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 Savings Programs for Low-Income Medicare Enrollees below.
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 is available at the Medicare Interactive website.
Medicare Savings 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) is for those with income at or below 110% of the Federal Poverty Level (in 2024: $1,401 + $20 disregard for one person, $1,894+ $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. There is no longer a resource limit to determine eligibility.
Special Low-Income Medicare Beneficiary (SLMB) is for those with income between 110% and 120% of the Federal Poverty Level (in 2024, $1,526 + $20 disregard for one person, $2,064 + $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. There is no longer a resource limit to determine eligibility.
Expanded Special Low-Income Medicare Beneficiary (ESLMB, or "QI-1") is for those with income between 120% and 138% FPL (in 2024, $1,752 + $20 disregard for one person, $2,371 + $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. There is no longer a resource limit to determine eligibility.
Qualified Disabled Working Individuals (QDWI) is for individuals under age 65 with income between 135% and 200% FPL (in 2024, $2,530 + $20 disregard for one person, $3,427 + $20 disregard for two people). The program pays their Medicare Part A premiums. There is no longer a resource limit to determine eligibility.
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.
SSI-Related Categorically Needy Apple Health
Who Is Eligible?
People who are considered disabled (according to Social Security's definition), blind, or are 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 co-payments.
Other Things to Know
Alternate coverage: Apple Health 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 Apple Health 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, or are considered 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 the chart at 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 2024, $943 + a $20 disregard for one person, called the Medically Needy Income Level or MNIL). You can learn more about the Medically Needy "Spenddown Program.
Those who are also on Medicare (“dual eligibles”) receive most prescription drugs through Medicare Part D and 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: Apple Health 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.
Other Programs for People with Disabilities
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 Housing and Essential Needs (HEN) or Aged Blind Disabled (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 you do not meet federal immigration requirements for Medicaid. There are some restrictions on which immigration statuses are included. 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 the chart at WAC 182-501-0060(6), listing MCS covered service categories.
Retroactive coverage is not available.
Other Things to Know
You can learn more about ABD/HEN or apply for coverage 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?
Washington state residents who meet federal disability requirements and are employed on a full-time or part-time basis, including self-employed persons can be eligible for the Apple Health for Workers with Disabilities (HWD) Program. Immigration status and other general requirements apply. There is no income limit or upper age limit and no resource limit.
What Is Covered?
Enrollees receive Categorically Needy coverage (CN). The general categories of CN service are listed in the chart at 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. The maximum premium is 7.5% of counted earned plus unearned income but may be less.
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 you can apply online through Washington Connection.
For more information, see the Health Care Authority’s HWD brochure and eligibility manual.
HWD enrollees can keep savings from their earnings without the risk of losing health coverage if they must switch later to a different Medicaid program with resource limits. These savings must be designated by the enrollee and placed into an account that has no other funds in it. Switching to a different Medicaid program may be necessary if the worker stops meeting the work or any other requirement for the HWD program.
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 will need to pay premiums for the retroactive coverage.
An individual enrolled in HWD may also receive long term services and supports from the Developmental Disabilities Administration (DDA) or the Aging and Long Term Support Administration (ALTSA) when the person meets the functional requirements for those programs, is approved for those services, and chooses to enroll in HWD.
Updated April 15, 2024.
The information contained on this website is intended for general information only and does not constitute legal advice. For individual legal advice on your particular situation, contact an attorney. CLEAR (Coordinated Legal Education, Advice and Referral) is a toll-free legal hotline for people with low incomes, managed by Northwest Justice Project, an organization providing legal assistance to eligible low-income families and individuals needing help with civil (non-criminal) legal problems in Washington state.