Eligibility Overview
Washington Apple Health (Medicaid) Programs
HCA 22-315 (3/24)
1
What is Washington Apple Health (Medicaid)? 2
How to use this guide 2
Scope of care 3
Modied Adjusted Gross Income (MAGI) Programs 3
Adults
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 Only (P06)
After-Pregnancy Coverage (N04, N24, N07, N27)
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 6
Breast and Cervical Cancer Treatment Program
(BCCTP) (S30)
Foster care and adoption support (D01, D02, D26)
Medical Care Services (A01, A05)
Refugee (R02, R03)
Non-Citizen Program 7
Alien Emergency Medical (AEM) (K03, N21, N25,
S07)
State-funded long-term care services (L04, L24)
Supplemental Security Income (SSI)
Related Programs 8
SSI 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 9
Medicare Savings Programs (MSP) 10
Qualied Medicare Beneciary (QMB) (S03)
Specied Low-Income Medicare Beneciary
(SLMB) (S05)
Qualied Individual (QI-1) (S06)
Qualied Disabled Working Individual
(QDWI) (S04)
Long-term services and supports (LTSS)
and Hospice 11
Covered services—scope of service 11
Scope of service categories
Table: Benet packages by program
Other services 14
Non-emergency Medical Transportation (brokered
transport)
Interpreter Services for Sign and Spoken
Language
Where to apply for health care coverage 14
MAGI Programs
Classic Medicaid Programs
Long-term Care
Aged, Blind, Disabled Coverage
Resources 15
Apple Health Toll-free Customer Services
(through the Health Care Authority)
HCA Online Resources
Scope of Care WACs
Denitions 16
Contents
2
Medicaid 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
“brand name” for all Washington State medical
assistance programs, including Medicaid. The brand
name may be shortened to “Apple Health.”
The Health Care Authority (HCA) administers most
Washington Apple Health programs. (The Department
of Social and Health Services administers the
Supplemental Security Income (SSI), SSI-related, State-
funded Medical Care Services (MCS), and Medicare
Savings programs.)
Medicaid expansion: Building on compassion
The Patient Protection and Aordable 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 2024
that translated to about $20,784 for a single person
or $43,056 for a family of four.
Many low-income adults suering 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 signicantly with higher income limits.
Others who had previously qualied but not enrolled
also obtained coverage. By 2024, 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 is helpful in understanding the dierences
between the programs. Refer to the Denitions 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 specic program standards change yearly, but in
dierent 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
.
3
Scope of care describes which medical and health
care services a particular Apple Health program
covers. There are four categories of scope of care:
• Categorically Needy (CN): The broadest, most
comprehensive scope of health care services covered.
• Alternative Benets Plan (ABP): The same scope of
care as CN, with the addition of habilitative services,
applicable to the Apple Health for Adults program.
• 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.
• 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 Disabled–cash or the Housing Essential
Needs (HEN) program.
Adults
Adult Medical (N05):
This program provides ABP coverage to adults with
countable income at or below 138 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 benets.
Scope of care
Modied Adjusted Gross Income
(MAGI) Programs
Eective April 1, 2024
Household Size Monthly Income Limit
1 $1,732
2 $2,351
3 $2,969
4 $3,588
5 $4,207
6 $4,825
Eective April 1, 2024
Household Size Monthly Income Limit
1 $511
2 $658
3 $820
4 $972
5 $1,127
6 $1,284
4
Pregnancy and Family Planning
Pregnancy Medical (N03, N23):
This program provides CN coverage to pregnant
individuals with countable income at or below 198
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 for 12
months after the pregnancy ends through the After-
Pregnancy Coverage (APC) program.
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 198 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
198 percent FPL standard.
Family Planning Only (P06):
This program provides coverage for pre-pregnancy
family planning services to help participants,
regardless of gender, take charge of their lives and
prevent unintended pregnancies.
Family Planning Only:
• One comprehensive preventive family planning
visit every year (365 days).
• Counseling, education, and/or risk reduction.
• Education and supplies for Food and Drug
Administration (FDA) approved contraceptives,
natural family planning, and/or abstinence.
