WSR 08-05-018

PERMANENT RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Health and Recovery Services Administration)

[ Filed February 12, 2008, 8:34 a.m. , effective March 14, 2008 ]


Effective Date of Rule: Thirty-one days after filing.

Purpose: The department is amending rules to comply with the provisions of chapter 5, Laws of 2007 (2SSB 5093) which authorize medical assistance coverage for all children living in households with income at or below 250% of the federal poverty level (FPL). An emergency rule has been in effect since July 22, 2007, while HRSA completed the permanent rule-making process. When effective, this rule replaces the emergency rule filed [as] WSR 07-23-057.

Citation of Existing Rules Affected by this Order: Amending WAC 388-416-0015, 388-418-0025, 388-450-0210, 388-478-0075, 388-505-0210, 388-505-0211, 388-542-0010, 388-542-0020, 388-542-0050, and 388-542-0300.

Statutory Authority for Adoption: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, and 74.09.700.

Other Authority: Chapter 5, Laws of 2007 (2SSB 5093).

Adopted under notice filed as WSR 07-22-038 on October 30, 2007.

Changes Other than Editing from Proposed to Adopted Version: WAC 388-505-0210 (2)(d), family income is at or below 200% federal poverty level (FPL), as described in WAC 388-478-0075 at each application or review; or

WAC 388-505-0210 (10)(c), they have income that exceeds children's healthcare program standards; or

(d) They are disqualified from receiving premium based children's healthcare coverage as described in subsection (4) of this section because of creditable coverage or nonpayment of premiums.

WAC 388-450-0210(3), unless modified by subsection (4) or (6) of this section,

WAC 388-450-0210 (4)(h), for nonrecurring lump sum payments see chapter 388-455 WAC; and WAC 388-475-0300(4). (Subsections (i) and (ii) removed.)

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 10, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 10, Repealed 0.

Date Adopted: February 7, 2008.

Stephanie E. Schiller

Rules Coordinator

3901.6
AMENDATORY SECTION(Amending WSR 06-24-036, filed 11/30/06, effective 1/1/07)

WAC 388-416-0015   Certification periods for categorically needy (CN) ((medical and state children's health insurance program (SCHIP))) scope of care medical assistance programs.   (1) A certification period is the period of time a person is determined eligible for a categorically needy (CN) scope of care medical program. Unless otherwise stated in this section, the certification period begins on the first day of the month of application and continues to the last day of the last month of the certification period.

(2) For a child eligible for the newborn medical program, the certification period begins on the child's date of birth and continues through the end of the month of the child's first birthday.

(3) For a woman eligible for a medical program based on pregnancy, the certification period ends the last day of the month that includes the sixtieth day from the day the pregnancy ends.

(4) For families the certification period is twelve months with a six-month report required as a condition of eligibility as described in WAC 388-418-0011.

(5) For children, the certification period is twelve months. Eligibility is continuous without regard to changes in circumstances other than aging out of the program, moving out of state, failing to pay a required premium(s), incarceration or death. ((When the medical assistance unit is also receiving benefits under a cash or food assistance program, the medical certification period is updated to begin anew at each:

(a) Approved application for cash or food assistance; or

(b) Completed eligibility review.))

(6) ((For an SSI-related person the certification period is twelve months.

(7))) When the child turns nineteen the certification period ends even if the twelve-month period is not over. The certification period may be extended past the end of the month the child turns nineteen when:

(a) The child is receiving inpatient services (see WAC 388-505-0230) on the last day of the month the child turns nineteen;

(b) The inpatient stay continues into the following month or months; and

(c) The child remains eligible except for exceeding age nineteen.

(((8))) (7) For an SSI-related person the certification period is twelve months.

(8) When the medical assistance unit is also receiving benefits under a cash or food assistance program, the medical certification period is updated to begin anew at each:

(a) Approved application for cash or food assistance; or

(b) Completed eligibility review.

(9) A retroactive certification period can begin up to three months immediately before the month of application when:

(a) The client would have been eligible for medical assistance if the client had applied; and

(b) The client received covered medical services as described in WAC 388-501-0060 and 388-501-0065.

(((9))) (10) If the client is eligible only during the three-month retroactive period, that period is the only period of certification.

(((10))) (11) Any months of a retroactive certification period are added to the designated certification periods described in this section.

