Who Is Eligible For Medicaid In Washington
Apple Health provides health insurance coverage for qualifying children, pregnant women, parents, seniors, and individuals with disabilities. See the Eligibility page on the Washington State Health Care Authority website for details. Below is a summary of income limits for non-elderly adults and children.
- Adults with incomes up to 138% of the federal poverty level
- Children with household incomes up to 210% of poverty
- Pregnant women with incomes up to 193% of poverty.
- Children are eligible for CHIP with household incomes up to 312% of poverty.
Apple Health for Kids is available to children even if they are undocumented immigrants. In that case, only state Medicaid funds are used to provide coverage, and families with income above 200% of the poverty level will have to pay higher premiums to cover a child who is undocumented. Pregnant undocumented immigrants are also eligible for state-funded Apple Health coverage.
How Much Will It Pay Out
The lifetime benefit is slated to start at $36,500. Originally the benefit was defined as a maximum of $100 per day up to that amount, but now there is no daily limit, just the overall cap.
Though it is not set in the law that created the fund, it is expected that the benefit will be increased each year for inflation. An actuarial report solicited by the state to make sure the fund will remain solvent assumed that the benefit would increase by 2.5 percent each year.
Under that assumption, for someone who is 30 in 2022, the benefit could be more than $80,430 by the time they are 65. However, most people don’t use long-term care until they’re in their 80s or 90s, Veghte says. By the time that person hits their 80s the benefit could be more than $116,000.
Currently, the program is expected to cover one year of in-home care, or it can be used for nursing home care or other long-term care needs.
Medicaid Asset Rules In Washington
Medicaid for LTC has different resource rules than those for other Apple Health programs. Resources are assets like real property, personal property, life insurance with a cash value, vehicles, motorhomes, boats, IRAs, bank accounts and cash. You will have to total up all of these to determine how much you have in resources.
If you are a single person, you can have only up to $2,000 in resources with a few allowable exclusions such as a car and your home . If you are married, your non-applicant spouse at home can keep up to $126,420 worth of joint assets.
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Nursing Home Admissions Under A Modified Adjusted Gross Income Medical Group
The instructions for financial workers below are limited to individuals on SSI-related Medicaid programs.
Individuals active on a MAGI-based program determined by the Health Benefit Exchange are eligible to receive nursing facility services as part of the state plan or alternate benefit plan . The only exception is the AEM MAGI programs called N21 and N25 in ACES. AEM does not cover NF care.
The AH MCO plan is responsible to pay for rehabilitation and skilled nursing in a NF. Once rehabilitation ends, the NF is paid by Provider One as a claim.
No NF award letter is issued for a client receiving N track MAGI based medical.
No participation is paid to the NF provider for MAGI based clients.
Days Or More Admissions
- Once a classic aged, blind, disabled AH MCO client is in a NF 30 days or more, make the necessary changes in the ACES system.
- The authorization date on the INST for a recipient is normally the first date DSHS was notified of the admission. If the PBS has information from the NF via DSHS 15-031 NOA that the rehabilitation days have ended, indicate the day after the rehab end date as the authorization date on the INST screen.
- ACES will issue an award letter even though the client may still be receiving rehabilitative services under the AH MCO . Indicate in the text of the award letter “Washington Apple Health Managed Care Rehabilitation Admission”.
- During rehabilitation days paid by the AH MCO, the client does not participate toward the cost of care. If the client is close to the resource limit, monitor the resources with the same process used as Medicare days in the NF.
- Indicate in the ACES narrative “AH Managed Care rehab admit” and the date, if the NF reports AH MCO rehabilitation ends, indicate AH MCO rehab end date.
Example: Short Stay #1
S02/SSI related client, not on Medicare admits to a NF on 11/5/2016. 15-031 NOA from NF indicates the 11/5/2016 admission under AH MCO rehabilitation. A 2nd NOA from the NF indicates a discharge date of 11/20/2016 back home. In this example, a short stay letter is not needed. A NFLOC determination from the HCS SW is not needed. The NF admission is covered by the AH MCO. Added CFC to note.
Example: Short Stay #2
Example: Short Stay #3.
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Is The Program Valid Under Federal Law
A question still remains whether the Program is preempted by The Employee Retirement Income Security Act , a federal law that sets rules and standards for plans established or maintained by employers for the purpose of providing medical, surgical, or hospital benefits in the event of sickness, accident, disability, death, or unemployment. Under the doctrine of preemption, when a state law interferes or conflicts with a federal law, the federal law displaces the state law.
