Effective Date of Rule: April 1, 2010.

     Purpose: The recent passage of the federal Children's Health Insurance Program Reauthorization Act (CHIPRA) requires the department to amend its rules regarding newborn eligibility for medical assistance. Per clarification from the federal Centers for Medicare and Medicaid Services' (CMS), CHIPRA also requires the elimination of the three-month sanction for nonpayment of the children's health insurance program (CHIP) premium, and allow for medical coverage to be reinstated for all months within the certification period when payment of the delinquent premium is made prior to the end of the certification period. This change to Washington's CHIP program will meet "continuous eligibility" as an enrollment and retention strategy as defined in CHIPRA, which will qualify Washington for the performance bonus described in CHIPRA Section 104.

     Citation of Existing Rules Affected by this Order: Amending WAC 388-416-0015, 388-450-0215, 388-505-0210, 388-505-0211, and 388-542-0020.

     Statutory Authority for Adoption: RCW 74.04.050, 74.04.057, 74.08.090; Apple Health for Kids Act (ESHB 2128); and 42 U.S.C. 1305.

     Other Authority: Public Law 111-3 (Children's Health Insurance Program Reauthorization Act of 2009).

     Under RCW 34.05.350 the agency for good cause finds that immediate adoption, amendment, or repeal of a rule is necessary for the preservation of the public health, safety, or general welfare, and that observing the time requirements of notice and opportunity to comment upon adoption of a permanent rule would be contrary to the public interest; and that state or federal law or federal rule or a federal deadline for state receipt of federal funds requires immediate adoption of a rule.

     Reasons for this Finding: This change will allow the department to extend medical assistance to newborns who are not eligible under the current rule and will allow vulnerable children to remain connected to healthcare coverage. This change will also allow Washington to qualify for performance bonus funding as described in CHIPRA, Section 104.

     Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 5, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

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

     Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 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 5, Repealed 0.

     Date Adopted: March 23, 2010.

Katherine I. Vasquez

Rules Coordinator

     (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.

     (6) 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.

     (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.

     (10) If the client is eligible only during the three-month retroactive period, that period is the only period of certification, except when:

     (a) A pregnant woman is eligible in one of the three months preceding the month of application, but no earlier than the month of conception. Eligibility continues as described in subsection (3);

     (b) A child is eligible for a CN medical program as described in WAC 388-505-0210 (1) through (((4))) (5) and (((6))) (7) in one of the three months preceding the month of application. Eligibility continues for twelve months from the earliest month that the child is determined eligible.

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

     (12) Coverage under premium-based programs included in apple health for kids as described in WAC 388-505-0210 and chapter 388-542 WAC begins no sooner than the month after creditable coverage ends.

[Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.402, 74.09.470, and 2008 session law. 09-07-086, § 388-416-0015, filed 3/17/09, effective 4/17/09. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, 74.09.700, and 2007 c 5. 08-05-018, § 388-416-0015, filed 2/12/08, effective 3/14/08. 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.]

     (2) We use your current, past, and future circumstances for a representative estimate of your monthly income.

     (3) We may need proof of your circumstances to ensure our estimate is reasonable. This may include documents, statements from other people, or other proof as explained in WAC 388-490-0005.

     (4) We use one of two methods to estimate income:

     (a) Anticipating monthly income (AM): With this method, we base the estimate on the actual income we expect your AU to receive in the month (see subsection (5)); and

     (b) Averaging income (CA): With this method, we add the total income we expect your AU to receive for a period of time and divide by the number of months in the period (see subsection (6)).

     (5) Anticipating monthly income: We must use the anticipating monthly method:

     (a) For the month you apply for benefits unless:

     (i) We are determining eligibility for ((children's medical)) apple health for kids programs as listed in WAC 388-505-0210 (((3) through (6))), or pregnancy medical as listed in WAC 388-462-0015. For ((children's)) apple health for kids and pregnancy medical we can use either method; or

     (ii) You are paid less often than monthly (for example: you are paid quarterly or annually). If you are paid less often than monthly, we average your income for the month you apply. Section (6) explains how we average your income.

     (b) When we estimate income for anyone in your AU, if you or anyone in your AU receive SSI-related medical benefits under chapter 388-475 WAC.

     (c) When we must allocate income to someone who is receiving SSI-related medical benefits under chapter 388-475 WAC.

     (d) When you are a destitute migrant or destitute seasonal farmworker under WAC 388-406-0021. In this situation, we must use anticipating monthly (AM) for all your AU's income.

     (e) To budget SSI or Social Security benefits even if we average other sources of income your AU receives.

     (6) Averaging income: When we average your income, we consider changes we expect for your AU's income. We determine a monthly amount of your income based on how often you are paid:

     (a) If you are paid weekly, we multiply your expected income by 4.3;

     (b) If you are paid every other week, we multiply your expected income by 2.15;

     (c) In most cases if you receive your income other than weekly or every other week, we estimate your income over your certification period by:

     (i) Adding the total income for representative period of time;

     (ii) Dividing by the number of months in the time frame; and

     (iii) Using the result as a monthly average.

     (d) If you receive your yearly income over less than a year because you are self employed or work under a contract, we average this income over the year unless you are:

     (i) Paid on an hourly or piecework basis; or

     (ii) A migrant or seasonal farmworker under WAC 388-406-0021.

     (7) If we used the anticipating monthly income method for the month you applied for benefits, we may average your income for the rest of your certification period if we do not have to use this method for any other reason in section (5).