(((11))) (12) ((For a child determined eligible for SCHIP medical benefits as described in chapter 388-542 WAC:

(a) The certification periods are described in subsections (1), (5), and (7) of this section;

(b) There is not a retroactive eligibility period as described in subsections (8), (9), and (10); and

(c) For a child who has creditable coverage at the time of application, the certification period begins on the first of the month after the child's creditable coverage is no longer in effect, if:

(i) All other SCHIP eligibility factors are met; and

(ii) An eligibility decision is made per WAC 388-406-0035)) There is no retroactive eligibility for premium-based children's healthcare as described in WAC 388-505-0210 and chapter 388-542 WAC. If creditable coverage exists at the time of application, the certification period begins the month after creditable coverage ends.

[Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. 06-24-036, 388-416-0015, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090, 74.09.530, and 74.09.415. 05-19-031, 388-416-0015, filed 9/12/05, effective 10/13/05. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.04.510, and 2004 c 54. 04-21-064, 388-416-0015, filed 10/18/04, effective 11/18/04. Statutory Authority: RCW 74.08.090, 74.09.530, and 2003 c 10. 04-03-019, 388-416-0015, filed 1/12/04, effective 2/12/04. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.08.090 and 74.09.450. 00-08-002, 388-416-0015, filed 3/22/00, effective 5/1/00. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. 98-16-044, 388-416-0015, filed 7/31/98, effective 9/1/98. Formerly 388-509-0970, 388-521-2105, 388-522-2210 and 388-522-2230.]


AMENDATORY SECTION(Amending WSR 05-23-013, filed 11/4/05, effective 1/1/06)

WAC 388-418-0025   Effect of changes on medical program eligibility.   (1) You continue to be eligible for ((Medicaid)) medical assistance until the department determines your ineligibility or eligibility for another medical program. This applies to you if, during a certification period, you become ineligible for, or are terminated from, or request termination from:

(a) A CN Medicaid program; ((or))

(b) A children's healthcare program; or

(c) Any of the following cash grants:

(i) TANF;

(ii) SSI; or

(iii) GA-X. See WAC 388-434-0005 for changes reported during eligibility review.

(2) If you become ineligible for refugee cash assistance, refugee medical assistance can be continued through the eight-month limit, as described in WAC 388-400-0035(4).

(3) If you receive a TANF cash grant or family medical, you are eligible for a medical extension, as described under WAC 388-523-0100, when your cash grant or family medical program is terminated as a result of:

(a) Earned income; or

(b) Collection of child or spousal support.

(4) A change in income during a certification period does affect eligibility for all medical programs except:

(a) Pregnant women's medical programs;

(b) Children's ((medical for newborns (F05))) healthcare programs, except as specified in subsection (5); or

(c) ((Children's medical benefits (F06);

(d) Children's health program (F08); or

(e))) The first six months of the medical extension benefits.

(5) For a child receiving benefits under ((SCHIP)) the premium-based children's healthcare programs as described in WAC 388-505-0210 and chapter 388-542 WAC, the department must redetermine eligibility for a ((Medicaid)) nonpremium-based medical program when the family reports:

(a) Family income has decreased to less than two hundred percent federal poverty level (FPL);

(b) The child becomes pregnant;

(c) A change in family size; or

(d) The child receives SSI.

[Statutory Authority: RCW 74.08.090, 74.09.530, and 74.09.415. 05-23-013, 388-418-0025, filed 11/4/05, effective 1/1/06. Statutory Authority: RCW 74.08.090, 74.09.530, and 2003 c 10. 04-03-019, 388-418-0025, filed 1/12/04, effective 2/12/04. Statutory Authority: RCW 74.08.090, 74.08A.100, 74.09.080, and 74.09.415. 02-17-030, 388-418-0025, filed 8/12/02, effective 9/12/02. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.08.090 and 74.09.450. 00-08-002, 388-418-0025, filed 3/22/00, effective 5/1/00. Statutory Authority: RCW 74.04.050, 74.04.057 and Section 4731 of the BBA (Public Law 105-33). 99-10-064, 388-418-0025, filed 5/3/99, effective 6/3/99. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. 98-16-044, 388-418-0025, filed 7/31/98, effective 9/1/98. Formerly WAC 388-508-0840, 388-509-0920, 388-509-0960, 388-522-2205 and 388-522-2210.]


AMENDATORY SECTION(Amending WSR 05-23-013, filed 11/4/05, effective 1/1/06)

WAC 388-450-0210   Countable income for medical programs.   (1) For purposes of medical program eligibility, a client's countable income is income which remains when:

(a) The income cannot be specifically excluded; and

(b) All appropriate deductions and disregards allowed by a specific program, have been applied.

