Public Benefits are Key! Medicaid and Medicare – July 12th, 2023

Welcome Back to Public Benefits are Key!

Thank you for joining us for Public Benefits are Key! This training covered two complicated systems: Medicaid and Medicare. We hope with this training, you were able to learn new strategies for your clients and community members who deserve access to affordable health care.

Check out our slides and recording below to see the full presentation by Hannah Rosenberger, Public Benefits Attorney at Solid Ground’s Benefits Legal Assistance program.

Have questions about a client’s Medicaid or Medicare coverage? Solid Ground’s Ask a Lawyer Program by emailing benefitslegalhelp[at]solid-ground[dot]org (include “ask a lawyer” in the subject line) or calling 206-694-6742.

An Update on the Public Health Emergency Unwinding

As most of us are aware, from 2020 to 2023, recipients of public benefits like Medicaid were not subject to eligibility review – this allowed stability for many of our most vulnerable during the height of the COVID-19 Pandemic.

Starting in early 2023, an “unwinding” of the Public Health Emergency due to decreased impact by COVID-19 has re-started eligibility reviews and sadly, there has already been mass unenrollment from subsidized health care plans.

To avoid losing your Medicaid coverage, you must confirm or update your contact information with DSHS so you can be reached for an eligibility review. If you do not submit to an eligibility review by a certain deadline, you can lose your coverage!

For MAGI Medicaid recipients (those who are 19-64, children, pregnant, and not disabled), review your account at or call the Healthplanfinder Customer support Center at 1-855-923-4633.

For Classic Medicaid recipients (those who are 65+, blind, or disabled), review your account at or call DSHS at 1-877-501-2233.

What is Medicaid?

There are two main Medicaid programs (sometimes called Apple Health), known as “MAGI Medicaid” (Modified Adjusted Gross Income) and “Classic Medicaid”.

“MAGI Medicaid” is a no-cost health insurance program for households with low incomes and has been provided since the passage of the Affordable Care Act in 2011.

To be eligible for MAGI Medicaid, an applicant must be:

  • Age 19-64, and
  • A US citizen or have other eligible immigration status
  • A WA state resident
  • Not on Medicare
  • A Parent or caregiver
  • Someone on a family planning service program
  • At an income that is below 133% of the Federal Poverty Level (for most – see slides for more details)

*Children and pregnant people can be eligible for MAGI Medicaid at higher household income levels. To check eligibility visit the Health Care Authority website.

*A note on income: only some types of income are counted towards one’s income limit, such as wages, unemployment benefits, pensions, and social security benefits. Types of income not counted include VA benefits, child support, Native American Tribal income, or inheritance money. View the slides above for more information.

Unlike some public benefit programs, there are no resource or asset limits with MAGI Medicaid.

Under MAGI Medicaid, most beneficiaries will have a choice of 5 Managed Care Plans, which varies depending on plan availability in your region. To learn more about different plans and their benefits, visit

To apply, you will need share household monthly income, immigration information, dates of birth, and social security numbers for each household member. Unlike private insurance, you can apply any time of year and switch plans as much as monthly.

To apply for MAGI Medicaid:

“Classic Medicaid” is a no-cost health insurance program for those who are aged, blind, or disabled. Prior to the passage pf the Affordable Care Act, it was the only form of federally funded health coverage in Washington.

To be eligible for Classic Medicaid, an applicant must be:

  • Age 65+, or
  • Disabled, or
  • Blind, or
  • On a Medicaid plan with a Spenddown (more info on Spenddown below), or
  • Receiving SSI benefits

Under Classic Medicaid, there are distinct programs for those who are “categorically needy” – those with low income due to age or disability, and those who are “medically needy” – those with more income but also have significantly burdensome medical expenses.

Those who receive SSI benefits are automatically enrolled in the Categorically Needy program. To maintain coverage, a single-person household will need to maintain an income limit of $914/month and resource limit of $2,000 for an individual or an income limit $1,371 for two people and resource limits of $3,000.

To apply for the Categorically Needy program:

The Medically Needy program is available for those who are 65+, blind, or disabled, with incomes above $914/month for a single-person household (or $1,370 for two), and burdensome medical expenses that once paid, significantly reduces one’s household income. To maintain coverage, assets and resources must not exceed $2,000 for an individual or $3,000 for two, just like with the Categorically Needy Program.

