WSR 98-15-066

PERMANENT RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES

(Medical Assistance Administration)

[Filed July 13, 1998, 1:35 p.m., effective July 30, 1998]

Date of Adoption: July 13, 1998.

Purpose: These rules implement state and federal legislation concerning welfare and immigration reform as it impacts eligibility for medical programs. These rules have also been rewritten to meet the intent of the Governor's Executive Order 97-02. Adds a new section WAC 388-510-1005.

Citation of Existing Rules Affected by this Order: Amending WAC 388-500-0005, 388-503-0310, 388-505-0520, 388-507-0740, 388-510-1020, and 388-523-2305.

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

Other Authority: RCW 74.04.005, 74.08.331, 74.08A.010, [74.08A.]100, [74.08A.]210, [74.08A.]230, 74.09.510, 74.12.255, Public Law 104-193 (1997) and the Balanced Budget Act [of] 1997.

Adopted under notice filed as WSR 98-08-081 on April 1, 1998.

Changes Other than Editing from Proposed to Adopted Version: WAC 388-500-0005, editorial change in the definition of "nursing facility." Added cross-references in the definition of "categorically needy."

WAC 388-503-0310(13), added clarifying language concerning medical extensions.

WAC 388-503-0310(21), added clarifying language concerning a child eligible for SSI on August 22, 1996.

WAC 388-507-0740, added language concerning state family assistance (SFA) and SFA-related persons.

WAC 388-523-2305, added language concerning SFA and SFA-related persons.

These changes from the proposed language to the adopted versions were made based on public comments.

These changes were recommended to reflect intended medical assistance administration policy. Changes other than editorial were necessary to clarify that certain rules apply both to temporary assistance for needy families (TANF) and to state family assistance (SFA).

Number of Sections Adopted in Order to Comply with Federal Statute: New 1, amended 6, repealed 0; Federal Rules or Standards: New 0, amended 0, repealed 0; or Recently Enacted State Statutes: New 1, amended 6, repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, amended 0, repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, amended 0, repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, amended 0, repealed 0.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 1, amended 6, repealed 0.

Other Findings Required by Other Provisions of Law as Precondition to Adoption or Effectiveness of Rule: The department is required to implement, and comply with, state and federal welfare legislation by August 1, 1997. These rules have been in effect on an emergency basis which will expire on July 30, 1998.

Effective Date of Rule: July 30, 1998.

July 13, 1998

Marie Myerchin-Redifer, Manager

Rules and Policies Assistance Unit

AMENDATORY SECTION (Amending Order 3913, filed 10/25/95, effective 10/28/95)

WAC 388-500-0005  Medical definitions. Unless defined in this chapter or ((specifically defined)) in other chapters of the Washington Administrative Code, ((the department shall)) use definitions found in the Webster's New World Dictionary. This section contains definitions of words and phrases the department uses in rules for medical programs. Definitions of words used for both medical and financial programs are defined under WAC 388-22-030.

(("Application" for eligibility for medical programs means a written request to the department of social and health services (DSHS) on a department form, from the applicant, an authorized representative, or if the applicant is incompetent or incapacitated, someone acting responsibly for the applicant.

"Assignment Medicare" means the method by which the provider receives payment for services under Part B of Medicare.))

"Assignment of rights" means the client gives the state the right to payment and support for medical care from a third party.

(("Assistance unit" means a person or members of a family unit who are eligible for medical care.

"Authorization" means official approval for department action.))

"Base period" means the time period used in the limited casualty program which corresponds with the months considered for eligibility.

"Beneficiary" means an eligible person who receives:

* A federal cash Title XVI benefit; and/or

* State supplement under Title XVI; or

* Benefits under Title XVIII of the Social Security Act.

"Benefit period" means the time period used in determining whether Medicare can pay for covered Part A services. A benefit period begins the first day a beneficiary is furnished inpatient hospital or extended care services by a qualified provider. The benefit period ends when the beneficiary has not been an inpatient of a hospital or other facility primarily providing skilled nursing or rehabilitation services for sixty consecutive days. There is no limit to the number of benefit periods a beneficiary may receive. Benefit period also means a "spell of illness" for Medicare payments.

"Cabulance" means a ((for-hire)) vehicle for hire designed and used to transport a physically restricted person ((confined to a wheelchair or persons otherwise physically restricted)).

"Carrier" means:

* An organization contracting with the federal government to process claims under Part B of Medicare; or

* A health insurance plan contracting with the department.

"Categorical assistance unit (CAU)" means one or more family members whose eligibility for medical care is determined separately or together based on categorical relatedness.

"Categorically needy" means the status of a person who is eligible for medical care under Title XIX of the Social Security Act ((and is:

* A client receiving or eligible to receive cash assistance under:

* Aid to families with dependent children (AFDC);

* Supplemental security income (SSI), including a client grandfathered person and a person with an essential spouse:

* State supplement;

* Continuing state-funded cash assistance who is blind or disabled under SSI criteria, as described under WAC 388-511-1105; or

* Special categories.

* A financially eligible person under twenty-one years of age who would be eligible for AFDC but does not qualify as a dependent child and who is in:

* Foster care;

* Subsidized adoption;

* A nursing facility or intermediate care facility for mentally retarded; or

* An approved inpatient psychiatric facility.

* A person who would be eligible for cash assistance except for the person's institutional status.

* A person who is SSI categorically related and would not be eligible for cash assistance if the person was not institutionalized and whose gross income does not exceed the three hundred percent SSI benefit cap.

* A qualified severely impaired disabled person under sixty-five years of age who works.

* A person during a temporary period who lost AFDC because of increased earnings, increased hours, loss of earned income disregards, or by receiving child or spousal support payments.