(2) A client's countable income cannot exceed the income standard for the specific medical programs described in WAC 388-478-0065, 388-478-0070, 388-478-0075, 388-478-0080, or 388-513-1305, 388-513-1315, or 388-513-1395 unless the program allows for those limits to be exceeded.

(3) Unless modified by subsection (4) or (6) of this section, the TANF/SFA income rules, as described in this chapter, are used to determine a client's countable income for the following programs:

(a) Family medical program as described in WAC 388-505-0220;

(b) Medical extensions as described in chapter 388-523 WAC;

(c) Pregnant women's program as described in WAC 388-462-0015;

(d) Children's ((medical)) healthcare programs as described in WAC 388-505-0210; and

(e) ((Children's health program as described in WAC 388-505-0210; and

(f))) Psychiatric indigent inpatient (PII) program as described in WAC 388-865-0217.

(4) Exceptions to the TANF/SFA cash assistance methodology apply as follows:

(a) The financial responsibility of relatives when a client is applying for medical for families, children, pregnant women or for the psychiatric indigent inpatient program is specified in WAC 388-408-0055;

(b) Actual work-related child and dependent care expenses, which are the client's responsibility, are income deductions (the limits on this deduction in WAC 388-450-0170 (3) and (4) do not apply);

(c) Court or administratively ordered current or back support paid to meet the needs of legal dependents, are income deductions;

(d) Only income actually contributed to an alien client from the alien's sponsor is countable unless the sponsor signed the affidavit of support I-864 or I-864A. See subsection (5) of this section;

(e) TANF/SFA gross earned income limits as described in WAC 388-450-0165 do not apply;

(f) The fifty percent earned income deduction is not used to calculate countable income for CN scope of care programs with income levels based upon the federal poverty level (FPL). These programs are listed in subsections (3)(c)((,)) and (d) ((and (e) of this section)). The only work related income deductions for these programs are:

(i) Ninety dollars; and

(ii) Actual work-related child and dependent care expenses, as described in (b) of this subsection; and

(iii) Child support as described in (c) of this subsection.

(g) When determining medically needy (MN) or MN scope of care coverage for children or pregnant women for the programs described in subsections (3)(c)((,)) and (d), ((and (e),)) the exception described in subsection (4)(f) is not used as the MN income standards are not based on the FPL;

(h) ((A)) For nonrecurring lump sum ((payment is considered as income in the month the client receives payment, and a resource if the client retains the payment after the month of receipt)) payments, see chapter 388-455 WAC and WAC 388-475-0300(4);

(i) Diversion cash assistance (DCA), is not countable income;

(j) Effective April 1, 2002, the department will disregard an increase in earned income when:

(i) A family is receiving benefits under the family medical program; and

(ii) The increase occurs during the second or third month of eligibility. The disregard stops the last day of the third month of eligibility for a family medical program.

(5) When an alien's sponsor has signed the affidavit of support I-864 or I-864A, the sponsor's income and resources are counted as described in WAC 388-450-0155, 388-450-0156, 388-450-0160, and 388-470-0060.

(6) Except when this state has adopted more liberal rules, SSI income rules are used to determine a client's countable income for the following programs:

(a) SSI-related CN or MN; and

(b) Medicare savings programs. Refer to chapter 388-475 WAC.

[Statutory Authority: RCW 74.08.090, 74.09.530, and 74.09.415. 05-23-013, 388-450-0210, filed 11/4/05, effective 1/1/06. Statutory Authority: RCW 74.08.090, 74.08A.100, 74.09.080, and 74.09.415. 02-17-030, 388-450-0210, filed 8/12/02, effective 9/12/02. Statutory Authority: RCW 74.08.090, 74.08A.100, and Title XIX State Plan amendment 00-008. 02-03-009, 388-450-0210, filed 1/4/02, effective 2/4/02. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. 98-16-044, 388-450-0210, filed 7/31/98, effective 9/1/98. Formerly WAC 388-505-0580, 388-505-0590 and 388-519-1910.]


AMENDATORY SECTION(Amending WSR 06-16-026, filed 7/24/06, effective 8/24/06)

WAC 388-478-0075   Medical programs--Monthly income standards based on the federal poverty level (FPL).   (1) Each year, the federal government publishes new federal poverty level (FPL) income standards in the Federal Register found at http://aspe.hhs.gov/poverty/index.shtml. The income standards for the following medical programs change on the first of April every year based on the new FPL:

(a) ((Children's health program is one hundred percent of FPL;

(b))) Pregnant women's program up to one hundred eighty-five percent of FPL;

(((c))) (b) Children's ((categorically needy)) healthcare programs up to two hundred percent of FPL;

(((d))) (c) Healthcare for workers with disabilities (HWD) up to two hundred twenty percent of FPL; and

(((e) The state children's health insurance program (SCHIP) is)) (d) Premium-based coverage under the children's healthcare programs over two hundred percent of FPL but not over two hundred fifty percent of FPL.

