Facebook Live
Office of Medicaid Eligibility Policy
Medicaid Programs Division
November 09, 2021
Introduction and roles
COFA Navigators
Carlinda Jabjulan, Better Health Together
Rensa Mailo, Pacific Islander Health Board of WA
Health Care Authority
Paige Lewis
Stephen Kozak
Ariel Pyrtek
Roz Leon Guerrero
What we’ll cover today
Overview
Apple Health (Medicaid)
Classic Apple Health
Apple Health next steps
Open enrollment
Scenarios
Outreach efforts
Resources
Q&A session
Overview
Medicaid restoration
The Consolidated Appropriations Act, 2021, (Sec. 208) restored Medicaid benefits for
individuals from the Republic of Palau, The Federated States of Micronesia and the
Republic of the Marshall Islands.
Prior to the passing of this legislation, COFA islanders were limited in their ability to
receive Apple Health.
Children and pregnant individuals were and continue to be eligible for Apple
Health.
The Health Care Authority (HCA) has updated the eligibility system to allow COFA
islanders to receive Medicaid as qualified non-U.S. citizens exempt from the 5-year
bar.
COFA Islander programs transition
Individuals enrolled in COFA Islander programs who were:
Under age 65 and without Medicare transitioned to Apple Health for Adults on July 1.
Their COFA Islander programs and qualified health plans ended June 30 (they had
continuous coverage).
Age 65 and older or have Medicare must apply for Apple Health via Washington
Connection.
Their COFA Islander programs continued, which ensured there was no gap in
coverage while they applied with the Department of Social and Health Services
(DSHS).
Apple Health (Medicaid)
Apple Health
Apple Health (Medicaid) provides medical, vision, dental benefits and
health care services such as preventative care, cancer screenings,
treatment for diabetes and high blood pressure, and many other
health care services.
There are no co-payments, deductibles, and other out-of-pocket
expenses.
Apple Health eligibility
An application is required to determine if an individual is eligible for Apple Health.
Most individuals eligible for Apple Health (Medicaid) apply for coverage online at
wahealthplanfinder.org.
COFA islanders must meet all eligibility criteria for Apple Health, including income
limits, Social Security Number (SSN) requirements and Washington residency.
Income verification may be required before eligibility for Apple Health is
determined.
If proof of income is required, individuals will receive a notice with the request.
Classic Apple Health
Classic Apple Health
Classic Apple Health refers to programs administered by the Department of Social
and Health Services (DSHS).
Individuals who are age 65 years or older, have blindness or a disability, or need
Long-Term Services and Supports (LTSS), apply for Apple Health with DSHS.
Eligibility criteria varies for each program and is based on household size, income,
and resources.
Resources are
counted for
Classic Apple
Health.
Long-Term Care resource questions
Classic Apple Health programs and services
There are many Classic Apple Health programs and services available to eligible individuals,
including:
Apple Health for Workers with Disabilities (HWD) allows enrollees to earn and save
more money and to purchase health care coverage with monthly premium based on a
sliding scale.
Medicare Savings Programs (MSP) helps eligible individuals by paying Medicare
premiums, deductibles and other Medicare-related costs.
Tailored Support for Older Adults (TSOA) provides services to support unpaid caregivers
and provides a small personal care benefit to people who don’t have an unpaid family
caregiver to help them.
Medicaid Alternative Care (MAC) provides services to unpaid caregivers designed to
assist them in providing quality care to family members while also improving their own
well-being.
Spenddown
Spenddown is a Medicaid program for individuals who are over income for other
Classic Apple Health programs. When an individual has spenddown, they can choose
a three- or six-month base period. The base period is the number of months an
individual's income is counted.
Individuals are responsible for the expenses used to meet their approved
spenddown period and HCA will not pay them.
Once an individual has shown they have incurred expenses that meet the
spenddown liability, coverage will begin.
A new application is required at the end of each three- or six-month base period.
COFA islanders can apply for Classic Apple Health programs via:
Online: washingtonconnection.org
Paper: hca.wa.gov/apple-health-client-forms
Search “18-005”
Mail: PO Box 11699, Tacoma WA 98411-6699
Fax: 1-888-338-7410
In person: dshs.wa.gov/office-locations
Phone: DSHS at 1-877-501-2233
Classic Apple Health
Apple Health
next steps
Apple Health next steps
Individuals enrolled in Apple Health will:
Receive a ProviderOne Services card.
