Coverage for those who are over 65, have Disabilities, or Long-Term Care Needs

Medicare for Aged or Disabled

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 Is Covered?

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. Preventive care is provided without cost-sharing. In addition, Medicare requires recipients to pay premiums, deductibles, and co-payments. These premiums may be deducted from the recipient’s monthly Social Security check. For those who qualify, Medicaid will cover these premiums and many of the costs not paid by Medicare. See Medicare Buy-in Programs.

Prescription drugs –Part D: Provides some coverage for prescription drugs. 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. 

 

 

Other Things to Know

Apply for coverage and learn more through the federal Medicare website.

Additional information at the Medicare  Interactive website.

 

Medicare Buy-in Programs for Low-Income Medicare Enrollees

These Washington Apple Health (Medicaid) programs pay Medicare premiums and cost-sharing for very low-income individuals.
 

Who Is Eligible and What Is Covered?

Qualified Medicare Beneficiary (QMB): An individual with income at or below 100% of the Federal Poverty Level (in 2017: $1,005 + $20 disregard for one person, $1,353 + $20 disregard for two people). The program pays their Medicare deductibles, co-payments, coinsurance, Parts A and B premiums (or with Medicare Part C, the premiums for Part A and B). They also qualify for Medicare Part D without a premium and lower prescription drug co-payments. The resource limit is $7,390 for an individual and $11,090 for a couple in 2017.

Special Low-Income Medicare Beneficiary (SLMB): An individual with income between 100% and 120% of the Federal Poverty Level (in 2017, $1,206 +$20 disregard for one person, $1,624 + $20 disregard for two people). The program pays their Part B Premiums. They also qualify for Medicare Part D without a premium and lower prescription drug co-payments. The resource limit is $7,390 for an individual and $11,090 for a couple in 2017.

Expanded Special Low-Income Medicare Beneficiary (ESLMB, or "QI-1") is for those with income between 120% and 135% FPL (in 2017, $1,357 + $20 disregard for one person, $1,827 + $20 disregard for two people). The program pays their Medicare Part B premiums (subject to an annual agency funding limit). These individuals also qualify for Medicare Part D without a premium and lower prescription drug co-payments. The resource limit is $7,390 for an individual and $11,090 for a couple in 2017. 

Qualified Disabled Working Individuals (QDWI) is for individuals under age 65 with income between 135% and 200% FPL (in 2017, $2,010 + $20 disregard for one person, $2,707 + $20 disregard for two people). The resource limit is $4,000 for an individual and $6,000 for a couple in 2017.  The program pays their Medicare Part A premiums.

 

Other Things to Know

Apply for coverage by filling out a Supplemental Application through DSHS, online at Washington Connection or at a Community Services Office.

Washington Apple Health (Medicaid) Programs for people who are Disabled, Blind, or Age 65 or Older

SSI-Related Categorically Needy WAH

Who Is Eligible?

People who are disabled (according to Social Security's definition), blind, or age 65 or older and have limited income and resources.

Some people with income over the SSI limit (such as disabled widows/widowers) also qualify.

Immigration status requirements apply.

 

What Is Covered

Enrollees receive Categorically Needy (CN) coverage. The general categories of CN service are listed in WAC 182-501-0060(6).

Coverage goes back to the date of application, once it is approved. Retroactive coverage is available if disability is established.

There are no co-payments or deductibles for this program.

Some people on SSI-related Medicaid also receive Medicare coverage. For these "dual eligibles," most prescription drugs are available only through Medicare Part D, and they are required to pay small copayments.

 

Other Things to Know

Alternate coverage: WAH for Adults is also available for individuals in this income range who are under age 65 and not on Medicare, without the need to meet disability or other SSI-related requirements.

Apply for coverage through Washington Healthplanfinder. If you state you have a disability on the application, you will be asked to fill out a Supplemental Application through DSHS. If eligible you will receive WAH for Adults pending the DSHS determination.

 

Medically Needy Washington Apple Health for People Not on SSI, but Aged or Disabled

Who Is eligible?

People who have income over the "Medically Needy Income Level" and are age 65 or older, blind or disabled (according to Social Security’s definition).

