Apple Health and Medicare: How They Work Together in Washington
Apple Health is Washington's Medicaid program, and Medicare is the federal program you get at 65 or after a disability. They aren't alternatives. You can have both, and when you do, Medicare pays first and Apple Health pays after it. For a single person in 2026, full Apple Health on the basis of age or disability has an income limit of $994 a month in countable income and a $2,000 resource limit, while the Medicare Savings Programs that pay Part B premiums reach up to $1,855 a month with no asset test at all.
That gap is where most of the confusion lives. A lot of Washington retirees assume they're over "the Medicaid limit" and never apply, when the program that would actually help them is a different piece of Apple Health with a much higher income line. Below: how the two programs differ, who pays first, what Apple Health adds on top of Medicare, the two levels of help, the 2026 numbers from the Health Care Authority (HCA), long-term care, estate recovery, and where to apply.
Source: HCA, Washington Apple Health Income and Resource Standards, Oct. 1, 2026 (HCA 19-0096); HCA, Medicare Savings Program; CMS 2026 Part A and B amounts. The $994 line is compared with income after a $20 disregard; the $1,855 chart figure already includes it.
Two programs, two sets of rules
"Washington Apple Health" is the brand name for all of the state's medical assistance programs, Medicaid included, according to HCA's eligibility overview. HCA runs most of it. The Department of Social and Health Services (DSHS) handles the pieces that matter most to people on Medicare: the SSI-related programs and the Medicare Savings Programs.
Medicare doesn't care what you earn. Apple Health does. That's the core difference, and almost everything else follows from it.
| Medicare | Apple Health (Medicaid) | |
|---|---|---|
| Who runs it | Federal government (CMS) | Washington: HCA, with DSHS deciding eligibility for the aged, blind and disabled |
| Who qualifies | 65 and older, or under 65 with a qualifying disability or condition | Based on income and resources, plus age, disability or other category |
| Income test | None (higher incomes pay more for Part B and D) | Yes: $994/mo for one person for full aged/disabled coverage; up to $1,855/mo for premium help |
| Main job | Hospital, doctor and drug coverage | Fills Medicare's gaps; covers long-term care and other services Medicare doesn't |
| Order of payment | Pays first | Pays last |
Source: HCA 22-315 Eligibility Overview (4/26); HCA, Age 65 and older or Medicare eligible; Medicare.gov, Medicaid; HCA 19-0096 (10/26).
One thing that isn't changing for this group: Medicare.gov notes that the Medicaid work requirement starting January 1, 2027 "doesn't apply to people with Medicare."
If you're on Apple Health and turning 65
This trips people up. The Apple Health for Adults program, the one most working-age Washingtonians are on, is only for people 19 to 64 who are "not entitled to, or enrolled in, medicare benefits under Part A or B" (WAC 182-505-0250). Once Medicare starts, that coverage doesn't simply continue. You'd have to qualify under the Classic Medicaid rules for people who are aged, blind or disabled, which use different income limits and add a resource test.
Washington Healthplanfinder isn't the fallback either. HCA's 65-and-older page says you can't be entitled to or receiving Medicare to get health coverage there (dental plans are the exception). Classic Medicaid, the Medicare Savings Programs and long-term care all go through Washington Connection instead.
What to do: when your Medicare card arrives, apply on Washington Connection for Classic Medicaid and the Medicare Savings Programs at the same time, and answer every renewal letter from HCA or DSHS. If you're also sorting out when to sign up for Part B, our Washington Medicare page covers the basics.
Who pays first
HCA puts it plainly: any Apple Health coverage you're approved for while on Medicare "will work as a secondary insurance to Medicare." Medicare.gov says the same from the federal side: Medicare pays first for Medicare-covered services, and Medicaid pays last, "after Medicare and any other health insurance you have."
| Order | Who | What happens |
|---|---|---|
| 1 | Medicare (Original Medicare or a Medicare Advantage plan) | Processes the claim first for anything Medicare covers |
| 2 | Other health coverage you have (retiree plan, TRICARE, etc.) | Pays its share next, under its own rules |
| 3 | Apple Health | Pays last: premiums, cost sharing, and services Medicare doesn't cover, depending on your program |
Source: HCA, Age 65 and older or Medicare eligible; Medicare.gov, Medicaid.
Two Washington details. First, prescriptions: duals get drugs through a Medicare drug plan, not Apple Health; Medicare.gov says you'll be enrolled in one automatically. Second, behavioral health: HCA says dual-eligible clients have Medicare as primary for physical health, plus an Apple Health Behavioral Health Services Only (BHSO) managed care plan as secondary coverage for mental health and substance use treatment.
Two levels of help: MSP only, or full Apple Health
CMS splits people with both programs into two groups (Dual Eligibility Categories). "Partial-benefit" duals get only a Medicare Savings Program (MSP). "Full-benefit" duals get full Medicaid on top of Medicare. In Washington both run under the Apple Health name, and the income lines are far apart.