(2) The department uses the FPL income standards to determine:

(a) The mandatory or optional Medicaid status of an individual; and

(b) Premium amount, if any, for a ((Medicaid)) child.

(3) There are no resource limits for the programs under this section.

[Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500 and 42 U.S.C. 9902(2). 06-16-026, 388-478-0075, filed 7/24/06, effective 8/24/06. Statutory Authority: RCW 74.08.090, 74.09.415, 74.09.530 and 2005 c 279. 06-03-080, 388-478-0075, filed 1/12/06, effective 2/12/06. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 42 U.S.C. 9902(2). 05-17-157, 388-478-0075, filed 8/22/05, effective 9/22/05. Statutory Authority: RCW 74.08.090, 74.04.057, 74.04.050, and 74.09.530. 04-15-092, 388-478-0075, filed 7/16/04, effective 8/16/04. Statutory Authority: RCW 74.08.090, 74.04.050, 74.04.057, 74.09.530, and 42 U.S.C. 9902(2). 03-15-088, 388-478-0075, filed 7/17/03, effective 7/17/03. Statutory Authority: RCW 74.08.090, 74.08A.100, 74.09.080, and 74.09.415. 02-17-030, 388-478-0075, filed 8/12/02, effective 9/12/02. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.500, 74.09.510, and Section 1902 (a)(10)(A)(ii)(XV) and (XVI) of the Social Security Act. 02-07-090, 388-478-0075, filed 3/19/02, effective 4/1/02. Statutory Authority: RCW 74.08.090, 74.04.050, 74.04.057, 74.09.530, and Section 673(2) (42 U.S.C. 9902(2)). 01-18-056, 388-478-0075, filed 8/30/01, effective 9/30/01; 00-17-085, 388-478-0075, filed 8/14/00, effective 9/14/00; 99-19-005, 388-478-0075, filed 9/3/99, effective 10/4/99. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. 98-16-044, 388-478-0075, filed 7/31/98, effective 9/1/98. Formerly WAC 388-507-0805, 388-508-0810, 388-509-0910, 388-509-0920, 388-509-0940 and 388-509-0960.]


AMENDATORY SECTION(Amending WSR 05-23-013, filed 11/4/05, effective 1/1/06)

WAC 388-505-0210   Children's ((medical eligibility)) healthcare programs.   (((1) A child under the age of one is eligible for categorically needy (CN) medical assistance when:

(a) The child's mother was eligible for and receiving coverage under a medical program at the time of the child's birth; and

(b) The child remains with the mother and resides in the state.

(2) Children under the age of nineteen are eligible for CN medical assistance when they meet the requirements for:

(a) Citizenship or U.S. national status as defined in WAC 388-424-0001 or "qualified alien" status as described in WAC 388-424-0006 (1) or (4);

(b) State residence as described in chapter 388-468 WAC;

(c) A Social Security number as described in chapter 388-476 WAC; and

(d) Family income does not exceed two hundred percent federal poverty level (FPL) as described in WAC 388-478-0075 at each application or review.

(3) Children under the age of nineteen are eligible for the state children's health insurance program (SCHIP), as described in chapter 388-542 WAC, when:

(a) They meet the requirements of subsection (2)(a), (b), and (c) of this section;

(b) They do not have other creditable health insurance coverage; and

(c) Family income exceeds two hundred percent of the federal poverty level (FPL), but does not exceed two hundred fifty percent of the FPL as described in WAC 388-478-0075.

(4) Children under the age of twenty-one are eligible for CN medical assistance when they meet:

(a) Citizenship or immigrant status, state residence, and social security number requirements as described in subsection (2)(a), (b), and (c) of this section;

(b) Income levels described in WAC 388-478-0075; and

(c) One of the following criteria:

(i) Reside, or are expected to reside, in a medical hospital, intermediate care facility for mentally retarded (ICF/MR), or nursing facility for thirty days or more;

(ii) Reside in a psychiatric or chemical dependency facility for ninety days or more;

(iii) Are in foster care; or

(iv) Receive subsidized adoption services.

(d) For a child meeting the criteria (c)(i) of this subsection, the only parental income the department considers available to the child is the amount the parent chooses to contribute.