Some have argued that the Program conflicts with ERISA because it applies to the same type of plans that the ERISA governs . The Program is employer-maintained because employers are required to take payroll deductions and track exemptions. Further, the Program does not fall under an ERISA-exempted voluntary payroll practice because it requires participation by most employees.
Since the Program is arguably preempted by ERISA, parties may bring suit in federal court seeking to invalidate the Program. Employers should be aware that a legal question remains and should look out for lawsuits that may invalidate or delay the implementation of the Program.
Does Medicare Cover Long Term Care
Medicare is the federal health insurance program for people over 65 and for some younger people with disabilities. But Medicare does not pay for most long term care services. Specifically, Medicare does not pay for custodial care which makes up more than 90% of long term care. An example of custodial care is when someone needs help with walking, bathing, eating, dressing and using the toilet.
Custodial care is also what people need most when they have a physical impairment from a stroke. Or, due to cognitive impairment from dementia or Alzheimers disease.
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Medicare Savings Program And Long
Note: The date eligibility is established for QMB/S03 is based on the financial worker having all the information needed in order to make a decision on the application. HCA has clarified that QMB needs to be open the first of the following month the action could have been taken by the FW.
QMB/S03 starts the first of the month following the date eligibility is established. If institutional eligibility is needed in order to open S03 because income is over the FPL, then the S03 opens the first of the month following the date all verification was received to establish eligibility. The date eligibility is established is the date that is indicated on the VERF screen. HCA has given a clarification that if verifications is received, but LTC does not start until the following month, that the FSS would indicate the date the verifications are received on the VERF screen. If verifications were received in a prior month than the LTC start date, this would cause the S03 to open in the same month as the LTC. Even though the LTC eligibility is driving S03 eligibility, this is correct.
S05/SLMB starts in the month the individual is income/resource eligible for the program. This includes a retro month.
S06/QI 1 starts in the month the individual is income/resource eligible for the program. This includes a retro month.
What is a retro month? A retro month is 3 months prior to the date the application was received.
Note: For more information, see allowable medical expenses
Which Employees Are Subject To The Tax
All employees employed in Washington are subject to the tax. Employees are considered employed in Washington if their:
- Services are performed in Washington or
- Services are not localized in any state, but some services are performed in Washington and the employee bases their operations or directs services from Washington .
Employees subject to a collective bargaining agreement in existence on October 19, 2017 and self-employed individuals are not subject to the tax .
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Medicaid Assistance Programs For The Elderly
Medicaid Programs & Waivers
Medicaid, which is jointly administered by the federal government and each of the states, is a health insurance program for low-income individuals in the United States. The federal government sets basic parameters for the program, and each state is able to set its own rules within the given parameter. In Washington, the state Medicaid program is referred to as Washington Apple Health, or Apple Health, for short. In Washington, as with all the other states, the Medicaid program will cover the cost of nursing home care for seniors and disabled persons who require this type of care and meet eligibility requirements.
1. In Washington, the Medicaid Personal Care Program is part of the state Medicaid plan. This program offers elderly and disabled individuals assistance with activities of daily living, such as bathing, mobility, and toileting. Assistance can be provided in ones personal home, a residential community, an adult family home, or in an assisted living facility. This program allows for consumer-direction, meaning an individual can choose their own caregiver, including family members. Make note, as of the summer of 2015, this state Medicaid program has been mostly replaced by the Community First Choice Option. However, one major difference between the two programs is that MPC does not require an institutional level of care need. Click here for more information about the MPC Program.
What Happens If The System Automatically Enrolls An Individual With Creditable Coverage Into A Medicare D Prescription Drug Plan Once They Become Eligible For Medicaid
The individual or their representative will need to contact 1-800-Medicare and their creditable coverage insurance carrier to indicate they want to retain their creditable coverage health plan. There are times when Medicaid individuals are enrolled into a Medicare D PDP incorrectly when the individual has creditable coverage.
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Assisted Living / Memory Care
In Washington, as of 2021, per Genworths 2020 Cost of Care Survey, the average monthly cost of assisted living is $5,750 statewide. However, the average monthly cost ranges from $3,800 on the low end to $6,750 on the high end, based on ones geographic location. The most expensive assisted living found in Washington is in the areas of Mount Vernon and Seattle, with the average monthly cost between $5,850 and $6,750. In contrast, the area with the least expensive assisted living is Walla Walla, with an average cost of $3,800 / month. The areas of Bellingham, Spokane, Yakima, Longview, Kennewick, Olympia, and Bremerton also offer very affordable assisted living at an average cost of $4,738 / month $5,138 / month.
