Public Benefits are Key! Medicare, Medicaid, and Spenddown – November 16th, 2022

Welcome Back to Public Benefits are Key!

Thank you for joining us for Public Benefits are Key: Medicare, Medicaid, and Spenddown. 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 recording below to see the full presentation by Hannah Rosenberger, Public Benefits Attorney at Solid Ground.

Have client-related questions? 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.

What is Apple Health/Medicaid?

There are two main Apple Health/Medicaid programs, known as MAGI (“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 due to the passage of the Affordable Care Act starting in 2011.

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

  • Ages 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, some people with slightly higher income limits (see slides for more details)
  • *Children and pregnant people can be eligible for MAGI Medicaid at higher family income levels. To check eligibility visit the Health Care Authority website.

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

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.

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

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.

Note that MAGI Medicaid coverage has been extended for many due to the COVID-related state of emergency. While many are concerned that plans may be terminated due to the end of the waiver, no changes will be made without a 60-day notice from the Health Care Authority, which have not been issued as of the date of this blog post.

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
  • On a Medicaid plan with a Spenddown (more info on Spenddown below)
  • Receiving SSI benefits

Under Classic Medicaid, there are distinct programs for those who are “categorically needy” and those who are “medically needy” – those with more income but 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 income limits of $841/month and resource and asset limits of $2,000, the same limit set for SSI eligibility (see slides for larger household limits).

To apply for the Categorically Needy program:

The Medically Needy program is available for those who are aged, blind, or disabled, with incomes above $841/month for a single-person household, and medical expenses that once paid, significantly reduces one’s household income. To maintain coverage, assets and resources must not exceed $2,000, just like with the Categorically Needy Program.

Spenddown is a tool that allows health care coverage for those on the Medically Needy Program once health care out-of-pocket expenses have been incurred during a 3- or 6-month period. 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 your 3- or 6-month base period.

To see an example of the Spenddown formula, view the slides above.

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.

An example of a Medicare insurance card.

To be eligible for Medicare, an applicant must be:

  • Age 65+, and
  • Paid into SS or Railroad Retirement systems
  • A person with end-stage renal disease
  • A U.S. citizen or meet other citizenship requirements
  • *Certain younger people may qualify if they have disabilities or 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 acre not covered in Parts A and B
  • Part D covers prescription costs

Do you know someone with questions about Medicare? Contact Statewide health insurance Benefits Advisors (SHIBA) at 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
  • Age 65+
  • Receiving Social Security disability (SSDI) benefits
  • Meeting certain income limits

While MSP has historically set asset and resource limits, applicants will no longer be held to such limits starting January 2023.

There are 4 levels within the MSP:

  1. Qualified Medical Beneficiary, for those with income less than 100% of the Federal Poverty Level (FPL)
    1. 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
    1. Pays Part B premiums
  3. Qualified Individual, for those with income less than 135% of the FPL
    1. Pays Part B premiums
  4. Qualified Disabled Working Individual, for those with income less than 200% of the FPL
    1. Pays Part A premiums

To apply for MSP:

What are Common Benefit Pitfalls? How Do I Avoid Them?

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

In many of these cases, legal services can help!

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.

Your client can also request an appeal of their decision, which may result in granted insurance benefits or coverage of medically necessary treatment.

To request an appeal, a client can request an administrative hearing within 90 days, in which a judge reviews the facts of the case and restore benefits or coverage. A client has the right to be accompanied to this hearing by a lawyer, care advocate, friend, or family member. If pre-existing coverage is suspended, a client 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 at 1-800-583-8271