* A pregnant woman:

* Who meets AFDC financial eligibility standards;

* Who would qualify for AFDC if the baby was already born;

* Whose family income does not exceed one hundred eighty-five percent of the federal poverty level; or

* Who was eligible for and receiving Medicaid while pregnant continues to be eligible through a sixty-day postpartum period that extends through the month that contains the sixtieth day after birth.

* An infant until the infant's first birthday when the infant lives with the mother and the mother was Medicaid eligible at the time the infant was born;

* An infant under one year of age whose family income does not exceed one hundred eighty-five percent of the federal poverty level;

* A child under six years of age or until the child is no longer an inpatient if the inpatient stay began before six years of age and whose family income does not exceed one hundred thirty-three percent of the federal poverty level.

* A child born after September 30, 1983, who has attained six years of age or until the child is no longer an inpatient if the inpatient stay began before eighteen years of age, but not attained eighteen years of age whose family income does not exceed one hundred percent of the federal poverty level.

* A child up to eighteen years of age or until the child is no longer an inpatient if the inpatient stay began before eighteen years of age, born before September 30, 1983, with income allowed by AFDC.

* A certain widow, widower, and other qualified person who fails to meet SSI standards because of Social Security coverage or increase in Social Security coverage.

* A Medicare-eligible person whose income does not exceed one hundred percent of the federal poverty level and whose resources do not exceed twice the SSI resource eligibility level.

* A disabled working person entitled to enroll in Medicare Part A, whose income does not exceed two hundred percent of the federal poverty level and whose resources do not exceed twice the SSI resource eligibility level.

* An alien as defined under WAC 388-510-1020; or

* A person whose categorical eligibility is protected by statute)). See WAC 388-503-0310, chapter 388-517 WAC and WAC 388-523-2305.

"Children's health program" means a state-funded medical program for children under age eighteen ((years of age)):

* Whose family income does not exceed one hundred percent of the federal poverty level; and

* Who are not otherwise eligible under Title XIX of the Social Security Act.

(("Client" means an applicant for or recipient of DSHS medical care programs.))

"Coinsurance-Medicare" means the portion of reimbursable hospital and medical expenses, after subtraction of any deductible, which Medicare does not pay. Under Part A, coinsurance is a per day dollar amount. Under Part B, coinsurance is twenty percent of reasonable charges.

"Community services office (CSO)" means an office of the department which administers social and health services at the community level.

(("Copayment" means a fixed dollar amount that is the responsibility of the client.))

"Couple" means, for the purposes of an SSI-related client, an SSI-related client living with a person of the opposite sex and both presenting themselves to the community as husband and wife. The department shall consider the income and resources of such couple as if the couple were married except when determining institutional eligibility.

"Deductible-Medicare" means an initial specified amount that is the responsibility of the client.

* "Part A of Medicare-inpatient hospital deductible" means an initial amount of the medical care cost in each benefit period which Medicare does not pay.

* "Part B of Medicare-physician deductible" means an initial amount of Medicare Part B covered expenses in each calendar year which Medicare does not pay.

"Delayed certification" means ((a)) department approval of a person's eligibility for medicaid made after the established application processing time limits.

"Department" means the state department of social and health services.

"Early and periodic screening, diagnosis and treatment (EPSDT)" also known as the "healthy kids" program, means a program providing early and periodic screening, diagnosis and treatment to persons under twenty-one years of age who are eligible for Medicaid or the children's health program.

"Electronic fund transfers (EFT)" means automatic bank deposits to a client's or provider's account.

"Emergency medical condition" means the sudden onset of a medical condition (including labor and delivery) manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:

* Placing the patient's health in serious jeopardy;

* Serious impairment to bodily functions; or

* Serious dysfunction of any bodily organ or part.

"Emergency medical expense requirement" means a specified amount of expenses for ambulance, emergency room or hospital services, including physician services in a hospital, incurred for an emergency medical condition that a client must incur prior to certification for the medically indigent program.

"Essential spouse" see "spouse."

"Extended care patient" means a recently hospitalized Medicare patient needing relatively short-term skilled nursing and rehabilitative care in a skilled nursing facility.

"Garnishment" means withholding an amount from earned or unearned income to satisfy a debt or legal obligation.

"Grandfathered client" means:

* A noninstitutionalized person who meets all current requirements for Medicaid eligibility except the criteria for blindness or disability; and

* Was eligible for Medicaid in December 1973 as blind or disabled whether or not the person was receiving cash assistance in December 1973; and

* Continues to meet the criteria for blindness or disability and other conditions of eligibility used under the Medicaid plan in December 1973; and

* An institutionalized person who was eligible for Medicaid in December 1973 or any part of that month, as an inpatient of a medical institution or resident of an intermediate care facility that was participating in the Medicaid program and for each consecutive month after December 1973 who:

* Continues to meet the requirements for Medicaid eligibility that were in effect under the state's plan in December 1973 for institutionalized persons; and

* Remains institutionalized.

(("Health insuring organization (HIO)" means an entity that arranges and pays for medical services provided to an eligible enrolled client in exchange for a premium or subscription charge paid by the department on a prepaid capitation risk basis.))

"Health maintenance organization (HMO)" means an entity ((that)) licensed by the office of the insurance commissioner to provide((s)) comprehensive medical services directly to an eligible enrolled client in exchange for a premium paid by the department on a prepaid capitation risk basis.

"Healthy kids," see "EPSDT."

"Home health agency" means an agency or organization certified under Medicare to provide comprehensive health care on a part-time or intermittent basis to a patient in the patient's place of residence.

"Hospital" means an institution licensed as a hospital by the ((official state licensing authority)) department of health.

"Income for an SSI-related client," means((, for an SSI-related client,)) the receipt by an individual of any property or service which the client can apply either directly, by sale, or conversion to meet the client's basic needs for food, clothing, and shelter.

