medicine_stuff.txt

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Universal health care (also called universal health coverage, universal coverage, or universal care) is a health care system in which all residents of a particular country or region are assured access to health care. It is generally organized around providing either all residents or only those who cannot afford on their own, with either health services or the means to acquire them, with the end goal of improving health outcomes.[1]

Some universal healthcare systems are government-funded, while others are based on a requirement that all citizens purchase private health insurance. Universal healthcare can be determined by three critical dimensions: who is covered, what services are covered, and how much of the cost is covered.[1] It is described by the World Health Organization as a situation where citizens can access health services without incurring financial hardship.[2] Then-Director General of the WHO Margaret Chan described universal health coverage as the "single most powerful concept that public health has to offer" since it unifies "services and delivers them in a comprehensive and integrated way".[3] One of the goals with universal healthcare is to create a system of protection which provides equality of opportunity for people to enjoy the highest possible level of health.[4] Critics say that universal healthcare leads to longer wait times and worse quality healthcare.[5]

As part of Sustainable Development Goals, United Nations member states have agreed to work toward worldwide universal health coverage by 2030.[6][better source needed] Therefore, the inclusion of the universal health coverage (UHC) within the SDGs targets can be related to the reiterated endorsements operated by the WHO.[7]

History
See also: List of countries with universal health care
Note: Links in table are "Healthcare in COUNTRY".

Universal health care start.[8][better source needed]
Country	Year
 Algeria[9]	1975
 Armenia[10]	2023
 Australia	1975
 Austria	1967
 Bahrain	1957
 Belgium	1945
 Bhutan	1970
 Brazil	1988
 Brunei	1958
 Canada	1966
 China	2009
 Cyprus	1980
 Denmark	1973
 Finland	1972
 France	1974
 Germany	1941
 Greece	1983
 Hong Kong	1993
 Iceland	1990
 Indonesia	2014
 Ireland	1977
 Israel	1995
 Italy	1978
 Japan	1961[11][12]
 Kuwait	1950
 Luxembourg	1973
 Malaysia	1980s
 Netherlands	1966
 New Zealand	1938
 Norway	1956[13]
 Portugal	1979
 Russian SFSR	1918[14][15]
 Saudi Arabia	2019
 Singapore	1993
 Slovenia	1972
 South Korea	1988
 Spain	1986
 Sweden	1955
 Switzerland	1994
 Taiwan	1995
 Turkey[16]	2003
 United Arab Emirates	1971
 United Kingdom	1948
The first move towards a national health insurance system was launched in Germany in 1883, with the Sickness Insurance Law. Industrial employers were mandated to provide injury and illness insurance for their low-wage workers, and the system was funded and administered by employees and employers through "sick funds", which were drawn from deductions in workers' wages and from employers' contributions. This social health insurance model, named the Bismarck Model after Prussian Chancellor Otto von Bismarck, was the first form of universal care in modern times.[17] Other countries soon began to follow suit. In the United Kingdom, the National Insurance Act 1911 provided coverage for primary care (but not specialist or hospital care) for wage earners, covering about one-third of the population. The Russian Empire established a similar system in 1912, and other industrialized countries began following suit. By the 1930s, similar systems existed in virtually all of Western and Central Europe. Japan introduced an employee health insurance law in 1927, expanding further upon it in 1935 and 1940.

Following the Russian Revolution of 1917, the Bolsheviks established the world's first fully free and universal health care system was established in Soviet Russia in July 1918.[18][19] The system was highly centralized, and while nominally any person regardless of his status was covered, the actual coverage, especially in the more remote and impoverished areas was virtually non-existent.

In New Zealand, a universal health care system was created in a series of steps, from 1938 to 1941.[20][21] In Australia, the state of Queensland introduced a free public hospital system in 1946.

Following World War II, universal health care systems began to be set up around the world. On July 5, 1948, the United Kingdom launched its universal National Health Service. Universal health care was next introduced in the Nordic countries of Sweden (1955),[22] Iceland (1956),[23] Norway (1956),[24] Denmark (1961)[25] and Finland (1964).[26] Universal health insurance was introduced in Japan in 1961, and in Canada through stages, starting with the province of Saskatchewan in 1962, followed by the rest of Canada from 1968 to 1972.[20][27] A public healthcare system was introduced in Egypt following the Egyptian revolution of 1952. Centralized public healthcare systems were set up in the Eastern bloc countries. The Soviet Union extended universal health care to its rural residents in 1969.[20][28] Kuwait and Bahrain introduced their universal healthcare systems in 1950 and 1957 respectively (prior to independence).[29] Italy introduced its Servizio Sanitario Nazionale (National Health Service) in 1978. Universal health insurance was implemented in Australia in 1975 with the Medibank, which led to universal coverage under the current Medicare system from 1984.[citation needed]

From the 1970s to the 2000s, Western European countries began introducing universal coverage, most of them building upon previous health insurance programs to cover the whole population. For example, France built upon its 1928 national health insurance system, with subsequent legislation covering a larger and larger percentage of the population, until the remaining 1% of the population that was uninsured received coverage in 2000.[30][31] Single payer healthcare systems were introduced in Finland (1972), Portugal (1979), Cyprus (1980), Spain (1986) and Iceland (1990). Switzerland introduced a universal healthcare system based on an insurance mandate in 1994.[32][29] In addition, universal health coverage was introduced in some Asian countries, including Malaysia (1980s),[33] South Korea (1989), Taiwan (1995), Singapore (1993), Israel (1995) and Thailand (2001).

Following the collapse of the Soviet Union, Russia retained and reformed its universal health care system,[34] as did other now-independent former Soviet republics and Eastern bloc countries.

Beyond the 1990s, many countries in Latin America, the Caribbean, Africa and the Asia-Pacific region, including developing countries, took steps to bring their populations under universal health coverage, including China[35] and Brazil's SUS[36] which improved coverage up to 80% of the population.[37] Taiwan implemented its system in 1995.[38] India introduced a tax-payer funded decentralised universal healthcare system as well as comprehensive public and private health insurances that helped reduce mortality rates drastically and improved healthcare infrastructure across the country dramatically.[39] A 2012 study examined progress being made by these countries, focusing on nine in particular: Ghana, Rwanda, Nigeria, Mali, Kenya, Indonesia, the Philippines and Vietnam.[40][41]

Currently, most industrialized countries and many developing countries operate some form of publicly funded health care with universal coverage as the goal. According to the National Academy of Medicine and others, the United States is the only wealthy, industrialized nation that does not provide universal health care. The only forms of government-provided healthcare available are Medicare (for elderly patients above age 65 as well as people with disabilities), Medicaid (for low-income people),[42][43] the Military Health System (active, reserve, and retired military personnel and dependants), and the Indian Health Service (members of federally recognized Native American tribes).

Funding models
See also: Health care economics

Health spending by country. Percent of GDP (Gross domestic product). For example: 11.2% for Canada in 2022. 16.6% for the United States in 2022.[44]

Total healthcare cost per person. Public and private spending. US dollars PPP. For example: $6,319 for Canada in 2022. $12,555 for the US in 2022.[44]
Universal health care in most countries has been achieved by a mixed model of funding. General taxation revenue is the primary source of funding, but in many countries it is supplemented by specific charge (which may be charged to the individual or an employer) or with the option of private payments (by direct or optional insurance) for services beyond those covered by the public system. Almost all European systems are financed through a mix of public and private contributions.[45] Most universal health care systems are funded primarily by tax revenue (as in Portugal,[45] India, Spain, Denmark and Sweden). Some nations, such as Germany, France,[46] and Japan,[47] employ a multi-payer system in which health care is funded by private and public contributions. However, much of the non-government funding comes from contributions from employers and employees to regulated non-profit sickness funds. Contributions are compulsory and defined according to law. A distinction is also made between municipal and national healthcare funding. For example, one model is that the bulk of the healthcare is funded by the municipality, specialty healthcare is provided and possibly funded by a larger entity, such as a municipal co-operation board or the state, and medications are paid for by a state agency. A paper by Sherry A. Glied from Columbia University found that universal health care systems are modestly redistributive and that the progressivity of health care financing has limited implications for overall income inequality.[48]

Compulsory insurance
Main article: National health insurance
This is usually enforced via legislation requiring residents to purchase insurance, but sometimes the government provides the insurance. Sometimes there may be a choice of multiple public and private funds providing a standard service (as in Germany) or sometimes just a single public fund. Healthcare in Switzerland is based on compulsory insurance.[49][50]

In some European countries where private insurance and universal health care coexist, such as Germany, Belgium and the Netherlands, the problem of adverse selection is overcome by using a risk compensation pool to equalize, as far as possible, the risks between funds. Thus, a fund with a predominantly healthy, younger population has to pay into a compensation pool and a fund with an older and predominantly less healthy population would receive funds from the pool. In this way, sickness funds compete on price and there is no advantage in eliminating people with higher risks because they are compensated for by means of risk-adjusted capitation payments. Funds are not allowed to pick and choose their policyholders or deny coverage, but they compete mainly on price and service. In some countries, the basic coverage level is set by the government and cannot be modified.[51]

The Republic of Ireland at one time had a "community rating" system by VHI, effectively a single-payer or common risk pool. The government later opened VHI to competition, but without a compensation pool. That resulted in foreign insurance companies entering the Irish market and offering much less expensive health insurance to relatively healthy segments of the market, which then made higher profits at VHI's expense. The government later reintroduced community rating by a pooling arrangement and at least one main major insurance company, Bupa, withdrew from the Irish market.[citation needed]

In Poland, people are obliged to pay a percentage of the average monthly wage to the state, even if they are covered by private insurance.[52] People working under a employment contract pay a percentage of their wage, while entrepreneurs pay a fixed rate, based on the average national wage. Unemployed people are insured by the labor office.

Among the potential solutions posited by economists are single-payer systems as well as other methods of ensuring that health insurance is universal, such as by requiring all citizens to purchase insurance or by limiting the ability of insurance companies to deny insurance to individuals or vary price between individuals.[53][54]

Single-payer
Main article: Single-payer healthcare
Single-payer health care is a system in which the government, rather than private insurers, pays for all health care costs.[55] Single-payer systems may contract for healthcare services from private organizations, or own and employ healthcare resources and personnel (as was the case in England before the introduction of the Health and Social Care Act). In some instances, such as Italy and Spain, both these realities may exist at the same time.[17] "Single-payer" thus describes only the funding mechanism and refers to health care financed by a single public body from a single fund and does not specify the type of delivery or for whom doctors work. Although the fund holder is usually the state, some forms of single-payer use a mixed public-private system.[citation needed]

Tax-based financing
In tax-based financing, individuals contribute to the provision of health services through various taxes. These are typically pooled across the whole population unless local governments raise and retain tax revenues. Some countries (notably Spain, the United Kingdom, Ireland, New Zealand, Italy, Brazil, Portugal, India and the Nordic countries) choose to fund public health care directly from taxation alone. Other countries with insurance-based systems effectively meet the cost of insuring those unable to insure themselves via social security arrangements funded from taxation, either by directly paying their medical bills or by paying for insurance premiums for those affected.[citation needed]

Social health insurance
Main article: Bismarck Model
In a social health insurance system, contributions from workers, the self-employed, enterprises and governments are pooled into single or multiple funds on a compulsory basis. This is based on risk pooling.[56] The social health insurance model is also referred to as the Bismarck Model, after German Chancellor Otto von Bismarck, who introduced the first universal health care system in Germany in the 19th century.[57] The funds typically contract with a mix of public and private providers for the provision of a specified benefit package. Preventive and public health care may be provided by these funds or responsibility kept solely by the Ministry of Health. Within social health insurance, a number of functions may be executed by parastatal or non-governmental sickness funds, or in a few cases, by private health insurance companies. Social health insurance is used in a number of Western European countries and increasingly in Eastern Europe as well as in Israel and Japan.[58]

Private insurance
In private health insurance, premiums are paid directly from employers, associations, individuals and families to insurance companies, which pool risks across their membership base. Private insurance includes policies sold by commercial for-profit firms, non-profit companies and community health insurers. Generally, private insurance is voluntary in contrast to social insurance programs, which tend to be compulsory.[59]

In some countries with universal coverage, private insurance often excludes certain health conditions that are expensive and the state health care system can provide coverage. For example, in the United Kingdom, one of the largest private health care providers is Bupa, which has a long list of general exclusions even in its highest coverage policy,[60] most of which are routinely provided by the National Health Service. In the Netherlands, which has regulated competition for its main insurance system (but is subject to a budget cap), insurers must cover a basic package for all enrollees, but may choose which additional services they offer in supplementary plans; which most people possess [citation needed].

The Planning Commission of India has also suggested that the country should embrace insurance to achieve universal health coverage.[61] General tax revenue is currently used to meet the essential health requirements of all people.

Community-based health insurance
A particular form of private health insurance that has often emerged, if financial risk protection mechanisms have only a limited impact, is community-based health insurance.[62] Individual members of a specific community pay to a collective health fund which they can draw from when they need medical care. Contributions are not risk-related and there is generally a high level of community involvement in the running of these plans. Community-based health insurance generally only play a limited role in helping countries move towards universal health coverage. Challenges includes inequitable access by the poorest[63] that health service utilization of members generally increase after enrollment.[62]

Implementation and comparisons
For a more comprehensive list, see List of countries with universal health care.
See also: Health system and Health care systems by country

Health spending per capita, in US$ purchasing power parity-adjusted, among various OECD countries. For later data see List of countries by total health expenditure per capita.
Universal health care systems vary according to the degree of government involvement in providing care or health insurance. In some countries, such as Canada, the UK, Italy, Australia, and the Nordic countries, the government has a high degree of involvement in the commissioning or delivery of health care services and access is based on residence rights, not on the purchase of insurance. Others have a much more pluralistic delivery system, based on obligatory health with contributory insurance rates related to salaries or income and usually funded by employers and beneficiaries jointly.[citation needed]

Sometimes, the health funds are derived from a mixture of insurance premiums, salary-related mandatory contributions by employees or employers to regulated sickness funds, and by government taxes. These insurance based systems tend to reimburse private or public medical providers, often at heavily regulated rates, through mutual or publicly owned medical insurers. A few countries, such as the Netherlands and Switzerland, operate via privately owned but heavily regulated private insurers, which are not allowed to make a profit from the mandatory element of insurance but can profit by selling supplemental insurance.[citation needed]

Universal health care is a broad concept that has been implemented in several ways. The common denominator for all such programs is some form of government action aimed at extending access to health care as widely as possible and setting minimum standards. Most implement universal health care through legislation, regulation, and taxation. Legislation and regulation direct what care must be provided, to whom, and on what basis. Usually, some costs are borne by the patient at the time of consumption, but the bulk of costs come from a combination of compulsory insurance and tax revenues. Some programs are paid for entirely out of tax revenues. In others, tax revenues are used either to fund insurance for the very poor or for those needing long-term chronic care.

A critical concept in the delivery of universal healthcare is that of population healthcare. This is a way of organizing the delivery, and allocating resources, of healthcare (and potentially social care) based on populations in a given geography with a common need (such as asthma, end of life, urgent care). Rather than focus on institutions such as hospitals, primary care, community care etc. the system focuses on the population with a common as a whole. This includes people currently being treated, and those that are not being treated but should be (i.e. where there is health inequity). This approach encourages integrated care and a more effective use of resources.[64]

The United Kingdom National Audit Office in 2003 published an international comparison of ten different health care systems in ten developed countries, nine universal systems against one non-universal system (the United States), and their relative costs and key health outcomes.[65] A wider international comparison of 16 countries, each with universal health care, was published by the World Health Organization in 2004.[66] In some cases, government involvement also includes directly managing the health care system, but many countries use mixed public-private systems to deliver universal health care.

Overview of Health Coverage Reports
The 2023 report from the WHO and the World Bank indicates that the advancement towards Universal Health Coverage (UHC) by the year 2030 has not progressed since 2015. The UHC Service Coverage Index (SCI) has remained constant at a score of 68 from 2019 to 2021. It is reported that catastrophic out-of-pocket (OOP) health expenditures have impacted over 1 billion individuals globally. Additionally, in the year 2019, it was found that 2 billion people experienced financial difficulties due to health expenses, with ongoing, significant disparities in coverage. The report suggests several strategies to mitigate these challenges: it calls for the acceleration of essential health services, sustained attention to infectious disease management, improvement in health workforce and infrastructure, the elimination of financial barriers to care, an increase in pre-paid and pooled health financing, policy initiatives to curtail OOP expenses, a focus on primary healthcare to reinforce overall health systems, and the fortification of collaborative efforts to achieve UHC. These measures aim to increase health service coverage by an additional 477 million individuals by the year 2023 and to continue progress towards covering an extra billion people by the 2030 deadline.[67][68]

Criticism and support
Critics of universal healthcare claim that it leads to longer wait times and a decrease in the quality of healthcare.[clarification needed][5] They claim that quality is lower due to budget constraints and overburdened medical staff. For example, many patients in Canada may go to the United States for medical care due to the long wait times.[69] Some believe that government-run healthcare systems are less efficient than private ones, leading to potential waste and mismanagement.[70] Other critics point out the potential of overuse and abuse leading to insolvency.[71] Relatedly, some also argue that universal health care can be extremely expensive for governments to maintain, leading to higher taxes and potential strain on public finances, such as those in the Nordic countries, Australia, and New Zealand.[72] For countries that do not currently have universal healthcare like the United States, they argue it would raise healthcare expenditures due to the high cost of implementation that the United States government supposedly cannot afford.[5]

However, most of the resistance to universal healthcare in the United States is rooted in ideology. For example, critics of implementing universal healthcare in the United States claim that it would require healthy people to pay for the medical care of unhealthy people, which goes against the American values of personal responsibility. Also, they argue it represents unnecessary government overreach into the lives of American citizens and employers as it denies them individual choice. In other words, it may limit the choices available to patients, as the government may control which treatments and medications are covered. Lastly, it would unfairly limit the healthcare and health insurance industry.[5]

According to a 2020 study published in The Lancet, the proposed Medicare for All Act would save 68,000 lives and $450 billion in national healthcare expenditure annually.[73] A 2022 study published in the PNAS found that a single-payer universal healthcare system would have saved 212,000 lives and averted over $100 billion in medical costs during the COVID-19 pandemic in the United States in 2020 alone.[74] Given the high prevalence of uninsured and under-insured people in the United States, if implemented, universal health care would increase health care access for more than 25 million Americans.[75]

#medicaid.gov

Medicare Savings Programs (MSPs) are a specific type of Medicaid benefit offered by the state to help those with limited income pay for their Medicare premiums, copayments, and deductibles.

Medicare Savings Programs can provide assistance with premium costs, copayments, deductibles, and coinsurance for individuals entitled to Medicare and who meet program requirements.

There are no asset tests for MSPs. This means you won't be asked to verify any resources such as bank account balances.

Expenses covered
Qualified Medicare Beneficiary (QMB)
Pays Part A and Part B premiums.
Pays deductibles.
Pays copayments except for prescriptions.
Specified Low-Income Medicare Beneficiary (SLMB)
Pays Part B premiums
Qualified Individual (QI-1)
Pays Part B premiums.
Qualified Disabled Working Individual (QDWI)
Pays Part A premiums.

Medicaid is a joint federal and state program that, together with the Children’s Health Insurance Program (CHIP), provides health coverage to over 77.9 million Americans, including children, pregnant women, parents, seniors, and individuals with disabilities. Medicaid is the single largest source of health coverage in the United States.    

To participate in Medicaid, federal law requires states to cover certain groups of individuals. Low-income families, qualified pregnant women and children, and individuals receiving Supplemental Security Income (SSI) are examples of mandatory eligibility groups. States have additional options for coverage and may choose to cover other groups, such as individuals receiving home and community-based services and children in foster care who are not otherwise eligible.  

The Affordable Care Act of 2010 created the opportunity for states to expand Medicaid to cover nearly all low-income Americans under age 65. Eligibility for children was extended to at least 133% of the federal poverty level (FPL) in every state (most states cover children to higher income levels), and states were given the option to extend eligibility to adults with income at or below 133% of the FPL. Most states have chosen to expand coverage to adults, and those that have not yet expanded may choose to do so at any time. See if your state has expanded Medicaid coverage to low-income adults.

Financial Eligibility
The Affordable Care Act established a new methodology for determining income eligibility for Medicaid, which is based on Modified Adjusted Gross Income (MAGI).  MAGI is used to determine financial eligibility for Medicaid, CHIP, and premium tax credits and cost sharing reductions available through the health insurance marketplace.  By using one set of income counting rules and a single application across programs, the Affordable Care Act made it easier for people to apply and enroll in the appropriate program.

MAGI is the basis for determining Medicaid income eligibility for most children, pregnant women, parents, and adults. The MAGI-based methodology considers taxable income and tax filing relationships to determine financial eligibility for Medicaid. MAGI replaced the former process for calculating Medicaid eligibility, which was based on the methodologies of the Aid to Families with Dependent Children program that ended in 1996. The MAGI-based methodology does not allow for income disregards that vary by state or by eligibility group and does not allow for an asset or resource test.

Some individuals are exempt from the MAGI-based income counting rules, including those whose eligibility is based on blindness, disability, or age (65 and older). Medicaid eligibility for individuals 65 and older or who have blindness or a disability is generally determined using the income methodologies of the SSI program administered by the Social Security Administration (some states, known as 209(b) states, use certain more restrictive eligibility criteria than SSI, but still largely apply SSI methodologies). Eligibility for the Medicare Savings Programs, through which Medicaid pays Medicare premiums, deductibles, and/or coinsurance costs for beneficiaries eligible for both programs (often referred to as dual eligibles) is determined using SSI methodologies..  

Certain Medicaid eligibility groups do not require a determination of income by the Medicaid agency. This coverage may be based on enrollment in another program, such as SSI or the breast and cervical cancer treatment and prevention program. Children for whom an adoption assistance agreement is in effect under title IV-E of the Social Security Act are automatically eligible. Young adults who meet the requirements for eligibility as a former foster care recipient are also eligible at any income level.

Non-Financial Eligibility
To be eligible for Medicaid, individuals must also meet certain non-financial eligibility criteria. Medicaid beneficiaries generally must be residents of the state in which they are receiving Medicaid. They must be either citizens of the United States or certain qualified non-citizens, such as lawful permanent residents. In addition, some eligibility groups are limited by age, or by pregnancy or parenting status.

Effective Date of Coverage
Once an individual is determined eligible for Medicaid, coverage is effective either on the date of application or the first day of the month of application. Benefits also may be covered retroactively for up to three months prior to the month of application, if the individual would have been eligible during that period had he or she applied. Coverage generally stops at the end of the month in which a person no longer meets the requirements for eligibility.

