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Medicaid Pathways

There are different “pathways” to be eligible for Medicaid. Each pathway has certain rules around eligibility, income, resources, and the scope of services it covers. 

If you lose Medicaid under one pathway, the State will ask you to reapply for Medicaid to see if you qualify for Medicaid through a different pathway. This process is called a Medicaid “redetermination.”

In some situations, you may choose to move from one eligibility pathway to another pathway which will better meet your needs.

Watch Juan make decisions around his benefits and Medicaid, including moving from one Medicaid eligibility pathway (SSI, 1619b) to another (HWD).

Common Pathways

Here is a list of some common pathways to Medicaid eligibility. Please note, however, that this is not an extensive list of all possible pathways.

Supplemental Security Income (SSI) and 1619b

In Washington State, if you are eligible for SSI, you are automatically eligible for Medicaid. This Medicaid pathway may pay for long-term services and support.

While eligible for SSI, you cannot choose to switch to another Medicaid-eligibility pathway. 

Social Security sets limits on how many resources and how much income you can have to be eligible for SSI. Medicaid, at its foundation, follows the same rules. To understand these rules, visit What is SSI? and How does my income affect SSI?

1619b – A Medicaid Work Incentive

With SSI, Social Security looks at unearned income and earned income differently.

Through 1619b, Washington residents can earn up to $57,954 in 2024 without losing SSI and Medicaid eligibility. If you have high Medicaid costs, you may be eligible for a higher limit, called an Individualized Threshold.

To be eligible for 1619b, you must:

When answering the Medicaid Use Test, consider any services you use that are funded by Medicaid. For example, you may not have seen the doctor in the past 12 months, but you may have received in-home care (through Community First Choice) and employment support (through the Waiver). Those services are funded by Medicaid, and they would satisfy the Medicaid Use Test.

1619b income thresholds usually go up each year. New threshold amounts are often released between January and March of the year.

Social Security may reach out and ask you the Medicaid Use Test questions to confirm you are eligible for 1619b. If eligible, the State will keep you enrolled in Medicaid. 

Sometimes, it can take a couple of months for Social Security and the State to be in alignment on 1619b. During this period, you may receive a letter from Washington State saying your Medicaid has ended, and they would like you go through a Medicaid redetermination. Though this may be an error, we highly recommend you still complete any application the State sends you, so you can be in full compliance with their rules and not risk losing Medicaid.

The “CDB” or “DAC” Exclusion

If you lose your SSI eligibility due to receiving Social Security Child Disability Beneficiary (SSCDB) benefits, you may be able to keep your Medicaid through the CDB / DAC exclusion.

Social Security Child Disability Beneficiary (SSCDB), also called Social Security Disabled Adult Child (DAC) is a cash benefit for people who:

    • Are age 18 or older; 
    • Have a disability which started before age 22; 
    • Have not married, unless the spouse is a Title II beneficiary; and
    • Have a parent who is disabled, retired, or deceased, and the parent is insured with Social Security. 

If you SSI, you may later become eligible for SSCDB if your parent dies, retires, or becomes disabled (and you meet the other criteria). 

SSCDB is considered unearned income. If the SSCDB check is larger than your full SSI check by more than $20, you will lose your SSI eligibility. 

In this situation, you may be allowed to keep your Medicaid through the CDB / DAC exclusion, as if you were still eligible for SSI. 

How does this Medicaid protection work? 

If, as an adult, you stop receiving SSI, because you become eligible for SSCDB, financial workers will exclude your CDB cash amount each month from your countable income when determining Medicaid eligibility. If after the exclusion you would qualify for at least one dollar of SSI, you will remain eligible for Medicaid. 

You do not actually receive SSI in this situation. This is only a calculation to determine Medicaid eligibility under this pathway. 

To maintain this Medicaid eligibility, you must continue to follow all the SSI rules, even though you no longer are eligible for SSI. Also, if the calculation of your countable income, minus the CDB exclusion, reveals you would not qualify for any SSI in a month, you will no longer be able to use the CDB / DAC exclusion.

Apple Health for Workers with Disabilities (HWD)

If you have a disability and you are working, you may be able to buy Medicaid coverage through Apple Health for Workers with Disabilities (HWD).

HWD offers an incredible opportunity for you to earn and save money without risk of losing your Medicaid. With HWD:

To be eligible for HWD, you must:

How much does it cost?

The most you will pay is 7.5% of your total monthly income. For some people, it can be as low as 2.5% of your monthly income.

How do I apply?

What if I stop working while on HWD?

If you stop working, you should report this change to an HWD specialist.

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With HWD, you have an annual review date when the State determines if you are still eligible for the program.

An important note about saving money

Many pathways to Medicaid have a $2,000 resource limit. HWD does not have a resource limit, which is one reason the program is so attractive.

If you have saved more money than $2,000 while on HWD, and you later lose HWD for any reason, the money you have saved could prevent you from qualifying for Medicaid through a different eligibility pathway. 

Here are some ways to manage this situation:

Do you pay toward your cost of care? (“Participation”)

When using Medicaid to help pay for your long-term support needs, depending on your living situation and your Medicaid eligibility pathway, you may be required to “participate” or pay toward the cost of your care. If this applies to you, you could be spending a lot of your monthly income as Participation. 

When eligible for HWD, you do not have to pay Participation. While HWD does have a monthly premium, the premium will usually cost far less than your participation amount. 

If you are paying for your cost of care, we recommend you speak with a Benefits Planner. A Benefits Planner can determine if it is possible for you to move to HWD, and if so, what the cost savings might be.

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MAGI: Medicaid without a disability requirement

Modified Adjusted Gross Income (MAGI) is another pathway to Medicaid eligibility. With this pathway, you are not required to have a disability to qualify. SSI recipients and those with Medicare eligibility cannot be eligible for MAGI.

Under MAGI:

    • A single adult must have a monthly modified adjusted gross income limit of less than $1,731 (2024). Larger households, children, and pregnant women may have different income limits. 
    • You have no resource restriction
    • You have no “SGA” test
    • You are not required to pay for your cost of care (“Participation”)
    • If you have personal care needs, you may be eligible for Community First Choice
    • You may be eligible for other Medicaid funded services, but not the DDA waivers. 

To apply for MAGI:

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