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What is Medicaid?

Medicaid provides healthcare coverage. It also can pay for therapies, assistive technology, and services you may need to live and work in your community.

Medicaid is funded through a partnership between the state and the federal government. It may also be funded through premiums and a user’s contribution to their cost of care. In Washington State, the Health Care Authority administers Medicaid. 

 “Apple Health” is the brand name of Medicaid in Washington State.  Some people also refer to it as Provider One. 

An example of a WA Services Provider One card.

Medicaid is not the same as Medicare. If you are not sure which you receive (you may be eligible for both), visit What Medical Benefits Do I Receive?

Who is eligible for Medicaid?

As a rule in Washington State, if you are eligible for SSI, you are automatically eligible for Medicaid.

At its foundation, Medicaid is a means-tested program that follows SSI rules. Like SSI, it is intended for people with limited income and resources.

The state can make exceptions to these rules. You can think of these exceptions as “pathways” to Medicaid that do not require SSI eligibility. Each pathway has different rules regarding income, resources, and the services it pays for.

In some cases, you may be able to choose the pathway which works best for you. For example, if you are working and have a disability, you may wish to purchase Medicaid through Apple Health for Workers with Disabilities, because this pathway has no income or resource restrictions. To learn more about this pathway and others, visit Medicaid Pathways.

What healthcare coverage does Medicaid provide?

Medicaid provides medical care coverage, including inpatient / outpatient hospital services, doctor’s care, nursing facility services, lab and X-ray services, and transportation to medical care.

In Washington State, Medicaid also covers prescription drugs, physical, occupational, and speech therapies, and some dental services.

When you enroll in Medicaid, you must also enroll in a managed health care plan. Your plan coordinates physical health, mental health, and other services to provide care under one health plan.

Not everyone will accept Medicaid and your health care plan. You can contact your health care plan to find out which practitioners are accepting this coverage.

How do I enroll in Medicaid?

If you are eligible for SSI, you will automatically be enrolled in Medicaid. 

If you are not eligible for SSI, you can apply for Medicaid (and other Washington State services) through washingtonconnection.org.

This website provides additional information.

Other services paid for through Medicaid

Medicaid is not limited to healthcare coverage. It can also pay for services and support you may need to live and work in your community.

Different state programs offer a range of Medicaid-funded services. Eligibility for these programs depends on which Medicaid pathway you are on, what your support needs are, and other factors. You may be eligible for more than one program.

Medicaid-funded services include:

These two programs offer in-home care. Community First Choice also offers assistive technology, skills training, and other services. 

Eligibility for Medicaid Personal Care (MPC) and Community First Choice is determined by DSHS Developmental Disabilities Administration and DSHS Home and Community Services. MPC eligibility can also be assessed by the WA Area Agency on Aging.

Home and Community Based Services (HCBS) Waivers offer long-term support and services for eligible people with disabilities. There are several HCBS Waivers available in Washington, including: Individual and Family Services; Basic Plus; Core; Community Protection; COPES; New Freedom; and others. 

HCBS Waivers offer a wide range of services, including employment support, community engagement, respite care for your care provider, stabilization services, staff and family consultation, and many others. 

People eligible for HCBS Waiver may also be eligible for Community First Choice. 

Eligibility for HCBS Waiver services is determined by DSHS Developmental Disabilities Administration and DSHS Home and Community Services.

If you receive a letter about your “long term services,” it is often referring to your Waiver and / or Community First Choice services.

FCS is funded through a Medicaid demonstration Waiver. This program offers housing assistance, employment support, and access to mental health and substance abuse treatment. 

Amerigroup manages eligibility for FCS. Anyone can refer a person to Amerigroup to be considered for FCS services by emailing them at FCSTPA@amerigroup.com.

A man reading his mail.

Can I have other insurance in addition to Medicaid?

Yes! You can have private insurance, Medicare, and Medicaid at the same time. If you have all three, they are usually billed in this order:

    1. Private Insurance
    2. Medicare
    3. Medicaid

If your private insurance is from an employer, the size of the employer can change this billing order. Medicaid is always the payer of last resort.

How often is Medicaid eligibility re-determined?

Your eligibility for Medicaid is re-determined at least once every 12 months. If you do not receive SSI, you may be asked by the state to complete and return information about your income, resources, and other details. 

We also recommend you report life changes when they occur. Examples of changes include:

    • Starting a job
    • An increase or decrease in monthly income
    • Moving to a new address
    • Marriage or other relationship change

You can report these changes at washingtonconnection.org.

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Can I lose my Medicaid?

Yes. If you stop meeting the rules of your Medicaid eligibility pathway, you can lose eligibility.

If you become ineligible for your Medicaid pathway, the state is required to see if you can qualify for another Medicaid pathway before terminating your Medicaid coverage. Many people who found ineligible for one pathway continue eligibility for Medicaid through a different pathway.

Medicaid can help with other costs

If you receive Medicaid and Medicare:

  • You will not have to pay Medicare Part B premiums, coinsurance, and deductibles
  • You will be required to use Medicare Part D for your prescription coverage, but you will pay $0 or the least amount for your prescriptions.

Through the Premium Payment Program, you may be reimbursed for the cost of your private health insurance premium. Health insurance can come from an employer, a private policy, or COBRA. If you are covered under a parent’s health plan, the premium cost may still be reimbursed, if it is considered by the State to be cost effective. 

Health care plans purchased through the Washington Health Benefit Exchange or the Washington Healthplanfinder with Premium Tax Credits are not eligible for reimbursement.

To apply:

Complete the “Application for HCA Premium Payment Program” and a W9

Mail them to:

Premium Payment Program
Health Care Authority
PO Box 45518
Olympia, WA 98504-5518

or Fax to: 877-893-3810

Why will Medicaid reimburse you for your healthcare premium? Medicaid is a payer of last resort. It can be less expensive to cover the cost of private health insurance premium that to cover the bulk of medical expenses.

Estate Recovery

In some circumstances, the State can recover the costs of long-term care and other medical services paid for by Medicaid from a person’s estate. For more information, check out this Estate Recovery information sheet.

Where can I get help?

For a list of resources that may offer assistance, check out our Get Help page.

Learn all about Medicaid and Medicare through our video training series: A Look at Medicaid and Medicare

Updated for 2024 

This video series, broken down into chapters, features two benefits planners who discuss Medicaid and Medicare rules and share their insights.

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