• Permanent methods such as tubal ligations (tubes
tied), hysteroscopic sterilization, or vasectomy.
• When appropriate, pregnancy testing and cervical
cancer screening.
• Sexually transmitted infection screening, testing,
and treatment.
• Human papillomavirus (HPV) vaccinations.
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.
Eective April 1, 2024
Household Size Monthly Income Limit
1 N/A
2 $3,373
3 $4,260
4 $5,148
5 $6,036
6 $6,923
Eective April 1, 2024
Household Size Monthly Income Limit
1 $2,485
2 $3,373
3 $4,260
4 $5,148
5 $6,036
6 $6,923
After-Pregnancy Coverage
After-Pregnancy Coverage (APC) is comprehensive Apple Health coverage for individuals to access health care
services any time in the 12 months after their pregnancy ends.
This program provides CN coverage to individuals with income at or below 198 percent of the FPL, regardless
of immigration status.
• Already enrolled in Apple Health at end of pregnancy (N04, N24)
• Not enrolled in Apple Health at end of pregnancy (N07, N27)
5
Apple Health for Kids
Apple Health for Kids coverage is free to children in households with income at or below 215 percent of the FPL
and available for a monthly premium to children in households with income at or below 317 percent of the FPL.
Apple Health for Newborns (N10):
This program provides 12 months of CN coverage if
the mother was enrolled in an Apple Health program
when the child was born. There is no resource or
income limit for this program.
Apple Health for Kids (N11, N31):
This program provides CN coverage to children under
age 19 whose families have income at or below
215 percent of the FPL. Children who would have
been eligible for Apple Health for Kids had they met
immigration status requirements receive CN coverage
under state-funded Apple Health for Kids.
Apple Health for Kids with Premiums (N13, N33):
This program provides CN coverage to children
under age 19 whose families have income above
215 percent and at or below 317 percent of the
FPL. Participants pay a low-cost monthly premium.
Children who would have been eligible for Apple
Health for Kids with Premiums had they met
immigration status requirements receive CN
coverage under state-funded Apple Health for Kids
with Premiums.
Apple Health for Medically Needy Kids (F99):
This program provides MN coverage to children
under age 19 whose families have income above
317 percent of the FPL. Children who qualify and are
enrolled in Apple Health for Medically Needy Kids
become eligible for MN coverage after incurring
medical costs equal to the amount of the household
income that is above the 317 percent FPL standard.
Eective April 1, 2024
Household
Size
Monthly Income Limit
215% FPL
(No Cost)
Monthly Income Limit
265% FPL
($20 Premium/Child,
$40 Family Maximum)
Monthly Income Limit
317%% FPL
($30 Premium/Child,
$60 Family Maximum)
1 $2,698 $3,326 $3,978
2 $3,662 $4,514 $5,400
3 $4,626 $5,702 $6,821
4 $5,590 $6,890 $8,242
5 $6,554 $8,078 $9,663
6 $7,518 $9,266 $11,084
6
Breast 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 certied by the BCCHP.
An individual is eligible if they meets all of the
following criteria:
• Screened for breast or cervical cancer under the
BCCHP.
• Requires treatment for either breast or cervical
cancer or for a related pre-cancerous condition.
• Is under age 65.
• Is not covered for another CN (Categorically Needy)
Apple Health program.
• Has no insurance or has insurance that is not
creditable coverage.
• Meets residency requirements.
• Meets social security number requirements.
• Meets citizenship or immigration status
requirements.
• Meets income limits set by the BCCHP.
For further information, go to the DOH website:
doh.wa.gov/YouandYourFamily/IllnessandDisease/
Cancer/BreastCervicalandColonHealth
Foster care and adoption support (D01, D02, D26):
This program provides CN coverage to children
receiving foster care and adoption support. 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, A24):
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 Disabled–cash, the Housing Essential Needs
(HEN) program, or the Survivors of Certain Crimes
(SCC) program, which includes victims of human
tracking as described in RCW 74.04.005.
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 twelve 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
7
Non-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:
• Be categorically relatable to 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
• 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.
• 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:
• 182-507-0110: Alien Medical Programs: This explains
the eligibility requirements for the program.
