SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)
Date of Adoption: April 7, 2004.
Purpose: Chapter 388-475 WAC, SSI-Related Medical--Part 1 of 4, SSI-related medical eligibility rules are being combined into one Washington Administrative Code (WAC) chapter, chapter 388-475 WAC, for easier reference. In some instances, the rules have been rewritten according to the clear writing standards of the Governor's Executive Order 97-02.
New sections WAC 388-475-0050 General information, 388-475-0100 CN medical eligibility, 388-475-0150 MN medical eligibility, 388-475-0200 Definition of resources, 388-475-0250 Ownership and availability of resources, and 388-475-0300 Resources eligibility.
Statutory Authority for Adoption: RCW 74.04.050, 74.08.090.
Adopted under notice filed as WSR 03-20-076 on September 29, 2003.
Changes Other than Editing from Proposed to Adopted Version:
|•||WAC 388-475-0050(1) and subsection (b) were changed to clarify that clients must be either aged, blind or disabled, but not all three. Subsection (1) now reads: "The department provides medical benefits under the categorically needy (CN) and medically needed (MN) SSI-related programs for SSI-related people, meaning those who meet at least one of the federal SSI program criteria as being: "At the end of subsection (b)(ii), the connector", or; "was added.|
|•||WAC 388-475-0100(3): Clarifying that an ineligible spouse of an SSI recipient may be determined eligible for family medical program if meeting eligibility criteria. The subsection now reads: "An ineligible spouse of an SSI recipient is ineligible for noninstitutional SSI-related CN benefits. If an ineligible spouse of an SSI recipient has dependent children in the home, eligibility may be determined for family medical programs."|
|•||WAC 388-475-0150(6), changed "a" to "an" in the second sentence, after "For..."|
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 6, Amended 0, Repealed 0.
Number of Sections Adopted Using Negotiated Rule Making:
Pilot Rule Making:
or Other Alternative Rule Making:
Effective Date of Rule: June 1, 2004.
April 7, 2004
Brian H. Lindgren, Manager
Rules and Policies Assistance Unit3286.7
(a) Age sixty-five or older;
(b) Blind with:
(i) Central visual acuity of 20/200 or less in the better eye with the use of a correcting lens; or
(ii) A field of vision limitation so the widest diameter of the visual field subtends an angle no greater than twenty degrees.
(i) "Disabled" means unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment, which:
(A) Can be expected to result in death; or
(B) Has lasted or can be expected to last for a continuous period of not less than twelve months; or
(C) In the case of a child seventeen years of age or younger, if the child suffers from any medically determinable physical or mental impairment of comparable severity.
(ii) Decisions on SSI-related disability are subject to the authority of:
(A) Federal statutes and regulations codified at 42 USC Sec 1382c and 20 CFR, parts 404 and 416, as amended; and
(B) Controlling federal court decisions, which define the OASDI and SSI disability standard and determination process.
(2) A denial of Title II or Title XVI federal benefits by SSA solely due to failure to meet the blindness or disability criteria is binding on the department unless the applicant's:
(a) Denial is under appeal in the reconsideration stage in SSA's administrative hearing process, or SSA's appeals council; or
(b) Medical condition has changed since the SSA denial was issued.
(3) The department considers a client who meets the special requirements for SSI status under Sections 1619(a) or 1619(b) of the Social Security Act as an SSI recipient. Such a client is eligible for CN medical coverage under WAC 388-474-0005.
(4) Individuals referred to in subsection (1) must also meet appropriate eligibility criteria found in the following WAC and EA-Z Manual sections:
(a) For all programs:
(i) WAC 388-408-0055, Medical assistance units;
(ii) WAC 388-416-0015, Categorically needy and WAC 388-416-0020, Medically needy certification periods;
(iii) Program specific requirements in chapter 388-475 WAC;
(iv) WAC 388-490-0005, Verification;
(v) WAC 388-503-0505, General eligibility requirements for medical programs;
(vi) WAC 388-505-0540, Assignment of rights and cooperation;
(vii) Chapter 388-561 WAC, Trusts, annuities and life estates.
(b) For LTC programs:
(i) Chapter 388-513 WAC, Long-term care services
(ii) Chapter 388-515 WAC, Waiver services.
(c) For MN, chapter 388-519 WAC, Spenddown;
(d) For HWD, program specific requirements in chapter 388-475 WAC.
(5) Aliens who qualify for Medicaid benefits, but are determined ineligible because of alien status may be eligible for programs as specified in WAC 388-438-0110.
(6) The department pays for a client's medical care outside of Washington according to WAC 388-501-0180.
(7) The department follows income and resource methodologies of the Supplemental Security Income (SSI) program defined in federal law when determining eligibility for SSI-related medical or Medicare Cost Savings programs unless the department adopts rules that are less restrictive than those of the SSI program.
(8) Refer to WAC 388-418-0025 for effects of changes on medical assistance for redetermination of eligibility.
(a) Meets the criteria in WAC 388-475-0050, SSI-related medical -- General information; or
(b) Meets the criteria for the state-funded general assistance - expedited Medicaid disability (GA-X) program by meeting the:
(i) Requirements of the cash program in WAC 388-400-0025 and 388-478-0030; or
(ii) SSI-related disability standards but who cannot get the SSI cash grant due solely to immigration status or sponsor deeming issues.
(2) To be eligible for SSI-related CN medical programs, a person must also have:
(a) Countable income and resources at or below the SSI-related CN medical monthly standard (refer to WAC 388-478-0080) or be eligible for an SSI cash grant but choose not to receive it; or
(b) Countable resources at or below the SSI resource standard and income above the SSI-related CN medical monthly standard, but the countable income falls below that standard after applying special income disregards as described in WAC 388-475-880; or
(c) Met requirements for long-term care (LTC) CN income and resource requirements that are found in chapter 388-513 and 388-515 WAC if wanting LTC or waiver services.