Medically Needy
States have the option to establish a “medically needy program” for individuals with significant health needs whose income is too high to otherwise qualify for Medicaid under other eligibility groups. Medically needy individuals can still become eligible by “spending down” the amount of income that is above a state's medically needy income standard. Individuals spend down by incurring expenses for medical and remedial care for which they do not have health insurance. Once an individual’s incurred expenses exceed the difference between the individual’s income and the state’s medically needy income level (the “spenddown” amount), the person can be eligible for Medicaid. The Medicaid program then pays the cost of services that exceeds the expenses the individual had to incur to become eligible.

In addition to states with medically needy programs, 209(b) states also must allow a spenddown to the income eligibility levels eligibility groups based on blindness, disability, or age (65 and older), even if the state also has a medically needy program. Thirty-six states and the District of Columbia use spenddown programs, either as medically needy programs or as 209(b) states.

Appeals
States must provide individuals the opportunity to request a fair hearing regarding a denial, an action taken by the state agency that he or she believes was erroneous, or if the state has not acted with reasonable promptness. States have options for how to structure their appeals processes. Appeals may be conducted by the Medicaid agency or delegated to the Exchange or Exchange Appeals Entity (for appeals of denials of eligibility for individuals whose income is determined based on MAGI). Appeals also may be delegated to another state agency, if a state obtains approval from CMS under the Intergovernmental Cooperation Act of 1968.

#hca.wa.gov

Apple Health for Newborns (N10):
This program provides 12 months of CN coverage if
the mother was enrolled in an Apple Health program
when the child was born. There is no resource or
income limit for this program.
Apple Health for Kids (N11, N31):
This program provides CN coverage to children under
age 19 whose families have income at or below
215 percent of the FPL. Children who would have
been eligible for Apple Health for Kids had they met
immigration status requirements receive CN coverage
under state-funded Apple Health for Kids.
Apple Health for Kids with Premiums (N13, N33):
This program provides CN coverage to children
under age 19 whose families have income above
215 percent and at or below 317 percent of the
FPL. Participants pay a low-cost monthly premium.
Children who would have been eligible for Apple
Health for Kids with Premiums had they met
immigration status requirements receive CN
coverage under state-funded Apple Health for Kids
with Premiums.
Apple Health for Medically Needy Kids (F99):
This program provides MN coverage to children
under age 19 whose families have income above
317 percent of the FPL. Children who qualify and are
enrolled in Apple Health for Medically Needy Kids
become eligible for MN coverage after incurring
medical costs equal to the amount of the household
income that is above the 317 percent FPL standard.

Breast and Cervical Cancer Treatment Program
(BCCTP) (S30):
This federally-funded program provides health
care coverage for individuals diagnosed with
breast or cervical cancer or a related pre-cancerous
condition. Eligibility is determined by the Breast,
Cervical, and Colon Health Program (BCCHP) in the
Washington State Department of Health (DOH). DOH
is responsible for screening and eligibility, while
HCA administers enrollment and provider payment.
Coverage continues through the full course of
treatment as certified by the BCCHP.
An individual is eligible if they meets all of the
following criteria:
• Screened for breast or cervical cancer under the
BCCHP.
• Requires treatment for either breast or cervical
cancer or for a related pre-cancerous condition.
• Is under age 65.
• Is not covered for another CN (Categorically Needy)
Apple Health program.
• Has no insurance or has insurance that is not
creditable coverage.
• Meets residency requirements.
• Meets social security number requirements.
• Meets citizenship or immigration status
requirements.
• Meets income limits set by the BCCHP.
For further information, go to the DOH website:
doh.wa.gov/YouandYourFamily/IllnessandDisease/
Cancer/BreastCervicalandColonHealth
Foster care and adoption support (D01, D02, D26):
This program provides CN coverage to children
receiving foster care and adoption support. This
program also provides CN coverage to individuals
from the age of 18 up to 26 who age out of foster
care in Washington State.
Medical Care Services (A01, A05, A24):
This state-funded program provides limited health
care coverage to adults who are not eligible for Apple
Health programs with CN, ABP, or MN scope of care
and meet the eligibility criteria for either the Aged,
Blind or Disabled–cash, the Housing Essential Needs
(HEN) program, or the Survivors of Certain Crimes
(SCC) program, which includes victims of human
trafficking as described in RCW 74.04.005.
Refugee (R02, R03):
The Refugee Medical Assistance program (RMA)
provides CN coverage to refugees who are not eligible
for Apple Health programs with CN or ABP scope of
care and who meet the income and resource standards
for this program. RMA is a 100 percent federally funded
program for persons granted asylum in the U.S. as
refugees or asylees. Individuals enrolled in RMA are
covered from the date they entered the U.S.
Eligibility for refugees/asylees that have been in
the United States for more than twelve months is
determined the same as for U.S. citizens.
Immigrants from Iraq and Afghanistan who were
granted Special Immigrant status under Section
101(a)(27) of the Immigration and Nationality Act
(INA) are eligible for Medicaid and Refugees Medical
Assistance (RMA) the same as refugees.
this chat bot was made by Sundus,Ingrid, Aasia, and Kemi

Alien Emergency Medical (AEM) (K03, N21, N25, S07):
This program covers health care services to treat
qualifying emergency medical conditions. To be eligible
for AEM, an individual must:
• Be categorically relatable to an Apple Health program
but not eligible for the an Apple Health program
solely due to immigration status requirements (which
program an individual is related to determines whether
they follow the MAGI or Classic Medicaid eligibility rules
and application processing); and
• Have a qualifying emergency medical condition as
described in WAC 182-507-0115, or 182-507-0120, that
is approved by HCA’s medical consultant team.
• Income and resource limits are the same as for
the program to which the AEM applications are
categorically relatable.
Below is a summary of the 3 WACs that cover the Alien
Emergency Medical Programs:
• 182-507-0110: Alien Medical Programs: This explains
the eligibility requirements for the program.
• 182-507-0115: Alien Emergency Medical (AEM):
The qualifying services must be provided in a hospital
setting (inpatient, outpatient surgery, emergency
room) that includes evaluation and management visits
by a physician and be needed to treat the emergency
medical condition. Certification is limited to the dates
on which the qualifying services were provided.
• 182-507-0120: Alien Medical for Dialysis and Cancer
Treatment: The qualifying services must be needed to
treat the qualifying condition of cancer, acute renal
failure, or end stage renal disease, or be anti-rejection
medication. These services do not need to be provided
in a hospital setting.
State-funded long-term care services (L04, L24)
• This program provides in-home, residential, or nursing
facility care for a limited number of individuals who are not eligible for an Apple Health due to immigration
status who need long-term care services.
• 182-507-0125: State-funded long-term care services –
The applicant must meet all other eligibility factors for
placement including receiving an assessment that the
person meets nursing facility level of care, and receive
prior authorization by the Aging & Long-Term Support
Administration (ALTSA), Home and Community Services
(HCS). This program is subject to caseload limits.

Medically Needy (F99, G95, G99, K95, K99, L95, L99,
P99, S95, S99):
The Medically Needy (MN) program is a federal and
state-funded Apple Health program for individuals
who are aged, blind, disabled, pregnant, or a child with
income above the applicable CN limits. MN provides
slightly less health care coverage than CN and requires
greater financial participation by the individual.
Spenddown
An individual with income above the limits for
the applicable CN program may enroll in the MN
program. An enrollee is given a base period, typically
three or six months, to spend down excess income—
in other words, to incur financial obligations for
medical expenses equal to their spenddown amount.
(Spenddown is the amount of the individual’s income
minus the income limit for their particular program.)
The enrollee is responsible for paying these medical
expenses.
The enrollee receives MN health care coverage for the
selected base period once the spenddown is met.
Medically Needy (MN) and Spenddown
Example: Martha is 67 years of age and applies for Apple Health for MN coverage
in April. Her monthly Social Security benefit is $1,207. After disregarding $20
from her Social Security benefit, which leaves $1,187, she is over the SSI monthly
income limit of $967 by $220.
Martha is found eligible for the MN spenddown program for the aged. She selects
a six- month spenddown base period. Her spenddown amount is $1,320 ($220x 6
months) for April through September. This means that Martha is responsible for
the first $1,320 in medical costs she incurs.
On May 12, Martha has surgery. After Medicare pays the eligible 80 percent of the
bill, there remains a balance of $5,200 that Martha is responsible to pay. Based on
her participation in the MN spenddown program, she is liable for $1,320. Once her
spenddown has been met, Apple Health will pay the remaining amount of the bill. Her certification period is May 12 to September 30.
If Martha’s monthly income were below $967, she would have qualified for the
no-cost Apple Health for the Aged program for 12 months coverage.

The Medicare Savings Program (MSP) can provide
assistance with premium costs, copayments,
deductibles, and co-insurance for individuals who are
entitled to Medicare and meet program requirements.
Qualified Medicare Beneficiary (QMB) (S03)
• Pays Part A and Part B premiums.
• Pays deductibles.
• Pays copayments except for prescriptions.
Specified Low-Income Medicare Beneficiary
(SLMB) (S05)
• Pays Part B premiums.
Qualified Individual (QI-1) (S06)
• Pays Part B premiums.
Qualified Disabled Working Individual
(QDWI) (S04)
• Pays Part A premiums. 

Hospice services
Apple Health benefits include hospice services for
people who are eligible under categorically needy
(CN), medically needy (MN), or alternative benefit 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 notifies 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 fit 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 financial eligibility criteria.
Different income standards are used to determine
eligibility for CN or MN coverage for LTSS. To be
eligible for most LTSS programs, a person must
file an application and meet financial eligibility
criteria and functional eligibility criteria (based on a
comprehensive assessment).
For more information about nursing home care, or
home & community based services offered by HCS,
contact a local HCS office. To locate the closest HCS office: visit
dshs.wa.gov/ALTSA/resources.
For information about financial 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) 
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 Benefits
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
specific 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 benefits, coverage, and interpretation of
benefits 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.

Nonemergency Medical Transportation (Brokered
Transport)
HCA covers nonemergency medical transportation
for eligible clients to or from covered services
through contracted brokers. The brokers arrange
and pay for trips for qualifying clients. Currently,
eligible clients are those enrolled in Apple Health
and other state-funded medical assistance programs
that include a transportation benefit. Transportation
may be authorized for individuals who have no other
means to access medical care.
The most common types of transportation available
include: public transit bus, gas vouchers, client
and volunteer mileage reimbursement, taxi,
wheelchair van or accessible vehicle, commercial
bus and air, and ferry tickets. More information is
available online at: hca.wa.gov/transportationhelp. Comments and questions may be directed to
HCA Transportation Services at hcanemttrans@hca.
wa.gov.
Interpreter services - sign language
HCA covers the cost of sign language interpreters
for eligible clients. This service must be requested by
Apple Health providers, HCA staff or HCA-authorized
DSHS staff, and must be provided by the HCAapproved contractor.
Interpreter services - spoken language
HCA covers interpreter service for eligible clients
through the HCA approved contractor. Requests
for this service must be submitted by Apple Health
providers, HCA staff, or HCA-authorized DSHS staff.
Other services
Modified Adjusted Gross Income
(MAGI) programs
• Online: wahealthplanfinder.org.
• Phone: 1-855-923-4633
• Paper: HCA Form 18-001P (Application for Health
Care Coverage) available at hca.wa.gov/assets/
free-or-low-cost/18-001P.pdf.
To submit a completed application by mail:
Washington Healthplanfinder
P.O. Box 946, Olympia, WA 98507
Or send it by fax to: 1-855-867-4467
If you want help applying, you can work with an inperson assister or call Healthplanfinder Customer
Support at 1-855-923-4633.
Aged, Blind, Disabled Coverage
Disability-based Washington Apple Health, refugee
coverage, coverage for seniors 65+, and programs
that help pay for Medicare premiums and expenses:
• Online: washingtonconnection.org
• Paper: HCA Form 18-005 (Application for ABD/LTC)
available at hca.wa.gov/assets/
free-or-low-cost/18-005.pdf.
To submit a completed application by mail:
DSHS – Community Services Division
P.O. Box 11699, Tacoma, WA 98411-6699
Or send it by fax to: 1-888-338-7410
• In-person: Visit a local Community Service Office.
For locations, go to dshs.wa.gov/esa/communityservices-find-an-office .
Questions? Call 1-877-501-2233
Long-Term Care
Nursing home care, in-home personal care, assistedliving facilities, and adult family home programs:
• Online: washingtonconnection.org.
• Paper: HCA Form 18-005 (Application for ABD/LTC)
available at hca.wa.gov/assets/
free-or-low-cost/18-005.pdf.
To submit a completed application by mail:
DSHS – Home & Community Services
P.O. Box 45826, Olympia, WA 98504-5826 Or send it by fax to: 1-855-635-8305
• In-person: Visit a local HCS office. For locations, go to
dshs.wa.gov/ALTSA/resources .
Questions? Call a local HCS office. For locations, go to
dshs.wa.gov/ALTSA/resources .

Apple Health
See Washington Apple Health
Managed Care
The majority of individuals enrolled in Apple Health
receive their health services through a designated
health care plan that contracts with the Health Care
Authority. This prepaid comprehensive system of
medical and health care services is usually called
managed care.
Classic Medicaid
The term used to describe the Medicaid health care
programs including Long-Term Care services and
Aged, Blind or Disabled coverage. The Modified
Adjusted Gross Income (MAGI) health care programs
are not Classic Medicaid.
Federal Poverty Level (FPL)
A guideline for determining eligibility for a
governmental program based on the Consumer Price
Index guide from the year just completed. Many
health care coverage programs determine eligibility
based on a percentage of the FPL.
Fee-for-Service
This is a health care service delivery system where
health care providers are paid for each service (such
as an office visit, test, or procedure). Individuals
who are not covered by Apple Health Managed
Care are covered by Apple Health Fee-for-Service
(also referred to as Apple Health coverage without a
managed care plan).
Health Care Authority (HCA)
HCA is a Washington State agency that administers a
number of programs related to health and wellness,
including most Washington Apple Health programs.
Medicaid
The federally matched medical aid programs under
Title XIX of the Social Security Act (and Title XXI of the
Social Security Act for the Children’s Health Insurance
Plan) that cover the Categorically Needy (CN) and
Medically Needy (MN) programs.
Modified Adjusted Gross Income (MAGI)
The methodology used for calculating income and
determining household composition to determine
eligibility for Apple Health for Adults, Kids, Families
and Caretaker Relatives, and Pregnant Individuals.
This method follows federal income tax filing rules
with a few exceptions and has no resource or asset
limits.
ProviderOne
The online payment system for health care providers
serving individuals enrolled in an Apple Health
program.
Scope of Care
Scope of care describes which medical and health
care services are covered by a particular Apple Health
program. There are four categories of scope of care:
Categorically Needy (CN), Alternative Benefits Plan
(ABP), Medically Needy (MN), and Medical Care
Services (MCS).
Spenddown
This process allows individuals with income above
the limits for the applicable CN program to spend
down excess income within a specified period of time
to become eligible for coverage.
Washington Apple Health
The brand name for all Washington State medical
assistance programs, including Medicaid. The brand
name may be shortened to “Apple Health.”

#healthinsurance.org

Apple Health (Washington’s Medicaid/CHIP) provides health insurance coverage for qualifying children, pregnant women, parents, seniors, and individuals with disabilities. See the Eligibility page on the Washington State Health Care Authority (HCA) website for details. Below is a summary of income limits for non-elderly adults and children, including an additional 5% income disregard that’s used for eligibility determinations:1

Adults with incomes up to 138% of the federal poverty level (FPL)
Pregnant women with incomes up to 198% of poverty. (coverage for the mother continues for 12 months after the baby is born)
Children with household incomes up to 215% of poverty (young children now have continuous eligibility until they turn 6, even if their circumstances change and they no would otherwise no longer meet the eligibility requirements)
Children are eligible for CHIP with household incomes up to 317% of poverty (this coverage does have premiums, and only 12 months of continuous eligibility; the continuous eligibility until age 6 only applies to children with household income up to 215% FPL).
Apple Health is available to children and pregnant women in the allowable income range even if they are undocumented immigrants. And as of July 2024, Apple Health became available to undocumented immigrant adults with eligible incomes.1 However, there was an enrollment cap of 13,000 for this population, since only a set amount of state funds had been allocated to provide Apple Health to undocumented immigrant adults (federal funding is not available for this). The enrollment cap was reached in just a few days, with the state announcing on July 3 that eligible residents should still submit an application that could “be considered if space opens in the program.”2

Washington was one of five states that utilized a provision in the ACA that allowed for early expansion of Medicaid, before 2014.  From 2011 through 2013, Washington used a waiver from CMS to allow for federal funding to cover adults with incomes up to 138% of poverty who were previously enrolled in three state-run programs (Basic Health, Medical Care Services, or Alcohol and Drug Addiction Treatment and Support Act). And the ACA’s full Medicaid expansion took effect in Washington as soon as it became available, in January 2014.

As a gubernatorial candidate in the fall of 2012, Democrat Jay Inslee expressed his support for Medicaid expansion, and he won the election that November. Soon after Inslee took office, he was encouraging lawmakers to move “quickly” to expand Medicaid in line with the ACA’s provisions. Rather than take a formal vote on the issue however, Medicaid expansion was added as a line item to the state budget (with bipartisan approval), and on June 30, 2013, Washington Governor Jay Inslee approved the budget for the upcoming fiscal year.

Washington has also taken steps to ensure access to Medicaid for children and pregnant women, regardless of immigration status, and that’s being expanded to all adults as of mid-2024.1

1,837,170 – Number of Washingtonians covered by Medicaid/CHIP as of October 20243
625,573 – Number of Washington residents covered by ACA Medicaid expansion as of June 20244
469,029 – Number of WA residents disenrolled from Medicaid as of April 20245
64% – Increase in total Medicaid/CHIP enrollment in Washington since late 20136

In Washington State, most Medicaid enrollment is managed through the state-run exchange, Washington Healthplanfinder. Unlike private health plans, Medicaid enrollment continues year-round; there is no specific time during the year that you must enroll.

But if you’re 65 or older or have Medicare, use this website to apply for Medicaid and several other social services benefits. You can also request an application by calling 1-877-501-2233. Visit a Department of Social and Health Services (DSHS) Community Services Office to apply in-person for Medicaid for the aged, blind, and disabled; visit a Home and Community Services Office to apply for long-term care benefits.

Many Medicare beneficiaries receive Medicaid financial assistance that can help them with Medicare premiums, lower prescription drug costs, and pay for expenses not covered by Medicare – including long-term care.

Our guide to financial assistance for Medicare enrollees in Washington includes overviews of these programs, including Medicaid long-term care benefits, Extra Help, and eligibility guidelines for assistance.

During the COVID public health emergency, states did not disenroll anyone from Medicaid, even if they no longer met the eligibility criteria. That continuous coverage rule was in place for three years, from March 2020 through March 2023. But in the spring of 2023, states began disenrolling people who were no longer eligible for Medicaid, in a year-long process referred to as the “unwinding” of the pandemic-era continuous coverage rule.

Washington began redetermining eligibility in May 2023, and the first disenrollments were effective as of June.3 By April 2024, more than 469,000 people had been disenrolled from Apple Health, the majority of whom did not complete their renewal packets7 (and thus may or may not actually still be eligible for coverage).

People who are no longer eligible for Apple Health can secure new coverage, either through an employer, Medicare, or Washington Healthplanfinder (the state-run exchange/Marketplace). A person’s circumstances will determine which of those coverage options is available to them, but all of them offer a special enrollment period during which a person can transition to the new coverage after losing Apple Health coverage.

People who are eligible for Cascade Care savings can enroll in that coverage at any time (Cascade Care savings is available through Washington Healthplanfinder for people who earn up to 250% of the poverty level and who select a standardized silver or gold plan). For those who aren’t eligible for Cascade Care savings, a special enrollment period was available due to the loss of their Apple Health coverage. Employer-sponsored health plans must have at least a 60-day special enrollment period for people who lose Medicaid. And Medicare has offered a six-month enrollment period for people who lost Medicaid and are now eligible for Medicare.

If a person loses Apple Health but is still eligible (perhaps because they didn’t respond to the renewal packet in time), they have 90 days to complete the renewal and their coverage will be reinstated as if it never ended.

By March 2024, Apple Health enrollment stood at just under 1.9 million people.8

Enrollment had been higher in 2023, with about 2.3 million people enrolled before the start of the “unwinding” period described above.9

#nolo.com

The average monthly cost of a private room in a nursing home in Washington was over $13,600 in 2024. Anyone who thinks they might need long-term care (LTC) will want to ensure they have a way to pay for that care. For most people, long-term care is paid for using:

private funds (your own money)
nursing home (LTC) insurance, or
Medicaid.
Washington's state legislature has established a groundbreaking public LTC insurance program (the WA Cares Fund), but it is only providing partial LTC benefits to eligible beneficiaries in 2025. Full benefits won't be available until July 2026, and the maximum lifetime benefit is $36,500 (adjusted annually for inflation).

So, while WA Cares Fund benefits can help cover the cost of some of your long-term care needs, it won't pay your nursing home costs long-term. And once you've received the maximum benefit amount, it's gone.

If you can't afford to pay privately, don't have LTC insurance, or you've exhausted your WA Cares Fund benefits, Washington's Medicaid program might pay for your care.

Washington Medicaid for Long-Term Care Services
Medicaid is a medical assistance program funded by the federal and state governments that pays for long-term care for people who meet certain requirements, such as being over 65, disabled, or blind. Other types of Medicaid services have different eligibility guidelines than the rules for long-term care Medicaid.

Patients who live in skilled nursing facilities, intermediate care facilities, or hospitals for 30 days or more and are determined by Medicaid to need this care might qualify for Medicaid benefits if they meet the income and resource qualifications of Washington's Medicaid program.

Washington also offers some Medicaid waiver programs that provide services for people who still live at home but would otherwise require a nursing home. These have similar income and asset rules to nursing home Medicaid.

Medicaid Eligibility for Nursing Homes in Washington
Medicaid is a government health insurance program available to people with limited income and resources. If you're 65 or older, blind, or disabled and meet income and resource requirements, Washington's Medicaid program, called Apple Health, provides coverage for nursing home residents under certain circumstances.

To get Apple Health coverage for nursing home care, you must be financially eligible, and you must need the kind of care nursing homes provide, which could include:

24-hour supervised nursing care
personal care, and
therapy.
People who live in skilled nursing facilities, intermediate care facilities, or hospitals for 30 days or more automatically meet Washington Medicaid's "institutional level-of-care" requirement. (Wash. Admin. Code § 182-513-1320.) That means they can qualify for Medicaid benefits if they also meet the state Medicaid program's income and resource qualifications (see below).

To apply for Medicaid long-term care coverage, you must apply to the Washington Department of Social and Health Services (DSHS), using either Form 18-005 or by completing an online application. Typically, your nursing care facility can assist you with the Medicaid application process or you can apply at your local DSHS office. Before you apply, make sure you meet the eligibility criteria.

