State & Federal Medical Programs

Many low-income people can get their medical care covered by medical programs run by 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 are different in name, each has slightly different financial and other eligibility requirements, and some of them fund different services.

Accessing DSHS Programs

An individual should apply for DSHS medical coverage at the local Community Services Office (CSO). An individual need 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.

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

One medical program not run by DSHS is called Medicare. It is run 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 – consider Basic Health)
• Families who may not be on WorkFirst/TANF but meet WorkFirst/TANF financial eligibility requirements for income and resources
• 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 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 388-502-0060(5), listing covered service categories.

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. 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 2007, this is $2,111/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 388-501-0060(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

Who is eligible?
Newborns are automatically eligible for Medicaid 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 are eligible for children’s healthcare programs if they live in families with income of less that 200% of the federal poverty level (FPL) (or $2,862 per month for a family of three). This program may also be referred to as “BH+”. Immigrant children under age 19 who are not eligible for Medicaid because of their immigration status are now eligible for the Children’s Health program. This program was restored in 2006 and as of July 2007 is available to all children with family income below 200% FPL. These children have always had the option of enrolling in Basic Health, but the benefits in that program are more restricted.

Children under age 19 whose family income is too high for Medicaid may be eligible for the Children’s Premium Based Children's Healthcare program. To be eligible, children must be in families whose income is below 250% FPL ($3,578 per month for a family of three), ineligible for Medicaid, and cannot be covered by other insurance. Additionally, 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.

What does the program cover?
Children receiving Medicaid, CHIP and the Children’s Health program for immigrant children also provide the CN scope of medical services. The general categories of CN service are listed in WAC 388-501-0060 (5)
Children receiving Medicaid 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 on General Assistance (GA) & ADATSA

People Who Are On General Assistance May Get GA-X

Who is eligible?
People who qualify for General Assistance and Medicaid get what is called GA-X. Immigrant eligibility depends on immigration status and date of entry into the United States.

The decision whether to award GA-X is made by a DSHS employee called the incapacity social worker (ISW) after the ISW has awarded GA financial assistance due to incapacity. The ISW then reviews the medical evaluation done for the GA application and determines whether the GA recipient is likely to meet SSI disability criteria. If so, they get GA-X.

GA recipients who are considered unlikely to meet SSI disability criteria are instead awarded GA-U medical (see below). Persons who are denied GA-X 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 GA-X.
• A person is terminated from GA-X when the SSI application is denied and either not pursued or all administrative appeals are exhausted.

 

What does the program cover?
GA-X provides CN medical coverage, including:

• Physician services
• Prescriptions
• Hospital Care
• Vision care, mental health services, some dental, and other services which are “medically necessary”
• Retroactive coverage up to three months prior to application.

 

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People On General Assistance May Get State Medical Assistance

Who is eligible?
People on GA whom DSHS does not expect to qualify for SSI get state-funded GA-U medical coverage, called medical care services (MCS). Legal immigrants are eligible including those who are Permanently Residing Under Color Of Law (PRUCOL).

What does the program cover?
GA-U medical covers a more limited range of services than CN.

It does not cover:

• Mental health services
• Dental coverage, except tooth extraction
• 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 388-501-0060(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 state-funded medical coverage. Legal immigrants are eligible including those who are residing here under color of law (PRUCOL).

What does the program cover?
This medical program covers the same limited range of services as the GA-U medical described above.

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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 388-501-0060(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, with DSHS paying the 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?
Coverage is not as comprehensive as for people on SSI or GA-X. See WAC 388-501-0060(5), listing MN covered service categories.
For those on Medicare (“dual eligibles”), most prescription drugs are available only through Medicare Part D, with DSHS paying the co payments.

Spend downs
The state may require a person to pay some of their medical costs, called a “spend down” 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 spend down amount is based on income. The amount by which countable income exceeds a certain level ($623 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 spend down 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 Section D.
• 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 website.

 

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 ($851 + $20 disregard for one person, $1,141 + $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 $4,000 for an individual and $6,000 for a couple.

Special Low-Income Medicare Beneficiary (SLMB): An individual with income between the Federal Poverty level and 120% of the Federal Poverty Level ($1,021 +$20 disregard for one person, $1,369 + $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 $4,000 for an individual and $6,000 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 on the DSHS website

 

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 website.

Transfer of asset restrictions
In one respect, eligibility for long term care is more restrictive than eligibility for regular Medicaid programs. That is, clients may be made ineligible for giving away assets. “Transfer of assets” provisions are described in detail in the COPES and Nursing Home pamphlets on Broad Coverage.

Broad coverage, flexible programs
SSI-related (aged/blind/disabled) Medicaid recipients may have most, if not all, of their long term care expenses paid by the Medicaid long term care programs. Long term care expenses 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 nursing homes, in community based facilities (“assisted living,” boarding homes, adult family homes), or in the client’s own home.  The waiver program covering most of the services outside nursing homes is called “COPES.” Another community-based waiver, now called “HCBS waivers” (formerly called “CAP”), provides long term care services to children and adults eligible for services from DSHS’s Division of Developmental Disabilities (DDD).

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 website.

Assessments for services: The CARE tool controversy
The amount of care paid for under the COPES and DDD waivers is now being assessed and awarded using an instrument known as the CARE tool. Although many clients have received the same or increased levels of service after assessment by this new instrument, some clients face large reductions. This has caused numerous administrative appeals and some litigation.

Washington State Medical Coverage: Other Programs

Problem Solving

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