(3) An ineligible spouse of an SSI recipient is not eligible for noninstitutional SSI-related CN medical benefits. If an ineligible spouse of an SSI recipient has dependent children in the home, eligibility may be determined for family medical programs.
(a) A person who is SSI-related and not eligible for CN medical coverage because they have countable income that is above the CN income standard (or for long-term care (LTC) clients, above the special income limit (SIL)):
(i) Their countable income is at or below MN standards, leaving them with no spenddown requirement; or
(ii) Their countable income is above MN standards requiring them to spenddown their excess income (see subsection (4) below). See WAC 388-475-0500 through 388-475-0800 for rules on determining countable income, and WAC 388-478-0080 for program standards or chapter 388-513 WAC for institutional standards.
(b) An SSI-related ineligible spouse of an SSI recipient;
(c) An adult who meets SSI program criteria but is not eligible for the SSI cash grant due to immigration status or sponsor deeming. See WAC 388-424-0010 for limits on eligibility for aliens;
(d) A person who meets the MN LTC services requirements of chapter 388-513 WAC and WAC 388-515-1540;
(e) A person who lives in an alternate living facility and meets the requirements of WAC 388-513-1305; or
(f) A person who meets resource requirements as described in chapter 388-475 WAC, elects and is certified for hospice services per chapter 388-551 WAC.
(2) Clients whose countable resources are above the SSI resource standards are not eligible for MN noninstitutional medical benefits. See WAC 388-475-0200 through 388-475-0550 to determine countable resources.
(3) Clients who qualify for services under long term care have different criteria and may spend down excess resources to become eligible for LTC institutional or waiver medical benefits. Refer to WAC 388-513-1315 and 388-513-1395.
(4) A client with income over the medically needy income limit (MNIL) may become eligible for MN coverage when they have incurred medical expenses that are equal to the excess income. This is the process of meeting spenddown. Refer to chapter 388-519 WAC for spenddown information.
(5) A client may be eligible for medical coverage for up to three months immediately prior to the month of application, if the client:
(a) Met all eligibility requirements for the months being considered; and
(b) Received medical services covered by Medicaid during that time.
(6) A client eligible for MN without a spenddown is certified for up to twelve months. For an MN client with spenddown, refer to WAC 388-519-0110. For a long-term care MN client, refer to WAC 388-513-1305 and 388-513-1315.
(7) A client must reapply for each certification period. There is no continuous eligibility for MN. Although each additional certification period requires a new application, if the medical benefits have been closed less than thirty days, an eligibility review form may be used to reapply.
(b) Has the right, authority, or power to convert to cash (if not already cash); and
(c) Has the legal right to use for his/her support and maintenance.
(2) The value of a resource may change. However, the property (personal or real) still remains a resource.
(3) Some assets are not resources. Any asset that does not meet the criteria in subsection (1) above is not a resource.
(4) When an SSI-related client owns a bank account or time deposit jointly with others who are also SSI-related clients, we consider the funds as being available to the SSI-related individuals in equal shares, unless sufficient evidence to the contrary is provided.
(5) When an SSI-related client owns a bank account or time deposit jointly with others who are not SSI-related, we consider all funds in the joint account as available to the client unless sufficient evidence to the contrary is provided.
(6) When an SSI-related client jointly owns either real or personal property other than bank accounts or time deposits, the department considers that the client owns and has available only his or her fractional interest in the property unless sufficient evidence to the contrary is provided.
(7) A resource is countable toward the resource limit only if it is available and is not excluded.
(a) Owns the property;
(b) Has the authority to convert the property into cash;
(c) Can expect to convert the property to cash within twenty working days; and
(d) May legally use the property for his/her support.
(2) A resource is considered available on the first day of the month following the month of receipt unless a rule about a specific type of resource provides for a different time period.
(3) A resource, which ordinarily cannot be converted to cash within twenty working days, is considered unavailable as long as a reasonable effort is being made to convert the resource to cash.
(4) A client may provide evidence showing that a resource is unavailable. A resource is not counted if a client shows sufficient evidence that the resource is unavailable.
(5) We do not count the resources of victims of family violence, as defined in WAC 388-452-0010, when:
(a) The resource is owned jointly with members of the former household;
(b) Availability of the resource depends on an agreement of the joint owner; or
(c) Making the resource available would place the client at risk of harm.
(6) The value of a resource is its fair market value minus encumbrances.
(7) Refer to WAC 388-470-0060 to consider additional resources when an alien has a sponsor.
(2) An excluded resource converted to another excluded resource remains excluded.
(3) Cash received from the sale of an excluded resource becomes a countable resource the first of the month following conversion unless the cash is;
(a) Used to replace the excluded resource; or
(b) Invested in another excluded resource in the same month or within the longer time allowed for home sales under WAC 388-475-0350; or
(4) The unspent portion of a nonrecurring lump sum payment is counted as a resource on the first of the month following its receipt with the following exception: the unspent portion of any Title II (SSA) or Title XVI (SSI) retroactive payment is excluded as a resource for six months following the month of receipt. These exclusions apply to lump sums received by the client, client's spouse or other any other person who is financially responsible for the client.
(5) Clients applying for SSI-related medical coverage for long-term care (LTC) services must meet different resource rules. See chapter 388-513 WAC for LTC rules.
(6) The transfer of a resource without adequate consideration does not affect medical program eligibility except for LTC and waiver services programs. In those programs, the transfer may make a client ineligible for medical benefits for a period of time. See WAC 388-513-1364 through 388-513-1366 for LTC rules.