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STATE OF WASHINGTON

DEPARTMENT OF SOCIAL AND HEALTH SERVICES

Aging and Long-Term Support Administration

Home and Community Services Division

PO Box 45600, Olympia, WA 98504-5600

H14-030 - Information

May 23, 2014

|TO: |Area Agency on Aging (AAA) Directors |

| |Home and Community Services (HCS) Division Regional Administrators Developmental Disabilities Administration |

| |(DDA) Regional Administrators |

|FROM: |Bea Rector, Director, Home and Community Services Division |

| |Don Clintsman, Deputy Assistant Secretary, Developmental Disabilities Administration |

|SUBJECT: |New “Classic Medicaid” Washington Apple Health Application Form |

|Purpose: |To inform HCS, AAA, and DDA staff of changes to the Washington Apple Health Supplemental Form. |

|Background: |The Health Care Authority (HCA) is changing the HCA 18-005 Washington Apple Health Supplemental Form. |

| |Effective 05/01/14, a new version of the form will be used as a stand-alone Washington Apple Health |

| |Application for Long Term Care/Aged, Blind, Disabled Coverage. |

|What’s new, changed, or |Individuals may now apply for the following “Classic Medicaid” programs using the new form: |

|Clarified | |

| |Long-term care services |

| |Coverage for those age 65 or older |

| |Disability-based coverage |

| |Medicare Savings Program |

| |This new form enables direct routing of applications for clients who need long-term care services or |

| |disability-based health coverage to the local HCS or AAA office to make the eligibility determinations. |

| | |

| |“Classic Medicaid” applicants no longer need to complete both the HCA 18-001 Application for Health Care |

| |Coverage and the old HCA 18-005 forms if they use the new stand-alone application. Clients may continue to |

| |apply online via Washington Connection at . |

| | |

| |There is no change to the HCA 18-001 Application for Health Care Coverage used by individuals to apply for |

| |MAGI-based Family, Children’s, Pregnancy, and Adult medical programs. These applications may continue to be |

| |submitted online via Washington Healthplanfinder at . |

|ACTION: |Stakeholders, community partners, JRP’s, AAA offices, DDA offices, and HCS offices are asked to destroy all |

| |old stock of form HCA 18-005 (5/13) Washington Apple Health Supplemental Form and replace it with the new HCA|

| |18-005 (3/14) version effective May 1st, 2014. |

| | |

| |This new form can be found online at hca.medicaid/forms/Pages/index.aspx in English and the eight |

| |supported languages on April 28th for use beginning May 1st |

|ATTACHMENT(S): |[pic] |

|CONTACT(S): |Catherine Fisher, Financial Unit Manager |

| |HCS |

| |(360) 725-2318 |

| |Catherine.Fisher@dshs. |

| | |

| |Shannon Manion |

| |DDA |

| |360.725.3454 |

| |ManioSK@dshs. |

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