(e) For a child meeting the criteria in (c)(ii) of this subsection, parental income is counted as described in WAC 388-408-0055 (1)(c).

(5) Children are eligible for CN medical assistance if they:

(a) Receive Supplemental Security Income (SSI) payments based upon their own disability; or

(b) Received SSI cash assistance for August 1996, and except for the August 1996 passage of amendments to federal disability definitions, would be eligible for SSI cash assistance.

(6) Children under the age of nineteen are eligible for medically needy (MN) medical assistance as defined in chapter 388-500 WAC when they:

(a) Meet citizenship or immigrant status, state residence, and social security number requirements as described in subsection (2)(a), (b), and (c); and

(b) Have income above two hundred fifty percent federal poverty level (FPL) as described in WAC 388-478-0075.

(7) A child is eligible for SSI-related MN when the child:

(a) Meets the blind and/or disability criteria of the federal SSI program or the condition in subsection (5)(b); and

(b) Has countable income above the level described in WAC 388-478-0070(1).

(8) Noncitizen children under the age of eighteen, including visitors or students from another country, undocumented children and "qualified alien" children as defined in WAC 388-424-0001 who are ineligible due to the five-year bar as described in WAC 388-424-0006(3), are eligible for the state-funded children's health program, if:

(a) The department determines the child ineligible for any CN or MN scope of care medical program;

(b) Family income does not exceed one hundred percent federal poverty level (FPL) as described in WAC 388-478-0075;

(c) They meet state residence as described in chapter 388-468 WAC; and

(d) Program limits established by the legislature would not result in an overexpenditure of funds.

(9) There are no resource limits for children under CN, MN, SCHIP, or children's health coverage.

(10) Children may also be eligible for:

(a) Family medical as described in WAC 388-505-0220; or

(b) Medical extensions as described in WAC 388-523-0100.

(11) Except for a client described in subsection (4)(c)(i) and (ii), an inmate of a public institution, as defined in WAC 388-500-0005, is not eligible for CN or MN medical coverage)) Funding for children's healthcare coverage may come through Title XIX (Medicaid) or Title XXI for the Social Security Act (SCHIP), or through state-funded programs. There are no resource limits for children's medical programs, but children must meet the eligibility criteria below to qualify for these programs.

(1) Newborns are eligible for federally matched categorically needy (CN) coverage through their first birthday when:

(a) The child's mother was eligible for and receiving medical assistance at the time of the child's birth; and

(b) The child remains with the mother and resides in the state.

(2) Children under the age of nineteen who are U.S. citizens, U.S. nationals, or qualified aliens as described in WAC 388-424-0001 and WAC 388-424-0006 (1) and (4) are eligible for federally matched CN coverage under children's healthcare programs when they meet the following criteria:

(a) State residence as described in chapter 388-468 WAC;

(b) A social security number or application as described in chapter 388-476 WAC;

(c) Proof of citizenship or immigrant status and identity as required by WAC 388-490-0005(11);

(d) Family income is at or below two-hundred percent federal poverty level (FPL), as described in WAC 388-478-0075 at each application or review; or

(e) They received supplemental security income (SSI) cash payments in August 1996 and would continue to be eligible for those payments except for the August 1996 passage of amendments to federal disability definitions; or

(f) They are eligible for SSI-related CN or MN coverage.

(3) Noncitizen children under the age of nineteen, who do not meet qualified alien status as described in WAC 388-424-0006 (1) or (4), or are ineligible due to the five-year ban as described in WAC 388-424-0006(3), are eligible for state-funded CN coverage under children's healthcare programs when they meet the following criteria:

(a) State residence as described in chapter 388-468 WAC; and

(b) Family income is at or below two hundred percent FPL at each application or review.

(4) Children under the age of nineteen are eligible for premium-based CN coverage under children's healthcare programs as described in chapter 388-542 WAC when they meet the following criteria:

(a) State residence as described in chapter 388-468 WAC;

(b) Family income is over two-hundred percent FPL, as described in WAC 388-478-0075, but not over two-hundred fifty percent FPL at each application or review;

(c) They do not have other creditable health insurance as described in WAC 388-542-0050; and

(d) They pay the required monthly premiums as described in WAC 388-505-0211

(5) Children under age nineteen are eligible for the medically needy (MN) Medicaid program when they meet:

(a) Citizenship or immigrant status, state residence, and social security number requirements as described in subsection (2)(a), (b), and (c); and

(b) They are ineligible for other federal Medicaid programs; and

(c) Meet their spenddown obligation as described in WAC 388-519-0100 and 388-519-0110.