Medicaid Income Limits in Washington for Long-Term Care
In Washington, a single person can have a monthly income up to $2,901 in 2025 and qualify for Apple Health-paid nursing home care. (This is 300% of the SSI payment level.) The Medicaid income limit for a married couple, with both spouses applying, is $5,802 per month in 2025. These LTC income limits are higher than the income limit for those applying for other health care benefits from Medicaid.

If you qualify for Medicaid and live in a nursing home, you'll be expected to spend almost all your income on your care. Washington allows nursing home residents receiving Medicaid to keep only $103.20 per month as a personal needs allowance.

What Income Counts Toward the Medicaid Limit?
In determining your Medicaid eligibility, DSHS considers any income you receive from any source. But when only one spouse of a married couple applies for LTC Medicaid, the income of the non-applicant spouse doesn't count, to ensure the spouse has enough funds to live on.

Additionally, federal law entitles the non-applicant spouse to a minimum monthly needs allowance (MMNA). (42 C.F.R § 435.725(c)(2).) In Washington, the 2025 MMNA ranges from $2,555 to $3,948 per month. If your non-applicant spouse's income is less, a portion of your income can be transferred to your spouse.

Can You Qualify for LTC Medicaid If Your Income Is Over the Limit?
If your income is above the LTC Medicaid limit, you still might be able to qualify for Apple Health if you meet the "medically needy" criteria. To do that, your medical expenses must be higher than the amount of extra income you have.

Washington's "medically needy" program allows people who are 65 or older, blind, or disabled to use their monthly medical bills to "spend down" their income until it meets the income limit. Even unpaid medical bills count toward the spend down.

In 2025, Washington's medically needy income limit is $967 per month (whether you're single or married). After subtracting the amount of your monthly medical bills from your monthly income, if your remaining income doesn't exceed the medically needy income limit, you'll meet the income requirement for Medicaid long-term care.

Medicaid Asset Rules in Washington
Medicaid for long-term care has different resource rules than those for other Apple Health programs. Resources are assets like:

real property (real estate)
personal property
life insurance with a cash value
vehicles, including motorhomes
boats
IRAs and 401Ks
bank accounts, and
cash.
Some assets are exempt—meaning Washington doesn't count them toward the LTC Medicaid resource limit. Exempt assets generally include your home (with equity up to $1,097,000 in 2025), household furnishings, one vehicle, and your personal belongings.

Total up the values of your non-exempt assets to determine how much you have in resources. If you're a single person, you can have only up to $2,000 in countable resources. If you're married, your non-applicant spouse at home can keep up to $157,920 worth of countable joint assets.

Washington Home and Community-Based Waivers and Care Options
Besides covering the cost of nursing home care, Apple Health's LTC Medicaid program recognizes that people who qualify for nursing home coverage might prefer to live in their own homes or alternate care environments, such as assisted living residences. Living outside of a nursing facility could be less expensive for the state and more convenient and desirable for the individuals.

So, Washington's Apple Health will also pay for some services for people who can receive the care they need at home or in an adult group care facility. Home and community-based services (HCBS) programs operate through regular Medicaid programs and special HCBS "waiver" programs. These programs can help you maintain your independence—sometimes in your own home—as an alternative to nursing home placement.

Eligibility for Apple Health's Home and Community-Based Waiver Programs
You must meet Apple Health's regular income and asset limits to qualify for home care services provided by regular Medicaid (entitlement coverage). But Washington's HCBS waiver programs don't have the same strict income limit.

Instead, HCBS waiver programs use the same financial eligibility rules that Medicaid uses for long-term care. For a single person in 2025, the limits are:

$2,901 in monthly income, and
no more than $2,000 in assets.
Apple Health offers certain Medicaid waiver programs that provide coverage for home and community-based options for those needing nursing home-level care. Other state Medicaid programs are available for those who don't need this level of care.

Community First Choice Option and Medicaid Personal Care
Through Apple Health's Community First Choice Option (CFC) and Medicaid Personal Care (MPC) programs, Medicaid recipients can receive services like personal care assistance and respite care. CFC and MPC also provide personal emergency response systems and transitional services to help participants move out of nursing homes and back into the community.

CFC serves Medicaid recipients who need a nursing home level of care. Washington's Medicaid Personal Care (MPC) program provides similar services for participants who don't need that level of care.

MPC and CFC primarily provide assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs), such as:

eating
dressing
toileting
bathing
grocery shopping, and
meal preparation.
Both CFC and MPC program participants can choose their own caregivers, including certain family members. And because these programs are entitlements under regular Medicaid, there are no waitlists and any eligible applicant can receive services.

Washington's Community Options Program Entry System Waiver
Apple Health also offers a waiver program called the Community Options Program Entry System (COPES). Through the COPES home and community-based services program, individuals requiring nursing home-level care can get care in their homes or alternative care environments.

COPES also provides other support services to help Medicaid recipients successfully transition to independent or assisted living. These supports include coverage for:

adult day care and assisted living
case management
durable medical equipment
home health care
certain home or vehicle modifications
personal emergency response services
transportation assistance, and
other transition support services.
Because COPES is a waiver program and not an entitlement program, only a limited number of slots are available, and you might encounter waiting lists to receive services.

Under certain circumstances, program participants can receive assistance simultaneously under CFC and COPES. If you're a Washington resident who needs Medicaid assistance, but you're not sure whether you meet the relevant income and asset limits, you can read more about eligibility and contact the Washington State Health Care Authority for more guidance.

Other Apple Care HCBS Waiver Programs
Medicaid waivers allow state medical assistance programs to target specific groups of eligible Medicaid recipients. Some of Washington's Medicaid HCBS waiver programs target people with certain medical issues and those who live in specific counties.

For example, the Specialized Dementia Care Program (SDCP) covers personal care and other services for patients with dementia who are living in assisted living centers and memory care residences. And residents of King and Pierce Counties can receive assistance through the New Freedom (NF) waiver program, including:

in-home personal care
financial help with home modifications, and
education and training for family caregivers.
Learn how to apply for these and other Apple Care long-term services and support programs through one of the local resources listed on the DSHS resources page or by calling DSHS at 360-725-2300.

Washington MAC and TSOA Family Caregiver Support Programs
Washington's Medicaid Alternative Care (MAC) program provides support to individuals at home and their caregivers, helping recipients continue living in their homes or the homes of relatives. The MAC program has eligibility requirements that apply to you and to your caregiver regarding:

age
living arrangement
function, and
finances.
Those who are eligible to receive services under the MAC program must choose between receiving those benefits or more traditional LTC services, such as those offered through the COPES and CFC waiver programs.

Through the MAC program, Medicaid-eligible individuals can receive services such as:

light house cleaning
grocery shopping and delivered meals
respite care
adult day care
personal emergency response systems, and
transportation.
Visit the DSHS website for more information about the MAC program, and apply by visiting your local Community Living Connections office.

For those age 55 or older who are "at risk" of needing long-term services and support, and who aren't currently eligible for Medicaid, the Tailored Supports for Older Adults (TSOA) program might provide assistance.

The TSOA program allows for services similar to those available under the MAC program, but it's for non-Medicaid recipients. So, if you need LTC but are financially ineligible for Medicaid, you might want to learn more about TSOA and find out whether you meet program requirements.

#From Wikipedia, the free encyclopedia

This article is about the United States government program. For other uses, see Medicare (disambiguation).
Not to be confused with Medicaid or Centers for Medicare & Medicaid Services.

Medicare is a federal health insurance program in the United States for people age 65 or older and younger people with disabilities, including those with end stage renal disease and amyotrophic lateral sclerosis (ALS or Lou Gehrig's disease). It started in 1965 under the Social Security Administration and is now administered by the Centers for Medicare and Medicaid Services (CMS).

Medicare is divided into four parts: A, B, C and D. Part A covers hospital, skilled nursing, and hospice services. Part B covers outpatient services. Part D covers self-administered prescription drugs. Part C is an alternative that allows patients to choose private plans with different benefit structures that provide the same services as Parts A and B, usually with additional benefits.

In 2022, Medicare provided health insurance for 65.0 million individuals—more than 57 million people aged 65 and older and about 8 million younger people.[1] According to annual Medicare Trustees reports and research by Congress' MedPAC group, Medicare covers about half of healthcare expenses of those enrolled.[2] Enrollees cover most of the remaining costs by taking additional private insurance (medi-gap insurance), by enrolling in a Medicare Part D prescription drug plan, or by joining a private Medicare Part C (Medicare Advantage) plan. In 2022, spending by the Medicare Trustees topped $900 billion per the Trustees report Table II.B.1, of which $423 billion came from the U.S. Treasury and the rest primarily from the Part A Trust Fund (which is funded by payroll taxes) and premiums paid by beneficiaries. Households that retired in 2013 paid only 13 to 41 percent of the benefit dollars they are expected to receive.[3][4]

Beneficiaries typically have other healthcare-related costs, including Medicare Part A, B and D deductibles and Part B and C co-pays; the costs of long-term custodial care (which are not covered by Medicare); and the costs resulting from Medicare's lifetime and per-incident limits.[5]

Originally, the name "Medicare" in the United States referred to a program providing medical care for families of people serving in the military as part of the Dependents' Medical Care Act, which was passed in 1956.[6] President Dwight D. Eisenhower held the first White House Conference on Aging in January 1961, in which creating a health care program for social security beneficiaries was proposed.[7][8]

Various attempts were made in Congress to pass a bill providing for healthcare for the elderly, all without success. In 1963, however, a bill providing for both Medicare and an increase in Social Security benefits passed the Senate by 68–20 votes. As noted by one study, this was the first time that either chamber "had passed a bill embodying the principle of federal financial responsibility for health coverage, however limited it may have been." There was uncertainty over whether this bill would pass the House, however, as White House aide Henry Wilson's tally of House members’ votes on a conference bill that included Medicare “disclosed 180 “reasonably certain votes for Medicare, 29 “probable/possible,” 222 “against,” and 4 seats vacant.”[9] Following the 1964 elections however, pro-Medicare forces obtained 44 votes in the House and 4 in the Senate.[10] In July 1965,[11] under the leadership of President Lyndon Johnson, Congress enacted Medicare under Title XVIII of the Social Security Act to provide health insurance to people age 65 and older, regardless of income or medical history.[12][13] Johnson signed the Social Security Amendments of 1965 into law on July 30, 1965, at the Harry S. Truman Presidential Library in Independence, Missouri. Former president Harry S. Truman and his wife, former first lady Bess Truman, became the first recipients of the program.[14]

Before Medicare was created, approximately 60% of people over the age of 65 had health insurance (as opposed to about 70% of the population younger than that), with coverage often unavailable or unaffordable to many others, because older adults paid more than three times as much for health insurance as younger people. Many of this group (about 20% of the total in 2022, 75% of whom were eligible for all Medicaid benefits) became "dual eligible" for both Medicare and Medicaid (which was created by the same 1965 law). In 1966, Medicare spurred the racial integration of thousands of waiting rooms, hospital floors, and physician practices by making payments to health care providers conditional on desegregation.[15]

Medicare has undergone several major changes since 1965; provisions have expanded to include benefits for speech, physical, and chiropractic therapy in 1972.[16] In the 1970s the option of payments to health maintenance organizations (HMOs) was added[16] and in 1982, hospice benefits to aid elderly people on a temporary basis,[16] which was made permanent in 1984.

Congress further expanded Medicare in 2001 to cover younger people with amyotrophic lateral sclerosis (ALS, or Lou Gehrig's disease). As the years progressed, Congress expanded Medicare eligibility to younger people with permanent disabilities who receive Social Security Disability Insurance (SSDI) payments and to those with end-stage renal disease (ESRD).

The association with HMOs that began in the 1970s was formalized and expanded under President Bill Clinton in 1997 as Medicare Part C (although not all Part C health plans sponsors have to be HMOs, about 75% are). In 2003, under President George W. Bush, a Medicare program for covering almost all self-administered prescription drugs was passed (and went into effect in 2006) as Medicare Part D.[17]

The Centers for Medicare and Medicaid Services (CMS), a component of the U.S. Department of Health and Human Services (HHS), administers Medicare, Medicaid, the Children's Health Insurance Program (CHIP), the Clinical Laboratory Improvement Amendments (CLIA), and parts of the Affordable Care Act (ACA) ("Obamacare").[18] Along with the Departments of Labor and Treasury, the CMS also implements the insurance reform provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and most aspects of the Patient Protection and Affordable Care Act of 2010 as amended. The Social Security Administration is responsible for determining Medicare eligibility, eligibility for and payment of Extra Help/Low Income Subsidy payments related to Parts C and D of Medicare, and collecting most premium payments for the Medicare program.

The Chief Actuary of the CMS must provide accounting information and cost-projections to the Medicare Board of Trustees to assist them in assessing the program's financial health. The Trustees are required by law to issue annual reports on the financial status of the Medicare Trust Funds, and those reports are required to contain a statement of actuarial opinion by the Chief Actuary.[19][20]

The Specialty Society Relative Value Scale Update Committee (or Relative Value Update Committee; RUC), composed of physicians associated with the American Medical Association, advises the government about pay standards for Medicare patient procedures performed by doctors and other professionals under Medicare Part B.[21] A similar but different CMS process determines the rates paid for acute care and other hospitals—including skilled nursing facilities—under Medicare Part A. The rates paid for both Part A and Part B type services under Part C are whatever is agreed upon between the sponsor and the provider. The amounts paid for mostly self-administered drugs under Part D are whatever is agreed upon between the sponsor (almost always through a pharmacy benefit manager also used in commercial insurance) and pharmaceutical distributors and/or manufacturers.

Medicare has several sources of financing.

Part A's inpatient admitted hospital and skilled nursing coverage is largely funded by revenue from a 2.9% payroll tax levied on employers and workers (each pays 1.45%). Until December 31, 1993, the law provided a maximum amount of compensation on which the Medicare tax could be imposed annually, in the same way that the Social Security payroll tax operates.[22] Beginning on January 1, 1994, the compensation limit was removed. Self-employed individuals must calculate the entire 2.9% tax on self-employed net earnings (because they are both employee and employer), but they may deduct half of the tax from the income in calculating income tax.[23] Beginning in 2013, the rate of Part A tax on earned income exceeding $200,000 for individuals ($250,000 for married couples filing jointly) rose to 3.8%, in order to pay part of the cost of the subsidies to people not on Medicare mandated by the Affordable Care Act.[24]

In 2022, Medicare spending was over $900 billion, near 4% of U.S. gross domestic product according to the Trustees Figure 1.1 and over 15% of total US federal spending.[25] Because of the two Trust funds and their differing revenue sources (one dedicated and one not), the Trustees analyze Medicare spending as a percent of GDP rather than versus the Federal budget.

The aging of the Baby Boom generation into Medicare is projected by 2030 (when the last of the baby boom turns 65) to increase enrollment to more than 80 million. In addition, the fact that the number of payroll tax payors per enrollee will decline over time and that overall health care costs in the nation are rising pose substantial financial challenges to the program. Medicare spending is projected to increase from near 4% of GDP in 2022 to almost 6% in 2046.[25] Baby-boomers are projected to have longer life spans, which will add to the future Medicare spending. In response to these financial challenges, Congress made substantial cuts to future payouts to providers (primarily acute care hospitals and skilled nursing facilities) as part of PPACA in 2010 and the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and individual Congresspeople have offered many additional competing proposals to stabilize Medicare spending further. Many other factors have complicated the forecasting of Medicare Trust Fund health and spending trends including but not limited to the Covid pandemic, the overwhelming preference of people joining Medicare this century for Part C, and the increasing number of dual eligible (Medicaid and Medicare eligibility) beneficiaries.

In 2013 the Urban Institute published a report which analyzed the amounts that various households (single male, single female, married single-earner, married dual-earner, low income, average income, high income) contributed to the Medicare program over their lifetimes, and how much someone living to the statistically expected age would expect to receive in benefits.[3][4] They found differing amounts for the different scenarios, but even the group with the "worst" return on their Medicare taxes would have concluded their working years with $158,000 in Medicare contributions and growth (assuming annual growth equal to inflation plus 2%) but would receive $385,000 in Medicare benefits (both numbers are in 2013 inflation adjusted dollars).[3][4] Overall, the groups paid into the system 13 to 41 percent of what they were expected to receive.[3][4]

Cost reduction is influenced by factors including reduction in inappropriate and unnecessary care by evaluating evidence-based practices as well as reducing the amount of unnecessary, duplicative, and inappropriate care. Cost reduction may also be effected by reducing medical errors, investment in healthcare information technology, improving transparency of cost and quality data, increasing administrative efficiency, and by developing both clinical/non-clinical guidelines and quality standards.[26] Of course all of these factors relate to the entire United States health care delivery system and not just to Medicare.

Eligibility
U.S. citizens or permanent residents who have lived in the U.S. for at least five continuous years are eligible. Those who are 65 and older who choose to enroll in Part A Medicare must pay a monthly premium to remain enrolled in Medicare Part A if they or their spouse have not paid the qualifying Medicare payroll taxes.[27] There are some instances where U.S. citizens might be able to enroll in Medicare earlier than age 65. For example, people with long term disabilities that prevent them from working (such as end-stage renal disease or amyotrophic lateral sclerosis) may be eligible at an earlier age.[28] Individuals receiving Social Security Disability Insurance (SSDI) benefits for 24 months are automatically enrolled in Medicare Parts A and B in the 25th month. Individuals with permanent kidney failure requiring dialysis or a transplant may qualify for Medicare, regardless of age. Individuals diagnosed with ALS are automatically enrolled in Medicare Parts A and B the month their disability benefits begin.

Medicare has four parts: Part A, B, C, & D. Coverage under the first two (Parts A and B), as opposed to Part C plans, is referred to as Original Medicare.[31]

In April 2018, CMS began mailing out new Medicare cards with new ID numbers to all beneficiaries.[32] Previous cards had ID numbers containing beneficiaries' Social Security numbers; the new ID numbers are randomly generated and not tied to any other personally identifying information.[33][34]


Part A: Hospital/hospice insurance
Part A covers inpatient hospital stays. The maximum length of stay that Medicare Part A covers in a hospital admitted inpatient stay or series of stays is typically 90 days. The first 60 days would be paid by Medicare in full, except one copay (also and more commonly referred to as a "deductible") at the beginning of the 60 days of $1632 as of 2024.[35] Days 61–90 require a co-payment of $408 per day as of 2024.[35] The beneficiary is also allocated "lifetime reserve days" that can be used after 90 days. These lifetime reserve days require a copayment of $816 per day as of 2024, and the beneficiary can use a total of only 60 of these days throughout their lifetime.[36] A new pool of 90 hospital days, with new copays of $1632 in 2024 and $408 per day for days 61–90, starts only after the beneficiary has 60 days continuously with no payment from Medicare for hospital or Skilled Nursing Facility confinement.[37]

Some "hospital services" are provided as inpatient services, which would be reimbursed under Part A; or as outpatient services, which would be reimbursed, not under Part A, but under Part B instead. The "Two-Midnight Rule" decides which is which. In August 2013, the Centers for Medicare and Medicaid Services announced a final rule concerning eligibility for hospital inpatient services effective October 1, 2013. Under the new rule, if a physician admits a Medicare beneficiary as an inpatient with an expectation that the patient will require hospital care that "crosses two midnights", Medicare Part A payment is "generally appropriate". However, if it is anticipated that the patient will require hospital care for less than two midnights, Medicare Part A payment is generally not appropriate; payment such as is approved will be paid under Part B.[38] The time a patient spends in the hospital before an inpatient admission is formally ordered is considered outpatient time. But, hospitals and physicians can take into consideration the pre-inpatient admission time when determining if a patient's care will reasonably be expected to cross two midnights to be covered under Part A.[39] In addition to deciding which trust fund is used to pay for these various outpatient versus inpatient charges, the number of days for which a person is formally considered an admitted patient affects eligibility for Part A skilled nursing services.

Medicare penalizes hospitals for readmissions. After making initial payments for hospital stays, Medicare will take back from the hospital these payments, plus a penalty of 4 to 18 times the initial payment, if an above-average number of patients from the hospital are readmitted within 30 days. These readmission penalties apply after some of the most common treatments: pneumonia, heart failure, heart attack, COPD, knee replacement, and hip replacement.[40][41] A study of 18 states conducted by the Agency for Healthcare Research and Quality (AHRQ) found that 1.8 million Medicare patients aged 65 and older were readmitted within 30 days of an initial hospital stay in 2011; the conditions with the highest readmission rates were congestive heart failure, sepsis, pneumonia, and COPD and bronchiectasis.[42]

The highest penalties on hospitals are charged after knee or hip replacements, $265,000 per excess readmission.[43] The goals are to encourage better post-hospital care and more referrals to hospice and end-of-life care in lieu of treatment,[44][45] while the effect is also to reduce coverage in hospitals that treat poor and frail patients.[46][47] The total penalties for above-average readmissions in 2013 are $280 million,[48] for 7,000 excess readmissions, or $40,000 for each readmission above the US average rate.[49]

Part A fully covers brief stays for rehabilitation or convalescence in a skilled nursing facility and up to 100 days per medical necessity with a co-pay if certain criteria are met:[36][50]

A preceding hospital stay must be at least three days as an inpatient, three midnights, not counting the discharge date.
The skilled nursing facility stay must be for something diagnosed during the hospital stay or for the main cause of hospital stay.
If the patient is not receiving rehabilitation but has some other ailment that requires skilled nursing supervision (e.g., wound management) then the nursing home stay would be covered.
The care being rendered by the nursing home must be skilled. Medicare part A does not pay for stays that only provide custodial, non-skilled, or long-term care activities, including activities of daily living (ADL) such as personal hygiene, cooking, cleaning, etc.
The care must be medically necessary and progress against some set plan must be made on some schedule determined by a doctor.
The first 20 days would be paid for in full by Medicare with the remaining 80 days requiring a co-payment of $204 per day as of 2024.[36] Many insurance group retiree, Medigap and Part C insurance plans have a provision for additional coverage of skilled nursing care in the indemnity insurance policies they sell or health plans they sponsor. If a beneficiary uses some portion of their Part A benefit and then goes at least 60 days without receiving facility-based skilled services, the 90-day hospital clock and 100-day nursing home clock are reset and the person qualifies for new benefit periods.

Hospice benefits are also provided under Part A of Medicare for terminally ill persons with less than six months to live, as determined by the patient's physician. The terminally ill person must sign a statement that hospice care has been chosen over other Medicare-covered benefits, (e.g. assisted living or hospital care).[51] Treatment provided includes pharmaceutical products for symptom control and pain relief as well as other services not otherwise covered by Medicare such as grief counseling. Hospice is covered 100% with no co-pay or deductible by Medicare Part A except that patients are responsible for a copay for outpatient drugs and respite care, if needed.[52]

The Monthly Premium for Part B for 2025 is $185.00 per month (for 2024 it was $174.70 per month).[36]

Part B coverage begins once a patient meets his or her deductible ($257 for 2025), then typically Medicare covers 80% of the RUC-set rate for approved services, while the remaining 20% is the responsibility of the patient,[36][53] either directly or indirectly by private group retiree or Medigap insurance. Part B coverage covers 100% for preventive services such as yearly mammogram screenings, osteoporosis screening, and many other preventive screenings.