• 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. Certication is limited to the dates
on which the qualifying services were provided.
• 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)
• 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.
• 182-507-0125: State-funded long-term care services –
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), Home and Community Services
(HCS). This program is subject to caseload limits.
8
Supplemental Security Income (SSI)
Related Programs
SSI Program (S01):
This program provides CN coverage to individuals
receiving SSI (Supplemental Security Income) cash
benets.
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:
• 65 years old or older (aged).
• Blind (as dened by the Social Security
Administration and determined by DSHS).
• Disabled (as dened 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
blindness or a disability (aged 16 and above) who are
employed with earnings. Health care premiums are
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 benets, 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.
Eective January 1, 2024
Household Size Monthly
Income Limit
Resource
Limit
1 $943 $2,000
2 $1,415 $3,000
Eective January 1, 2024
Household Size Monthly Income Limit
1 $943
2 $943
3 $943
4 $943
5 $943
6 $975
9
Medically 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 income—
in other words, to incur nancial obligations for
medical expenses equal to their spenddown amount.
(Spenddown is the amount of the individual’s income
minus the income limit for their 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 $943 by $244.
Martha is found eligible for the MN spenddown program for the aged. She selects
a six- month spenddown base period. Her spenddown amount is $1,464 ($244x 6
months) for April through September. This means that Martha is responsible for
the first $1,464 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 $1,464. 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 $943, she would have qualified for the
no-cost Apple Health for the Aged program for 12 months coverage.
10
The Medicare Savings Program (MSP) can provide
assistance with premium costs, copayments,
deductibles, and co-insurance for individuals who are
entitled to Medicare and meet program requirements.
Qualied Medicare Beneciary (QMB) (S03)
• Pays Part A and Part B premiums.
• Pays deductibles.
• Pays copayments except for prescriptions.
Specied Low-Income Medicare Beneciary
(SLMB) (S05)
• Pays Part B premiums.
Qualied Individual (QI-1) (S06)
• Pays Part B premiums.
Qualied Disabled Working Individual
(QDWI) (S04)
• Pays Part A premiums.
Income Limits–Eective April 1, 2024 (Below limits include a $20 disregard allowed to all households)
Medicare Savings
Program
Federal Poverty Level
(FPL)
Monthly Income Limit –
One Person
Monthly Income Limit –
Two Persons
QMB 110% $1,401 $1,894
SLMB 120% $1,526 $2,064
QI-1 138% $1,752 $2,371
QDWI 200% $2,530 $3,427
Medicare Savings Program (MSP)
11
Apple Health provides access to a wide range of
medical services. Not all eligibility groups receive
all services. Coverage is broadest under the
Categorically Needy (CN) and Alternative Benets
Plan (ABP) programs.
The scope of services covered for any individual
depends on the Apple Health program in which the
individual is enrolled. The table on pages 12-13 lists
specic health care services and shows which scope of
service category covers which services. An individual’s
age is also a factor. Some services may require prior
authorization from HCA, the individual’s Apple Health
Managed Care plan, or DSHS as applicable.
This table is provided for general information only
and does not in any way guarantee that any service
will actually be covered at the time of inquiry,
because benets, coverage, and interpretation of
benets and coverage may change at any time.
Coverage limitations can be found in federal statutes
and regulations, state statutes and regulations,
state budget provisions, and Apple Health provider
guides. Individuals with questions regarding
coverage should call the 800 number on the back of
their Services Card.
Covered services—scope of service
Long-Term Services and Supports (LTSS) and Hospice
Hospice services
Apple Health benets include hospice services for
people who are eligible under categorically needy
(CN), medically needy (MN), or alternative benet plan
(ABP) programs. If a person is not eligible for CN, MN,
or ABP, a determination can be made using eligibility
rules under a separate Hospice program. The hospice
provider noties the agency when hospice services are
elected. The Hospice program pays for hospice care at
home, a hospice care center, or hospice in a nursing
facility.