Resource limits apply.

Immigration status requirements apply.

 

What Is Covered?

Enrollees receive Medically Needy (MN) coverage. The general categories of MN service are listed in WAC 182-501-0060(6).

The state does not provide coverage until you incur a specified level of medical costs, called a “spenddown” amount. The spenddown amount is based on income. it is the amount by which countable income exceeds a certain income level (in 2017, $735 + a $20 disregard for one person, called the Medically Needy Income Level or MNIL). You can learn more about spenddown here.

Those who are also on Medicare (“dual eligibles”) receive most prescription drugs through Medicare Part D, and they are required to pay co-payments that vary according to income.

 

Other Things to Know

Apply for coverage through Washington Healthplanfinder. If you state you have a disability on the application, you will be asked to fill out a Supplemental Application through DSHS.

Alternate coverage: WAH for Adults may also be available without the need to meet disability or other SSI-related requirements, for adults under age 65 and not on Medicare, with income below 138% FPL. Qualified Health Plan coverage with subsidies is an option for some adults above 138% FPL not on Medicare. In some cases this may cost less than Medically Needy coverage. For more information, see The Medically Needy Spenddown Program.

Other Programs for People with Disabilities

Medical Care Services

Who Is Eligible?

Low-income persons who receive ABD or HEN financial assistance and do not qualify for Medicaid, usually due to their immigration status, are in these programs.

Medical Care Services for Immigrants who are over age 65 or incapacitated

Who Is Eligible?

People whom the state does not expect to qualify for Medicaid, but who meet the incapacity or age standards of the HEN or ABD program, can get Medical Care Services (MCS) coverage through the Department of Social and Health Services.

To qualify, you must receive HEN or ABD and be ineligible for an adult Medicaid program, because you are either over age 65 or an immigrant who is lawfully present but does not meet federal immigration requirements for Medicaid. Income and resource standards apply.

 

What Is Covered?

MCS covers a more limited range of services than Categorically Needy Medicaid. For example, it does not cover hospice care or personal care services. See WAC 182-501-0060(6), listing MCS covered service categories.

Retroactive coverage is not available.

 

Other Things to Know

Apply for coverage for ABD/HEN at a DSHS Community Services Office. You will also be screened for Medicaid and MCS when you apply for these programs.

Washington Healthplanfinder does not yet screen for MCS eligibility, but if it identifies you as potentially eligible, you may receive a letter about how to apply through DSHS.

Health Care for Workers with Disabilities

Who Is Eligible?

Individuals age 16 to 64 who are Washington State residents and meet federal disability requirements, have a net income at or below 220% of the Federal Poverty Level, and are employed on a full-time or part-time basis, including self-employed persons. Immigration status and other general requirements apply.

What Is Covered?

Enrollees receive Categorically Needy coverage (CN). The general categories of CN service are listed in WAC 182-501-0060(6); all medically necessary services are covered.

Enrollees must pay a monthly premium based on their income for the insurance coverage provided by HWD.

Other Things to Know

Apply for coverage by phone or online. By phone: call 1 (800) 871-9275 to leave a message with designated staff who complete HWD applications. They will contact you directly and check their direct message line daily. Or apply online through Washington Connection:  www.washingtonconnection.org.

Click here for a Health Care Authority brochure about HWD.

Enrollees are approved for HWD for a 12-month period, effective the first month the enrollee applies and meets the program requirements. If you experience job loss within the 12-month period, you may keep your coverage under HWD if the job loss was the result of an involuntary dismissal or health crisis and you continue to pay your monthly premium.

Retroactive coverage is available for up to 3 months before you apply for the program as long as you met the eligibility requirements during that time. If eligible, you are expected to pay their premiums for the retroactive coverage.

People enrolled in HWD may also receive services from the Developmental Disabilities Administration (DDA) or Home and Community Services (HCS). However, long-term care (LTC) services are not provided under the program. To receive LTC services, you must qualify and participate in the cost of care according to the rules of those programs.

 

Updated October 9, 2017.
Thanks to Andrea Kelso for her help updating this information.