Part B also helps with durable medical equipment (DME), including but not limited to canes, walkers, lift chairs, wheelchairs, and mobility scooters for those with mobility impairments. Prosthetic devices such as artificial limbs and breast prosthesis following mastectomy, as well as one pair of eyeglasses following cataract surgery, and oxygen for home use are also covered.[54]

Medically necessary emergency ambulance transport is covered by Part B if transport by any other method is dangerous to health.[55] Non-emergency ambulance transport, or transport when not suffering from a medical emergency, may be covered if a physician orders that ambulance transport is medically necessary. Transport by an air ambulance, either fixed-wing or helicopter, may also be covered if specialized services are required that are unable to be provided by ground services.[56]

Anyone on Social Security (SS) in 2019 is "held harmless" from the 2019 amount if the increase in their SS monthly benefit does not cover the increase in their Part B premium from 2019 to 2020. This hold harmless provision is significant in years when SS does not increase but that is not the case for 2020. There are additional income-weighted surtaxes for those with incomes more than $85,000 per annum.

Public Part C Medicare Advantage and other Part C health plans are required to offer coverage that meets or exceeds the standards set by Original Medicare but they do not have to cover every benefit in the same way (the plan must be actuarially equivalent to Original Medicare benefits). After approval by the Centers for Medicare and Medicaid Services, if a Part C plan chooses to cover less than Original Medicare for some benefits, such as Skilled Nursing Facility care, the savings may be passed along to consumers by offering even lower co-payments for doctor visits (or any other plus or minus aggregation approved by CMS).[57]

Public Part C Medicare Advantage health plan members typically also pay a monthly premium in addition to the Medicare Part B premium to cover items not covered by Original Medicare (Parts A & B), such as the out-of-pocket (OOP) limit, self-administered prescription drugs, dental care, vision care, annual physicals, coverage outside the United States, and even gym or health club memberships as well as—and probably most importantly—reduce the 20% co-pays and high deductibles associated with Original Medicare.[58] But in some situations the benefits are more limited (but they can never be more limited than Original Medicare and must always include an OOP limit) and there is no premium. The OOP limit can be as low as $1500 and as high as but no higher than $9350 (as with all insurance, the lower the limit, the higher the premium).[citation needed] In some cases, the sponsor even rebates part or all of the Part B premium, though these types of Part C plans are becoming rare.

Medicare Part D went into effect on January 1, 2006. Anyone with Part A or B is eligible for Part D, which covers mostly self-administered drugs.[citation needed] It was made possible by the passage of the Medicare Modernization Act of 2003. To receive this benefit, a person with Medicare must enroll in a stand-alone Prescription Drug Plan (PDP) or public Part C health plan with integrated prescription drug coverage (MA-PD). These plans are approved and regulated by the Medicare program, but are actually designed and administered by various sponsors including charities, integrated health delivery systems, unions and health insurance companies; almost all these sponsors in turn use pharmacy benefit managers in the same way as they are used by sponsors of health insurance for those not on Medicare. Unlike Original Medicare (Part A and B), Part D coverage is not standardized (though it is highly regulated by the Centers for Medicare and Medicaid Services). Plans choose which drugs they wish to cover (but must cover at least two drugs in 148 different categories and cover all or "substantially all" drugs in the following protected classes of drugs: anti-cancer; anti-psychotic; anti-convulsant, anti-depressants, immuno-suppressant, and HIV and AIDS drugs). The plans can also specify, with CMS approval, at what level (or tier) they wish to cover it, and are encouraged to use step therapy. Some drugs are excluded from coverage altogether and Part D plans that cover excluded drugs are not allowed to pass those costs on to Medicare, and plans are required to repay CMS if they are found to have billed Medicare in these cases.[59]

Out-of-pocket costs
No part of Medicare pays for all of a beneficiary's covered medical costs and many costs and services are not covered at all. The program contains premiums, deductibles and coinsurance, which the covered individual must pay out-of-pocket. A study published by the Kaiser Family Foundation in 2008 found the Fee-for-Service Medicare benefit package was less generous than either the typical large employer preferred provider organization plan or the Federal Employees Health Benefits Program Standard Option.[60] Some people may qualify to have other governmental programs (such as Medicaid) pay premiums and some or all of the costs associated with Medicare.

Most Medicare enrollees do not pay a monthly Part A premium, because they (or a spouse) have had 40 or more 3-month quarters in which they paid Federal Insurance Contributions Act taxes. The benefit is the same no matter how much or how little the beneficiary paid as long as the minimum number of quarters is reached. Medicare-eligible persons who do not have 40 or more quarters of Medicare-covered employment may buy into Part A for an annual adjusted monthly premium of:

$248.00 per month (as of 2012)[61] for those with 30–39 quarters of Medicare-covered employment, or
$451.00 per month (as of 2012)[61] for those with fewer than 30 quarters of Medicare-covered employment and who are not otherwise eligible for premium-free Part A coverage.[62]
Part B
Most Medicare Part B enrollees pay an insurance premium for this coverage; the standard Part B premium for 2019 is $135.50 a month. A new income-based premium surtax schema has been in effect since 2007, wherein Part B premiums are higher for beneficiaries with incomes exceeding $85,000 for individuals or $170,000 for married couples. Depending on the extent to which beneficiary earnings exceed the base income, these higher Part B premiums are from 30% to 70% higher with the highest premium paid by individuals earning more than $214,000, or married couples earning more than $428,000.[63] This extra amount is called the Income Related Monthly Adjustment Amount (IRMAA). The IRMAA surcharge changes for individuals annually and fluctuates along with changes in an individual’s income. The IRMAA calculation has a lag time of two years.[64][65]

Deductible and coinsurance
Part A—For each benefit period, a beneficiary pays an annually adjusted:

A Part A deductible of $1,632 in 2024 for a hospital stay of 1–60 days.[35]
A $408 per day co-pay in 2024 for days 61–90 of a hospital stay.[35]
A $816 per day co-pay in 2024 for days 91–150 of a hospital stay, as part of their limited Lifetime Reserve Days.[35]
All costs for each day beyond 150 days[66]
Coinsurance for a Skilled Nursing Facility is $204 per day in 2024 for days 21100 for each benefit period (no co-pay for the first 20 days).[35]

A blood deductible of the first 3 pints of blood needed in a calendar year, unless replaced. There is a 3-pint blood deductible for both Part A and Part B, and these separate deductibles do not overlap.
Part B—After beneficiaries meet the yearly deductible of $240 for 2024, they will be required to pay a co-insurance of 20% of the Medicare-approved amount for all services covered by Part B[35] with the exception of most lab services, which are covered at 100%. Previously, outpatient mental health services was covered at 50%, but under the Medicare Improvements for Patients and Providers Act of 2008, it gradually decreased over several years and now matches the 20% required for other services.[67] They are also required to pay an excess charge of 15% for services rendered by physicians who do not accept assignment.

The deductibles, co-pays, and coinsurance charges for Part C and D plans vary from plan to plan. All Part C plans include an annual out-of-pocket (OOP) upper spend limit. Original Medicare does not include an OOP limit.

Medicare supplement (Medigap) policies
Main article: Medigap

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All insurance companies that sell Medigap policies are required to make Plan A available, and if they offer any other policies, they must also make either Plan C available as well. Plan F is no longer offered as of 2020, but anyone who has a Plan F may keep it.[68] Many of the insurance companies that offer Medigap insurance policies also sponsor Part C health plans, but most Part C health plans are sponsored by integrated health delivery systems and their spin-offs, charities, and unions as opposed to insurance companies.

Medicare contracts with regional insurance companies to process over one billion fee-for-service claims per year. In 2008, Medicare accounted for 13% ($386 billion) of the federal budget. In 2016 it was projected to account for close to 15% ($683 billion) of the total expenditures. For the decade 2010–2019 Medicare was projected to cost 6.4 trillion dollars.[69]

Reimbursement for Part A services
For institutional care, such as hospital and nursing home care, Medicare uses prospective payment systems. In a prospective payment system, the health care institution receives a set amount of money for each episode of care provided to a patient, regardless of the actual amount of care. The actual allotment of funds is based on a list of diagnosis-related groups (DRG). The actual amount depends on the primary diagnosis that is actually made at the hospital. There are some issues surrounding Medicare's use of DRGs because if the patient uses less care, the hospital gets to keep the remainder. This, in theory, should balance the costs for the hospital. However, if the patient uses more care, then the hospital has to cover its own losses. This results in the issue of "upcoding", when a physician makes a more severe diagnosis to hedge against accidental costs.[70]

Reimbursement for Part B services
Payment for physician services under Medicare has evolved since the program was created in 1965. Initially, Medicare compensated physicians based on the physician's charges, and allowed physicians to bill Medicare beneficiaries the amount in excess of Medicare's reimbursement. In 1975, annual increases in physician fees were limited by the Medicare Economic Index (MEI). The MEI was designed to measure changes in costs of physician's time and operating expenses, adjusted for changes in physician productivity. From 1984 to 1991, the yearly change in fees was determined by legislation. This was done because physician fees were rising faster than projected.

The Omnibus Budget Reconciliation Act of 1989 made several changes to physician payments under Medicare. Firstly, it introduced the Medicare Fee Schedule, which took effect in 1992. Secondly, it limited the amount Medicare non-providers could balance bill Medicare beneficiaries. Thirdly, it introduced the Medicare Volume Performance Standards (MVPS) as a way to control costs.[71]

On January 1, 1992, Medicare introduced the Medicare Fee Schedule (MFS), a list of about 7,000 services that can be billed for. Each service is priced within the Resource-Based Relative Value Scale (RBRVS) with three Relative Value Units (RVUs) values largely determining the price. The three RVUs for a procedure are each geographically weighted and the weighted RVU value is multiplied by a global Conversion Factor (CF), yielding a price in dollars. The RVUs themselves are largely decided by a private group of 29 (mostly specialist) physicians—the American Medical Association's Specialty Society Relative Value Scale Update Committee (RUC).[72]

From 1992 to 1997, adjustments to physician payments were adjusted using the MEI and the MVPS, which essentially tried to compensate for the increasing volume of services provided by physicians by decreasing their reimbursement per service.

In 1998, Congress replaced the VPS with the Sustainable Growth Rate (SGR). This was done because of highly variable payment rates under the MVPS. The SGR attempts to control spending by setting yearly and cumulative spending targets. If actual spending for a given year exceeds the spending target for that year, reimbursement rates are adjusted downward by decreasing the Conversion Factor (CF) for RBRVS RVUs.

In 2002, payment rates were cut by 4.8%. In 2003, payment rates were scheduled to be reduced by 4.4%. However, Congress boosted the cumulative SGR target in the Consolidated Appropriation Resolution of 2003 (P.L. 108–7), allowing payments for physician services to rise 1.6%. In 2004 and 2005, payment rates were again scheduled to be reduced. The Medicare Modernization Act (P.L. 108–173) increased payments by 1.5% for those two years.

In 2006, the SGR mechanism was scheduled to decrease physician payments by 4.4%. (This number results from a 7% decrease in physician payments times a 2.8% inflation adjustment increase.) Congress overrode this decrease in the Deficit Reduction Act (P.L. 109–362), and held physician payments in 2006 at their 2005 levels. Similarly, another congressional act held 2007 payments at their 2006 levels, and HR 6331 held 2008 physician payments to their 2007 levels, and provided for a 1.1% increase in physician payments in 2009. Without further continuing congressional intervention, the SGR is expected to decrease physician payments from 25% to 35% over the next several years.

MFS has been criticized for not paying doctors enough because of the low conversion factor. By adjustments to the MFS conversion factor, it is possible to make global adjustments in payments to all doctors.[73]

The SGR was the subject of possible reform legislation again in 2014. On March 14, 2014, the United States House of Representatives passed the SGR Repeal and Medicare Provider Payment Modernization Act of 2014 (H.R. 4015; 113th Congress), a bill that would have replaced the (SGR) formula with new systems for establishing those payment rates.[74] However, the bill would pay for these changes by delaying the Affordable Care Act's individual mandate requirement, a proposal that was very unpopular with Democrats.[75] The SGR was expected to cause Medicare reimbursement cuts of 24 percent on April 1, 2014, if a solution to reform or delay the SGR was not found.[76] This led to another bill, the Protecting Access to Medicare Act of 2014 (H.R. 4302; 113th Congress), which would delay those cuts until March 2015.[76] This bill was also controversial. The American Medical Association and other medical groups opposed it, asking Congress to provide a permanent solution instead of just another delay.[77]

The SGR process was replaced by new rules as of the passage of MACRA in 2015.

Provider participation
There are two ways for providers to be reimbursed in Medicare. "Participating" providers accept "assignment", which means that they accept Medicare's approved rate for their services as payment (typically 80% from Medicare and 20% from the beneficiary). Some non-participating doctors do not take assignment, but they also treat Medicare enrollees and are authorized to balance bills no more than a small fixed amount above Medicare's approved rate. A minority of doctors are "private contractors" from a Medicare perspective, which means they opt out of Medicare and refuse to accept Medicare payments altogether. These doctors are required to inform patients that they will be liable for the full cost of their services out-of-pocket, often in advance of treatment.[78]

While the majority of providers accept Medicare assignments, (97 percent for some specialties),[79] and most physicians still accept at least some new Medicare patients, that number is in decline.[80] While 80% of physicians in the Texas Medical Association accepted new Medicare patients in 2000, only 60% were doing so by 2012.[81] A study published in 2012 concluded that the Centers for Medicare and Medicaid Services (CMS) relies on the recommendations of an American Medical Association

advisory panel. The study led by Miriam J. Laugesen, of Columbia Mailman School of Public Health, and colleagues at UCLA and the University of Illinois, shows that for services provided between 1994 and 2010, CMS agreed with 87.4% of the recommendations of the committee, known as RUC or the Relative Value Update Committee.[82]

Office medication reimbursement
Chemotherapy and other medications dispensed in a physician's office are reimbursed according to the Average Sales Price (ASP),[83] a number computed by taking the total dollar sales of a drug as the numerator and the number of units sold nationwide as the denominator.[84] The current reimbursement formula is known as "ASP+6" since it reimburses physicians at 106% of the ASP of drugs. Pharmaceutical company discounts and rebates are included in the calculation of ASP, and tend to reduce it. In addition, Medicare pays 80% of ASP+6, which is the equivalent of 84.8% of the actual average cost of the drug. Some patients have supplemental insurance or can afford the co-pay. Large numbers do not. This leaves the payment to physicians for most of the drugs in an "underwater" state. ASP+6 superseded Average Wholesale Price in 2005,[85] after a 2003 front-page New York Times article drew attention to the inaccuracies of Average Wholesale Price calculations.[86]

This procedure is scheduled to change dramatically in 2017 under a CMS proposal that will likely be finalized in October 2016.

Medicare 10 percent incentive payments
"Physicians in geographic Health Professional Shortage Areas (HPSAs) and Physician Scarcity Areas (PSAs) can receive incentive payments from Medicare. Payments are made on a quarterly basis, rather than claim-by-claim, and are handled by each area's Medicare carrier."[87][88]

Generally, if an individual already receives Social Security payments, at age 65 the individual becomes automatically enrolled in Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance).[citation needed] If the individual chooses not to enroll in Part B (typically because the individual is still working and receiving employer insurance), then the individual must proactively opt out of it when receiving the automatic enrollment package. Delay in enrollment in Part B carries no penalty if the individual has other insurance (e.g., the employment situation noted above), but may be penalized under other circumstances. An individual who does not receive Social Security benefits upon turning 65 must sign up for Medicare if they want it. Penalties may apply if the individual chooses not to enroll at age 65 and does not have other insurance.[citation needed]

Parts A & B
Part A Late Enrollment Penalty
If an individual is not eligible for premium-free Part A, and they do not buy a premium-based Part A when they are first eligible, the monthly premium may go up 10%.[89] The individual must pay the higher premium for twice the number of years that they could have had Part A, but did not sign up. For example, if they were eligible for Part A for two years but did not sign up, they must pay the higher premium for four years. Usually, individuals do not have to pay a penalty if they meet certain conditions that allow them to sign up for Part A during a Special Enrollment Period.

Part B Late Enrollment Penalty
If an individual does not sign up for Part B when they are first eligible, they may have to pay a late enrollment penalty for as long as they have Medicare. Their monthly premium for Part B may go up 10% for each full 12-month period that they could have had Part B, but did not sign up for it. Usually, they do not pay a late enrollment penalty if they meet certain conditions that allow them to sign up for Part B during a special enrollment period.[90]

Medicare differs from private insurance available to working Americans in that it is a social insurance program. Social insurance programs provide statutorily guaranteed benefits to the entire population (under certain circumstances, such as old age or unemployment). These benefits are financed in significant part through universal taxes. In effect, Medicare is a mechanism by which the state takes a portion of its citizens' resources to provide health and financial security to its citizens in old age or in case of disability, helping them cope with the cost of health care. In its universality, Medicare differs substantially from private insurers, which decide whom to cover and what benefits to offer to manage their risk pools and ensure that their costs do not exceed premiums.[citation needed]

Because the federal government is legally obligated to provide Medicare benefits to older and some disabled Americans, it cannot cut costs by restricting eligibility or benefits, except by going through a difficult legislative process, or by revising its interpretation of medical necessity. By statute, Medicare may only pay for items and services that are "reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member", unless there is another statutory authorization for payment.[91] Cutting costs by cutting benefits is difficult, but the program can also achieve substantial economies of scale in the prices it pays for health care and administrative expenses—and, as a result, private insurers' costs have grown almost 60% more than Medicare's since 1970.[citation needed][92][original research?][93] Medicare's cost growth is now the same as GDP growth and expected to stay well below private insurance's for the next decade.[94]

Because Medicare offers statutorily determined benefits, its coverage policies and payment rates are publicly known, and all enrollees are entitled to the same coverage. In the private insurance market, plans can be tailored to offer different benefits to different customers, enabling individuals to reduce coverage costs while assuming risks for care that is not covered. Insurers, however, have far fewer disclosure requirements than Medicare, and studies show that customers in the private sector can find it difficult to know what their policy covers,[95] and at what cost.[96] Moreover, since Medicare collects data about utilization and costs for its enrollees—data that private insurers treat as trade secrets—it gives researchers key information about health care system performance.

Medicare also has an important role in driving changes in the entire health care system. Because Medicare pays for a huge share of health care in every region of the country, it has a great deal of power to set delivery and payment policies. For example, Medicare promoted the adaptation of prospective payments based on DRGs, which prevents unscrupulous providers from setting their own exorbitant prices.[97] Meanwhile, the Patient Protection and Affordable Care Act has given Medicare the mandate to promote cost-containment throughout the health care system, for example, by promoting the creation of accountable care organizations or by replacing fee-for-service payments with bundled payments.[98]

Over the long-term, Medicare faces significant financial challenges because of rising overall health care costs, increasing enrollment as the population ages, and a decreasing ratio of workers to enrollees. Total Medicare spending was projected to increase from $523 billion in 2010 to around $900 billion by 2020. From 2010 to 2030, Medicare enrollment is projected to increase, from 47 million to 79 million, and the ratio of workers to enrollees is expected to decrease from 3.7 to 2.4.[99] However, the ratio of workers to retirees has declined steadily for decades, and social insurance systems have remained sustainable due to rising worker productivity. There is some evidence that productivity gains will continue to offset demographic trends in the near future.[100]

The Congressional Budget Office (CBO) wrote in 2008 that "future growth in spending per beneficiary for Medicare and Medicaid—the federal government's major health care programs—will be the most important determinant of long-term trends in federal spending. Changing those programs in ways that reduce the growth of costs—which will be difficult, in part because of the complexity of health policy choices—is ultimately the nation's central long-term challenge in setting federal fiscal policy."[101]

Overall health care costs were projected in 2011 to increase by 5.8 percent annually from 2010 to 2020, in part because of increased use of medical services, higher prices for services, and new technologies.[102] Health care costs are rising faster than inflation across the board, but the cost of insurance has risen dramatically for families and employers as well as the federal government. Since 1970, the per-capita cost of private insurance coverage has grown roughly one percentage point faster each year than the per-capita cost of Medicare. Since the late 1990s, Medicare has performed especially well relative to private insurers.[103] Over the next decade, Medicare's per capita spending is projected to grow at a rate of 2.5 percent each year, compared to private insurance's 4.8 percent.[104] Nonetheless, most experts and policymakers agree containing health care costs is essential to the nation's fiscal outlook. Much of the debate over the future of Medicare revolves around whether per capita costs should be reduced by limiting payments to providers or by shifting more costs to Medicare enrollees.

Indicators
Several measures serve as indicators of the long-term financial status of Medicare. These include total Medicare spending as a share of gross domestic product (GDP), the solvency of the Medicare HI trust fund, Medicare per-capita spending growth relative to inflation and per-capita GDP growth; general fund revenue as a share of total Medicare spending; and actuarial estimates of unfunded liability over the 75-year timeframe and the infinite horizon (netting expected premium/tax revenue against expected costs). The major issue these indicators is comparing any future projections against current law vs. what actuaries expect to happen. For example, current law specifies that Part A payments to hospitals and skilled nursing facilities will be cut substantially after 2028 and that doctors will get no raises after 2025. Actuaries expect that the law will change to keep these events from happening.

This measure, which examines Medicare spending in the context of the US economy as a whole, is projected to increase from 3.7 percent in 2017 to 6.2 percent by 2092[104] under current law and over 9 percent under what actuaries really expect will happen (called an "illustrative example" in recent-year Trustees Reports).

The solvency of the Medicare HI trust fund
This measure involves only Medicare Part A. The trust fund is considered insolvent when available revenue plus any existing balances will not cover 100 percent of annual projected costs. According to the 2018 estimate by the Medicare trustees, the trust fund was expected to become insolvent in 8 years (2026), at which time available revenue will cover around 85 percent of annual projected costs for Part A services.[105] Since Medicare began, this solvency projection has ranged from two to 28 years, with an average of 11.3 years.[106] This and other projections in Medicare Trustees reports are based on what its actuaries call the intermediate scenario but the reports also include worst-case and best-case projections that are quite different (other scenarios presume Congress will change present law).

Medicare per-capita spending growth relative to inflation and per-capita GDP growth
Per capita spending relative to inflation per-capita GDP growth was to be an important factor used by the PPACA-specified Independent Payment Advisory Board (IPAB), as a measure to determine whether it must recommend to Congress proposals to reduce Medicare costs. However, the IPAB never formed and was formally repealed by the Balanced Budget Act of 2018.