If a COFA islander had Apple Health in the past,
it is still valid. They will not receive a new card.
Enroll in a plan with a Managed Care Organization
(MCO).
For more information visit HCA Apple Health
managed care
.*
* hca.wa.gov/health-care-services-supports/apple-health-medicaid-coverage/apple-health-managed-
care#contact-your-apple-health-plan
Managed care enrollment
Individuals
should take their
health plan ID
card when the go
to a doctor,
pharmacy or
other health care
provider.
Apple Health renewals
Renewal of Apple Health eligibility is required at least every twelve months. There
are some exceptions such as:
Apple Health medically needy spenddown, a new application is required at
the end of each three- or six-month base period.
Individuals turning 65 within the next 12 months.
When a renewal is due a notice will be sent to the individual with the next steps.
Apple Health renewal timeframe
An individual can renew coverage:
60 days prior to the end of their certification period
Up to 90 days after the coverage has ended
If a renewal is not received a termination notice is sent 20 days before the end of
the certification period.
If an eligible individual submits a completed renewal within 90 days after
coverage closed, Apple Health will be restored without a gap in coverage.
Open Enrollment
COFA Islander programs eligibility
COFA Islander Health Care and COFA Islander Dental Care is still available for COFA
islanders who are:
Over resources for Classic Apple Health.
Approved for a spenddown but have not met their spenddown amount.
Entering the U.S. with another status such as permanent resident, spouse of a
U.S. citizen.
Individuals must meet all eligibility criteria for COFA Islander programs, including
filing taxes and meeting income limits.
Individuals who do not respond to a request related to Apple Health eligibility will
not be eligible for COFA Islander programs.
2022 plan year
All silver level qualified health plans and family dental plans offered in 2022 are
available for COFA Islander Health Care and COFA Islander Dental Care.
There is no separate renewal process for COFA Islander programs.
COFA islanders currently enrolled in the program will remain enrolled in COFA
Islander Health Care as long as they meet eligibility criteria.
COFA islanders currently enrolled in COFA Islander programs will have to manually
renew their QHP and QDP during open enrollment to determine 2022 eligibility.
COFA Islander programs renewal letter
Scenarios
Apply for Apple health any time!
Scenario one
Maree, age 30, is new to Washington State and needs health insurance. Her aunt
told her about COFA Islander Health Care but that she cannot apply until
November 1.
Does Maree need to wait for open enrollment to apply?
No. Maree does not need to wait. Apple Health does not have an Open Enrollment
period, individuals can apply all year round.
Maree applies through Washington Healthplanfinder because she is under the age
of 65 and is approved for Apple Health for Adults.
I was denied COFA, can I get Apple Health?
Scenario two
Jack, age 23, applied for COFA Islander Health Care in November 2020, but was
denied because he was over income. Since COFA islanders are now eligible for Apple
Health, Jack is wondering if he can re-apply for coverage.
Can Jack re-apply for coverage?
Yes. COFA islanders, who were previously denied or terminated, are encouraged to
update their Washington Healthplanfinder applications. COFA islanders must meet
all eligibility requirements to qualify for Apple Health programs.
Jack updates his application, and he is now approved for Apple Health for Adults
since his income has changed.
MCO change
Scenario three
Lisa is enrolled in Apple Health for Adults, and her two children are enrolled in
Apple Health for Kids. Lisa is looking for a different provider and finds out there are
other managed care plans in her county. Lisa would like to change her managed care
plan for her family.
Can Lisa change her managed care plan?
Yes. Lisa can switch to a different plan available in her area. She can change it online
through Washington Healthplanfinder, by visiting her ProviderOne portal, or by
calling HCA Medical Assistance Customer Service Center (MACSC) at 1-800-562-
3022.
Apply for Classic Apple Health
Scenario four
Joe is over age 65 and needs to see a doctor. His pension income is $1200/month.
He does not have health insurance and is not eligible for Medicare.
How does he get coverage?
Since Joe is over age 65, he will need to apply with the Department of Social and
Health Services (DSHS). His income is over the limit of $841* but he is under
resources. He will be put on a spenddown and chooses a three-month base period.
• $1200- $20 (standard disregard)= $1180
• $1180- $841 (income limit)= $339
• $339 x 3 (three-month base period)= $1017
*Based on January 2022 income limits.