Source: HCA Income and Resource Standards, Oct. 1, 2026 (HCA 19-0096)
Show the numbers
| Program | Monthly line |
|---|---|
| Medically Needy income level | $994 |
| Aged, blind or disabled (SSI-related CN) | $994 |
| QMB (110% of poverty) | $1,483 |
| SLMB (120%) | $1,616 |
| QI-1 (138%) | $1,855 |
| Long-term care special income level | $2,982 |
| Program | Income, 1 person | Income, couple | Resources, 1 person (couple) | What it pays |
|---|---|---|---|---|
| QMB | $1,483 | $2,004 | No asset test | Part A and B premiums plus Medicare cost sharing |
| SLMB | $1,616 | $2,185 | No asset test | Part B premium |
| QI-1 | $1,855 | $2,510 | No asset test | Part B premium |
| Apple Health for aged, blind or disabled (CN) | $994 | $1,491 | $2,000 ($3,000) | Full Medicaid scope on top of Medicare |
| Medically Needy (spenddown) | Above $994 | Above $994 | $2,000 ($3,000) | Medicaid after you incur medical bills equal to your spenddown |
Source: HCA 19-0096 (10/26) (MSP lines effective 4/1/2026 and include the $20 disregard; SSI-related and Medically Needy lines effective 1/1/2026); HCA, Medicare Savings Program; HCA 22-315.
The MSP rows matter more than they look. Washington dropped the asset test for MSPs: HCA says "you won't be asked to verify any resources such as bank account balances." Say you have $80,000 in savings and $1,500 a month from Social Security: you're under the SLMB line of $1,616, so you can still get the Part B premium paid. At $202.90 a month in 2026, that's $2,434.80 a year. QMB goes further: Medicare.gov says providers aren't allowed to bill QMB enrollees for Medicare deductibles, coinsurance or copays, so show both your Medicare card and your ProviderOne card every visit.
Full Apple Health is a much tighter door: $994 a month and $2,000 in countable resources for one person. Your home (if you or your spouse live there or you intend to return), household goods and personal effects are excluded under WAC 182-512-0350, so the resource test is mostly about cash, accounts and investments. The full MSP walkthrough, with timing and paperwork, is in our Medicare Savings Program in Washington guide.
Over the limit? How spenddown works
Income a little over $994 doesn't end the conversation. The Medically Needy program lets you "spend down" the excess. Under WAC 182-519-0110, you pick a three-month or six-month base period starting the month you apply (and can ask for a retroactive base period covering up to three months before that). DSHS adds up the income over the limit for those months. Once your medical bills reach that total, Apple Health covers the rest of the base period. Medicare premiums, deductibles, coinsurance and copays are the first expenses counted.
HCA's own eligibility guide works through an example, and it's worth seeing the math.
Source: HCA 22-315 Eligibility Overview (4/26), Medically Needy and Spenddown; subtraction by author
Show the numbers
| Dollars | |
|---|---|
| Balance after Medicare | $5,200 |
| Martha's spenddown | $1,158 |
| Apple Health pays | $4,042 |
My read on that example: HCA built it to show spenddown, but at $1,207 a month Martha's gross income is also under Washington's QMB line of $1,483. QMB could pay her Part B premium and Medicare cost sharing without any spenddown. That's exactly why you apply for everything at once and let DSHS sort out which programs fit. Medically Needy also covers slightly fewer services than full (categorically needy) Apple Health; HCA's benefit table shows personal care services, for example, aren't in the Medically Needy package.
Long-term care: the part Medicare doesn't do
Medicare.gov is blunt: Medicare and most health insurance, Medigap included, don't pay for long-term care, whether that's in a nursing home or at home. Medicare's skilled nursing benefit is limited care after a qualifying three-day hospital stay, with coinsurance of $217 a day for days 21-100 in 2026, and Medicare pays nothing after day 100.
Apple Health long-term services and supports (LTSS) pick up where that ends. HCA lists care at home, in an adult family home, assisted living or other residential setting, or in a nursing facility. Programs run through DSHS Home and Community Services include COPES, Community First Choice, Medicaid Personal Care, PACE and nursing facility care. To qualify you need to pass both a financial test and a functional assessment, and services start once DSHS finds you meet nursing facility level of care and a caregiver is in place.
| Washington LTSS standard | Amount |
|---|---|
| Special income level (SIL), one person | $2,982/mo |
| Community spouse maintenance needs allowance, maximum | $4,066.50/mo |
| Federal spousal resource maximum | $162,660 |
| Home equity limit | $1,130,000 |
| Personal needs allowance, nursing facility | $108.74/mo |
| Monthly private nursing facility rate (Oct. 1, 2026) | $14,759 |
Source: HCA 19-0096 (10/26), Long Term Services and Supports Income and Resource Standards; most figures effective 1/1/2026.