General fund revenue as a share of total Medicare spending
This measure, established under the Medicare Modernization Act (MMA), examines Medicare spending in the context of the federal budget. Each year, MMA requires the Medicare trustees to make a determination about whether general fund revenue is projected to exceed 45 percent of total program spending within a seven-year period. If the Medicare trustees make this determination in two consecutive years, a "funding warning" is issued. In response, the president must submit cost-saving legislation to Congress, which must consider this legislation on an expedited basis. This threshold was reached and a warning issued every year between 2006 and 2013 but it has not been reached since that time and was not expected to be reached in the 2016–2022 "window". This is a reflection of the reduced spending growth mandated by the ACA according to the Trustees.

Unfunded obligation
Medicare's unfunded obligation is the total amount of money that would have to be set aside today such that the principal and interest would cover the gap between projected revenues (mostly Part B premiums and Part A payroll taxes to be paid over the timeframe under current law) and spending over a given timeframe. By law the timeframe used is 75 years though the Medicare actuaries also give an infinite-horizon estimate because life expectancy consistently increases and other economic factors underlying the estimates change.

As of January 1, 2016, Medicare's unfunded obligation over the 75-year time frame is $3.8 trillion for the Part A Trust Fund and $28.6 trillion for Part B. Over an infinite timeframe, the combined unfunded liability for both programs combined is over $50 trillion, with the difference primarily in the Part B estimate.[105] These estimates assume that CMS will pay full benefits as currently specified over those periods though that would be contrary to current United States law. In addition, as discussed throughout each annual Trustees' report, "the Medicare projections shown could be substantially understated as a result of other potentially unsustainable elements of current law."[citation needed] For example, current law effectively provides no raises for doctors after 2025; that is unlikely to happen. It is impossible for actuaries to estimate unfunded liability other than assuming current law is followed (except relative to benefits as noted), the Trustees state "that actual long-range present values for (Part A) expenditures and (Part B/D) expenditures and revenues could exceed the amounts estimated by a substantial margin."[citation needed]

Public opinion
Popular opinion surveys show that the public views Medicare's problems as serious, but not as urgent as other concerns. In January 2006, the Pew Research Center found 62 percent of the public said addressing Medicare's financial problems should be a high priority for the government, but that still put it behind other priorities.[107] Surveys suggest that there is no public consensus behind any specific strategy to keep the program solvent.[108]

Fraud and waste
Main article: Medicare fraud
The Government Accountability Office lists Medicare as a "high-risk" government program in need of reform, in part because of its vulnerability to fraud and partly because of its long-term financial problems.[109][110][111] Fewer than 5% of Medicare claims are audited.[112]

Criticism
Robert M. Ball, a former commissioner of Social Security under President Kennedy in 1961 and later under Johnson and Nixon, defined the major obstacle to financing health insurance for the elderly: the high cost of care for the aged combined with the generally low incomes of retired people. Because retired older people use much more medical care than younger employed people, an insurance premium related to the risk for older people needed to be high, but if the high premium had to be paid after retirement, when incomes are low, it was an almost impossible burden for the average person. The only feasible approach, he said, was to finance health insurance in the same way as cash benefits for retirement, by contributions paid while at work, when the payments are least burdensome, with the protection furnished in retirement without further payment.[113] In the early 1960s relatively few of the elderly had health insurance, and what they had was usually inadequate. Insurers such as Blue Cross, which had originally applied the principle of community rating, faced competition from other commercial insurers that did not community rate, and so were forced to raise their rates for the elderly.[114]

Medicare is not generally an unearned entitlement. Entitlement is most commonly based on a record of contributions to the Medicare fund. As such it is a form of social insurance making it feasible for people to pay for insurance for sickness in old age when they are young and able to work and be assured of getting back benefits when they are older and no longer working. Some people will pay in more than they receive back and others will receive more benefits than they paid in. Unlike private insurance where some amount must be paid to attain coverage, all eligible persons can receive coverage regardless of how much or if they had ever paid in.

Politicized payment
Bruce Vladeck, director of the Health Care Financing Administration in the Clinton administration, has argued that lobbyists have changed the Medicare program "from one that provides a legal entitlement to beneficiaries to one that provides a de facto political entitlement to providers."[115]

Quality of beneficiary services
A 2001 study by the Government Accountability Office evaluated the quality of responses given by Medicare contractor customer service representatives to provider (physician) questions. The evaluators assembled a list of questions, which they asked during a random sampling of calls to Medicare contractors. The rate of complete, accurate information provided by Medicare customer service representatives was 15%.[116] Since then, steps have been taken to improve the quality of customer service given by Medicare contractors, specifically the 1-800-MEDICARE contractor. As a result, 1-800-MEDICARE customer service representatives (CSR) have seen an increase in training, quality assurance monitoring has significantly increased, and a customer satisfaction survey is offered to random callers.

Hospital accreditation
In most states the Joint Commission, a private, non-profit organization for accrediting hospitals, decides whether or not a hospital is able to participate in Medicare, as currently there are no competitor organizations recognized by CMS.

Other organizations can also accredit hospitals for Medicare.[citation needed] These include the Community Health Accreditation Program, the Accreditation Commission for Health Care, the Compliance Team and the Healthcare Quality Association on Accreditation.

Accreditation is voluntary and an organization may choose to be evaluated by their State Survey Agency or by CMS directly.[117]

Graduate medical education
Medicare funds the vast majority of residency training in the US. This tax-based financing covers resident salaries and benefits through payments called Direct Medical Education payments. Medicare also uses taxes for Indirect Medical Education, a subsidy paid to teaching hospitals in exchange for training resident physicians.[118] For the 2008 fiscal year these payments were $2.7 billion and $5.7 billion, respectively.[119] Overall funding levels have remained at the same level since 1996, so that the same number or fewer residents have been trained under this program.[120] Meanwhile, the US population continues to grow both older and larger, which has led to greater demand for physicians, in part due to higher rates of illness and disease among the elderly compared to younger individuals. At the same time the cost of medical services continue rising rapidly and many geographic areas face physician shortages, both trends suggesting the supply of physicians remains too low.[121]

Medicare thus finds itself in the odd position of having assumed control of the single largest funding source for graduate medical education, currently facing major budget constraints, and as a result, freezing funding for graduate medical education, as well as for physician reimbursement rates. This has forced hospitals to look for alternative sources of funding for residency slots.[120] This halt in funding in turn exacerbates the exact problem Medicare sought to solve in the first place: improving the availability of medical care. However, some healthcare administration experts believe that the shortage of physicians may be an opportunity for providers to reorganize their delivery systems to become less costly and more efficient. Physician assistants and Advanced Registered Nurse Practitioners may begin assuming more responsibilities that traditionally fell to doctors, but do not necessarily require the advanced training and skill of a physician.[122]

In 1977, the Health Care Financing Administration (HCFA) was established as a federal agency responsible for the administration of Medicare and Medicaid. This would be renamed to Centers for Medicare & Medicaid Services (CMS) in 2001.[126] By 1983, the diagnosis-related group (DRG) replaced pay for service reimbursements to hospitals for Medicare patients.[127]

President Bill Clinton attempted an overhaul of Medicare through his health care reform plan in 1993–1994 but was unable to get the legislation passed by Congress.[128]

In 2003, Congress passed the Medicare Prescription Drug, Improvement, and Modernization Act, which President George W. Bush signed into law on December 8, 2003.[129] Part of this legislation included filling gaps in prescription-drug coverage left by the Medicare Secondary Payer Act that was enacted in 1980. The 2003 bill strengthened the Workers' Compensation Medicare Set-Aside Program (WCMSA) that is monitored and administered by CMS.

On August 1, 2007, the US House of Representatives voted to reduce payments to Medicare Advantage providers in order to pay for expanded coverage of children's health under the SCHIP program. As of 2008, Medicare Advantage plans cost, on average, 13 percent more per person insured for like beneficiaries than direct payment plans.[130] Many health economists have concluded that payments to Medicare Advantage providers have been excessive.[131][132] The Senate, after heavy lobbying from the insurance industry, declined to agree to the cuts in Medicare Advantage proposed by the House. President Bush subsequently vetoed the SCHIP extension.[133]

Effects of the Patient Protection and Affordable Care Act
The Patient Protection and Affordable Care Act (PPACA) of 2010 made a number of changes to the Medicare program. Several provisions of the law were designed to reduce the cost of Medicare. The most substantial provisions slowed the growth rate of payments to hospitals and skilled nursing facilities under Part A of Medicare, through a variety of methods (e.g., percentage cuts, penalties for readmissions).

Congress also attempted to reduce payments to public Part C Medicare health plans by aligning the rules that establish Part C plans' capitated fees more closely with the FFS paid for comparable care to "similar beneficiaries" under Parts A and B of Medicare. Primarily these reductions involved much discretion on the part of CMS. Examples of what CMS did included effectively ending a Part C program Congress had previously initiated to increase the use of Part C in rural areas (the so-called Part C PFFS plan) and reducing over time a program that encouraged employers and unions to create their own Part C plans not available to the general Medicare beneficiary base (so-called Part C EGWP plans) by providing higher reimbursement. These two types of Part C plans had been identified by MedPAC as the programs that most negatively affected parity between the cost of Medicare beneficiaries on Parts A/B/C and the costs of beneficiaries not on Parts A/B/C. These efforts to reach parity have been more than successful. As of 2015, all beneficiaries on A/B/C cost 4% less per person than all beneficiaries not on A/B/C. But whether that is because the cost of the former decreased or the cost of the latter increased is not known.

PPACA also slightly reduced annual increases in payments to physicians and to hospitals that serve a disproportionate share of low-income patients. Along with other minor adjustments, these changes reduced Medicare's projected cost over the next decade by $455 billion.[134]

Additionally, the PPACA created the Independent Payment Advisory Board (IPAB), which was empowered to submit legislative proposals to reduce the cost of Medicare if the program's per-capita spending grows faster than per-capita GDP plus one percent. The IPAB was never formed and was formally repealed by the Balanced Budget Act of 2018.

The PPACA also made some changes to Medicare enrollees' benefits. By 2020, it "closed" the so-called "donut hole" between Part D plans' initial spend phase coverage limits and the catastrophic cap on out-of-pocket spending, reducing a Part D enrollee's' exposure to the cost of prescription drugs by an average of $2,000 a year.[135] That is, the template co-pay in the gap (which legally still exists) will be the same as the template co-pay in the initial spend phase, 25%. This lowered costs for about 5% of the people on Medicare. Limits were also placed on out-of-pocket costs for in-network care for public Part C health plan enrollees.[136] Most of these plans had such a limit but ACA formalized the annual out of pocket spend limit. Beneficiaries on traditional Medicare do not get such a limit but can effectively arrange for one through private insurance.

Meanwhile, Medicare Part B and D premiums were restructured in ways that reduced costs for most people while raising contributions from the wealthiest people with Medicare.[137] The law also expanded coverage of or eliminated co-pays for some preventive services.[138]

The PPACA instituted a number of measures to control Medicare fraud and abuse, such as longer oversight periods, provider screenings, stronger standards for certain providers, the creation of databases to share data between federal and state agencies, and stiffer penalties for violators. The law also created mechanisms, such as the Center for Medicare and Medicaid Innovation to fund experiments to identify new payment and delivery models that could conceivably be expanded to reduce the cost of health care while improving quality.[98]

Proposals for reforming Medicare
As legislators continue to seek new ways to control the cost of Medicare, a number of new proposals to reform Medicare have been introduced in recent years.

Premium support
Since the mid-1990s, there have been a number of proposals to change Medicare from a publicly run social insurance program with a defined benefit, for which there is no limit to the government's expenses, into a publicly run health plan program that offers "premium support" for enrollees.[139][140] The basic concept behind the proposals is that the government would make a defined contribution, that is a premium support, to the health plan of a Medicare enrollee's choice. Sponsors would compete to provide Medicare benefits and this competition would set the level of fixed contribution. Additionally, enrollees would be able to purchase greater coverage by paying more in addition to the fixed government contribution. Conversely, enrollees could choose lower cost coverage and keep the difference between their coverage costs and the fixed government contribution.[141][142] The goal of premium Medicare plans is for greater cost-effectiveness; if such a proposal worked as planned, the financial incentive would be greatest for Medicare plans that offer the best care at the lowest cost.[139][142]

This concept is basically how public Medicare Part C already works (but with a much more complicated competitive bidding process that drives up costs for the Trustees, but is advantageous to the beneficiaries). Given that only about 1% of people on Medicare got premium support when Aaron and Reischauer first wrote their proposal in 1995 and the percentage is now 35%, on the way to 50% by 2040 according to the Trustees, perhaps no further reform is needed.

There have been a number of criticisms of the premium support model. Some have raised concern about risk selection, where insurers find ways to avoid covering people expected to have high health care costs.[143] Premium support proposals, such as the 2011 plan proposed by Senator Ron Wyden and Rep. Paul Ryan (R–Wis.), have aimed to avoid risk selection by including protection language mandating that plans participating in such coverage must provide insurance to all beneficiaries and are not able to avoid covering higher risk beneficiaries.[144] Some critics are concerned that the Medicare population, which has particularly high rates of cognitive impairment and dementia, would have a hard time choosing between competing health plans.[145] Robert Moffit, a senior fellow of The Heritage Foundation responded to this concern, stating that while there may be research indicating that individuals have difficulty making the correct choice of health care plan, there is no evidence to show that government officials can make better choices.[141] Henry Aaron, one of the original proponents of premium supports, has since argued that the idea should not be implemented, given that Medicare Advantage plans have not successfully contained costs more effectively than traditional Medicare and because the political climate is hostile to the kinds of regulations that would be needed to make the idea workable.[140]

Currently, public Part C Medicare health plans avoid this issue with an indexed risk formula that provides lower per capita payments to sponsors for relatively (remember all these people are over 65 years old) healthy plan members and higher per capita payments for less healthy members.

Changing the age of eligibility
A number of different plans have been introduced that would raise the age of Medicare eligibility.[146][147][148][149] Some have argued that, as the population ages and the ratio of workers to retirees increases, programs for the elderly need to be reduced. Since the age at which Americans can retire with full Social Security benefits has risen from 65 to 67, it is argued that the age of eligibility for Medicare should rise with it (though people can begin receiving reduced Social Security benefits as early as age 62).

The CBO projected that raising the age of Medicare eligibility would save $113 billion over 10 years after accounting for the necessary expansion of Medicaid and state health insurance exchange subsidies under health care reform, which are needed to help those who could not afford insurance purchase it.[150] The Kaiser Family Foundation found that raising the age of eligibility would save the federal government $5.7 billion a year, while raising costs for other payers. According to Kaiser, raising the age would cost $3.7 billion to 65- and 66-year-olds, $2.8 billion to other consumers whose premiums would rise as insurance pools absorbed more risk, $4.5 billion to employers offering insurance, and $0.7 billion to states expanding their Medicaid rolls. Ultimately Kaiser found that the plan would raise total social costs by more than twice the savings to the federal government.[151]

During the 2020 presidential campaign, Joe Biden proposed lowering the age of Medicare eligibility to 60 years old.[152] A Kaiser Family Foundation study found that lowering the age to 60 could reduce costs for employer health plans by up to 15% if all eligible employees shifted to Medicare.[153]

Negotiating the prices of prescription drugs
Currently, people with Medicare can get prescription drug coverage through a public Medicare Part C plan or through the standalone Part D prescription drug plans (PDPs) program. Each plan sponsor establishes its own coverage policies and could, if desired, independently negotiate the prices it pays to drug manufacturers. But because each plan has a much smaller coverage pool than the entire Medicare program, many argue that this system of paying for prescription drugs undermines the government's bargaining power and artificially raises the cost of drug coverage. Conversely, negotiating for the sponsors is almost always done by one of three or four companies typically tied to pharmacy retailers each of whom alone has much more buying power than the entire Medicare program. That pharmacy-centric versus government-centric approach appears to have worked given that Part D has cost 50% or more under original projected spending and has held average annual drug spending by seniors in absolute dollars fairly constant for over 10 years.

Many look to the Veterans Health Administration (VHA) as a model of lower cost prescription drug coverage. Since the VHA provides healthcare directly, it maintains its own formulary and negotiates prices with manufacturers. Studies show that the VHA pays substantially less for drugs than the PDP plans Medicare Part D subsidizes.[154][155] One analysis found that adopting a formulary similar to the VHA's would save Medicare $14 billion a year.[156]

There are other proposals for savings on prescription drugs that do not require such fundamental changes to Medicare Part D's payment and coverage policies. Manufacturers who supply drugs to Medicaid are required to offer a 15 percent rebate on the average manufacturer's price. Low-income elderly individuals who qualify for both Medicare and Medicaid receive drug coverage through Medicare Part D, and no reimbursement is paid for the drugs the government purchases for them. Reinstating that rebate would yield savings of $112 billion, according to a recent CBO estimate.[157] Some have questioned the ability of the federal government to achieve greater savings than the largest PDPs, since some of the larger plans have coverage pools comparable to Medicare's, though the evidence from the VHA is promising. Some also worry that controlling the prices of prescription drugs would reduce incentives for manufacturers to invest in research and development, though the same could be said of anything that would reduce costs.[155] However, the comparisons with the VHA point out that the VHA covers about half the drugs as Part D.

Reforming care for the "dual-eligibles"
Roughly nine million Americans—mostly older adults with low incomes—are eligible for both Medicare and Medicaid. These men and women tend to have particularly poor health—more than half are being treated for five or more chronic conditions[158]—and high costs. Average annual per-capita spending for "dual-eligibles" is $20,000,[159] compared to $10,900 for the Medicare population as a whole.[93]

The dual-eligible population comprises roughly 20 percent of Medicare's enrollees but accounts for 36 percent of its costs.[160] There is substantial evidence that these individuals receive highly inefficient care because responsibility for their care is split between the Medicare and Medicaid programs[161]—most see a number of different providers without any kind of mechanism to coordinate their care, and they face high rates of potentially preventable hospitalizations.[162] Because Medicaid and Medicare cover different aspects of health care, both have a financial incentive to shunt patients into care the other program pays for.

Many experts have suggested that establishing mechanisms to coordinate care for the dual-eligibles could yield substantial savings in the Medicare program, mostly by reducing hospitalizations. Such programs would connect patients with primary care, create an individualized health plan, assist enrollees in receiving social and human services as well as medical care, reconcile medications prescribed by different doctors to ensure they do not undermine one another, and oversee behavior to improve health.[163] The general ethos of these proposals is to "treat the patient, not the condition,"[158] and maintain health while avoiding costly treatments.

There is some controversy over who exactly should take responsibility for coordinating the care of the dual-eligibles. There have been some proposals to transfer dual-eligibles into existing Medicaid managed care plans, which are controlled by individual states.[164] But many states facing severe budget shortfalls might have some incentive to stint on necessary care or otherwise shift costs to enrollees and their families to capture some Medicaid savings. Medicare has more experience managing the care of older adults, and is already expanding coordinated care programs under the ACA,[165] though there are some questions about private Medicare plans' capacity to manage care and achieve meaningful cost savings.[166]

Estimated savings from more effective coordinated care for the dual eligibles range from $125 billion[158] to over $200 billion,[167] mostly by eliminating unnecessary, expensive hospital admissions.

Income-relating Medicare premiums
Both House Republicans and President Obama proposed increasing the additional premiums paid by the wealthiest people with Medicare, compounding several reforms in the ACA that would increase the number of wealthier individuals paying higher, income-related Part B and Part D premiums. Such proposals were projected to save $20 billion over the course of a decade,[164] and would ultimately result in more than a quarter of Medicare enrollees paying between 35 and 90 percent of their Part B costs by 2035, rather than the typical 25 percent. If the brackets mandated for 2035 were implemented today,[when?] it would mean that anyone earning more than $47,000 (as an individual) or $94,000 (as a couple) would be affected. Under the Republican proposals, affected individuals would pay 40 percent of the total Part B and Part D premiums, which would be equivalent of $2,500.[168]

More limited income-relation of premiums only raises limited revenue. Currently, 5 percent of Medicare enrollees pay an income-related premium, and most pay 35 percent of their total costs (on average), compared to the 25 percent most people pay. Only a negligible number of enrollees fall into the higher income brackets required to bear a more substantial share of their costs—roughly half a percent of individuals and less than three percent of married couples currently pay more than 35 percent of their total Part B costs.[169]

There is some concern that tying premiums to income would weaken Medicare politically over the long run, since people tend to be more supportive of universal social programs than of means-tested ones.[170]

Medigap restrictions
Some Medicare supplemental insurance (or "Medigap") plans cover all of an enrollee's cost-sharing, insulating them from any out-of-pocket costs and guaranteeing financial security to individuals with significant health care needs. Many policymakers believe that such plans raise the cost of Medicare by creating a perverse incentive that leads patients to seek unnecessary, costly treatments. Many argue that unnecessary treatments are a major cause of rising costs and propose that people with Medicare should feel more of the cost of their care to create incentives to seek the most efficient alternatives. Various restrictions and surcharges on Medigap coverage have appeared in some deficit reduction proposals.[171][172][173] One of the furthest-reaching reforms proposed, which would prevent Medigap from covering any of the first $500 of coinsurance charges and limit it to covering 50 percent of all costs beyond that, could save $50 billion over 10 years.[174] But it would also increase health care costs substantially for people with costly health care needs.

There is some evidence that claims of Medigap's tendency to cause over-treatment may be exaggerated and that potential savings from restricting it might be smaller than expected.[175] Meanwhile, there are some concerns about the potential effects on enrollees. Individuals who face high charges with every episode of care have been shown to delay or forgo needed care, jeopardizing their health and possibly increasing their health care costs over time.[176] Given their lack of medical training, most patients tend to have difficulty distinguishing between necessary and unnecessary treatments. The problem could be exaggerated among the Medicare population, which has low levels of health literacy.[full citation needed]

Vision Coverage
The Build Back Better legislation was passed in Congress in November 2021, and adds hearing services subject to Medicare Part B deductible and 20% coinsurance beginning in 2023. The initial proposal of this bill also aimed to address gaps in Medicare such as dental and vision coverage, however both services were removed following objections in the Senate. A study performed by Urban Institute showed that Medicare enrollees spend more on routine vision services ($8.4 billion) than routine hearing services ($5.7 billion), of which $5.4 billion and $4.7 billion were spent out of pocket respectively.[177] In addition, nearly 1 in 3 Medicare beneficiaries used vision services annually, and averages a spending of $411 per person;[177] as such, the impact of expanding Medicare to include vision services would benefit many people. There is an income gradient seen in those who use vision services and a severe unmet needs for these services in those with lower incomes. Enrollees below the federal poverty level spent $190, whereas those 400% above the level spent $465;[177] and a likely trend that far fewer non-Hispanic Black and Hispanic beneficiaries use and spend on vision services—which is in keeping with the trend seen with hearing aids.[178][179]

Medicare for All
The Medicare for All Act would dramatically expand the Medicare program to cover all US residents with automatic enrollment upon birth or residency providing coverage for items and services that are medically necessary to maintain health or to diagnose, treat, or rehabilitate a health condition, including hospital services, prescription drugs, mental health and substance abuse treatment, dental and vision services, home- and community-based long-term care, gender affirming care, and reproductive care, including contraception and abortions. The bill was first introduced in the US House of Representatives by Representative John Conyers in 2003.[180] The act was most recently introduced in the US Senate by Senator Bernie Sanders on May 17th, 2023

Washington Apple Health includes Medicaid, CHIP, and state programs. Medicaid and CHIP are medical insurance programs administered by the state and funded by the federal government and the state. The state also funds some programs and services separately. To qualify for these, you must have low-income or special health needs, such as pregnancy or disability. Apple Health programs are run by the state’s Health Care Authority (HCA) and Department of Social and Health Services (DSHS), in partnership with the state’s Health Benefit Exchange (known as Washington Healthplanfinder). You can apply for these programs through Washington Healthplanfinder, but some programs may require additional screening by DSHS.