Long-Term Services and Supports (LTSS)
Long-term Services and Supports (LTSS) are tailored
to t client individual needs and situations. Services
may be authorized through the Department of Social
and Health Services (DSHS) by Home and Community
Services (HCS) or the Developmental Disabilities
Administration (DDA). These services enable people to
continue living in their homes with help meeting their
physical, medical, and social needs. When these needs
can’t be met at home, care in a residential or nursing
facility is available.
In HCS, there are also programs available that provide
help to caregivers and people without a caregiver—
Tailored Supports for Older Adults and Medicaid
Alternative Care. The person in need of care must be
age 55 or older and meet nancial eligibility criteria.
Dierent income standards are used to determine
eligibility for CN or MN coverage for LTSS. To be
eligible for most LTSS programs, a person must
le an application and meet nancial eligibility
criteria and functional eligibility criteria (based on a
comprehensive assessment).
For more information about nursing home care, or
home & community based services oered by HCS,
contact a local HCS oce. To locate the closest HCS oce: visit
dshs.wa.gov/ALTSA/resources.
For information about nancial eligibility for the DDA services,
contact the LTC Specialty Unit at 1-855-873-0642.
For information about functional eligibility criteria for home
and community-based services through DDA, go to dshs.
wa.gov/dda.
LTSS services include the following programs:
Through HCS:
• Community Options Program Entry System (COPES), New
Freedom, and Residential Support Waiver (RSW) (L21, L22)
• Community First Choice (CFC), Medicaid Personal
Care (MPC) (L51, L52)
• Roads to Community Living (RCL) (L41, L42)
• Program of All-Inclusive Care for the Elderly
(PACE) (L31, L32)
• Nursing Facility care (L01, L02, L95, L99)
• Tailored Supports for Older Adults (T02)
• Medicaid Alternative Care (MAC)
• Limited funding for state-funded Long-term
services for non-citizens (L04, L24)
• LTSS Presumptive Eligibility (S32)
Through DDA:
• Developmental Disabilities Administration (DDA)
Waivers (L21, L22)
• Community First Choice (CFC), Medicaid Personal
Care (MPC) (L51, L52)
• Roads to Community Living (RCL) (L41, L42)
• DDA Residential Habitation Centers and Intermediate
Care Facilities (L01, L02, L95, L99)
• Hospice program (L31, L32)
• Limited funding for state-funded long-term services
for non-citizens (L04, L24)
12
Benet packages by program
Service ABP
20-
ABP
21+
CN
1
20-
CN
21+
MN
20-
MN
21+
MCS
Ambulance (Ground/Air) Y Y Y Y Y Y Y
Applied Behavior Analysis (ABA) Y Y Y Y Y Y N
Behavioral health services Y Y Y Y Y Y Y
Blood/blood products/related services Y Y Y Y Y Y Y
Dental services Y Y Y Y Y Y Y
Diagnostic services (lab and X-ray) Y Y Y Y Y Y Y
Early and periodic screening, diagnosis, and
treatment (EPSDT) services
Y N Y N Y N N
Enteral nutrition program Y Y Y Y Y Y Y
Habilitative services Y Y N N N N N
Health care professional services Y Y Y Y Y Y Y
Health homes Y Y Y Y N N N
Hearing evaluations Y Y Y Y Y Y Y
Hearing aids Y Y Y Y Y Y Y
Home health services Y Y Y Y Y Y Y
Home infusion therapy/parenteral nutrition
program
Y Y Y Y Y Y Y
Hospice services Y Y Y Y Y Y N
Hospital services Inpatient/outpatient Y Y Y Y Y Y Y
Intermediate care facility/services for persons
with intellectual disabilities
Y Y Y Y Y Y Y
Maternity care & delivery services Y Y Y Y Y Y Y
Medical equipment, durable (DME) Y Y Y Y Y Y Y
Medical nutrition therapy Y Y Y Y Y Y Y
Nursing facility services Y Y Y Y Y Y Y
Organ transplants Y Y Y Y Y Y Y
Orthodontic services Y N Y N Y N N
Out-of-state services Y Y Y Y Y Y N
Outpatient rehabilitation services (OT, PT, ST) Y Y Y Y Y N Y
Personal care services Y Y Y Y N N N
Prescription drugs Y Y Y Y Y Y Y
Private duty nursing Y Y Y Y Y Y N
Prosthetic/orthotic devices Y Y Y Y Y Y Y
13
Benet packages by program
LEGEND
Y = A service category is included for that program. Services within each service category are subject to
limitations and restrictions listed in the specic medical assistance program rules and agency issuances.