* "Earned income" means gross wages for services rendered and/or net earnings from self-employment. ((Earned income received at predictable intervals other than monthly or in unequal amounts will be converted to a monthly basis. If income is weekly, the amount is multiplied by 4.3 to arrive at a monthly figure.))

* "Unearned income" means all other income.

"Institution" means an establishment which furnishes food, shelter, medically-related services, and medical care to four or more persons unrelated to the proprietor. This includes medical facilities, nursing facilities, and institutions for the mentally retarded((, but does not include correctional institutions)).

* "Institution-public" means an institution, including a correctional institution that is the responsibility of a governmental unit or over which a governmental unit exercises administrative control.

* "Institution for mental diseases" means an institution primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases including medical attention, nursing care, and related services.

* "Institution for the mentally retarded or a person with related conditions" means an institution that:

* Is primarily for the diagnosis, treatment or rehabilitation of the mentally retarded or a person with related conditions; and

* Provides, in a protected residential setting, on-going care, twenty-four hour supervision, evaluation, and planning to help each person function at the greatest ability.

* "Institution for tuberculosis" means an institution for the diagnosis, treatment, and care of a person with tuberculosis.

* "Medical institution" means an institution:

* Organized to provide medical care, including nursing and convalescent care;

* With the necessary professional personnel, equipment and facilities to manage the health needs of the patient on a continuing basis in accordance with acceptable standards;

* Authorized under state law to provide medical care; and

* Staffed by professional personnel. Services include adequate physician and nursing care.

"Intermediary" means an organization having an agreement with the federal government to process Medicare claims under Part A.

"Legal dependent" means a person for whom another person is required by law to provide support.

"Limited casualty program (LCP)" means a medical care program for medically needy, as defined under WAC 388-503-0320 and for medically indigent, as defined under WAC 388-503-0370.

"Medicaid" means the federal aid Title XIX program under which medical care is provided to persons eligible for:

* Categorically needy program as defined in WAC 388-503-0310 and ((388-503-1105)) 388-511-1105; or

* Medically needy program as defined in WAC 388-503-0320.

"Medical assistance." ((means the federal aid Title XIX program under which medical care is provided to the categorically needy as defined in WAC 388-503-0310 and 388-503-1105.)) See "Medicaid."

"Medical assistance administration (MAA)" means the unit within the department of social and health services authorized to administer the Title XIX Medicaid and the state-funded medical care programs.

"Medical assistance unit (MAU)" means one or more family members whose eligibility for medical care is determined separately or together based on financial responsibility.

"Medical care services" means the limited scope of care financed by state funds and provided to general assistance (GAU) and ADATSA clients.

"Medical consultant" means a physician employed by the department.

"Medical facility" see "Institution."

"Medically indigent (MI)" means a state-funded medical program((, part of the limited casualty program,)) for a person ((with limited income and resources)) who has an emergency medical condition requiring hospital-based services.

"Medically necessary" is a term for describing requested service which is reasonably calculated to prevent, diagnose, correct, cure, alleviate or prevent worsening of conditions in the client that endanger life, or cause suffering or pain, or result in an illness or infirmity, or threaten to cause or aggravate a handicap, or cause physical deformity or malfunction((, and)). There is no other equally effective, more conservative or substantially less costly course of treatment available or suitable for the client requesting the service. For the purpose of this section, "course of treatment" may include mere observation or, where appropriate, no treatment at all.

"Medically needy (MN)" is the status of a person who is eligible for a federally matched medical program under Title XIX of the Social Security Act, who, but for income ((and/or resources)) above the categorically needy level, would be eligible as categorically needy. Effective January 1, 1996, an AFDC-related adult is not eligible for MN.

"Medicare" means the federal government health insurance program for certain aged or disabled clients under Titles II and XVIII of the Social Security Act. Medicare has two parts:

* "Part A" covers the Medicare inpatient hospital, post-hospital skilled nursing facility care, home health services, and hospice care.

* "Part B" is the supplementary medical insurance benefit (SMIB) covering the Medicare doctor's services, outpatient hospital care, outpatient physical therapy and speech pathology services, home health care, and other health services and supplies not covered under Part A of Medicare.

"Medicare assignment" means the method by which the provider receives payment for services under Part B of Medicare.

"Month of application" means the calendar month a person files the application for medical care ((unless)). When the application is for the medically needy program, ((then,)) at the person's request and if the application is filed in the last ten days of that month, the month of application may be the following month.

"Nursing facility" means any institution or facility the department licenses as a nursing facility, or a nursing facility unit of a licensed hospital, that the:

* Department certifies; and

* Facility and the department agree the facility may provide skilled nursing facility care.

"Outpatient" means a nonhospitalized patient receiving care in a hospital outpatient or hospital emergency department, or away from a hospital such as in a physician's office, the patient's own home, or a nursing facility.

"Patient transportation" means client transportation to and from covered medical services under the federal Medicaid and state medical care programs.

"Physician" means a doctor of medicine, osteopathy, or podiatry who is legally authorized to perform the functions of the profession by the state in which the services are performed.

"Professional activity study (PAS)" means a compilation of inpatient hospital data ((by diagnosis and age)), conducted by the commission of professional and hospital activities, to determine the average length of hospital stay for patients. ((These data were published in a book entitled, Length of Stay in PAS Hospitals, Western. The department has adopted this book as the basis for authorizing payment for the maximum number of inpatient hospital days for clients of state-funded programs, or where no memorandum of understanding with a professional review organization (PRO) exists.))

"Professional review organization for Washington (PRO-W)" means the state level organization responsible for determining whether health care activities:

* Are medically necessary;

* Meet professionally acceptable standards of health care; and

* Are appropriately provided in an outpatient or institutional setting for beneficiaries of Medicare and clients of Medicaid and maternal and child health.