(6) Children under the age of twenty-one who reside or expect to reside in a medical institution, intermediate care facility for the mentally retarded (ICF/MR), hospice care center, nursing home, or psychiatric facility may be eligible for medical coverage. See WAC 388-505-0230 "Family related institutional medical" and WAC 388-513-1320 "Determining institutional status for long-term care."

(7) Children who are in foster care under the legal responsibility of the state, or a federally recognized tribe located within the state, are eligible for federally matched CN Medicaid coverage through the month of their:

(a) Eighteenth birthday;

(b) Twenty-first birthday if children's administration determines they remain eligible for continued foster care services; or

(c) Twenty-first birthday if they were in foster care on their eighteenth birthday and that birthday was on or after July 22, 2007.

(8) Children who receive subsidized adoption services are eligible for federally matched CN Medicaid coverage.

(9) Children under age of nineteen may also be eligible for:

(a) Family medical as described in WAC 388-505-0220;

(b) Medical extensions as described in WAC 388-523-0100; or

(c) SSI-related MN if they:

(i) Meet the blind and/or disability criteria of the federal SSI program, or the condition of subsection (2)(e); and

(ii) Have countable income above the level described in WAC 388-478-0070(1).

(10) Children who are ineligible for other children's healthcare programs due to citizenship or immigrant status requirements may be eligible for the alien emergency medical program (AEM) if they meet the following criteria:

(a) They have a documented emergent medical condition as defined in WAC 388-500-0005;

(b) They meet the other AEM program requirements as described in WAC 388-438-0110; and

(c) They have income that exceeds children's healthcare program standards; or

(d) They are disqualified from receiving premium-based children's healthcare coverage as described in subsection (4) of this section because of creditable coverage or nonpayment of premiums.

(11) Except for a client described in subsection (6), an inmate of a public institution, as defined in WAC 388-500-0005, is not eligible for children's healthcare programs.

[Statutory Authority: RCW 74.08.090, 74.09.530, and 74.09.415. 05-23-013, 388-505-0210, filed 11/4/05, effective 1/1/06. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.08.090. 04-15-057, 388-505-0210, filed 7/13/04, effective 8/13/04. Statutory Authority: RCW 74.08.090 and 74.04.050. 03-14-107, 388-505-0210, filed 6/30/03, effective 7/31/03. Statutory Authority: RCW 74.08.090, 74.08A.100, 74.09.080, and 74.09.415. 02-17-030, 388-505-0210, filed 8/12/02, effective 9/12/02. Statutory Authority: RCW 74.08.090, 74.04.050, [74.04.]055, and [74.04.]057. 01-11-110, 388-505-0210, filed 5/21/01, effective 6/21/01. Statutory Authority: RCW 74.08.090 and 74.08A.100. 99-17-023, 388-505-0210, filed 8/10/99, effective 9/10/99. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. 98-16-044, 388-505-0210, filed 7/31/98, effective 9/1/98. Formerly WAC 388-509-0905, 388-509-0910 and 388-509-0920.]


AMENDATORY SECTION(Amending WSR 04-16-064, filed 7/30/04, effective 8/30/04)

WAC 388-505-0211   Premium requirements for ((SCHIP)) premium-based children's healthcare programs.   (1) For the purposes of this chapter, "premium" means an amount paid for medical coverage.

(2) ((For a child found eligible for the state children's health insurance program (SCHIP) under WAC 388-505-0210(3), payment of a premium is required as a condition of eligibility)) Payment of a premium is required as a condition of eligibility for premium-based children's healthcare coverage, as described in WAC 388-505-0210(4), unless the child is:

(a) Pregnant; or

(b) An American Indian or Alaska native.

(3) ((A child is exempt from the premium requirement if the child meets one of the following:

(a) The child is pregnant; or

(b) The child is an American Indian or Alaska native.

(4))) The premium requirement begins the first of the month following the determination of eligibility. There is no premium requirement for medical coverage received in a month or months before the determination of eligibility.

(((5))) (4) The premium amount for the assistance unit is based on the net available income as described in WAC 388-450-0005. If the household includes more than one assistance unit, the premium amount billed for the assistance units may be different amounts.

(((6))) (5) The premium amount for each ((SCHIP)) eligible child is fifteen dollars per month per child, up to a maximum of forty-five dollars per month, per household.

(((7) The department bills the family for the lesser of:

(a) A maximum of forty-five dollars per month; or

(b) The total of the highest premiums, for up to three children in the assistance unit.