Elderly individuals with Alzheimers disease or a related dementia who require a higher level of care and security are able to do so via Memory Care units. These units, sometimes referred to as Alzheimers care, are frequently located in assisted living facilities. On average, these types of units cost approximately $950 / month to $1,687 / month more than does traditional assisted living.
Medicare Premiums As A Participation Deduction
Only out-of-pocket Medicare premiums are an allowable participation reduction. If the Medicare premium is covered under a Medicare savings program or state buy-in, it is not an allowable participation reduction. Consult the Allowable medical expenses in the Apple Health eligibility manual for complete information on medical expenses used as a participation reduction.
All FBDE individuals are automatically enrolled in the LIS/Extra help subsidy for Medicare D prescription drug coverage unless the individual has creditable coverage for prescriptions under another plan. If a LTC elects to have a non benchmark Medicare D plan, the out-of-pocket cost is an allowable medical expense deduction from participation. For new LTC clients that have these nonbenchmark premiums, the FSS should monitor when LIS subsidy begins for client and update the deduction in ACES. This can be monitored for when the PDP or MA-PD premium is deducted from SSA, by checking SOLQ and cross-match with SHIBA plan guides.
Any expense deducted from room and board is coded as an ETR. Signed ETRs are needed to deduct any expense from room and board. Do not request an ETR if there is available participation.
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Who Needs Long Term Care
Someone turning age 65 today has about a 70 percent chance of needing some type of long term care during their lifetime. While one-third may never need long term care, 20 percent will need it for longer than 5 years. The average length of time people need long term care services is 3 years.1.
In Washington State, the average cost for 3 years of long term care is $376,791 at 2021 rates. That cost is projected to be $680,526 in 2041.2.
And its not only seniors that need long term care. Over 35 percent of people currently receiving long term care services are between 18 and 64.3.
Washington’s Medicaid Program Apple Health Will Pay For A Nursing Home Assisted Living Or Home Care If You Have Limited Income And You Need The Appropriate Level Of Care
With the average monthly cost of a private room in a nursing home in Washington approaching $10,000 in 2018, those who are likely to need long-term care should pay serious attention to ensure they have a way to pay for that care. LTC is usually paid for by private funds, nursing home insurance, or Medicaid. In 2019, Washington’s state legislature established a groundbreaking public LTC insurance program, but it will not provide LTC benefits to eligible beneficiaries until 2025. In the meantime, if a patient cannot afford to pay privately and does not have LTC insurance, Washington’s Medicaid program might pay for his or her care.
Medicaid is a medical assistance program funded by the federal and state governments to pay for LTC for persons who meet certain requirements, such as being over 65, disabled, or blind. Other types of Medicaid services have different eligibility guidelines than the rules for LTC.
Patients who live in skilled nursing facilities, intermediate care facilities, or hospitals for 30 days or more and are determined by Medicaid to need this care may qualify for Medicaid benefits, if they meet the income and resource qualifications of Washington’s Medicaid program.
There are also some limited services for people who still live at home but would otherwise require a nursing home. These are called home-based waiver programs. Similar income and asset rules apply for these programs.
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Nonformulary Part D Drugs
PDPs and MA-PDs are required to develop transition plans for institutionalized individuals. Plans may allow for limited coverage of drugs that are not part of the plans formulary. Each PDP/MA-PDs transition plan may vary. Plans must issue a periodic statement to the beneficiary explaining all benefits paid and denied. Part D drugs that are not covered by the plan may not be covered by Medicaid, and absent other drug coverage, these would remain the responsibility of the individual. These charges may be allowable deductions in the post-eligibility calculation. To determine whether or not prescription charges should be allowed in post-eligibility, apply the following rules:
Medicaid Client Participation During Medicare Days Including Coinsurance Days
Facilities may not collect participation from Medicaid clients during Medicare days, including Medicare coinsurance days. Client participation which is indicated on the nursing facility Medicaid award letter is only applicable for Medicaid days.
Client participation is not an eligibility factor for Medicare coverage. This includes cases where the Medicaid rate is higher than the Medicare coinsurance rate and DSHS is billed for the coinsurance up to the Medicaid rate. Clients or their representatives are responsible to report if their resources exceed Medicaid standards when clients are in Medicare status as they are not participating their monthly income toward the cost of care during Medicare days.
Note: The agency cannot use Medicaid funds to pay the recipient’s coinsurance responsibility beyond the amount Medicaid would pay for the service and cannot allow nursing facilities to write off the unpaid amounts as bad debts on their Medicaid cost reports.
Nursing Home Providers may contact the nursing home claims processing unit at the Health Care Authority with questions regarding the billing during Medicare days.
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