"Prosthetic devices" means replacement, corrective, or supportive devices prescribed by a physician or other licensed practitioner of the healing arts within the scope of his or her practice as defined by state law to:

* Artificially replace a missing portion of the body;

* Prevent or correct physical deformity or malfunction; or

* Support a weak or deformed portion of the body.

"Provider" or "provider of service" means an institution, agency, or person:

* ((Having)) Who has a signed agreement with the department to furnish medical care ((and)), goods, and/or services to clients; and

* Is eligible to receive payment from the department.

"Resources for an SSI-related client," ((mean, for an SSI-related client,)) means cash or other liquid assets or any real or personal property that an individual or spouse, if any, owns and could convert to cash to be used for support or maintenance.

* If an individual can reduce a liquid asset to cash, it is a resource.

* If an individual cannot reduce an asset to cash, it is not considered an available resource.

* Liquid ((-)) means properties that are in cash or are financial instruments which are convertible to cash such as, but not limited to, cash ((in hand, stocks)), savings, checking accounts, stocks, mutual fund shares, mortgage, or a promissory note((s)).

* Nonliquid ((-)) means all other property both real and personal ((shall be)) evaluated ((according to)) at the price the item can reasonably be expected to sell for on the open market ((in the particular geographical area involved)).

"((Retroactivity)) Retroactive period" means the ((period of no more than)) three calendar months before the month of application ((month of an otherwise eligible person under the Federal aid Title XIX program)).

"Spell of illness" see "benefit period."

"Spenddown" means the process by which a person uses incurred medical expenses to offset income and/or resources to meet the financial standards established by the department.

"Spouse" means:

* "Community spouse" means a person living in the community and married to an institutionalized person or to a person receiving services from a home and community-based waivered program as described under chapter 388-515 WAC.

* "Eligible spouse" means an aged, blind or disabled husband or wife of an SSI-eligible person, with whom such ((spouse)) a person lives.

* "Essential spouse" means, ((for the purposes of SSI,)) a ((spouse)) husband or wife whose needs were taken into account in determining ((the need of an)) old age assistance (OAA), aid to the blind (AB), or disability assistance (DA) client for December 1973, who continues to live in the home and to be the spouse of such client.

* "Ineligible spouse" means the husband or wife of an SSI-eligible person, who lives with the SSI-eligible person and who has not applied or is not eligible to receive SSI.

* "Institutionalized spouse" means a married person in an institution or receiving services from a home or community-based waivered program.

* "Nonapplying spouse" means ((the)) an SSI-eligible person's husband or wife, who has not applied for assistance((, of an SSI-eligible person)).

"SSI-related" means an aged, blind or disabled person not receiving an SSI cash grant.

(("State office or SO" means the medical assistance administration of the department of social and health services.))

"Supplemental security income (SSI) program, Title XVI" means the federal grant program for aged, blind, and disabled established by section 301 of the Social Security amendments of 1972, and subsequent amendments, and administered by the Social Security Administration (SSA).

"Supplementary payment (SSP)" means the state money payment to persons receiving benefits under Title XVI, or who would, but for the person's income, be eligible for such benefits, as assistance based on need in supplementation of SSI benefits. This payment includes:

* "Mandatory state supplement" means the state money payment to a person who, for December 1973, was a client receiving cash assistance under the department's former programs of old age assistance, aid to the blind and disability assistance; and

* "Optional state supplement" means the elective state money payment to a person eligible for SSI benefits or who, except for the level of the person's income, would be eligible for SSI benefits.

"Third party" means any entity that is or may be liable to pay all or part of the medical cost of care of a ((federal Medicaid or state)) medical ((care)) program client.

"Title XIX" is the portion of the federal Social Security Act that authorizes grants to states for medical assistance programs. Title XIX is also called Medicaid.

"Transfer" means any act or omission to act when title to or any interest in property is assigned, set over, or otherwise vested or allowed to vest in another person; including delivery of personal property, bills of sale, deeds, mortgages, pledges, or any other instrument conveying or relinquishing an interest in property. Transfer of title to a resource occurs by:

* An intentional act or transfer; or

* Failure to act to preserve title to the resource.

"Value-fair market for an SSI-related person" means((, for SSI-related medical eligibility,)) the current value of a resource at the ((going)) price for which the resource can reasonably be expected to sell on the open market ((in the particular geographic area involved)).

"Value of compensation received" means, for SSI-related medical eligibility, the gross amount paid or agreed to be paid by the purchaser of a resource.

"Value-uncompensated" means, for SSI-related medical eligibility, the fair market value of a resource, minus the amount of compensation received in exchange for the resource.

[Statutory Authority: RCW 74.08.090. 95-22-039 (Order 3913, #100246), § 388-500-0005, filed 10/25/95, effective 10/28/95; 94-10-065 (Order 3732), § 388-500-0005, filed 5/3/94, effective 6/3/94. Formerly parts of WAC 388-80-005, 388-82-006, 388-92-005 and 388-93-005.]

Reviser's note: The typographical error in the above section occurred in the copy filed by the agency and appears in the Register pursuant to the requirements of RCW 34.08.040.

Reviser's note: RCW 34.05.395 requires the use of underlining and deletion marks to indicate amendments to existing rules. The rule published above varies from its predecessor in certain respects not indicated by the use of these markings.

AMENDATORY SECTION (Amending WSR 97-03-036, filed 1/9/97, effective 2/9/97)

WAC 388-503-0310  Categorically needy eligible persons. ((The department shall determine)) A person eligible for categorically needy medical assistance ((a client who)) is:

(1) Not eligible for or receiving temporary assistance for needy families (TANF) cash benefits but who meets the eligibility criteria for aid to families with dependent children (AFDC) that were in effect on July 16, 1996 except the person's:

(a) Earned income is treated as described under WAC 388-507-0740; and

(b) Resources are treated as described under WAC 388-505-0580.

