spenddown amount is $2,358 ($393 x 6 months ) for April through September. This means that Martha is responsible for the first $2,358 in medical costs she incurs. On May 12, Martha has surgery. After Medicare pays the eligible 80 percent of the bill, there remains a balance of $5,200 that Martha is responsible to pay. Based on her participation in the MN spenddown program, she is liable for $2,358. Once her spenddown has been met, Apple Health will pay the remaining amount of the bill. Her certification period is May 12 to September 30. If Martha™s monthly income were below $794, she would have qualified for the no-cost Apple Health for the Aged program for 12 months coverage.
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