Medicare is a medical insurance program administered and funded by the federal government, not the state. This program is run through the federal Social Security Administration, which is also where you can apply. Some Medicare enrollees purchase supplemental insurance through the Washington State Health Insurance Pool.

Qualified Health Plans are commercial (private)  health insurance plans that meet health reform standards and offer federal subsidies to help with costs for those that meet income standards.  These plans are regulated by the Office of Insurance Commissioner and the Health Benefit Exchange. You can buy these plans through the Washington Healthplanfinder.

Commercial Insurance Plans are private health insurance plans for individuals or employers. These plans are regulated by the Office of Insurance Commissioner. You can buy these plans directly from insurance companies or insurance brokers.

Washington State Health Insurance Pool is a health insurance program for persons with significant medical needs or seeking coverage to supplement Medicare. This program is currently closed to new enrollees, except the Medicare supplement program.

Coverage for Adults
Washington Apple Health for Families, Pregnant Women, and Adults
Who Is Eligible?
New Coverage for Immigrants: Starting July 1, 2024, undocumented adult immigrants will be eligible to enroll in Apple Health Expansion, a Medicaid-like program for people below 138% of the Federal Poverty Level (in 2024: $1,732 for one person, $2,351 for two people). Enrollment will be limited due to funding. For more information, see Immigrant Access to Health Care in WA. For other health care options for immigrants, see below.

Apple Health for Adults: Adults aged 19-64 may qualify for Apple Health. To qualify, you cannot be on Medicare and you must have monthly household income under 138% of the FPL (in 2024: $1,732 for one person, $2,351 for two people). You must also meet other requirements to qualify, such as US citizenship or qualifying immigration status, and state residency. Enrollment in Apple Health for Adults is year-round—you can apply any time. For more information, see the Apple Health section in Health Care Coverage Options in Washington State. If you have a disability, visual impairment, or are age 65 or older, see Coverage for Those Who Are Over 65, or Have Long-Term Care Needs below.

Apple Health for Families: Medicaid benefits are available to parents and other relatives caring for children through Washington Apple Health for Families. To qualify, you must have monthly household income under $511/month for an individual or $658/month for a 2-person household (in 2024) or experienced a recent increase above that level due to earnings. Since a person whose income increases above that level would also qualify for Apple Health for Adults, this mainly benefits those whose income increases to a level above 138% of the FPL because as custodial parents and relatives, they can get an extension of Medicaid. You must also meet other requirements to be eligible, such as US citizenship or qualifying immigration status, and state residency. Adults and children who are not eligible may still qualify for the Apple Health programs below.

Apple Health for Pregnant Women: People who are pregnant or postpartum can get Medicaid through Apple Health for Pregnant Individuals and After Pregnancy Coverage. To qualify, you must have monthly household income under 198% of the FPL (in 2024: $3,373 for two people, $4,260 for three people). In November 2024, the FPL amount will increase to 210%. Note that a pregnant person's household size is increased by the number of unborn children. You do not need to be a citizen or have a qualifying immigration status to be eligible, but you must be a Washington state resident. You can get After Pregnancy Coverage for up to a year after your pregnancy ends, even if you did not previously have coverage during your pregnancy. Pregnancy and After Pregnancy coverage are available even if your pregnancy ends in miscarriage or abortion.

Coverage for Immigrants: Alien Emergency Medical (AEM) offers limited coverage for other immigrants who have an emergency medical condition. These programs are available for emergency hospital care, cancer treatment, kidney dialysis, COVID care, and nursing facility care. For more information, see Immigrant Access to Health Care In WA.

What Is Covered?
Enrollees in Apple Health for Adults receive full-scope coverage with a broad range of services; for a list, see those under the "ABP" category.

Enrollees are not required to pay cost sharing, co-payments, or deductibles for any service.

Enrollees are usually required to be in a managed care plan called Apple Health Managed Care. This means you must have a primary provider who is the gatekeeper to other medical providers, and the plan determines which providers will be covered under their plan. There are exemptions from Apple Health Managed Care for certain reasons, such as the need to continue with a treating provider, status as an American Indian/Alaska Native, living in a county where managed care participation is voluntary, or being a Medicare enrollee.

Coverage may be retroactive, up to 3 months before the month you apply. You can use this form to request retroactive coverage.

Other Things to Know
Pregnant teens under age 19 can apply on their own without their parents. They must use a paper application to apply, available from the Health Care Authority.

There are no time limits, work requirements or limits on resources you can own.

You can apply for Apple Health coverage year-round or renew your coverage through Washington Healthplanfinder. You can also apply or renew with in-person assistance with applying or renewing. Find a navigator in your community.

If your family income changes over the year, you may apply based on an average of that income.

Family Planning Coverage:

The Washington State Health Care Authority offers Family Planning Only for individuals not eligible for full Apple Health coverage, individuals age 18 or younger, and others who need confidential services. The income limit is 265% of the FPL ($3,326/month for an individual in 2024) and there is no resource limit. This program is available regardless of immigration status. Individuals can apply through family planning providers or on their own. If you're a teen, you may be eligible for Apple Health coverage on your own. More information is available by calling Washington Healthplanfinder at 1-855-923-4633.

Qualified Health Plans and Other Individual Insurance
Adults and children can buy private health insurance known as Qualified Health Plans (QHPs) if they are US citizens or have a qualifying immigration status, are state residents, and are not in jail/prison.

Adults and children can get subsidies to help with the costs of buying a QHP if they meet other requirements, including: having household income under 400% of the Federal Poverty Level (some exceptions); not qualifying for public programs like Apple Health (Medicaid and CHIP) and Medicare (some exceptions); not having an affordable offer of coverage through an employer; and filing taxes (jointly if married).

You can enroll in QHP coverage only if you apply during open enrollment, unless you have a life event that qualifies you for a Special Enrollment Period.

You can shop and apply for coverage at Washington Healthplanfinder. Other individual health insurance plans are available outside the QHP marketplace at full price. Learn more about individual health insurance options.

Coverage for Children
Washington Apple Health for Children (Apple Health for Kids)
Who Is Eligible?
Newborns are automatically eligible when born to a parent who received Apple Health at the time of the child's birth. The eligibility will last for 12 months.

Children under age 19 may be eligible if their family’s monthly income is less than 317% of the FPL (in 2024: $3,978 for one person, $5,400 for two people). Children under age 6 remain eligible regardless of changes in income. To be eligible above 215% of FPL, children must not be covered by other insurance, and families must pay a monthly premium to HCA (between $20-30 per child). You do not need to provide a citizenship or immigrant status to be eligible, but you must be a Washington State resident.

What Is Covered?
Enrollees receive Categorically Needy (CN) coverage, which is comprehensive. The general categories of CN service are listed in WAC 182-501-0060(6); all medically necessary services are covered.

Enrollees are not required to pay cost-sharing, co-payments or deductibles for any service.

Enrollees are usually required to be in a managed care plan called Apple Health Managed Care. This means you must have a primary provider who is the gatekeeper to other medical providers, and the plan determines which providers will be covered under their plan. There are exemptions from Apple Health Managed Care for certain reasons, such as the need to continue with a treating provider, status as an American Indian/Alaska Native, living in a county where managed care participation is voluntary, or being a Medicare enrollee).

Coverage may be retroactive, up to 3 months before you apply. You can use this form to request retroactive coverage.

Other Things to Know
There are no time limits, work requirements, or limits on assets you can own.

Apply for coverage and renew coverage through Washington Healthplanfinder.

If your family income changes over the year, you may apply based on an average of that income.

Qualified Health Plans and Other Individual Insurance
Children and adults can buy Qualified Health Plans if they are state residents, and are not in jail/prison.

Children and adults can get subsidies to help with the costs of buying a Qualified Health Plan if they meet other requirements, including: having household income below 400% of the Federal Poverty Level with some exceptions; not qualifying for public programs like Apple Health (Medicaid and CHIP) or Medicare with some exceptions; and not having an affordable offer of coverage through a parent's employer.

You can shop and apply for coverage at Washington Healthplanfinder. Other individual health insurance plans are available outside the QHP marketplace at full price. Learn more about individual health insurance options.

Coverage for Those Who Are Over 65, Have Disabilities, or Long-Term Care Needs
Medicare for Aged or Disabled
Who Is Eligible?
Coverage begins at age 65, or two years after an individual becomes eligible for Social Security Disability Insurance (SSDI) benefits.

There are no financial eligibility requirements.

What Is Covered?
Hospital Insurance—Part A: Covers some of the cost of hospital and related care, home health care, hospice care and care in a skilled nursing facility following a hospital stay.

Medical Insurance—Part B: Covers some of the cost of physician visits, outpatient hospital services, and other services. Preventive care is provided without cost-sharing. In addition, Medicare requires recipients to pay premiums, deductibles, and co-payments. These premiums may be deducted from the recipient’s monthly Social Security check. For those who qualify, Medicaid will cover these premiums and many of the costs not paid by Medicare. See Medicare Savings Programs for Low-Income Medicare Enrollees below.

Prescription Drugs–Part D: Provides some coverage for prescription drugs. Enrollees must select a Prescription Drug Plan available in the region; each plan has its own drug formulary. “Dual eligibles” and others with limited income qualify for extra help—a Part D subsidy from the federal government.

Other Things to Know
Apply for coverage and learn more through the federal Medicare website.

Additional information is available at the Medicare Interactive website.

Medicare Savings Programs for Low-Income Medicare Enrollees
These Washington Apple Health (Medicaid) programs pay Medicare premiums and cost-sharing for very low-income individuals.

Who Is Eligible and What Is Covered?

Qualified Medicare Beneficiary (QMB) is for those with income at or below 110% of the Federal Poverty Level (in 2024: $1,401 + $20 disregard for one person, $1,894+ $20 disregard for two people). The program pays their Medicare deductibles, co-payments, coinsurance, Parts A and B premiums (or with Medicare Part C, the premiums for Part A and B). They also qualify for Medicare Part D without a premium and lower prescription drug co-payments. There is no  longer a resource limit to determine eligibility.

Special Low-Income Medicare Beneficiary (SLMB) is for those with income between 110% and 120% of the Federal Poverty Level (in 2024, $1,526 + $20 disregard for one person, $2,064 + $20 disregard for two people). The program pays their Part B Premiums. They also qualify for Medicare Part D without a premium and lower prescription drug co-payments. There is no longer a resource limit to determine eligibility.

Expanded Special Low-Income Medicare Beneficiary (ESLMB, or "QI-1") is for those with income between 120% and 138% FPL (in 2024, $1,752 + $20 disregard for one person, $2,371 + $20 disregard for two people). The program pays their Medicare Part B premiums (subject to an annual agency funding limit). These individuals also qualify for Medicare Part D without a premium and lower prescription drug co-payments. There is no longer a resource limit to determine eligibility.

Qualified Disabled Working Individuals (QDWI)  is for individuals under age 65 with income between 135% and 200% FPL (in 2024, $2,530 + $20 disregard for one person, $3,427 + $20 disregard for two people).  The program pays their Medicare Part A premiums. There is no longer a resource limit to determine eligibility.

Other Things to Know

Apply for coverage by filling out a Supplemental Application through DSHS, online at Washington Connection or at a Community Services Office.

SSI-Related Categorically Needy Apple Health
Who Is Eligible?
People who are considered disabled (according to Social Security's definition), blind, or are age 65 or older and have limited income and resources.

Some people with income over the SSI limit (such as disabled widows/widowers) also qualify.

Immigration status requirements apply.

What Is Covered?
Enrollees receive Categorically Needy (CN) coverage. The general categories of CN service are listed in WAC 182-501-0060(6).

Coverage goes back to the date of application, once it is approved. Retroactive coverage is available if disability is established.

There are no co-payments or deductibles for this program.

Some people on SSI-related Medicaid also receive Medicare coverage. For these "dual eligibles," most prescription drugs are available only through Medicare Part D, and they are required to pay small co-payments.

Other Things to Know
Alternate coverage: Apple Health for Adults is also available for individuals in this income range who are under age 65 and not on Medicare, without the need to meet disability or other SSI-related requirements.

Apply for coverage through Washington Healthplanfinder. If you state you have a disability on the application, you will be asked to fill out a Supplemental Application through DSHS. If eligible, you will receive Apple Health for Adults pending the DSHS determination.

Medically Needy Washington Apple Health for People Not on SSI, But Aged or Disabled
Who Is eligible?
People who have income over the "Medically Needy Income Level" and are age 65 or older, or are considered blind or disabled (according to Social Security’s definition).

Resource limits apply.

Immigration status requirements apply.

What Is Covered?
Enrollees receive Medically Needy (MN) coverage. The general categories of MN service are listed in the chart at WAC 182-501-0060(6).

The state does not provide coverage until you incur a specified level of medical costs, called a “spenddown” amount. The spenddown amount is based on income. It is the amount by which countable income exceeds a certain income level (in 2024, $943 + a $20 disregard for one person, called the Medically Needy Income Level or MNIL). You can learn more about the Medically Needy "Spenddown Program.

Those who are also on Medicare (“dual eligibles”) receive most prescription drugs through Medicare Part D and are required to pay co-payments that vary according to income.

Other Things to Know
Apply for coverage through Washington Healthplanfinder. If you state you have a disability on the application, you will be asked to fill out a Supplemental Application through DSHS.

Alternate coverage: Apple Health for Adults may also be available without the need to meet disability or other SSI-related requirements for adults under age 65 and not on Medicare, with income below 138% FPL. Qualified Health Plan coverage with subsidies is an option for some adults above 138% FPL not on Medicare. In some cases, this may cost less than Medically Needy coverage.

Other Programs for People with Disabilities
Medical Care Services for Immigrants Who Are Over Age 65 or Incapacitated
Who Is Eligible?
People whom the state does not expect to qualify for Medicaid, but who meet the incapacity or age standards of the Housing and Essential Needs (HEN) or Aged Blind Disabled (ABD) program, can get Medical Care Services (MCS) coverage through the Department of Social and Health Services.

To qualify, you must receive HEN or ABD and be ineligible for an adult Medicaid program, because you are either over age 65 or you do not meet federal immigration requirements for Medicaid. There are some restrictions on which immigration statuses are included. Income and resource standards apply.

What Is Covered?
MCS covers a more limited range of services than Categorically Needy Medicaid. For example, it does not cover hospice care or personal care services. See the chart at WAC 182-501-0060(6), listing MCS covered service categories.

Retroactive coverage is not available.

Other Things to Know
You can learn more about ABD/HEN or apply for coverage at a DSHS Community Services Office. You will also be screened for Medicaid and MCS when you apply for these programs.

Washington Healthplanfinder does not yet screen for MCS eligibility, but if it identifies you as potentially eligible, you may receive a letter about how to apply through DSHS.

Health Care for Workers with Disabilities
Who Is Eligible?
Washington state residents who meet federal disability requirements and are employed on a full-time or part-time basis, including self-employed persons can be eligible for the Apple Health for Workers with Disabilities (HWD) Program. Immigration status and other general requirements apply. There is no income limit or upper age limit and no resource limit.

What Is Covered?
Enrollees receive Categorically Needy coverage (CN). The general categories of CN service are listed in the chart at WAC 182-501-0060(6); all medically necessary services are covered.

Enrollees must pay a monthly premium based on their income for the insurance coverage provided by HWD. The maximum premium is 7.5% of counted earned plus unearned income but may be less.

Other Things to Know
Apply for coverage by phone or online. By phone: call 1 (800) 871-9275 to leave a message with designated staff who complete HWD applications. They will contact you directly and check their direct message line daily or you can apply online through Washington Connection.

For more information, see the Health Care Authority’s HWD brochure and eligibility manual.

HWD enrollees can keep savings from their earnings without the risk of losing health coverage if they must switch later to a different Medicaid program with resource limits. These savings must be designated by the enrollee and placed into an account that has no other funds in it. Switching to a different Medicaid program may be necessary if the worker stops meeting the work or any other requirement for the HWD program.

Enrollees are approved for HWD for a 12-month period, effective the first month the enrollee applies and meets the program requirements. If you experience job loss within the 12-month period, you may keep your coverage under HWD if the job loss was the result of an involuntary dismissal or health crisis and you continue to pay your monthly premium.

Retroactive coverage is available for up to 3 months before you apply for the program as long as you met the eligibility requirements during that time. If eligible, you will need to pay premiums for the retroactive coverage.

An individual enrolled in HWD may also receive long term services and supports from the Developmental Disabilities Administration (DDA) or the Aging and Long Term Support Administration  (ALTSA) when the person meets the functional requirements for those programs, is approved for those services, and chooses to enroll in HWD.

#moultonlaw.com

Spokane Estate & Probate Lawyers / Blog / Medicaid Planning / Understanding Medicaid & Trust Eligibility in Washington
Understanding Medicaid & Trust Eligibility in Washington
medicaid trust eligibility
Learn about Medicaid and trust eligibility in Washington State to help secure your future. Our easy-to-understand guide makes navigating these complex topics a breeze for seniors. We will discuss how to qualify for Medicaid, how income and assets affect eligibility, the differences between a trust and a will, and much more. With this knowledge in hand, you can ensure your wishes are followed and that your retirement years are secure and comfortable.

Additionally, we will provide information about resources such as community-based organizations and government programs to help you access additional services and secure the safety net you need. Whether you’re just starting to think about planning for your future or are already an expert, this guide will provide you with the information you need to make sound decisions in Washington State.

An Intro to Using Medicaid for Trust Planning
As you approach your golden years, understanding your financial options is crucial for securing your future. For many seniors, Medicaid and trust eligibility are essential components of long-term care and estate planning. This simple guide will explore how Medicaid and trust eligibility work in Washington State. We hope these easy-to-follow explanations will empower you to make well-informed decisions about your healthcare and financial future.

As you can see from the following image from the Washington HCA website, navigating the complex maze of Medicaid Eligibility in Washington State may not be as straightforward as you’d hoped. Many conditions exist to ensure those who should be paying for their own needs do, and these rules can surprise folks. In this guide, we’ll explain what qualifies you for Medicaid and Trust Eligibility, how to estimate your financial needs, and how taxes can play a role in beneficiary distributions.

Spokane Estate & Probate Lawyers / Blog / Medicaid Planning / Understanding Medicaid & Trust Eligibility in Washington
Understanding Medicaid & Trust Eligibility in Washington
medicaid trust eligibility
Learn about Medicaid and trust eligibility in Washington State to help secure your future. Our easy-to-understand guide makes navigating these complex topics a breeze for seniors. We will discuss how to qualify for Medicaid, how income and assets affect eligibility, the differences between a trust and a will, and much more. With this knowledge in hand, you can ensure your wishes are followed and that your retirement years are secure and comfortable.

Additionally, we will provide information about resources such as community-based organizations and government programs to help you access additional services and secure the safety net you need. Whether you’re just starting to think about planning for your future or are already an expert, this guide will provide you with the information you need to make sound decisions in Washington State.

An Intro to Using Medicaid for Trust Planning
As you approach your golden years, understanding your financial options is crucial for securing your future. For many seniors, Medicaid and trust eligibility are essential components of long-term care and estate planning. This simple guide will explore how Medicaid and trust eligibility work in Washington State. We hope these easy-to-follow explanations will empower you to make well-informed decisions about your healthcare and financial future.

As you can see from the following image from the Washington HCA website, navigating the complex maze of Medicaid Eligibility in Washington State may not be as straightforward as you’d hoped. Many conditions exist to ensure those who should be paying for their own needs do, and these rules can surprise folks. In this guide, we’ll explain what qualifies you for Medicaid and Trust Eligibility, how to estimate your financial needs, and how taxes can play a role in beneficiary distributions.



Medicaid in Washington State
Washington State’s Medicaid program, known as Washington Apple Health, provides healthcare coverage to eligible low-income residents, including seniors. Medicaid can help cover long-term care costs like nursing homes or in-home care services. However, understanding the eligibility criteria for Medicaid is vital to ensure you receive the support you need.

Income and Asset Limits
You must meet specific income and asset requirements to qualify for Medicaid in Washington State. The income limit for seniors 65 and older is 100% of the Federal Poverty Level (FPL). The asset limit is $2,000 for an individual applicant and $3,000 for a couple applying together.

Exempt Assets
Certain assets are exempt from the asset limit calculation, meaning they won’t affect your Medicaid eligibility.

These include:

Your primary residence
One vehicle
Personal belongings
Household items
Burial plots
A small amount of life insurance
The Five-Year Look-Back Period
When you apply for Medicaid, the state will look back at your financial transactions from the past five years to ensure you haven’t transferred assets to qualify for the program. If you have made such transfers, you may face a penalty period during which you will be ineligible for Medicaid coverage. The five-year look-back period is a critical aspect of determining Medicaid eligibility, as it aims to prevent applicants from transferring assets to qualify for the program artificially. In this section, we will explain the five-year look-back period in Washington State in more detail.

Suppose the Health Care Authority finds that you have transferred assets for less than the fair market value during the five-year look-back period. In that case, you may be subject to a penalty period. The penalty period is a length of time during which you will not receive Medicaid benefits, even if you meet all other eligibility criteria. The length of the penalty period is determined by dividing the total value of the transferred assets by the average monthly cost of nursing home care in Washington State.

Trusts and Medicaid Eligibility
A trust is a legal arrangement that allows a third party (the trustee) to hold and manage assets on behalf of the trust’s beneficiaries. Trusts can play a crucial role in protecting your assets and ensuring Medicaid eligibility.

Irrevocable Trusts
When structured correctly, an irrevocable trust can help you qualify for Medicaid while preserving your assets for your beneficiaries. An irrevocable trust cannot be modified or revoked after its creation, meaning that the assets in the trust are no longer considered part of your estate. However, working with an experienced attorney is essential to ensure your trust complies with Washington State’s Medicaid rules.

Revocable Trusts
A revocable trust, also known as a living trust, can be altered or revoked during your lifetime. While revocable trusts are helpful for estate planning purposes, they typically do not protect your assets from being counted towards the Medicaid asset limit.