This group shall include, but is not limited to, the special situations described under WAC 388-507-0740.

(2) Receiving or eligible to receive a cash assistance payment under:

(a) ((Aid to families with dependent children ())TANF. For the purpose of determining eligibility for a medical program, any reference to AFDC(())) includes TANF; or

(b) Supplemental security income (SSI) including a grandfathered person and a person with an essential spouse; or

(c) State supplemental payment (SSP) to a person as assistance based on need in supplementation of SSI benefits. This payment includes mandatory state supplement or optional state supplement as defined under WAC 388-500-0005. The ineligible spouse of an SSI beneficiary receiving a state supplement payment for the ineligible spouse is not eligible for noninstitutional categorically needy medical assistance.

(((2))) (3) A person twenty years of age or younger who ((meets the)):

(a) Meets the one-person ((AFDC)) TANF financial requirements and is in:

(i) ((Foster care; or

(ii) Subsidized adoption; or

(iii))) A nursing facility or intermediate care facility for mentally retarded (ICF/MR); or

(((iv))) (ii) An approved inpatient psychiatric facility.

(b) ((Eligibility requirements under chapter 388-509 WAC)) Is in foster care; or

(c) Receives subsidized adoption.

(((3))) (4) A current client of Title II, Social Security Administration (SSA) benefits who:

(a) Was a concurrent client of Title II and SSI benefits;

(b) Is ineligible for SSI benefits and/or state supplementary payments; and

(c) Would be eligible for SSI benefits if the department deducts the following from the current Title II benefit amount:

(i) All Title II cost-of-living benefit increases under P.L. 94-566, Section 503 received by the client since termination from SSI/SSP; and

(ii) All Title II cost-of-living benefit increases received during the time period in subsection (((3))) (4)(c)(i) of this section by the client's spouse and/or other financially responsible family member living in the same household.

(((4))) (5) An SSI client, after January 1, 1981, who continues to be eligible for medical assistance under P.L. 96-265 and 99-643;

(((5))) (6) A currently disabled client receiving widow's or widower's benefits under Section 202 (e) or (f) of the Social Security Act if the disabled client:

(a) Was entitled to a monthly insurance benefit under Title II of the Social Security Act for December 1983; ((and))

(b) Was entitled to and received a widow's or widower's benefit based on a disability under Section 202 (e) or (f) of the Social Security Act for January 1984;

(c) Became ineligible for SSI/SSP in the first month in which the increase provided under Section 134 of P.L. 98-21 was paid to the client;

(d) Has been continuously entitled to a widow's or widower's benefit under Section 202 (e) or (f) of the act;

(e) Would be eligible for SSI/SSP benefits if the amount of that increase, and any subsequent cost-of-living increases provided under Section 215(i) of the act, were disregarded;

(f) Is fifty through fifty-nine years of age; and

(g) Filed an application for Medicaid coverage before July 1, 1988.

(((6) Effective January 1, 1991,))

(7) Any person receiving Title II disabled widow/widower benefits (DWB) under Section 202 (e) or (f) of the SSA, if the person:

(a) Is not eligible for the hospital insurance benefits under Medicare Part A of Title XVIII;

(b) Received SSI/SSP payments in the month before receiving such Title II benefits;

(c) Became ineligible for SSI/SSP due to receipt of or increase in such Title II benefits; and

(d) Would be eligible for SSI/SSP if the amount of such Title II benefits or increase in such Title II benefits under Section 202 (e) or (f) of the SSA, and any subsequent cost-of-living increases provided under Section 215(i) of the act were disregarded.

(((7))) (8) A disabled or blind client receiving Title II Disabled Adult Childhood (DAC) benefits under Section 202(d) of the SSA if the client:

(a) Has attained eighteen years of age;

(b) Lost SSI/SSP on or after July 1, 1988, due to receipt of or increase in DAC benefits; and

(c) Would be eligible for SSI/SSP if the amount of the DAC benefits or increase under Section 202(d) of the SSA and any subsequent cost-of-living increases provided under Section 215(i) of the SSA Act were disregarded.

(((8))) (9) A client who:

(a) In August 1972, received:

(i) Old age assistance (OAA);

(ii) Aid to blind (AB);

(iii) Aid to families with dependent children (AFDC); or

(iv) Aid to the permanently and totally disabled (APTD); ((and))

(b) Was entitled to or received retirement, survivors, and disability insurance (RSDI) benefits; or

(c) Is ineligible for OAA, AB, AFDC, SSI or APTD solely because of the twenty percent increase in Social Security benefits under P.L. 92-336.

(((9))) (10) A pregnant woman whose family income is at or below one hundred eighty-five percent of the Federal Poverty Level (FPL), or postpartum woman as described under WAC 388-508-0830;

(((10))) (11) A child, born to a woman eligible for and receiving medical assistance on the date of the child's birth, from the date of birth for a period of one year when the child remains a member of the mother's household;

(((11))) (12) A child ((eighteen years of)) under age ((or younger)) nineteen meeting residence, citizenship, and Social Security number requirements whose countable family income is at or under two hundred percent of the FPL.

(((12) In)) (13) A family ((unit)) member who is ineligible for ((AFDC financial)) medical assistance ((as a result (wholly or in part))) because of the collection or increased collection of child or spousal support ((shall be)). The family is eligible for medical assistance for four months beginning with the month of ineligibility((,)) if the family ((unit)) received ((AFDC financial)) medical assistance in at least three of the six months immediately preceding the month of ineligibility;

(((13) In a family unit which becomes ineligible for AFDC before April 1, 1990, solely because of increased hours or increased income from employment shall remain categorically eligible for medical assistance for four calendar months beginning with the month of ineligibility, provided:

(a) The family received AFDC in at least three of the six months immediately preceding the month of ineligibility; and

(b) A member of such family continues to be employed; and

(c) The department considers earned income tax credits (EITC) as income for the purposes of this subsection.))