That last row is the reason this matters: $14,759 a month is HCA's posted private nursing facility rate. Very few retirement budgets absorb that for long.
Two smaller programs support unpaid caregivers when the person receiving care is 55 or older: Tailored Supports for Older Adults (TSOA), which has its own income and resource standards and doesn't require Apple Health, and Medicaid Alternative Care (MAC), for people already on Apple Health. And if you've been paying into WA Cares, its benefits aren't counted as income or resources for Medicaid eligibility (RCW 50B.04.150). Our WA Cares Fund guide explains how that $36,500 benefit works.
Spousal rules decide how much a husband or wife at home keeps when the other spouse needs care. How they apply to your accounts and house is legal territory. Talk to an elder law attorney before moving money.
Estate recovery
Here's what the rules actually say. Under WAC 182-527-2740, Washington can recover from your estate for certain Apple Health services you got on or after your 55th birthday. Which services is spelled out in WAC 182-527-2742: for current dates of service, it's long-term care (nursing facility, COPES, Community First Choice, Medicaid personal care, the long-term care portion of PACE), hospice, state-only funded services, and the hospital and drug services you got while receiving those.
| Help you receive | Subject to estate recovery? |
|---|---|
| Medicare Savings Programs (QMB, SLMB, QI-1) | No. HCA's MSP flyer says there is no estate recovery for MSPs |
| Medicare cost sharing paid for someone on Medicaid and an MSP (since 2010) | No, per WAC 182-527-2742(9) |
| Nursing facility, COPES, personal care, hospice, PACE long-term care portion | Yes, for services on or after age 55 |
| Hospital and drug services received while getting those long-term care services | Yes |
| Medicaid Alternative Care (MAC) and Tailored Supports for Older Adults (TSOA) | No, exempt since July 1, 2017 |
| WA Cares Fund benefits | No (WA Cares is not Medicaid) |
Source: WAC 182-527-2740; WAC 182-527-2742; HCA 22-500 Medicare Savings Programs flyer; HCA 19-0009; RCW 43.20B.080; WA Cares Fund FAQ.
Two more points. The "estate" isn't only what goes through probate: for deaths since September 14, 2006, it includes nonprobate assets and any life estate interest (WAC 182-527-2730). And heirs can ask the state to delay recovery for undue hardship, for example when the property is an heir's only income-producing asset or recovery would leave an heir without shelter they can afford (WAC 182-527-2750).
My read: estate recovery is a reason to understand long-term care Apple Health before you use it. It isn't a reason to skip a Medicare Savings Program, which it doesn't touch.
Drug coverage and changing plans as a dual
Anyone on full Apple Health, an MSP that pays the Part B premium, or SSI gets Extra Help with Medicare drug costs automatically (Medicare.gov). For 2027, Medicare.gov lists Extra Help copays of up to $5.80 per generic and $14.40 per brand-name drug, and nothing for covered drugs once you reach the $2,400 out-of-pocket threshold (which counts certain payments made on your behalf, like Extra Help). Full-benefit duals pay less. In its 2027 Rate Announcement (Table V-2), CMS caps 2027 copays for people with full Medicaid and income at or below 100% of the poverty level at $1.65 for generics and $5.00 for other drugs, and removes copays entirely for full-benefit duals in a nursing facility or getting certain home and community-based services in place of one. (Medicare.gov's Extra Help page still shows the 2026 figure of $4.90.) HCA's long-term care fact sheet adds that if you get COPES, your pharmacy can't charge you Part D copays. Our Washington Part D page covers how drug coverage works.
Duals also have more room to change coverage than other people on Medicare, under 42 CFR 423.38:
| Situation | What you can do | When |
|---|---|---|
| You have Apple Health or Extra Help | Switch Medicare drug plans, or leave a Medicare Advantage plan with drug coverage and return to Original Medicare by joining a stand-alone drug plan | Once a calendar month; starts the 1st of the next month |
| You have full Apple Health | Join or switch to an integrated dual eligible special needs plan (D-SNP), if one is available where you live | Once a calendar month; starts the 1st of the next month |
| You gain, lose or change Apple Health or Extra Help | Make a Medicare Advantage or drug plan change | Within 3 months of the change or the notice, whichever is later |
Source: 42 CFR 423.38(c)(4), (c)(9) and (c)(35) (eCFR, current Oct. 2026); Medicare.gov, Special Enrollment Periods.