Special Needs Trusts
If you have a disabled child or other family members who rely on government benefits. In that case, a special needs trust can ensure they maintain eligibility for these benefits while still receiving financial support from your estate.

Estate Recovery
Washington State’s Medicaid Estate Recovery Program seeks reimbursement for the cost of long-term care services provided by the program. Upon your death, the state may attempt to recover these costs from your estate.

Protecting Your Home
One of the primary concerns for Medicaid recipients is the potential loss of their home to estate recovery. However, several exemptions and strategies can help protect your home from estate recovery:

Surviving Spouse or Registered Domestic Partner: If you have a surviving spouse or registered domestic partner, the state will not pursue estate recovery until their death.
Minor or Disabled Child: Estate recovery is also postponed if you have a minor or disabled child living in the home.
Caretaker Relative: If a relative has lived in your home for at least two years and provided care that prevented your admission to a nursing home, they may be eligible for an exemption.
Hardship Waiver: Your heirs can apply for a hardship waiver, which may exempt your property from estate recovery if they can prove that the property loss would cause undue hardship.
Life Estate Deed
Another strategy to protect your home is to create a life estate deed. A life estate deed allows you to retain the right to live in your home for the rest of your life while transferring ownership to a designated beneficiary. This can help avoid probate and reduce the risk of estate recovery. However, it’s crucial to consult with an experienced attorney before pursuing this option, as it may have implications for Medicaid eligibility during the five-year look-back period.

Understanding Medicaid and trust eligibility in Washington State is crucial for seniors looking to secure their future and protect their assets. By familiarizing yourself with income and asset limits, the different types of trusts, and estate recovery rules, you’ll be better prepared to navigate the complex world of long-term care and estate planning. Working with an experienced elder law attorney can ensure you make the best decisions for your unique situation.

#snapscreener.com

Apr. 1, 2025 - Mar. 31, 2026
Medicaid Eligibility in Washington
Medicaid is a government-run health insurance program that provides health insurance to lower-income Americans. Over 75 million adults and children are enrolled in Medicaid. This page has eligibility information for the most common Apple Health (Medicaid) eligibility pathways for children and adults up to 65 who do not have a disability (in other words, for someone generally not Medicare eligible).

If a household's income is too high to receive Medicaid, CHIP (the Children's Health Insurance Program) also offers health insurance options for children and has a higher income limit.

Eligibility for Medicaid requires meeting an income limit that is based on your household size. There is no asset test. For comparing your income to the tables below, use the combined income from all household members from jobs and other sources, except for child support, Supplemental Security Income, and children's non-taxable income (like disability payments). Read more about how income is counted.

Even if you're not eligible for Medicaid, you could get a significant discount (sometimes up to 90%) off of your monthly health insurance premium payments on plans purchased through healthcare.gov. The amount of the premium discount is based on your income. Read more about the premium tax credit.

Please note: there are more Medicaid pathways available that are not listed on this page. For example if you are 65 years or older, have a disability, or have other specific health conditions, you may be eligible for additional Medicaid pathways that have other income and/or asset based eligibility criteria.

This information was collected from medicaid.gov and state Medicaid/CHIP resources but is not official. This website is not affiliated with any government organization or health program.
Medicaid Pathways Overview
Medicaid eligibility is based on your income relative to the Federal Poverty Level (FPL), which adjusts with household size. To qualify, your income must fall below the specified limit as percentage of the FPL.

In Washington, the income limit for most adults (ages 19-64) to qualify for Apple Health (Medicaid) is at or below 138% of the Federal Poverty Level (FPL). For a
single individual, this translates to approximately $1,800 monthly or $21,597 annually. For a family of four, the income limit is about $3,065 monthly or $44,367 annually
.

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Seattle, King County, 98104
Medical 206-788-3700 Dental 206-788-3757 Vision: 206-788-3505
SERVICES OFFERED
Alternative Medicine, Dental, Drug Dependency/Detox, Medical, Mental/Behavioral , Resource/Referral, Vision
 ICHS- Holly Park Medical and Dental Clinic
3815 S Othello Street
Seattle, King County, 98118
206-788-3500 Dental: 206-788-3502 Pharmacy: 206-788-3563 After Hours: 206-584-2586
SERVICES OFFERED
Dental, Drug Dependency/Detox, Medical, Mental/Behavioral , Resource/Referral
ICHS- Shoreline Medical and Dental Clinic
16549 Aurora Avenue N
Shoreline, King County, 98133
Medical 206-533-2600 Dental 206-533-2660 Pharmacy: 206-533-2720
SERVICES OFFERED
Dental, Drug Dependency/Detox, Medical, Resource/Referral

MAPS-MCRC Community Health Clinic
16255 NE 87th Street, Ste 140
Redmond, King County, 98052
888-404-6272  or 425-947-7146
SERVICES OFFERED
Homelessness Services, Medical, Mental/Behavioral , Resource/Referral
Pierce:
Puyallup Tribal Health Authority
2209 East 32nd
Tacoma, Pierce County, 98404
253-593-0232
SERVICES OFFERED
Dental, Drug Dependency/Detox, Medical, Mental/Behavioral , Resource/Referral

Sea Mar CHC: Tacoma Treatment Center
1415 Center St
Tacoma, Pierce County, 98409
253-280-9860
SERVICES OFFERED
Drug Dependency/Detox, Homelessness Services, Mental/Behavioral

End of Life Washington: Statewide
9311 SE 36th St, Suite 110
Mercer Island, Pierce County, 98040
206-256-1636
SERVICES OFFERED
Medical, Mental/Behavioral , Resource/Referral

Consejo Counseling & Referral Service - Graham
21120 Meridian Ave E
Graham, Pierce County, 98338
253-285-4750
SERVICES OFFERED
Drug Dependency/Detox, Mental/Behavioral , Resource/Referral
Care Net of Puget Sound: Lakewood
10828 Gravelly Lake Dr SW, Suite #101
Lakewood, Pierce County, 98499
253-984-6222
SERVICES OFFERED
Medical
Care Net of Puget Sound: Puyallup
10215 125th St Ct E
Puyallup, Pierce County, 98374
253-770-8697
SERVICES OFFERED
Medical
Care Net of Puget Sound: Gig Harbor
2727 Hollycroft Street, Suite 130
Gig Harbor, Pierce County, 98335
253-858-5585
SERVICES OFFERED
Medical

Sea Mar CHC: Tacoma Chemical Dependency Parenting In Recovery
7424 Bridgeport Way N #305
Lakewood, Pierce County, 98499
253-246-6820
SERVICES OFFERED
Drug Dependency/Detox, Resource/Referral

Sea Mar CHC: Tillicum Community Center
14916 Washington Ave SW
Lakewood, Pierce County, 98498
253-280-9890
SERVICES OFFERED
Medical, Resource/Referral

Sea Mar CHC: Puyallup Medical
10217 125th Street Ct E
Puyallup, Pierce County, 98374
253-864-4550
SERVICES OFFERED
Medical, Resource/Referral





Snohomish:
Cascade Valley Hospital
330 S. Stillaguamish
Arlington, Snohomish County, 98223
360-435-2133
SERVICES OFFERED
Medical, Mental/Behavioral , Physical/Occupational Therapy, Resource/Referral
CHC of Snohomish County: Arlington Medical and Dental Clinic
326 S. Stillaguamish Avenue
Arlington, Snohomish County, 98223
425-789-3789
SERVICES OFFERED
Dental, Medical, Mental/Behavioral , Resource/Referral
CHC of Snohomish County Everett: South Medical and Dental Clinic
1019 112th Street SW
Everett, Snohomish County, 98204
425-789-3789
SERVICES OFFERED
Dental, Medical, Physical/Occupational Therapy, Resource/Referral
Evergreen Health Monroe
14701 179th Avenue SE
Monroe, Snohomish County, 98272
360-794-7497
SERVICES OFFERED
Drug Dependency/Detox, Medical, Physical/Occupational Therapy, Resource/Referral
Lahai Health: Lynnwood @ Community Life Center
19820 Scriber Lake Road, 2nd Floor
Lynnwood, Snohomish County, 98036
206-899-4765
SERVICES OFFERED
Dental
Safe Harbor Free Clinic: Stanwood
7209 265th Suite 203
Stanwood, Snohomish County, 98292
425-870-7384
SERVICES OFFERED
Medical












Spokane county:
CHAS: Denny Murphy Clinic
1001 W. 2nd Avenue
Spokane, Spokane County, 99201
509-444-8200
SERVICES OFFERED
Dental, Homelessness Services, Medical, Mental/Behavioral , Resource/Referral
CHAS: Maple Street Clinic
3919 N. Maple Street
Spokane, Spokane County, 99205
509-444-8200 
SERVICES OFFERED
Dental, Drug Dependency/Detox, Medical, Mental/Behavioral
CHAS: North Central Medical Clinic
914 W. Carlisle Avenue
Spokane, Spokane County, 99205
509-444-8200
SERVICES OFFERED
Alternative Medicine, Drug Dependency/Detox, Medical, Mental/Behavioral
CHAS: North County Clinic
401 S. Main Street
Deer Park, Spokane County, 99006
509-444-8200
SERVICES OFFERED
Alternative Medicine, Dental, Drug Dependency/Detox, Medical, Mental/Behavioral
House of Charity
32 West 2nd Avenue (Medical Clinic)
Spokane, Spokane County, 99201
509-624-7821
SERVICES OFFERED
Drug Dependency/Detox, Homelessness Services, Medical, Mental/Behavioral , Resource/Referral
The Native Project
1803 W Maxwell Avenue
Spokane, Spokane County, 99201
Medical: 509-483-7535 Behavioral: 509-325-5502 Pharmacy: 509-483-4797
SERVICES OFFERED
Dental, Medical, Mental/Behavioral , Resource/Referral
Union Gospel Mission Inland Northwest
1224 E Trent Avenue
Spokane, Spokane County, 99220
509-535-8510
SERVICES OFFERED
Drug Dependency/Detox, Homelessness Services, Medical, Resource/Referral, Vision
Yakima Valley Farm Workers Clinic: Unify Community Health Northeast
4001 N. Cook Street
Spokane, Spokane County, 99207
Medical 509-326-4343 Dental 509-326-4382 Pharmacy 509-482-4069
SERVICES OFFERED
Dental, Medical, Mental/Behavioral , Resource/Referral, Vision
Compassionate Addiction Treatment
168 S Division Street
Spokane, Spokane County, 99202
509-919-3362
SERVICES OFFERED
Drug Dependency/Detox, Homelessness Services, Resource/Referral
Whitworth Graduate Health Sciences Teaching Clinic
300 W. Hawthorne Road
Spokane, Spokane County, 99251
509-777-3433
SERVICES OFFERED
Physical/Occupational Therapy







Jerfferson county:
Olympic Peninsula Community Clinic
819 E Georgiana Street
Port Angeles, Clallam, Jefferson County, 98362
360-457-4431
SERVICES OFFERED
Dental, Homelessness Services, Medical, Mental/Behavioral , Resource/Referral
Bayside - Port Hadlock
175 Chimacum Road
Port Hadlock, Jefferson County, 98339
360-385-4268
SERVICES OFFERED
Alternative Medicine, Drug Dependency/Detox, Medical, Mental/Behavioral , Physical/Occupational Therapy, Resource/Referral
Jefferson Healthcare: Medical Clinic
834 Sheridan Street
Port Townsend, Jefferson County, 98368
360-385-2200
SERVICES OFFERED
Medical, Mental/Behavioral , Physical/Occupational Therapy
End of Life Washington: Statewide
9311 SE 36th St, Suite 110
Mercer Island, Jefferson County, 98040
206-256-1636
SERVICES OFFERED
Medical, Mental/Behavioral , Resource/Referral
Access to Baby & Child Dentistry
Jefferson County
SERVICES OFFERED
Resource/Referral

Whiteman county:
Whitman Hospital and Medical Clinics
1200 W. Fairview Street
Colfax, Whitman County, 99111
509-397-3435
SERVICES OFFERED
Medical, Mental/Behavioral , Physical/Occupational Therapy, Resource/Referral, Vision
End of Life Washington: Statewide
9311 SE 36th St, Suite 110
Mercer Island, Whitman County, 98040
206-256-1636
SERVICES OFFERED
Medical, Mental/Behavioral , Resource/Referral
Pullman Regional Hospital: Palouse Health Center
305 E. Main St, Suite 102
Palouse, Whitman County, 99161
509-878-1890
SERVICES OFFERED
Hearing, Medical, Physical/Occupational Therapy
Dentistlink
Whitman County
844-888-5465
SERVICES OFFERED
Resource/Referral

Planned Parenthood: Pullman Health Center
1525 SE King Drive
Pullman, Whitman County, 99163
866-904-7721
SERVICES OFFERED
Medical, Resource/Referral
Adams county:
Adams County Health Department - Othello
425 E Main Street, Suite 700
Othello, Adams County, 99344
509-488-2031
SERVICES OFFERED
Drug Dependency/Detox, Medical, Mental/Behavioral , Resource/Referral
Adams County Health Department - Ritzville
108 W Main
Ritzville, Adams County, 99169
509-659-3315
SERVICES OFFERED
Drug Dependency/Detox, Medical, Mental/Behavioral , Resource/Referral
CBHA: Connell Clinic
1051 S Columbia Avenue
Connell, Adams County, 99326
509-234-0866
SERVICES OFFERED
Dental, Hearing, Medical, Mental/Behavioral , Vision, Resource/Referral
Dentistlink
Adams County
844-888-5465
SERVICES OFFERED
Resource/Referral
CBHA: Othello 14th Avenue Clinic
475 N 14th Avenue
Othello, Adams County, 99344
509-488-5256
SERVICES OFFERED
Mental/Behavioral , Resource/Referral
Asotin county:
Snake Rive Community Clinic
215 10th Street
Lewiston, Asotin County, 83501


SERVICES OFFERED
Dental, Medical, Resource/Referral, Vision
CHAS: Lewis and Clark Health Center
1203 Idaho Street
Lewiston, ID, Asotin County, 83501
208-848-8300 Pharmacy 208-848-8290
SERVICES OFFERED
Medical, Mental/Behavioral , Resource/Referral
CHAS Health: Lewis and Clark Dental Clinic
844 6th Street
Clarkston, Asotin County, 99403
208-848-8300
SERVICES OFFERED
Dental
Dentistlink
Asotin County
844-888-5465
SERVICES OFFERED
Resource/Referral
Access to Baby & Child Dentistry (ABCD)
Asotin County
509-843-3412
SERVICES OFFERED
Resource/Referral

Clallam county:
3Lower Elwha Health and Dental Clinic
243511 HWY 101 W
Port Angeles, Clallam County, 98363
360-452-6252
SERVICES OFFERED
Alternative Medicine, Dental, Drug Dependency/Detox, Medical, Mental/Behavioral , Resource/Referral
Forks Community Hospital: Bogachiel Medical Clinic
390 Founders Way
Forks, Clallam County, 98331
360-374-6998
SERVICES OFFERED
Medical, Mental/Behavioral , Resource/Referral

Jamestown Family Health Clinic
808 North 5th Avenue
Sequim, Clallam County, 98382
360-683-5900
SERVICES OFFERED
Medical, Mental/Behavioral , Physical/Occupational Therapy, Resource/Referral
Olympic Medical Center Hospital (and associated clinics)
939 Caroline Street
Port Angeles, Clallam County, 98362
Hospital: 360-417-7000 OMP Clinics: 360-565-0999
SERVICES OFFERED
Medical, Mental/Behavioral , Physical/Occupational Therapy, Resource/Referral
Serenity House
2203 W 18th Street
Port Angeles, Clallam County, Port Angeles
360-452-7224
SERVICES OFFERED
Homelessness Services
Douglas county:
Dentistlink
Douglas County
844-888-5465
SERVICES OFFERED
Resource/Referral
End of Life Washington: Statewide
9311 SE 36th Street, Suite 110
Mercer Island, Douglas County, 98040
206-256-1636
SERVICES OFFERED
Medical, Mental/Behavioral , Resource/Referral
CVCH: Express Care East Wenatchee
900 Eastmont Avenue
East Wenatchee, Douglas County, 98802
509-884-9000
SERVICES OFFERED
Medical
Access to Baby & Child Dentistry Program
Douglas County
509-886-6488
SERVICES OFFERED
Resource/Referral


Franklin county:
End of Life Washington: Statewide
           9311 SE 36th Street, Suite 110
Mercer Island, Franklin County, 98040
206-256-1636
SERVICES OFFERED
Medical, Mental/Behavioral , Resource/Referral
Planned Parenthood: Pasco Health Center
3901 W. Court Street
Pasco, Franklin County, 99301
866-904-7721
Website | Map
SERVICES OFFERED
Medical, Resource/Referral
CBHA: Pasco Clinic
6115 Burden Blvd D
Pasco, Franklin County, 99301
509-331-0150
SERVICES OFFERED
Medical, Mental/Behavioral
Yakima Valley Farm Workers Clinic: Miramar Health Center - Pasco
1608 N. Road 44
Pasco, Franklin County, 99301
509-543-9280
SERVICES OFFERED
Medical, Mental/Behavioral , Resource/Referral, Vision
Access to Baby & Child Dentistry
Franklin County
844-888-5465 (DentistLink)
SERVICES OFFERED
Resource/Referral
Lincoln county:
Odessa Memorial Healthcare Center
502 East Amende Drive
Odessa, Lincoln County, 99159
509- 982-2611
SERVICES OFFERED
Medical, Mental/Behavioral , Physical/Occupational Therapy, Resource/Referral
Lincoln Hospital and Davenport Clinic
10 Nicholls Street
Davenport, Lincoln County, 99122
Lincoln Hospital 509-725-7101 Davenport 509-725-7501
SERVICES OFFERED
Drug Dependency/Detox, Medical, Physical/Occupational Therapy, Resource/Referral
Lincoln Hospital and Clinics: Wilbur Clinic
214 SW Main
Wilbur, Lincoln County, 99185
509-647-5321
SERVICES OFFERED
Medical, Resource/Referral
Odessa Rural Healthcare Clinic
510 E Amende Drive
Odessa, Lincoln County, 99159
509-982-2614
SERVICES OFFERED
Medical, Mental/Behavioral
Pend Oreille county:
Camas Center Medical and Dental Clinic
1821 N. LeClerc Road #1
Cusick, Pend Oreille County, 99119
509-447-7111
SERVICES OFFERED
Alternative Medicine, Dental, Drug Dependency/Detox, Medical, Mental/Behavioral , Physical/Occupational Therapy
Newport Hospital and Health Services
714 West Pine Street
Newport, Pend Oreille County, 99156
509-447-2441
SERVICES OFFERED
Medical, Physical/Occupational Therapy
Pend Oreille County Counseling Services
105 S. Garden Avenue
Newport, Pend Oreille County, 99156
509-447-5651
SERVICES OFFERED
Mental/Behavioral , Resource/Referral
NEW Health: Selkirk Medical
208 Cedar Creek Terrace
Ione, Pend Oreille County, 99139
509-935-6004
SERVICES OFFERED
Medical
Dentistlink
Pend Oreille County
844-888-5465
SERVICES OFFERED
Resource/Referral
Skamania county:
One Community Health: Stevenson Clinic
875 SW Rock Creek Drive
Stevenson, Skamania County, 98648
509-427-4212
SERVICES OFFERED
Medical, Mental/Behavioral , Resource/Referral
Dentistlink
Skamania County
844-888-5465
SERVICES OFFERED
Resource/Referral
Skamania County Community Health
710 SW Rock Creek Drive
Stevenson, Skamania County, 98648
509-427-3950
SERVICES OFFERED
Drug Dependency/Detox, Mental/Behavioral , Resource/Referral
End of Life Washington: Statewide
9311 SE 36th St, Suite 110
Mercer Island, Skamania County, 98040
206-256-1636
SERVICES OFFERED
Medical, Mental/Behavioral , Resource/Referral
Stevens county:
Alliance Evaluation & Treatment Facility - Colville
982 E Columbia Avenue
Colville, Stevens County, 99114
509-685-5000
SERVICES OFFERED
Drug Dependency/Detox, Mental/Behavioral
IHS: David C. Wynecoop Memorial Clinic/Wellpinit Service Unit
6203 Agency Loop Road
Wellpinit, Stevens County, 99040
509-258-4517 ext. 4100
SERVICES OFFERED
Dental, Medical, Resource/Referral
Northeast Alliance Counseling Services: Colville Office
165 E. Hawthorne Avenue
Colville, Stevens County, 99114
509-684-4597
SERVICES OFFERED
Mental/Behavioral
Northeast Alliance Counseling Services: Chewelah
Chewelah Municipal Bldg E. 301 Clay Avenue, Room 201
Chewelah, Stevens County, 99109
509-935-4808
SERVICES OFFERED
Mental/Behavioral
NEW Health: Chewelah Medical
518 E Clay Avenue
Chewelah, Stevens County, 99109
509-935-6004
SERVICES OFFERED
Medical, Resource/Referral
Whatcom county:
Nooksack Tribal Clinic
2510 Sulwhanon Drive
Everson, Whatcom County, 98247
360-966-2106
SERVICES OFFERED
Dental, Drug Dependency/Detox, Medical, Mental/Behavioral , Resource/Referral
Lummi Tribal Health Center
2592 Kwina Road
Bellingham, Whatcom County, 98226
360-384-0464
SERVICES OFFERED
Dental, Medical, Mental/Behavioral , Physical/Occupational Therapy, Resource/Referral
Sea Mar CHC: Bellingham Medical Clinic
4455 Cordata Parkway
Bellingham, Whatcom County, 98226
Medical 360-671-3225 Dental 360-788-7101
SERVICES OFFERED
Dental, Drug Dependency/Detox, Homelessness Services, Medical, Mental/Behavioral , Resource/Referral
Sea Mar CHC: Visions Youth Treatment Center
1603 East Illinois Street
Bellingham, Whatcom County, 98226
360-647-4266
SERVICES OFFERED
Dental, Drug Dependency/Detox, Medical, Mental/Behavioral , Resource/Referral
Sea Mar CHC: Bellingham Behavioral Health
3350 Airport Drive
Bellingham, Whatcom County, 98226
360-734-5458
SERVICES OFFERED
Drug Dependency/Detox, Mental/Behavioral , Resource/Referral














Walla Wall:
Yakima Valley Farm Workers Clinic: Family Medical Center
1120 Rose Street
Walla Walla, Walla Walla County, 99362
Medical: 509-525-6650 Dental: 509-525-0247
SERVICES OFFERED
Dental, Medical, Resource/Referral, Vision
Planned Parenthood: Walla Walla Health Center
228 W Birch Street
Walla Walla, Walla Walla County, 99362
866-904-7721
SERVICES OFFERED
Medical, Resource/Referral
The Health Center
534 S 3rd, B-101
Walla Walla, Walla Walla County, 99362
509-525-0704
SERVICES OFFERED
Medical, Mental/Behavioral , Resource/Referral, Vision
SonBridge Center for Better Living: Dental Clinic and SOS Health Services (Co-located)
1200 SE 12th Street 
College Place, Walla Walla County, 99324
509-956-3165
SERVICES OFFERED
Dental
SOS Health Services
1200 SE 12th Street, Suite 4
College Place, Walla Walla County, 99324
509-529-1481
SERVICES OFFERED
Medical, Mental/Behavioral , Resource/Referral