(14) Denied ((AFDC)) TANF cash payments solely because of a departmental recovery of an overpayment;

(15) In a medical facility and:

(a) Who would be eligible for cash assistance if the person was not institutionalized; or

(b) Is an SSI-related institutionalized person and has gross income above the cash assistance level but below three hundred percent of the Federal Benefit Rate as defined under WAC 388-250-1700.

(16) Sixty-five years of age or older, a patient in an institution for mental diseases (IMD), and is resource and income eligible as described under subsection (15)(a) or (b) of this section;

(17) ((A person)) Eligible for and accepting hospice services as described under WAC 388-86-047 and who ((shall be)) is:

(a) SSI categorically related with gross income less than three hundred percent of the SSI Federal Benefit Rate; or

(b) AFDC or TANF categorically related.

(18) Blind or presumptively disabled under SSI criteria, as described under WAC 388-511-1105, and the person receives continuing general assistance (GA-X) cash assistance;

(19) An alien ineligible for ((AFDC)) TANF or SSI cash assistance because of deeming of income of the alien's sponsors as described under WAC 388-218-1695;

(20) ((Not an inmate of a public institution;

(21) Not receiving cash assistance because of special situations as defined under WAC 388-507-0740; or

(22))) A client who:

(a) Was entitled to RSDI benefits in August 1972; and

(b) Is ineligible for ((AFDC)) TANF or SSI solely because of the twenty percent increase in Social Security benefits under PL 92-336.

(21) A child who received SSI payments on August 22, 1996, and who, but for the change in disability criteria would continue to be eligible for SSI benefits;

(22) Not an inmate of a public institution.

[Statutory Authority: RCW 74.08.090 and 74.04.050. 97-03-036, § 388-503-0310, filed 1/9/97, effective 2/9/97. Statutory Authority: RCW 74.08.090 and SPA 95-11. 96-12-001 (Order 3981), § 388-503-0310, filed 5/22/96, effective 6/22/96. Statutory Authority: RCW 74.08.090. 94-17-036 (Order 3769), § 388-503-0310, filed 8/10/94, effective 9/10/94; 94-10-065 (Order 3732), § 388-503-0310, filed 5/3/94, effective 6/3/94. Formerly parts of WAC 388-82-010 and 388-82-115.]

AMENDATORY SECTION (Amending Order 3983, filed 6/6/96, effective 7/7/96)

WAC 388-505-0520  Citizenship ((and alien status)). (((1) The department shall provide Medicaid to)) An otherwise eligible person ((who is)) may receive Medicaid when the person is:

(((a))) (1) A citizen or national of the United States; ((or

(b))) (2) A North American Indian born in Canada claiming ((fifty percent)):

(((i))) (a) Fifty percent Indian blood; or

(((ii) Or)) (b) Less than fifty percent Indian blood ((and who)) when the person has maintained United States residency since ((before)) December 25, 1952((.

(c) An alien lawfully admitted for permanent residence or otherwise permanently residing under color of law (PRUCOL) in the United States; or

(d) An alien lawfully present in the United States according to sections 203 (a)(7), 207(c), 208, and 212 (d)(5) of the Immigration and Nationality Act (INA); or

(e) An alien granted lawful temporary residence, or permanent residence according to sections 245(a), 210, 210(f), and 210A of INA and sections 202 and 302 of the Immigration Reform and Control Act (IRCA), unless five years from the date Immigration and Naturalization Service (INS) grants lawful temporary resident status has not passed; or

(f) An alien approved by the INS under the family unity program, unless five years from the date INS grants lawful temporary resident status for the petitioning relative has not passed.

(2) When an alien as described under subsection (1)(e) or (f) of this section has not passed the five-year disqualification period, the department shall provide Medicaid to an otherwise eligible person when the alien is:

(a) Aged, blind, or disabled; or

(b) Seventeen years of age or under; or

(c) Pregnant; or

(d) A Cuban/Haitian entrant as defined in sections 501 (e)(1) and (2)(A) of P.L. 96-422.

(3) When an alien as described under subsection (1)(e) or (f) of this section is still under the five-year disqualification period, and is not described under subsection (2) of this section, the department shall provide medical care and services as necessary for treatment of the alien's emergency medical condition as defined under WAC 388-500-0005.

(4) For any other alien, when such alien meets the eligibility requirements of a Medicaid program other than citizenship or alien status requirements, the department shall provide Medicaid as follows:

(a) Full scope medical services for a pregnant woman; or

(b) Medical care and services as necessary for treatment of the alien's emergency medical condition as defined under WAC 388-500-0005.

(5) Medical care services and children's health programs do not require citizenship/alien status)); or

(3) A noncitizen who is otherwise eligible and who meets provisions described in chapter 388-510 WAC.

[Statutory Authority: RCW 74.08.090. 96-13-002 (Order 3983), § 388-505-0520, filed 6/6/96, effective 7/7/96. Statutory Authority: RCW 74.08.090 and 1995 2nd sp.s. c 18. 95-24-016 (Order 3923), § 388-505-0520, filed 11/22/95, effective 12/23/95. Statutory Authority: RCW 74.08.090. 94-10-065 (Order 3732), § 388-505-0520, filed 5/3/94, effective 6/3/94. Formerly WAC 388-83-015.]