The monthly drug-plan change isn't available if a Part D drug management program has flagged you as an "at-risk" or "potential at-risk" beneficiary; you'd get a letter. In Washington, HCA calls its contracted D-SNP arrangement "Apple Health Medicare Connect." Its 65-and-older page describes it as a special kind of Medicare Advantage plan for dual-eligible people that "works to coordinate Apple Health and Medicare services." Whether that or Original Medicare fits you depends on your doctors and prescriptions, which is the kind of question SHIBA answers without selling anything.
Open Enrollment (October 15 to December 7) is under way now. What can change for 2027 is in our Washington Open Enrollment guide.
How to apply in Washington
- Classic Medicaid, the Medicare Savings Programs and long-term care: online at Washington Connection; by phone with DSHS at 1-877-501-2233; in person at a DSHS Community Services Office; or on paper with HCA form 18-005, mailed to DSHS Community Services Division, PO Box 11699, Tacoma, WA 98411-6699 (fax 1-888-338-7410). There's also an MSP-only form, HCA 13-691.
- Long-term care questions: DSHS Home and Community Services, 1-800-422-3263. Paper LTSS applications on form 18-005 can go to DSHS Home and Community Services, PO Box 45826, Olympia, WA 98504-5826.
- Apple Health coverage questions: HCA at 1-800-562-3022.
- Unbiased Medicare help: SHIBA, run by the Washington Office of the Insurance Commissioner, at 1-800-562-6900, or 1-800-MEDICARE.
If you're approved, a ProviderOne services card arrives in about two weeks, according to HCA. If you're anywhere near a line in this article, apply and let DSHS decide; income deductions and resource exclusions don't fit in a table. More common questions are on our Washington insurance FAQ.
FAQ
Can you have Apple Health and Medicare at the same time?
Yes. People with both are called dual eligible. Medicare pays first, and Apple Health works as secondary coverage that pays after Medicare and any other insurance.
Is Apple Health Medicare or Medicaid?
Apple Health is Washington's name for Medicaid and its other state medical assistance programs. Medicare is a separate federal program. Apple Health can help pay Medicare premiums and costs if you qualify.
What is the Apple Health income limit for seniors in 2026?
For full Apple Health as an aged, blind or disabled person, HCA lists $994 a month for one person and $1,491 for a couple, with resource limits of $2,000 and $3,000. Medicare Savings Programs go up to $1,855 a month for one person, with no asset test.
Do I lose Apple Health when I turn 65?
Apple Health for Adults ends when you become entitled to Medicare, because that program is only for people under 65 without Medicare. You can apply for Classic Medicaid and the Medicare Savings Programs through Washington Connection instead.
Program rules, your own coverage documents and current state and federal law control what you get. Confirm your situation with DSHS, HCA, SHIBA or a licensed agent, and for estate or spousal planning questions, an elder law attorney.
Sources
- HCA: Washington Apple Health Income and Resource Standards, Oct. 1, 2026 (HCA 19-0096)
- HCA: Age 65 and older or Medicare eligible
- HCA: Aged, blind, or disabled
- HCA: Long-term care and hospice
- HCA: Eligibility Overview, Washington Apple Health Programs (22-315, 4/26)
- HCA: Apple Health Long-Term Services and Supports (19-0009)
- HCA: Health coverage options for individuals 65 and older or Medicare eligible (19-0003)
- HCA: Medicare Savings Program
- HCA: Medicare Savings Programs flyer (22-500)
- HCA: Application for Medicare Savings Programs (13-691)
- CMS: Announcement of Calendar Year 2027 Medicare Advantage Capitation Rates and Part C and Part D Payment Policies (Table V-2)
- WAC 182-505-0250: MAGI-based adult medical
- WAC 182-512-0350: Property excluded as resources
- WAC 182-519-0110: Spenddown for the medically needy program
- WAC 182-527-2730: Estate recovery definitions
- WAC 182-527-2740: Estate recovery, age-related limitations
- WAC 182-527-2742: Estate recovery, service-related limitations
- WAC 182-527-2750: Estate recovery, undue hardship
- RCW 43.20B.080: Recovery of medical assistance
- RCW 50B.04.150: WA Cares benefits not counted for other programs
- Medicare.gov: Medicaid
- Medicare.gov: Help with drug costs (Extra Help)
- Medicare.gov: Medicare Savings Programs
- Medicare.gov: Long-term care
- Medicare.gov: Skilled nursing facility care
- WA Cares Fund: Frequently asked questions
- Medicare.gov: Special Enrollment Periods
- eCFR: 42 CFR 423.38, enrollment periods
- CMS: 2026 Medicare Parts A and B premiums and deductibles
- CMS Medicare-Medicaid Coordination Office: Dual Eligibility Categories
- Washington OIC: SHIBA
This article is for general educational purposes only and is not legal, tax or insurance advice. Coverage depends on the actual policy, its terms, conditions and exclusions, and state law. Maru Insurance · WA License (WAOIC) #1365574 · FL License #G363233 · NPN 22261820.