N = A service category is not included for that program.
1
Clients enrolled in the Apple Health for Kids programs (with and without premium) receive CN-scope of
health care services. The Apple Health for Kids programs includes the children’s health insurance program
(CHIP).
ABBREVIATIONS
ABP - Alternative Benet Plan
CN - Categorically Needy Program
MCS - Medical Care Services
MN - Medically Needy Program
Service ABP
20-
ABP
21+
CN
1
20-
CN
21+
MN
20-
MN
21+
MCS
Reproductive health services Y Y Y Y Y Y Y
Respiratory care (oxygen) Y Y Y Y Y Y Y
School-based medical services Y N Y N Y N N
Vision care Exams, refractions, and ttings Y Y Y Y Y Y Y
Vision hardware Frames and lenses Y N Y N Y N N
14
Where to apply for health care coverage
Nonemergency Medical Transportation (Brokered
Transport)
HCA covers nonemergency medical transportation
for eligible clients to or from covered services
through contracted brokers. The brokers arrange
and pay for trips for qualifying clients. Currently,
eligible clients are those enrolled in Apple Health
and other state-funded medical assistance programs
that include a transportation benet. Transportation
may be authorized for individuals who have no other
means to access medical care.
The most common types of transportation available
include: public transit bus, gas vouchers, client
and volunteer mileage reimbursement, taxi,
wheelchair van or accessible vehicle, commercial
bus and air, and ferry tickets. More information is
available online at: hca.wa.gov/transportation-
help.
Comments and questions may be directed to
HCA Transportation Services at hcanemttrans@hca.
wa.gov.
Interpreter services - sign language
HCA covers the cost of sign language interpreters
for eligible clients. This service must be requested by
Apple Health providers, HCA sta or HCA-authorized
DSHS sta, and must be provided by the HCA-
approved contractor.
Interpreter services - spoken language
HCA covers interpreter service for eligible clients
through the HCA approved contractor. Requests
for this service must be submitted by Apple Health
providers, HCA sta, or HCA-authorized DSHS sta.
Other services
Modied Adjusted Gross Income
(MAGI) programs
• Online: wahealthplannder.org .
• Phone: 1-855-923-4633
• Paper: HCA Form 18-001P (Application for Health
Care Coverage) available at hca.wa.gov/assets/
free-or-low-cost/18-001P.pdf .
To submit a completed application by mail:
Washington Healthplannder
P.O. Box 946, Olympia, WA 98507
Or send it by fax to: 1-855-867-4467
If you want help applying, you can work with an in-
person assister or call Healthplannder Customer
Support at 1-855-923-4633.
Aged, Blind, Disabled Coverage
Disability-based Washington Apple Health, refugee
coverage, coverage for seniors 65+, and programs
that help pay for Medicare premiums and expenses:
• Online: washingtonconnection.org
• Paper: HCA Form 18-005 (Application for ABD/LTC)
available at hca.wa.gov/assets/
free-or-low-cost/18-005.pdf .
To submit a completed application by mail:
DSHS – Community Services Division
P.O. Box 11699, Tacoma, WA 98411-6699
Or send it by fax to: 1-888-338-7410
• In-person: Visit a local Community Service Oce.
For locations, go to dshs.wa.gov/esa/community-
services-nd-an-oce .
Questions? Call 1-877-501-2233
Long-Term Care
Nursing home care, in-home personal care, assisted-
living facilities, and adult family home programs:
• Online: washingtonconnection.org .
• Paper: HCA Form 18-005 (Application for ABD/LTC)
available at hca.wa.gov/assets/
free-or-low-cost/18-005.pdf .
To submit a completed application by mail:
DSHS – Home & Community Services
P.O. Box 45826, Olympia, WA 98504-5826
Or send it by fax to: 1-855-635-8305
• In-person: Visit a local HCS oce. For locations, go to
dshs.wa.gov/ALTSA/resources
.