AMENDATORY SECTION (Amending Order 3954, filed 3/13/96, effective 4/13/96)

WAC 388-507-0740  Special situations. (1) ((The department)) A client shall ((not allow the AFDC thirty dollars plus one-third earned income exemption for clients applying solely for medical assistance, unless the conditions under subsection (2) of this section apply)) receive a fifty percent family earned-income exemption and the actual dependent care amount deduction described in WAC 388-505-0590 when the client:

(a) Applies for or receives temporary assistance for needy families (TANF) or state family assistance (SFA) cash benefits;

(b) Applies for or receives TANF-related or SFA-related medical only benefits; or

(c) Is not eligible for or receiving TANF benefits but who meets the eligibility criteria for AFDC that were in effect on July 16, 1996.

This subsection does not apply to a client described in subsection (2) of this section.

(2) ((The department)) A client shall ((allow the exemption in subsection (1) of this section when the family has:

(a) Received AFDC cash assistance in one of the four preceding months; and

(b) Not already received the exemption for a maximum of four consecutive months; or

(c) Already received the exemption for the maximum period, but has subsequently not received AFDC cash assistance for at least twelve consecutive months)) receive a ninety dollar earned-income exemption, and the actual dependent care amount deduction, when a client applies for or receives noncash medical only benefits described under chapter 388-508 WAC, Pregnant women medical eligibility and chapter 388-509 WAC, Children's medical eligibility.

(3) ((The department shall consider an AFDC client terminated from cash assistance as)) A person is eligible for Medicaid ((when termination was solely due to an AFDC client:

(a) Ceasing to attend school; or

(b) Refusing)) if the person:

(a) Would be eligible for, but chooses not to receive, TANF; or

(b) Is not eligible for or receiving TANF solely because the person:

(i) Has received sixty months of financial assistance or is a member of an assistance unit which has received sixty months of financial assistance;

(ii) Is not attending school;

(iii) Refuses to participate in ((the job opportunities and basic skills (jobs) training program)) TANF work activities;

(iv) Is an unmarried minor parent and is not in a department-approved living situation as described under WAC 388-215-1660;

(v) Is a parent or caretaker relative who fails to notify the department within five days of the date the child leaves the home and the child's absence will exceed ninety days as described under WAC 388-215-1115;

(vi) Is a fleeing felon or fleeing to avoid prosecution for a felony charge, or a probation and parole violator;

(vii) Is convicted of a drug-related felony as described under WAC 388-215-1570;

(viii) Is convicted of receiving benefits unlawfully as described under WAC 388-46-110;

(ix) Is convicted of misrepresenting residence to obtain assistance in two or more states as described under WAC 388-46-120; or

(x) Has gross earnings exceeding the TANF gross income standard.

(4) ((The department shall not consider)) A person is eligible for SFA-related medical if the person:

(a) Would be eligible for, but chooses not to receive SFA; or

(b) Is not eligible for, or receiving, SFA solely because of the restrictions in subsection (3)(b) of this section.

(5) Diversion cash assistance, issued under chapter 388-222 WAC, is exempt income when determining eligibility for a medical program.

(6) The following requirements do not apply to a TANF-related or SFA-related family applying for or receiving medical:

(a) Work quarters as described under WAC 388-215-1385; or

(b) Unemployment as described under WAC 388-215-1375.

(7) The transfer of a resource ((when determining)) does not affect the medical program eligibility for a person who is not institutionalized. For an institutionalized client, refer to WAC 388-513-1365.

[Statutory Authority: RCW 74.08.090. 96-07-023 (Order 3954), § 388-507-0740, filed 3/13/96, effective 4/13/96; 94-10-065 (Order 3732), § 388-507-0740, filed 5/3/94, effective 6/3/94.]

SHS-2259:10

NEW SECTION

WAC 388-510-1005  Definitions--Aliens. "Legal immigrant" means an alien residing in the United States who is lawfully present with intent to remain. A legal immigrant includes, but is not limited to, an alien meeting PRUCOL criteria.

"Nonimmigrant" means an alien legally residing in the country but without an intent to remain permanently or who is not lawfully present.

"PRUCOL" means a person permanently residing under color of law.

"Qualified alien" means an alien:

(1) Who is lawfully admitted for permanent residence under the Immigration and Nationality Act (INA) (8 U.S.C. 12, Sec. 101 (a)(20));

(2) Who is a refugee admitted to the United States under section 207 of such Act;

(3) Who is granted asylum under section 208 of Act;

(4) Whose deportation is being withheld under section 243(h) of such Act;

(5) Who is paroled into the United States under section 212 (d)(5) of such Act for a period of at least one year;

(6) Who is granted conditional entry under section 203 (a)(7) of such Act as in effect prior to April 1, 1980;

(7) Who is a victim of domestic violence or an immigrant child that has been battered or subjected to extreme cruelty when:

(a) The immigrant petitions for legal status under section 204(a) of the INA or a petition for suspension of deportation under section 244(a) of the INA; and

(b) The person responsible for the battery no longer resides with the immigrant.

(8) Who is a Cuban or Haitian entrant as defined in section 501(e) of the Refugee Education Assistance Act of 1980; or

(9) Who is an Amerasian immigrant as defined in the Balanced Budget Agreement of 1997.

[]

AMENDATORY SECTION (Amending Order 3732, filed 5/3/94, effective 6/3/94)

WAC 388-510-1020  Alien--Eligibility. ((The department shall provide Medicaid to an otherwise eligible person who meets the criteria as described under WAC 388-505-0520.)) (1) For the purpose of determining eligibility for a medical program, the terms "qualified alien" or "nonqualified alien" indicates the immigration status of the alien, not the eligibility status for a particular medical program.

(2) An alien receiving temporary assistance for needy families (TANF) or Supplemental Security Income (SSI) is eligible for Medicaid.

(3) A qualified alien as described in WAC 388-510-0005 is eligible for categorically needy (CN) Medicaid who:

(a) Arrived in the United States on or before August 21, 1996; and

(b) Is otherwise eligible for a Medicaid program.

