Program Summary - Medical Programs
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Program Summary - Medical Programs

Revised October 28, 2007

Purpose: This section describes the eligibility requirements for the various medical programs and coverage administered by the department.

Medical Assistance Administration (MAA) provides a wide range of medical services based upon a client's circumstances and needs. Not all eligibility groups receive the same range of services. The differences in coverage are displayed in the SCOPE OF CARE category of this manual.

For a comprehensive Medical Assistance Eligibility Overview, you can visit the MAA website and choose either the Internet-based manual or the PDF version.

The following programs are described briefly in this summary:

Coverage or medical benefits are least restricted under the Medicaid - Categorically Needy (CN) program. "Medicaid" is the federal name for the state and federal funded medical benefit program.

The department considers a client's application for the least restricted coverage first and then considers programs in order down to the most restrictive coverage. Most often this meets the program's intent of considering federally-funded programs before state-funded programs. However, there are instances where a client can receive state-funded coverage for brief periods to obtain certain services and be reverted back to the federally-funded program after the special coverage need has been met.


WAC 388-503-0505 General eligibility requirements for medical programs.

MEDICAID - CATEGORICALLY NEEDY MEDICAL COVERAGE (CN)

The CN medical programs are funded with federal-state matched Medicaid (or Title XIX) dollars. They are called Categorically Needy (CN) because their needs fall into certain program categories created by federal or state law. Those categories are:

  1. Aged, Blind or Disabled persons who are eligible for CN if they are eligible for or relatable to the Supplemental Security Income program in the following ways:

    1. Receiving an SSI grant

    2. Eligible for an SSI grant but not receiving the cash

    3. Not eligible for an SSI grant but eligible for "SSI-related" medical coverage based on the medical-only program criteria in chapter 388-511 or 388-475 WAC.

  2. Persons eligible for or relatable to Temporary Assistance to Needy Families (TANF) are eligible for CN medical coverage as follows:

    1. Receiving TANF cash benefits;

    2. Eligible for TANF cash benefits but choosing not to receive a cash grant; and

    3. Not eligible for a TANF cash grant but eligible for "TANF-related" medical-only coverage as described in those portions of the manual.

  3. Effective October 1, 2002, a person receiving State Family Assistance (SFA) cash benefits is not eligible for a medical program, other than for pregnancy or for Alien Emergency Medical.  After October 2002, any reference to SFA medical is inadvertent and is not intended to imply continuing medical coverage.  Also effective October 1, 2002, medical coverage under the Children's Health (F08) program is eliminated.  After that date any reference to medical coverage under Children's Health (F08) medical is inadvertent and is not intended to imply continuing medical coverage.

  4. Persons receiving Refugee Program benefits as described in REFUGEE PROGRAMS.

These are the programs that provide the broadest scope of medical coverage. They are intended to cover all of a client's services that are "Medically Necessary" and covered by MAA.  The coverage is discussed in detail in SCOPE OF CARE.


WAC 388-503-0510 How a client is determined "related to" a categorical program.

CN COVERAGE FOR PERSONS ELIGIBLE FOR OR RECEIVING CASH ASSISTANCE


WAC 388-503-0515  Medical coverage resulting from a cash grant.


NOTE: Medical coverage associated with the General Assistance and ADATSA programs is discussed later in this summary.

CN COVERAGE FOR PERSONS NOT ELIGIBLE FOR CASH ASSISTANCE

Families or individuals who are not eligible for either TANF or SSI cash may still be eligible for CN medical-only coverage. There are CN medical programs based on the Federal Poverty Level (FPL) which are discussed later in this category. In addition, these families or individuals can be "related" to the categorical programs as provided under WAC 388-503-0510 and they may be considered for Medically Needy (MN) coverage. For more information see ADULT MEDICAL and FAMILY MEDICAL.

  1. Aged, Blind or Disabled Persons:

Primarily, this category applies to persons eligible for or receiving Supplemental Security Income (SSI) as administered by the Social Security Administration. However, persons who are Aged, Blind or Disabled and not eligible for SSI may be eligible for CN or MN coverage as "related" individuals under WAC 388-503-0510.

Some persons may be receiving benefits from Medicare. In addition to the programs listed on page one, there are MEDICARE SAVINGS PROGRAMS which may benefit clients.

Programs for persons under these categories are discussed in detail in the ADULT MEDICAL, or SSI-RELATED MEDICAL, SCOPE OF CARE and the MEDICARE portions of this manual.

  1. Children's CN Medical:

Medical programs for children and options other than CN coverage are discussed in detail in FAMILY MEDICAL.

The various types of coverage provided under the children's programs are discussed in SCOPE OF CARE. In addition, special coverage available for children is discussed in HEALTHY KIDS.