(8) Premium payment is a condition of eligibility for assistance units that include SCHIP children.)) (6) All ((SCHIP)) children in an assistance unit are ineligible for medical coverage when the head of household(('s)) fails to pay required premium payments ((are)) for three consecutive months ((in arrears)). ((Three months in arrears means a balance exists for three months.))

(((9))) (7) When the department terminates the medical coverage of a ((SCHIP)) child due to nonpayment of premiums, the child has a three-month period of ineligibility beginning the first of the following month. The three-month period of ineligibility is rescinded only when the:

(a) Past due premiums are paid in full prior to the begin date of the period of ineligibility; or

(b) ((SCHIP child has a change in circumstances such that)) The child becomes eligible for ((Medicaid)) a nonpremium-based medical program. The department ((cannot)) will not rescind the three-month period of ineligibility for reasons other than the criteria described in this subsection.

(((10))) (8) The department writes off past-due premiums after twelve months.

(((11))) (9) When the designated three-month period of ineligibility is over, all past due premiums that are an obligation of the head of household must be paid or written off before a child can become eligible for ((SCHIP)) premium-based children's healthcare.

(((12))) (10) A family cannot designate partial payment of the billed premium amount as payment for a specific child in the assistance unit. The full ((amount of the)) premium ((bill)) amount is the obligation of the head of household of the assistance unit. A family can decide to request medical coverage only for certain children in the assistance unit, if they want to reduce premium obligation.

(((13))) (11) A change that affects the premium amount is effective the month after the change is reported and processed.

(((14))) (12) A sponsor or other third party may pay the premium on behalf of the child or children in the assistance unit. The premium payment requirement remains the obligation of head of household of the assistance unit. The failure of a sponsor or other third party to pay the premium does not eliminate the:

(a) Establishment of the period of ineligibility described in subsection (((9))) (7) of this section; or

(b) Obligation of the head of household to pay past-due premiums.

[Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.522, 74.09.450, and 2004 c 276. 04-16-064, 388-505-0211, filed 7/30/04, effective 8/30/04. Statutory Authority: RCW 74.08.090, 74.09.055, 2004 c 276. 04-08-125, 388-505-0211, filed 4/7/04, effective 5/8/04.]


AMENDATORY SECTION(Amending WSR 06-15-134, filed 7/19/06, effective 8/19/06)

WAC 388-542-0010   Purpose and scope of ((SCHIP)) premium-based children's healthcare programs.   (((1))) The department administers ((the state children's health insurance program (SCHIP) to provide access to)) premium-based children's healthcare through a combination of state and federal funding sources as described below:

(((a) Medical care for children whose family income exceeds the limit for Medicaid eligibility but is not greater than two hundred fifty percent of the federal poverty level (FPL); and

(b) Prenatal care and medical services for a pregnant woman;

(i) Who is ineligible for Medicaid due to immigration status; and

(ii) Whose family income is at or below one hundred eighty-five percent FPL)) (1) Federally-matched healthcare coverage as authorized by Title XXI of the social security act (SCHIP) and RCW 74.09.450 for citizen and federally qualified immigrant children whose family income is above two hundred percent of the federal poverty level (FPL) but is not above two hundred fifty percent of the FPL.

(2) ((SCHIP is authorized by Title XXI of the Social Security Act and by RCW 74.09.450)) State funded healthcare coverage for noncitizen children with family income above two hundred percent FPL, but not above two hundred fifty percent FPL, who are ineligible for Title XXI federally matched children's healthcare coverage due to immigration issues.

[Statutory Authority: RCW 74.08.090, 74.09.050, and Title XXI of the Social Security Act. 06-15-134, 388-542-0010, filed 7/19/06, effective 8/19/06. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.522, 74.09.450, and 2004 c 276. 04-16-064, 388-542-0010, filed 7/30/04, effective 8/30/04.]


AMENDATORY SECTION(Amending WSR 06-07-014, filed 3/3/06, effective 4/3/06)

WAC 388-542-0020   Other rules that apply to ((SCHIP)) premium-based children's healthcare programs.   In addition to the rules of this chapter, ((SCHIP)) premium-based children's healthcare clients are subject to the following rules:

(1) Chapter 388-538 WAC, Managed care (except WAC 388-538-061, 388-538-063, and 388-538-065) if the child is covered under federally matched CN coverage;

(2) WAC 388-505-0210 (((3) and (8))) (4), Children's ((medical)) healthcare program eligibility;

(3) WAC 388-505-0211, Premium requirements for ((SCHIP children)) premium-based children's healthcare programs;

(4) WAC 388-416-0015(((10))) (12), Certification periods for categorically needy (CN) scope of care medical assistance programs; and

(5) WAC 388-418-0025 (((4) and (5))), ((Change of circumstance)) Effect of changes on medical program eligibility.