Spenddown is a tool that used  by those on the Medically Needy Program to measure out-of-pocket health expenses to authorize health care coverage for a 3- or 6-month period, after a person pays a certain minimum amount. It can be comparable to a private insurance plan’s deductible.

DSHS calculates Spenddown amounts by calculating a household’s ‘excess income’ not spent on medical expenses and multiplying by the number of months in a 3- or 6-month base period. In practice, clients must submit medical bills to DSHS once sufficient out-of-pocket expenses (their ‘spenddown’) has been reached to activate Medicaid coverage.

To hear more about the Spenddown formula, check out our YouTube video.

To apply for the Medically Needy Program and Spenddown:

What is Medicare?

Medicare is a low-cost health insurance program that covers seniors and certain individuals that are disabled.

To be eligible for Medicare, an applicant must be:

  • Age 65+, and
  • Have paid into Social Security or Railroad Retirement systems
  • A U.S. citizen or meets other citizenship requirements
  • *A person with end-stage renal disease will also qualify for Medicare
  • *Certain younger people may qualify if they have disabilities such as End-Stage Renal Disease or are dependent on a disabled parent

Medicare has 4 parts that an applicant can opt in to.

  • Part A covers hospital-related care
  • Part B covers physician and non-emergency-related care
  • Part C covers supplemental care not covered in Parts A and B
  • Part D covers prescription costs

To review premium costs for Medicare Parts A-D, visit

Do you know someone with questions about Medicare? Contact Statewide Health insurance Benefits Advisors (SHIBA), which can provide individualized support around determining eligibility, the application process, and referrals to other resources. Contact via the WA Insurance Commissioner website or by calling 800-562-6900.

While Medicare covers the majority of health care costs, it does not cover 100%. For assistance covering additional health care expenses, some Medicare clients can access the Medicare Savings Program (MSP), a program that can pay for health care premiums, deductibles, and cost-sharing.

To be eligible for MSP benefits, an applicant must be:

  • A Medicare recipient
  • A Washington state resident
  • Age 65+ or receiving SSDI
  • Meeting certain income limits

There are 4 levels within MSP:

  1. Qualified Medical Beneficiary, for those with income less than 100% of the Federal Poverty Level (FPL) – MSP pays Part A and B premiums, deductibles, and many co-payments
  2. Specified Low-Income Medicare Beneficiary, for those with income less than 120% of the FPL – MSP pays Part B premiums.
  3. Qualified Individual, for those with income less than 135% of the FPL – MSP pays Part B premium
  4. Qualified Disabled Working Individual, for those with income less than 200% of the FPL – MSP pays Part A premiums

To apply for MSP:

What are Common Benefit Pitfalls? How Can I Regain Coverage?

Sometimes, the Health Care Authority may deny or terminate medical insurance benefits due to no fault of the recipient. Other times, certain services, procedures, or prescriptions may not be covered, despite a recipient’s need.

To avoid any changes in benefit access, a beneficiary should immediately report life changes such as income fluctuations over $150 for at least two months, marriage or divorce, birth or adoption, incarceration, and other changes. View the slides above for more examples.

In cases where DSHS threatens to deny or terminate coverage, you can request an appeal, which may result in granted insurance benefits or coverage of medically necessary treatment.

To request an appeal, you can request an administrative hearing within 90 days, in which a judge reviews the facts of the case and restore benefits or coverage. You have the right to be accompanied to this hearing by a lawyer, care advocate, friend, or family member. If pre-existing coverage is suspended, you may also ask within 10 days for continued coverage during the appeal process.

To request an administrative hearing:

  • Call DSHS Customer Service at 1-877-501-2233
  • Call the Healthcare Authority Customer Service at 1-800-562-3022
  • Call the Office of Hearing Administration directly at 1-800-583-8271

You can also contact Solid Ground’s Ask a Lawyer Program by emailing benefitslegalhelp[at]solid-ground[dot]org (include “ask a lawyer” in the subject line) or calling 206-694-6742.