Questions? Call a local HCS oce. For locations, go to
dshs.wa.gov/ALTSA/resources
.
15
Telephone
Apple Health Medical Assistance
Customer Service Center (MACSC)
Open 7 a.m. – 5 p.m. (weekdays)
Clients
1-800-562-3022 (option 3) or
https://fortress.wa.gov/hca/p1contactus/
Providers
1-800-562-3022 (option 4) or
https://fortress.wa.gov/hca/p1contactus/
Orders for large print or Braille
1-800-562-3022 (option1, option 3, option 1)
TRS: 711
Apple Health Medical Eligibility
Determination Services (MEDS)
Open 8 a.m. – 5 p.m. (weekdays)
1-800-562-3022 or
https://fortress.wa.gov/hca/p1contactus/
TRS: 711
Online
Apple Health (Medicaid) hca.wa.gov/apple-health
Apple Health (Medicaid) Manual hca.wa.gov/free-or-low-cost-health-care/
program-administration/apple-health-eligibility-manual
Access to rules
Washington Administrative Code (WAC)
sections pertaining to “scope of care”
Healthcare general coverage:
http://apps.leg.wa.gov/WAC/default.aspx?cite=182-501-0050
Healthcare coverage
Scope of covered categories of service:
http://apps.leg.wa.gov/WAC/default.aspx?cite=182-501-0060
Healthcare coverage
Description of covered categories of service:
http://apps.leg.wa.gov/WAC/default.aspx?cite=182-501-0065
Resources
HCA complies with all applicable federal and Washington state civil rights laws and is committed
to providing equal access to our services.
If you need an accommodation, or require documents in another format or language,
please call 1-800-562-3022 (TRS: 711).
[Russian] ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода.
Звоните 1-800-562-3022 (TRS: 711).
[Spanish] ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame
al 1-800-562-3022 (TRS: 711).
16
Apple Health
See Washington Apple Health
Managed Care
The majority of individuals enrolled in Apple Health
receive their health services through a designated
health care plan that contracts with the Health Care
Authority. This prepaid comprehensive system of
medical and health care services is usually called
managed care.
Classic Medicaid
The term used to describe the Medicaid health care
programs including Long-Term Care services and
Aged, Blind or Disabled coverage. The Modied
Adjusted Gross Income (MAGI) health care programs
are not Classic Medicaid.
Federal Poverty Level (FPL)
A guideline for determining eligibility for a
governmental program based on the Consumer Price
Index guide from the year just completed. Many
health care coverage programs determine eligibility
based on a percentage of the FPL.
Fee-for-Service
This is a health care service delivery system where
health care providers are paid for each service (such
as an oce visit, test, or procedure). Individuals
who are not covered by Apple Health Managed
Care are covered by Apple Health Fee-for-Service
(also referred to as Apple Health coverage without a
managed care plan).
Health Care Authority (HCA)
HCA is a Washington State agency that administers a
number of programs related to health and wellness,
including most Washington Apple Health programs.
Medicaid
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 cover the Categorically Needy (CN) and
Medically Needy (MN) programs.
Modied Adjusted Gross Income (MAGI)
The methodology used for calculating income and
determining household composition to determine
eligibility for Apple Health for Adults, Kids, Families
and Caretaker Relatives, and Pregnant Individuals.
This method follows federal income tax ling rules
with a few exceptions and has no resource or asset
limits.
ProviderOne
The online payment system for health care providers
serving individuals enrolled in an Apple Health
program.
Scope of Care
Scope of care describes which medical and health
care services are covered by a particular Apple Health
program. There are four categories of scope of care:
Categorically Needy (CN), Alternative Benets Plan
(ABP), Medically Needy (MN), and Medical Care
Services (MCS).
Spenddown
This process allows individuals with income above
the limits for the applicable CN program to spend
down excess income within a specied period of time
to become eligible for coverage.
Washington Apple Health
The brand name for all Washington State medical
assistance programs, including Medicaid. The brand
name may be shortened to “Apple Health.”
Denitions
HCA administers Washington Apple Health (Medicaid).