(4) A legal immigrant is eligible for state-funded CN scope of care who:

(a) Arrived in the United States on or before August 21, 1996;

(b) Would be eligible for a Medicaid program but for immigration status; and

(c) Does not meet the definition of qualified alien in WAC 388-510-1005.

(5) An alien is eligible for CN Medicaid who:

(a) Arrived in the United States on or after August 22, 1996;

(b) Is otherwise eligible for to a Medicaid program; and

(c) Is a refugee, an asylee, an alien who has had deportation withheld, a Cuban/Haitian or an Amerasian as described in WAC 388-510-1005;

(d) Is an alien who is active duty with the United States military;

(e) Is an honorably discharged veteran of the United States Armed Forces, including the following who fought on behalf of the United States:

(i) Filipino soldiers in World War II;

(ii) Hmong and Lao soldiers during the Vietnam conflict;

(iii) The spouse or unmarried dependent child of a veteran described in subsection (5)(d) or (e) of this section.

(f) Is a qualified alien who has resided in the United States for five years.

(6) A family with child(ren) is eligible for state-funded CN scope of care who:

(a) Arrived in the United States on or after August 22, 1996;

(b) Has resided in Washington for twelve-consecutive months as described under WAC 388-215-1210; and

(c) Is determined eligible for or receiving state family assistance (SFA).

(7) A legal immigrant who does not meet the alien criteria described under subsection (5)(c), (d), (e) or (f) of this section is eligible for state-funded medical care services, as described under WAC 388-529-2930, who:

(a) Arrived in the United States on or after August 22, 1996; and

(b) Is determined eligible for and is receiving financial assistance under the general assistance - unemployable (GA-U) program.

(8) A noncitizen pregnant woman is eligible for state-funded CN scope of care:

(a) Who is not eligible for coverage under a CN Medicaid program;

(b) Regardless of date of arrival into the United States; and

(c) Who would be eligible under chapter 388-508 WAC.

(9) A noncitizen child is eligible for state-funded CN scope of care under the children's health program:

(a) Who is not eligible for coverage under a CN Medicaid program;

(b) Regardless of date of arrival into the United States; and

(c) Who would be eligible under WAC 388-509-0920.

(10) Regardless of the date of arrival into the United States, a noncitizen who meets Medicaid eligibility requirements, other than citizenship, is eligible for emergency medical care and services:

(a) Only for the necessary treatment of an emergency medical condition as defined under WAC 388-500-0005; and

(b) With the exception of routine prenatal or postpartum care or organ transplants as defined in WAC 388-87-115(2).

(11) Refer to chapter 388-518 WAC, Limited casualty program--Medically indigent for a noncitizen who:

(a) Does not meet Medicaid program requirements;

(b) Has an emergency medical condition; or

(c) Requires an organ transplant.

[Statutory Authority: RCW 74.08.090. 94-10-065 (Order 3732), § 388-510-1020, filed 5/3/94, effective 6/3/94.]

AMENDATORY SECTION (Amending Order 3732, filed 5/3/94, effective 6/3/94)

WAC 388-523-2305  Medical extensions. (1) Refer to:

(a) WAC 388-508-0830 for extensions for a pregnant woman; and

(b) WAC 388-508-0835 for the family planning extension.

(2) A family ((unit)) ineligible for ((AFDC cash)) medical assistance or state family assistance (SFA)-related medical because of the collection or increased collection of child or spousal support ((shall be)), is eligible for medical assistance for four months beginning with the month of ineligibility, provided the family ((unit)):

(a) Is eligible for and received ((AFDC cash)) medical assistance or SFA-related medical in three or more of the six months immediately preceding the month of ineligibility; and

(b) Continues to meet all AFDC, or temporary assistance for needy families (TANF), SFA, or related medical eligibility criteria except income.

(3) ((The department shall find eligible for medical assistance, an AFDC)) A family ((unit which becomes)), ineligible for or requesting termination from TANF or SFA medical or cash assistance because of((:

(a))) income from, or hours of, employment of the caretaker relative((; or

(b) The loss of the thirty dollars plus one-third earned income deduction; or

(c) The loss of the thirty-dollar earned income deduction.

Such AFDC family unit as described under (a), (b), or (c) of this subsection)) shall remain eligible for medical assistance for six calendar months when the family ((unit)):

(((i))) (a) Received ((AFDC)) medical assistance or SFA-related medical in three or more of the six months immediately preceding the month of ineligibility; and

(((ii))) (b) Includes a child.

(4) The ((AFDC)) family ((unit)), under subsection (3) of this section, shall be:

(a) Eligible for six additional calendar months of medical assistance or SFA-related medical provided the family ((unit)):

(i) Continues to include a child; and

(ii) Received TANF-related or SFA-related medical ((assistance)) for the entire six-month extension under subsection (3) of this section; and

(iii) Reports any family earnings and child care costs related to the employment of the caretaker relative for the preceding three-month period. The client shall report by the twenty-first day of the fourth month of the initial extension, unless good cause is established.

(b) Terminated from the six additional calendar months of medical assistance when the:

(i) Family's average gross monthly earned income, less the cost of child care related to employment of the caretaker relative, exceeds one hundred eighty-five percent of the Federal Poverty Level when averaged over the immediately preceding three-month period; or

(ii) Caretaker relative has no earnings in one or more of the three previous months, unless lack of earnings is due to good cause.

(5) An AFDC, TANF, or SFA family member shall not be eligible for the extensions in subsections (3) and (4) of this section when the department finds the person ineligible for AFDC, TANF, or SFA in any of the last six months before the extension because of fraud.

[Statutory Authority: RCW 74.08.090. 94-10-065 (Order 3732), § 388-523-2305, filed 5/3/94, effective 6/3/94. Formerly WAC 388-83-029.]

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