Long-Term Services and Supports (LTSS)
Scenario five
Leon’s dad, Rich, is over age 65 and needs Home and Community-Based Services
(HCBS) that will allow him to stay at home rather than a nursing facility. He applies
at DSHS and completes a CARE assessment with an HCS social worker. He is found to
be under the income limit, $2523*, and under the $2000 resource limit.
How does he get coverage?
He is approved for Long-Term Services and Supports (LTSS) and may have to
participate in the cost of his care. Typically, he gets to keep 100% of the Federal
Poverty Level which is currently $1074 but other circumstances may allow him to
keep more.
*Based on January 2022 income limits.
I need to refill my meds
Scenario six
Esther has monthly prescriptions and knew how to refill them when she had COFA
Islander Health Care. Now that she has Apple Health for Adults, she is not sure
where to get her prescriptions or how to pay for them.
Who can help Esther with her questions?
Esther's managed care plan can help. She calls her plan, and they give her
information on which pharmacies she can go to. Also, most health plans have an
online tool to help find a provider who accepts Apple Health clients. Apple Health
clients do not have to pay for covered drugs prescribed by their provider.
Apple Health benefits
Scenario seven
Smith has Apple Health and has a doctor appointment in a couple of days. They do not
have a way to get to their appointment and were wondering if Apple Health can help.
They call Apple Health customer service for information on transportation services.
Is transportation an Apple Health benefit? Can Smith get this benefit?
Yes, transportation services (nonemergency) are an Apple Health benefit.
Transportation may be approved for individuals that do not have transportation for
health care appointments. Smith contacts the transportation broker in their county for
help with this service.
Visit
HCA Transportation Services (nonemergency) webpage* for more details.
* hca.wa.gov/health-care-services-supports/apple-health-medicaid-coverage/transportation-services-non-emergency
Outreach efforts
Outreach efforts
The Health Care Authority is reaching out to the community by:
GovDelivery for intentional and consistent messaging
Social media campaigns: Facebook live events, webinars, Facebook posts, and
Instagram
Developing and translating informational materials in the six main COFA languages
Intentional outreach to COFA islanders informing them of the transition and how to
prepare for Apple Health and managed care enrollment
Phone calls
Letters through Washington Healthplanfinder
Outreach
HCA has contracted with Pacific Islander Health Board of Washington (PIHB), a
community-based organization for COFA Islander programs and Apple Health outreach,
education and enrollment.
Some of the responsibilities include:
Educational events
Development of outreach materials
Hosting quarterly workshops
Contact information:
Phone: 888-308-7113 Interpreters available
Website: pihealthboard.org
Social media post
Follow us on Instagram!
You can now follow HCA on Instagram
@wa_health_care
Resources
Resources
HCA Information on COVID-19:
hca.wa.gov/coronavirus
HCA Stakeholder Training & Education
resources:
hca.wa.gov/stakeholder-training
Cross-agency Desk Aid:
hca.wa.gov/assets/free-or-low-
cost/customer_support_center_referrals.
pdf
HCA Community-Based Specialists:
hca.wa.gov/hcacommunitystaff
HCA Apple Health eligibility COVID 19:
AHEligCovid19@hca.wa.gov
Apple Health eligibility:
AskMAGI@hca.wa.gov
Apple Health managed care:
HCAMCPrograms@hca.wa.gov
Document verification:
Apple@hca.wa.gov
COVID-19 billing, coding, or telehealth
policy:
HCAAH_COVID19@hca.wa.gov
COVID-19 behavioral health:
HCADBHRBHCOVID19@hca.wa.gov
Apple Health and COFA resources
Eligibility for Apple Health (Medicaid) coverage
First-timers’ Guide to Washington Apple Health
Apple Health restoration for COFA islanders
COFA Islander programs and Apple Health transition
COFA Islander Health Care brochure
HCA COVID-19 information
Washington Services and Apple Health And Long-Term for Adults Supports (LTSS)
DSHS Aging and Long-Term Support Administration (Medicaid)
COVID-19
Check with the plan for coverage options for COVID-19 testing, treatment and vaccines.
Health Resources & Services Administration (HRSA) has a provider reimbursement
program for the testing and treatment of uninsured individuals.
Information about novel coronavirus (COVID-19) can be found at
hca.wa.gov/coronavirus and view vaccination updates at hca.wa.gov/covid-vaccine.
Q&A session
