11
Apple Health provides access to a wide range of
medical services. Not all eligibility groups receive
all services. Coverage is broadest under the
Categorically Needy (CN) and Alternative Benets
Plan (ABP) programs.
The scope of services covered for any individual
depends on the Apple Health program in which the
individual is enrolled. The table on pages 12-13 lists
specic health care services and shows which scope of
service category covers which services. An individual’s
age is also a factor. Some services may require prior
authorization from HCA, the individual’s Apple Health
Managed Care plan, or DSHS as applicable.
This table is provided for general information only
and does not in any way guarantee that any service
will actually be covered at the time of inquiry,
because benets, coverage, and interpretation of
benets and coverage may change at any time.
Coverage limitations can be found in federal statutes
and regulations, state statutes and regulations,
state budget provisions, and Apple Health provider
guides. Individuals with questions regarding
coverage should call the 800 number on the back of
their Services Card.
Covered services—scope of service
Long-Term Services and Supports (LTSS) and Hospice
Hospice services
Apple Health benets include hospice services for
people who are eligible under categorically needy
(CN), medically needy (MN), or alternative benet plan
(ABP) programs. If a person is not eligible for CN, MN,
or ABP, a determination can be made using eligibility
rules under a separate Hospice program. The hospice
provider noties the agency when hospice services are
elected. The Hospice program pays for hospice care at
home, a hospice care center, or hospice in a nursing
facility.
Long-Term Services and Supports (LTSS)
Long-term Services and Supports (LTSS) are tailored
to t client individual needs and situations. Services
may be authorized through the Department of Social
and Health Services (DSHS) by Home and Community
Services (HCS) or the Developmental Disabilities
Administration (DDA). These services enable people to
continue living in their homes with help meeting their
physical, medical, and social needs. When these needs
can’t be met at home, care in a residential or nursing
facility is available.
In HCS, there are also programs available that provide
help to caregivers and people without a caregiver—
Tailored Supports for Older Adults and Medicaid
Alternative Care. The person in need of care must be
age 55 or older and meet nancial eligibility criteria.
Dierent income standards are used to determine
eligibility for CN or MN coverage for LTSS. To be
eligible for most LTSS programs, a person must
le an application and meet nancial eligibility
criteria and functional eligibility criteria (based on a
comprehensive assessment).
For more information about nursing home care, or
home & community based services oered by HCS,
contact a local HCS oce. To locate the closest HCS oce: visit
dshs.wa.gov/ALTSA/resources.
For information about nancial eligibility for the DDA services,
contact the LTC Specialty Unit at 1-855-873-0642.
For information about functional eligibility criteria for home
and community-based services through DDA, go to dshs.
wa.gov/dda.
LTSS services include the following programs:
Through HCS:
• Community Options Program Entry System (COPES), New
Freedom, and Residential Support Waiver (RSW) (L21, L22)
• Community First Choice (CFC), Medicaid Personal
Care (MPC) (L51, L52)
• Roads to Community Living (RCL) (L41, L42)
• Program of All-Inclusive Care for the Elderly
(PACE) (L31, L32)
• Nursing Facility care (L01, L02, L95, L99)
• Tailored Supports for Older Adults (T02)
• Medicaid Alternative Care (MAC)
• Limited funding for state-funded Long-term
services for non-citizens (L04, L24)
• LTSS Presumptive Eligibility (S32)
Through DDA:
• Developmental Disabilities Administration (DDA)
Waivers (L21, L22)
• Community First Choice (CFC), Medicaid Personal
Care (MPC) (L51, L52)
• Roads to Community Living (RCL) (L41, L42)
• DDA Residential Habitation Centers and Intermediate
Care Facilities (L01, L02, L95, L99)
• Hospice program (L31, L32)
• Limited funding for state-funded long-term services
for non-citizens (L04, L24)