Benton county:
Benton County Health Department - Kennewick Office
7102 W. Okanogan Place
Kennewick, Benton County, 99336
509-406-4200
SERVICES OFFERED
Resource/Referral
Greater Columbia Behavioral Health
101 N Edison Street
Kennewick, Benton County, 99336
888-545-3022


SERVICES OFFERED
Mental/Behavioral , Resource/Referral
Yakima Valley Farm Workers Clinic: Valley Vista Medical Group
820 Memorial Street, Suite 1
Prosser, Benton County, 99350
509-786-2010
SERVICES OFFERED
Medical, Mental/Behavioral , Resource/Referral, Vision
You Medical
5040 W Clearwater Avenue
Kennewick, Benton County, 99336
509-491-1101


SERVICES OFFERED
Medical, Resource/Referral
Tri-Cities Community Health Center - Richland
829 and 915 Goethals Drive
Richland, Benton County, 99352
509-547-2204
SERVICES OFFERED
Medical, Mental/Behavioral
CLARK county: 
1 Cascadia Dental Academy Clinic
12200 NE 28th Street
Vancouver, Clark County, 98682
360-604-1057
SERVICES OFFERED
Dental
2 Free Clinic of Southwest Washington
4100 Plomondon Street
Vancouver, Clark County, 98661
360-450-3044 Dental: 360-450-3044 x106
SERVICES OFFERED
Dental, Medical, Vision, Resource/Referral
3 Lifeline Connections: Vancouver VA Campus
1601 East Fourth Plain Blvd., Building 17, Suite A212
Vancouver, Clark County, 98661
360-397-8246
SERVICES OFFERED
Drug Dependency/Detox, Mental/Behavioral , Resource/Referral
4 New Heights Clinic
5912 NE 78th Street
Vancouver, Clark County, 98665
360-694-0355
SERVICES OFFERED
Medical, Resource/Referral
5 Battle Ground HealthCare
1910 SW 9th Avenue
Battle Ground, Clark County, 98604
360-687-8941
SERVICES OFFERED
Dental, Medical, Physical/Occupational Therapy, Vision, Resource/Referral
Columbia COUNTY: 
1 Columbia County Health System: Dayton General Hospital
1012 S. 3rd Street
Dayton, Columbia County, 99328
509-382-2531
SERVICES OFFERED
Medical
2 End of Life Washington: Statewide
9311 SE 36th Street, Suite 110
Mercer Island, Columbia County, 98040
206-256-1636
SERVICES OFFERED
Medical, Mental/Behavioral , Resource/Referral
3 Columbia County Health System: Columbia Family Clinic
1012 S. 3rd Street
Dayton, Columbia County, 99328
509-382-3200
SERVICES OFFERED
Dental, Medical, Mental/Behavioral
4 Access to Baby & Child Dentistry
Columbia County
509-382-2181
SERVICES OFFERED
Resource/Referral
5 Dentistlink
Columbia County
844-888-5465
SERVICES OFFERED
Resource/Referral
Ferry COUNTY
1. Lake Roosevelt Community Health Center: Inchelium Clinic
39 Shortcut Road
Inchelium, Ferry County, 99138
509-722-7006
SERVICES OFFERED
Alternative Medicine, Dental, Medical, Mental/Behavioral , Physical/Occupational Therapy, Resource/Referral
2. End of Life Washington: Statewide
9311 SE 36th Street, Suite 110
Mercer Island, Ferry County, 98040
206-256-1636
SERVICES OFFERED
Medical, Mental/Behavioral , Resource/Referral
3. Lake Roosevelt Community Health Center: Keller Clinic
11665 South Hwy 21
Keller, Ferry County, 99140
509-634-7300
SERVICES OFFERED
Alternative Medicine, Dental, Medical, Mental/Behavioral , Physical/Occupational Therapy, Resource/Referral
4. Ferry County (NE Tri-County Health District))
147 N Clark, Suite 1
Republic, Ferry County, 99166
509-775-3111
SERVICES OFFERED
Resource/Referral
5. Northeast Tri County Health District: Ferry County
147 N. Clark Suite 1
Republic, Ferry County, 99166
509-775-3111
SERVICES OFFERED
Resource/Referral


Garfield COUNTY:
1 Access to Baby & Child Dentistry
Garfield County
509-843-3412
SERVICES OFFERED
Resource/Referral
2 Garfield County Memorial Hospital
66 North Sixth Street
Pomeroy, Garfield County, 99347
509-843-1591
SERVICES OFFERED
Medical, Mental/Behavioral , Physical/Occupational Therapy
3 Garfield County Hospital District: Pomeroy Medical Clinic
446 Pataha Street
Pomeroy, Garfield County, 99347
509-843-1491
SERVICES OFFERED
Medical
4 End of Life Washington: Statewide
9311 SE 36th Street, Suite 110
Mercer Island, Garfield County, 98040
206-256-1636
SERVICES OFFERED
Medical, Mental/Behavioral , Resource/Referral
5 Garfield County Health District
121 South 10th Street
Pomeroy, Garfield County, 99347
509-843-3412
SERVICES OFFERED
Resource/Referral
Grays Harbor County:
Chehalis Tribal Wellness Center
21 Niederman Rd
Oakville, Grays Harbor County, 98568
360-273-5504
SERVICES OFFERED
Dental, Drug Dependency/Detox, Medical, Mental/Behavioral , Resource/Referral
2 Harbor Regional Health: Community Hospital
915 Anderson Drive
Aberdeen, Grays Harbor County, 98520
360-532-8330
SERVICES OFFERED
Drug Dependency/Detox, Medical, Mental/Behavioral , Physical/Occupational Therapy
3 Quinalt Wellness Center
511 West Heron Street
Aberdeen, Grays Harbor County, 98520
564-544-1950
SERVICES OFFERED
Dental, Drug Dependency/Detox, Medical, Mental/Behavioral , Resource/Referral
4 Sea Mar CHC: Aberdeen Medical and Behavioral Health
1813 Sumner Avenue
Aberdeen, Grays Harbor County, 98520
360-538-1293
SERVICES OFFERED
Drug Dependency/Detox, Medical, Mental/Behavioral
5 End of Life Washington: Statewide
9311 SE 36th St, Suite 110
Mercer Island, Grays Harbor County, 98040
206-256-1636
SERVICES OFFERED
Medical, Mental/Behavioral , Resource/Referral


ISLAND COUNTY: 
Sea Mar CHC: Oak Harbor Behavioral Health
830 SE Ireland Street
Oak Harbor, Island County, 98277
360-679-7676
SERVICES OFFERED
Drug Dependency/Detox, Mental/Behavioral
2 Camano Island Health System
1283 Elger Bay Road, Suite A
Camano Island, Island County, 98282
360-572-2202
SERVICES OFFERED
Alternative Medicine, Medical
3 End of Life Washington: Statewide
9311 SE 36th Street, Suite 110
Mercer Island, Island County, 98040
206-256-1636
SERVICES OFFERED
Medical, Mental/Behavioral , Resource/Referral
4 South Whidbey High School Health Fair
5675 Maxwelton Road
Langley, Island County, 98260
360-221-6808 x5420
SERVICES OFFERED
Medical, Resource/Referral
5 The Wabe of Whibey
1276 Engle Road
Coupeville, Island County, 98239
SERVICES OFFERED
Resource/Referral
Kittitas County:
1. Kittitas Valley Healthcare: Family Medicine - Cle Elum
201 Alpha Way
Cle Elum, Kittitas County, 98922
509-674-5331
SERVICES OFFERED
Drug Dependency/Detox, Medical, Mental/Behavioral , Physical/Occupational Therapy, Resource/Referral
2.Kittitas Valley Healthcare: Family Medicine-Ellensburg
100 E. Jackson Avenue, Suite 301
Ellensburg, Kittitas County, 98926
509-933-8777
SERVICES OFFERED
Drug Dependency/Detox, Medical
3.Kittitas Valley Healthcare: Physical Therapy - Cle Elum
201 Alpha Way
Cle Elum, Kittitas County, 98922
509.674.5210
SERVICES OFFERED
Physical/Occupational Therapy
4. End of Life Washington: Statewide
9311 SE 36th Street, Suite 110
Mercer Island, Kittitas County, 98040
206-256-1636
SERVICES OFFERED
Medical, Mental/Behavioral , Resource/Referral
5. Planned Parenthood: Ellensburg Health Center
613 N. Pine Street
Ellensburg, Kittitas County, 98926
866-904-7721
SERVICES OFFERED
Medical, Resource/Referral
Klickitat County:


1 Access to Baby & Child Dentistry Program: White Salmon
Klickitat County
509-493-1558
SERVICES OFFERED
Resource/Referral
2 NorthShore Medical Group: White Salmon
65371 Highway 14
White Salmon, Klickitat County, 98672
509-493-2133
SERVICES OFFERED
Medical, Mental/Behavioral , Resource/Referral
3 Klickitat Valley Health: Hospital and Family Medicine
310 South Roosevelt
Goldendale, Klickitat County, 98620
509-773-4022
SERVICES OFFERED
Medical, Mental/Behavioral , Physical/Occupational Therapy, Resource/Referral, Vision
4 End of Life Washington: Statewide
9311 SE 36th Street, Suite 110
Mercer Island, Klickitat County, 98040
206-256-1636
SERVICES OFFERED
Medical, Mental/Behavioral , Resource/Referral
5 Klickitat County Public Health Department: Goldendale
115 West Court
Goldendale, Klickitat County, 98620
509-773-4565
SERVICES OFFERED
Resource/Referral
Lewis County: 
1 Health & Hope Medical Outreach Tuesdays: 5:30PM-8PM
1911 Cooks Hill Road
Centralia, Lewis County, 98531
360-623-1485
SERVICES OFFERED
Medical, Resource/Referral
2 Popes Place
230 Washington Way
Centralia, Lewis County, 98531
360-736 9178
SERVICES OFFERED
Medical, Physical/Occupational Therapy, Resource/Referral
3 Valley View Health Center: Centralia Children's Dental
711 Harrison Avenue
Centralia, Lewis County, 98531
360-736-5405
SERVICES OFFERED
Dental
4. Valley View Health Center: Pe Ell
402 N Main Street
Pe Ell, Lewis County, 98572
360-291-3232
SERVICES OFFERED
Medical, Mental/Behavioral , Resource/Referral
5. Valley View Health Center: Onalska
1810 HWY 508
Onalaska, Lewis County, 98570
360-978-6600
SERVICES OFFERED
Dental, Medical, Mental/Behavioral , Resource/Referral
MASON COUNTY: 
1 Mason County Public Health and Human Services
2300 Kati Ct., Suite A
Shelton, Mason County, 98584
360-427-9670 ext 869
SERVICES OFFERED
Homelessness Services, Medical, Mental/Behavioral , Resource/Referral
2 Skokomish Wellness Center
N 100 Tribal Center Road
Skokomish , Mason County, 98584
360-426-5755
SERVICES OFFERED
Alternative Medicine, Drug Dependency/Detox, Dental, Medical, Mental/Behavioral , Resource/Referral
3 Squaxin Island Health Clinic
10 SE Squaxin Lane
Shelton, Mason County, 98584
360-427-9006 Pharmacy: 360-432-3990 Dental: 360-432-3990 Behavioral Health: 360-426-1482
SERVICES OFFERED
Dental, Medical, Mental/Behavioral , Resource/Referral
4 Consejo Counseling & Referral Service - Shelton
627 West Franklin Street
Shelton, Mason County, 98584
360-763-5610
SERVICES OFFERED
Drug Dependency/Detox, Mental/Behavioral , Resource/Referral
5 Mason Health: Mason Clinic
1701 North 13th Street
Shelton, Mason County, 98584
360-426-2653
SERVICES OFFERED
Medical, Mental/Behavioral , Physical/Occupational Therapy, Resource/Referral, Vision




Pacific County: 
1 End of Life Washington: Statewide
9311 SE 36th Street, Suite 110
Mercer Island, Pacific County, 98040
206-256-1636
SERVICES OFFERED
Medical, Mental/Behavioral , Resource/Referral
2 Valley View Health Center: Raymond
300 Ocean Avenue
Raymond, Pacific County, 98577
360-942-3040
SERVICES OFFERED
Dental, Medical, Mental/Behavioral
3 Pacific County Public Health: Long Beach Health Department
7013 Sandridge Road
Long Beach, Pacific County, 98631
360-642-9349
SERVICES OFFERED
Resource/Referral
4 Cowlitz Family Health Center: North Beach Clinic
21610 Pacific Hwy
Ocean Park, Pacific County, 98640
360-665-3000
SERVICES OFFERED
Medical, Mental/Behavioral
5 Dentistlink
Pacific County
844-888-5465
SERVICES OFFERED
Resource/Referral


San juan county :
1 Compass Health: Friday Harbor
520 Spring St
Friday Harbor, San Juan County, 98250
360-378-2669
SERVICES OFFERED
Drug Dependency/Detox, Mental/Behavioral , Resource/Referral
2 PeaceHealth: Peace Island Medical Center
1117 Spring Street
Friday Harbor, San Juan County, 98250
360-378-2141
SERVICES OFFERED
Medical, Mental/Behavioral , Physical/Occupational Therapy, Resource/Referral
3 End of Life Washington: Statewide
9311 SE 36th St, Suite 110
Mercer Island, San Juan County, 98040
206-256-1636
SERVICES OFFERED
Medical, Mental/Behavioral , Resource/Referral
4 San Juan County Health and Community Services
145 Rhone Street.
Friday Harbor, San Juan County, 98250
360-378-4474
SERVICES OFFERED
Resource/Referral
5 YMCA: Camp Orkila
PO Box 1149
Eastsound , San Juan County, 98245
360-376-2678 x 212
SERVICES OFFERED
Medical, Resource/Referral
Thurston County: 
1 Sea Mar CHC: Yelm Medical, Dental, Behavioral Health Center
202 Cullens Street NW
Yelm, Thurston County, 98597
360-400-4800 Dental: 360-400-4840 Behavioral: 360-400-4860
SERVICES OFFERED
Dental, Drug Dependency/Detox, Medical, Mental/Behavioral , Resource/Referral
2 The Olympia Free Clinic
520 Lilly Rd NE, Building 3
Olympia, Thurston County, 98506
360-890-4074x3
SERVICES OFFERED
Medical, Mental/Behavioral , Resource/Referral
3 The Olympia Bupe Clinic
1011 10th Ave SE
Olympia, Thurston County, 98501
369-349-0033
SERVICES OFFERED
Drug Dependency/Detox, Resource/Referral
4 End of Life Washington: Statewide
9311 SE 36th St, Suite 110
Mercer Island, Thurston County, 98040
206-256-1636
SERVICES OFFERED
Medical, Mental/Behavioral , Resource/Referral
5 Valley View Health Center: Tenino
273 Sussex Avenue E
Tenino, Thurston County, 98589
360-264-5665
SERVICES OFFERED
Medical



























































































Chelan County:
Confluence Health Hospital: Central Campus
1201 South Miller Street
Wenatchee, Chelan County, 98801
509-662-1511
SERVICES OFFERED
Medical, Mental/Behavioral , Physical/Occupational Therapy
CVCH: Childrens Behavioral Health
140 Easy Way
Wenatchee, Chelan County, 98801
509-662-4296
SERVICES OFFERED
Mental/Behavioral
CVCH: Medical & Dental Clinic - Chelan
105 South Apple Blossom Drive
Chelan, Chelan County, 98816
509-682-6000
SERVICES OFFERED
Dental, Medical, Mental/Behavioral
Cascade Medical Center
817 Commercial Street
Leavenworth , Chelan County, 98826
509-548-3420
SERVICES OFFERED
Medical, Mental/Behavioral , Physical/Occupational Therapy, Resource/Referral
Upper Valley Cares
817 Commercial Street
Leavenworth, Chelan County, 98826
509-300-1113
SERVICES OFFERED
Mental/Behavioral






Cowlitz:
Cowlitz Tribal Longview Medical Clinic
1044 11th Avenue
Longview, Cowlitz County, 98632
360-397-8228
SERVICES OFFERED
Medical, Mental/Behavioral , Resource/Referral
Cowlitz Family Health Center: Castle Rock Clinic
139 1st Avenue SW
Castle Rock, Cowlitz County, 98611
360-274-2353
SERVICES OFFERED
Medical, Mental/Behavioral , Resource/Referral
Cowlitz Family Health Center: Kelso Clinic
300 Oak Street, Suite B
Kelso, Cowlitz County, 98626
360-353-5511
SERVICES OFFERED
Medical, Mental/Behavioral
Cowlitz Family Health Center: Woodland Clinic
1251 Lewis River Road, Suite D
Woodland, Cowlitz County, 98674
360-225-4310
SERVICES OFFERED
Dental, Medical, Mental/Behavioral
Community Health Partners
945 Washington Way, Suite 141
Longview, Cowlitz County, 98632
360-442-4165
SERVICES OFFERED
Dental, Medical, Resource/Referral, Vision




























Grant:
Mattawa Community Medical Clinic
210 Government Road
Mattawa, Grant County, 99349
509-932-4499
SERVICES OFFERED
Dental, Medical, Mental/Behavioral , Resource/Referral
Moses Lake Community Health Center: Qunicey Community Health Center
1450 1st Avenue SW, Quincy
Quincy, Grant County, 98848
509-787-6423
SERVICES OFFERED
Dental, Drug Dependency/Detox, Medical, Mental/Behavioral
Moses Lake Community Health Center
605 S Coolidge Drive
Moses Lake, Grant County, 98837
509-765-0674
SERVICES OFFERED
Dental, Drug Dependency/Detox, Medical, Mental/Behavioral , Resource/Referral
Columbia Basin Hospital
200 Nat Washington Way 
Ephrata, Grant County, 98823
509-754-4631
SERVICES OFFERED
Medical, Physical/Occupational Therapy, Resource/Referral
CBHA: Wahluke Family Clinic
601 Government Way
Mattawa, Grant County, 99349
509-932-3535
SERVICES OFFERED
Dental, Hearing, Medical, Vision















Kitsap:

PCHS: Almira Clinic
5455 Almira Drive NE
Bremerton, Kitsap County, 98311
360-377-3776
SERVICES OFFERED
Dental, Medical, Resource/Referral
PCHS: Port Orchard Clinic
320 South Kitsap Blvd.
Port Orchard, Kitsap County, 98366
360-377-3776
SERVICES OFFERED
Medical, Mental/Behavioral , Resource/Referral
PCHS: Poulsbo Clinic
19917 7th Avenue, Suite 205
Poulsbo, Kitsap County, 98370
360-377-3776
SERVICES OFFERED
Medical, Mental/Behavioral , Resource/Referral
PCHS: Sixth Street Bremerton Clinic
616 Sixth Street
Bremerton, Kitsap County, 98337
360-377-3776
SERVICES OFFERED
Dental, Medical, Mental/Behavioral , Resource/Referral
PCHS: Port Orchard Dental Clinic
1950 Pottery Avenue, Suite 170/174
Port Orchard, Kitsap County, 98366
360-377-3776
SERVICES OFFERED
Dental


















Okanogan:
Confluence Health: Omak Campus General Clinic and Walk-in Clinic
916 Koala Drive
Omak, Okanogan County, 98841
509-826-1800
SERVICES OFFERED
Medical, Mental/Behavioral , Physical/Occupational Therapy
FHC: Brewster Clinic and Pharmacy
525 West Jay Avenue
Brewster, Okanogan County, 98812
Medical: 800-660-2129 Pharmacy: 509-422-7637
SERVICES OFFERED
Medical, Mental/Behavioral
Confluence Health: Regional Eye Center
717 Okoma Drive
Omak, Okanogan County, 98841
509-826-1191 or 509-826-1960
SERVICES OFFERED
Vision
FHC: Twisp Clinic
541 W 2nd Avenue
Twisp, Okanogan County, 98856
800-660-2129
SERVICES OFFERED
Medical
Confluence Health: Tonasket Clinic
17 S. Western Avenue
Tonasket, Okanogan County, 98855
509-486-2174
SERVICES OFFERED
Medical

Skagit:
Skagit Regional Health: Hospital Parkway Plaza
208 Hospital Pkwy
Mount Vernon, Skagit County, 98274
360-814-2600
SERVICES OFFERED
Medical
Sea Mar CHC: Concrete Medical Clinic
7438 S D Ave
Concrete, Skagit County, 98237
360-853-8183
SERVICES OFFERED
Medical, Resource/Referral
North Cascade Cares Clinic - Dental Clinic March 28 and 30th, 2025, Vision Clinic Fall 2025
800 Peacock Lane
Burlington, Skagit County, 98233
360-333-2393
SERVICES OFFERED
Dental, Vision
Swinomish Didgwalic Wellness Center
8212 S. March Point Road
Anacortes, Skagit County, 98221
360-588-2800
SERVICES OFFERED
Dental, Drug Dependency/Detox, Medical, Mental/Behavioral , Resource/Referral
PeaceHealth: United General Medical Center
2000 Hospital Drive
Sedro-Woolley, Skagit County, 98284
360-856-6021
SERVICES OFFERED
Medical, Physical/Occupational Therapy, Resource/Referral

Wahkiakum:
Wahkiakum County Public Health and Human Services
42 Elochoman Valley Road
Cathlamet, Wahkiakum County, 98612
888-452-0326
SERVICES OFFERED
Medical, Resource/Referral
Wahkiakum County Mental Health Services
42 Elochoman Valley Road
Cathlamet, Wahkiakum County, 98612
360-795-8630 option 1
SERVICES OFFERED
Mental/Behavioral
Wahkiakum County Substance Use Disorder
42 Elochoman Valley Road
Cathlamet, Wahkiakum County, 98612
360-795-8630 option. 3
SERVICES OFFERED
Drug Dependency/Detox, Homelessness Services, Mental/Behavioral , Resource/Referral
Cowlitz Family Health Center: Wahkiakum Clinic
335 Una Avenue
Cathlamet, Wahkiakum County, 98612
360-795-3201
SERVICES OFFERED
Medical


Medicaid (Washington State):
Adults under 65 may qualify if income is below 138% of the Federal Poverty Level

For 1 person, that’s roughly $20,783/year

For 2 people: $28,208/year

No premiums or deductibles

Medicare:
Generally for 65+ or people with certain disabilities

Covers hospital, doctor visits, and sometimes prescriptions

EBT (Food Stamps):
Income must be below a limit (about $2,266/month for 1 person)

Some assets like savings are also considered