Regarding eligibility determination, special attention may need to be paid to children with separate income or resources. This subject is discussed at MEDICAL ASSISTANCE UNITS - SNEEDE / KIZER.

  1. CN Coverage in Special Situations:

Some clients who are not eligible for TANF cash benefits may be eligible for medical coverage. These groups include:

  1. Teen parents who are not in an approved living situation and/or are not meeting school requirements; 

  2. Persons who have reached the 60-month TANF cash benefit limit;

  3. Families not eligible for TANF because they do not meet the work quarter requirements

  4. Persons who are not cooperating with WorkFirst activities

  5. Fleeing felons

  6. Persons moving from state to state (state hopping)

  7. Persons convicted of welfare fraud

  1. Pregnant Women:

CN medical coverage includes a full scope of coverage for pregnant women. This is discussed in SCOPE OF CARE. The programs are detailed in FAMILY MEDICAL and PREGNANCY.

Women who are pregnant and who have income equal to or less than 185% FPL usually are eligible for the CN program. The pregnant woman can be eligible at any time during her pregnancy. Once eligible, the woman continues to be eligible throughout the pregnancy regardless of changes in income and household composition.

When a woman is pregnant and not eligible for cash assistance, the medical programs consider the unborn child or children in determining the size of the woman's family. Unlike cash assistance programs, the medical program considers the unborn child or children as if they are born and living with the mother. This is discussed in detail in the PREGNANCY portion of this manual.

If a pregnant woman is not eligible for CN coverage, she is considered for the Medically Needy program which is discussed on the following pages. Medically Needy coverage may involve SPENDDOWN.

  1. Refugees

The Refugee Program, which is 100% federally funded, provides coverage for persons who have been granted asylum in the U.S. as a refugee or asylee. These individuals may receive cash benefits and Categorically Needy (CN) medical coverage for a maximum of eight months. Refugee families and single refugees are eligible for these cash and medical benefits.

Refugees / asylees who have income and/or resources above the limits for cash grants may be eligible for MN (Medically Needy). This program is detailed in the REFUGEE category.

Refugees and asylees who have been in the U.S. for more than eight months are determined eligible for medical benefits in the same manner as for U.S. citizens.

  1. Aliens

There are medical programs which provide benefits for persons who are non-citizens (aliens). These programs are discussed in detail in the CITIZENSHIP/ALIEN STATUS, EMERGENCY ASSISTANCE, ADULT MEDICAL, or SSI-RELATED MEDICAL,  PREGNANCY and FAMILY MEDICAL categories.


MEDICALLY NEEDY MEDICAL COVERAGE (MN)

The MN medical programs are funded with federal-state matched Medicaid dollars. They were established to provide medical coverage for those individuals whose income exceeded the more limited income standards required to qualify for CN coverage.

The program applies to persons who are aged, blind, disabled, refugees, pregnant women or children.

The applicant for Medically Needy coverage may:

  1. Meet all other program requirements except their income falls between the income limits for CN coverage and the Medically Needy Income Level (MNIL). These persons are eligible for MN coverage for up to twelve months at a time with no spenddown.

  2. Meet all program requirements except for their income. In this case, the applicant's income exceeds the MNIL. They may "become" eligible through the process of SPENDDOWN. See SPENDDOWN for more information.

The following are examples of persons who could be eligible for MN coverage:

  • Pregnant women not eligible for CN coverage because their income is above 185 % of the Federal Poverty Level (FPL).

  • Children not eligible for CN coverage because their income is above 200 % of FPL.

See the SCOPE OF CARE for information about the differences in coverage between CN and MN.


GENERAL ASSISTANCE

  1. GAX - General Assistance Expedited Medicaid Disability

    The GAX program provides state-funded cash benefits to persons who have a disability decision pending with SSA. Eligible persons receive CN medical coverage parallel to that provided to SSI recipients. Again, this is full scope medical coverage.

  2. GAU - (Unemployable)

    The GAU program provides cash benefits to persons who are physically and/or mentally incapacitated and unemployable for more than 90 days. This program differs from GAX in that no disability application is pending with the Social Security Administration. Eligible persons receive limited medical care coverage under the state-funded Medical Care Services (MCS) program.

  3. GAU - Immigrants

    Immigrants determined to meet eligibility requirements for GAU are eligible for state-funded medical coverage under MCS.


ADATSA

The ADATSA program provides cash benefits, treatment, and support for a person incapacitated from gainful employment due to alcoholism or drug addiction. Eligible persons receive limited medical coverage under MCS. A medical only ADATSA program exists for persons waiting to get into treatment.

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Modification Date: October 28, 2007
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