[Statutory Authority: RCW 74.08.090 and 74.09.522. 06-07-014, 388-542-0020, filed 3/3/06, effective 4/3/06. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.522, 74.09.450, and 2004 c 276. 04-16-064, 388-542-0020, filed 7/30/04, effective 8/30/04.]


AMENDATORY SECTION(Amending WSR 04-16-064, filed 7/30/04, effective 8/30/04)

WAC 388-542-0050   Definitions for ((SCHIP terms)) premium-based children's healthcare programs.   The following definitions, as well as those found in WAC 388-538-050 and in 388-500-0005 Medical definitions, apply to ((the state children's health insurance program (SCHIP))) premium-based children's healthcare programs.

"Creditable coverage" means most types of public and private health coverage, except Indian health services, that provides access to physicians, hospitals, laboratory services, and radiology services. This term applies to the coverage whether or not the coverage is equivalent to that offered under ((SCHIP)) premium-based children's healthcare programs. "Creditable coverage" is described in 42 U.S.C. Sec. 1397jj.

"Employer-sponsored dependent coverage" means creditable health coverage for dependents offered by a family member's employer or union, for which the employer or union may contribute in whole or part towards the premium. Extensions of such coverage (e.g., COBRA extensions) also qualify as employer-sponsored dependent coverage as long as there remains a contribution toward the premiums by the employer or union.

[Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.522, 74.09.450, and 2004 c 276. 04-16-064, 388-542-0050, filed 7/30/04, effective 8/30/04. Statutory Authority: RCW 74.09.080, 74.08.510, [74.08.]522, 74.09.450, 1115 Waiver, 42 U.S.C. 1396. 02-01-075, 388-542-0050, filed 12/14/01, effective 1/14/02. Statutory Authority: RCW 74.08.090, 74.09.450. 00-07-103, 388-542-0050, filed 3/17/00, effective 4/17/00.]


AMENDATORY SECTION(Amending WSR 04-16-064, filed 7/30/04, effective 8/30/04)

WAC 388-542-0300   Waiting period for ((SCHIP)) premium-based healthcare programs coverage following employer coverage.   (1) The ((medical assistance administration (MAA))) department requires applicants to serve a waiting period of four full consecutive months before ((SCHIP)) receiving premium-based children's healthcare programs coverage if the client or family:

(a) Chooses to end employer sponsored dependent coverage. The waiting period begins the day after the employment-based coverage ends; or

(b) Fails to exercise an optional coverage extension (e.g., COBRA) that meets the following conditions. The waiting period begins on the day there is a documented refusal of the coverage extension when the extended coverage is:

(i) Subsidized in part or in whole by the employer or union;

(ii) Available and accessible to the applicant or family; and

(iii) At a monthly cost to the family meeting the limitation of subsection (2)(b)(iv).

(2) ((MAA)) The department does not require a waiting period prior to ((SCHIP)) coverage under premium-based children's healthcare programs when:

(a) The client or family member has a medical condition that, without treatment, would be life-threatening or cause serious disability or loss of function; or

(b) The loss of employer-sponsored dependent coverage is due to any of the following:

(i) Loss of employment with no post-employment subsidized coverage as described in subsection (1)(b);

(ii) Death of the employee;

(iii) The employer discontinues employer-sponsored dependent coverage;

(iv) The family's total out-of-pocket maximum for employer-sponsored dependent coverage is fifty dollars per month or more;

(v) The plan terminates employer-sponsored dependent coverage for the client because the client reached the maximum lifetime coverage amount;

(vi) Coverage under a COBRA extension period expired;

(vii) Employer-sponsored dependent coverage is not reasonably available (e.g., client would have to travel to another city or state to access care); or

(viii) Domestic violence caused the loss of coverage for the victim.

[Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.522, 74.09.450, and 2004 c 276. 04-16-064, 388-542-0300, filed 7/30/04, effective 8/30/04. Statutory Authority: RCW 74.09.080, 74.08.510, [74.08.]522, 74.09.450, 1115 Waiver, 42 U.S.C. 1396. 02-01-075, 388-542-0300, filed 12/14/01, effective 1/14/02. Statutory Authority: RCW 74.08.090, 74.09.450. 00-07-103, 388-542-0300, filed 3/17/00, effective 4/17/00.]

Washington State Code Reviser's Office