     (8) If you report a change in your AU's income, and we expect the change to last through the end of the next month after you reported it, we update the estimate of your AU's income based on this change.

     (9) If your actual income is different than the income we estimated, we don't make you repay an overpayment under chapter 388-410 WAC or increase your benefits unless you meet one of the following conditions:

     (a) You provided incomplete or false information; or

     (b) We made an error in calculating your benefits.

[Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.04.510, and 74.08.090. 08-02-054, § 388-450-0215, filed 12/28/07, effective 2/1/08; 05-16-109, § 388-450-0215, filed 8/2/05, effective 10/1/05. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.04.510. 04-06-052, § 388-450-0215, filed 3/1/04, effective 4/1/04; 03-21-029, § 388-450-0215, filed 10/7/03, effective 11/1/03. Statutory Authority: RCW 74.08.090 and 74.04.510. 99-23-083, § 388-450-0215, filed 11/16/99, effective 1/1/00; 99-16-024, § 388-450-0215, filed 7/26/99, effective 9/1/99. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. 98-16-044, § 388-450-0215, filed 7/31/98, effective 9/1/98. Formerly WAC 388-505-0590.]

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

     (a) The ((child's)) newborn's mother ((was)) is eligible for ((and receiving)) medical assistance ((at the time)):

     (i) On the date of the ((child's)) newborn's birth, including a retroactive eligibility determination; ((and)) or

     (ii) Based on meeting a medically needy (MN) spenddown liability with expenses incurred on, or prior to, the date of the newborn's birth.

     (b) The ((child remains with the mother and resides in the state)) newborn is a resident of the state of Washington.

     (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 388-424-0006 (1), (4), and (5) are eligible for free federally matched CN coverage 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 of 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 or permanently residing under color of law (PRUCOL) status as described in WAC ((388-424-0006)) 388-424-0010, are eligible for free state-funded ((CN)) coverage with the same scope of services as children covered by CN medicaid 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 who are U.S. citizens, U.S. nationals, or qualified aliens as described in WAC 388-424-0001 and 388-424-0006 (1), (4), and (5) are eligible for premium-based federally-matched CN coverage as described in chapter 388-542 WAC 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 over two hundred percent FPL, as described in WAC 388-478-0075, but not over three-hundred percent FPL at each application or review;

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

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

     (5) Noncitizen children under the age of nineteen, who do not meet qualified alien or PRUCOL status as described in WAC 388-424-0010, are eligible for premium-based state-funded coverage with same scope of services as children covered by CN medicaid 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 three-hundred 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 premium as described in WAC 388-505-0211.

     (6) Children under age nineteen are eligible for the medically needy (MN) medicaid program when they meet the following criteria:

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

     (b) Are ineligible for other ((federal medicaid)) federally-matched CN programs; ((and))

     (c) Have income that exceeds three hundred percent FPL; or

     (d) Have income less than three hundred percent FPL, but do not qualify for premium-based coverage as described in subsection (4) of this section because of creditable coverage; and

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

     (((6))) (7) Children under the age of ((twenty-one)) nineteen who reside or are expected to reside in a medical institution, intermediate care facility for the mentally retarded (ICF/MR), hospice care center, nursing home, institution for mental diseases (IMD) or inpatient psychiatric facility may be eligible for apple health for kids healthcare coverage based upon institutional rules described in WAC 388-505-0260. Individuals between the age of nineteen and twenty-one may still be eligible for healthcare coverage but not under the apple health for kids programs. See WAC 388-505-0230 "Family related institutional medical" and WAC 388-513-1320 "Determining institutional status for long-term care((.))" for more information.

     (((7))) (8) Children who are in foster care under the legal responsibility of the state, or a federally recognized tribe located within the state, and who meet eligibility requirements for residency, social security number, and citizenship as described in subsection (2)(a), (b) and (c) are eligible for federally-matched CN medicaid coverage through the month of their:

     (a) Eighteenth birthday;

     (b) Twenty-first birthday if the 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))) (9) Children are eligible for state-funded CN coverage through the month of their eighteenth birthday if they:

     (a) Are in foster care under the legal responsibility of the state or a federally-recognized tribe located within the state; and

     (b) Do not meet social security number and citizenship requirements in subsection (2)(b) and (c) of this section.

     (10) Children who receive subsidized adoption services are eligible for federally-matched CN ((medicaid)) coverage.

     (((9))) (11) Children under the age of nineteen not eligible for apple health for kids programs listed above may ((also)) be eligible for one of the following medical assistance programs not included in apple health for kids:

     (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 programs included in apple health for kids 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 three hundred percent FPL; or

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

     (11))) (d) Home and community based waiver programs as described in chapter 388-515 WAC; or

     (e) Alien medical as described in WAC 388-438-0110, if they:

     (i) Have a documented emergency medical condition as defined in WAC 388-500-0005;

     (ii) Have income more than three hundred percent FPL; or

     (iii) Have income less than three hundred percent FPL, but do not qualify for premium-based coverage as described in subsection (5) of this section because of creditable coverage.

     (12) Except for a ((client)) child described in subsection (((6))) (7), an inmate of a public institution, as defined in WAC 388-500-0005, is not eligible for any ((children's healthcare)) apple health for kids program.

[Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.402, 74.09.470, and 2008 session law. 09-07-086, § 388-505-0210, filed 3/17/09, effective 4/17/09. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, 74.09.700, and 2007 c 5. 08-05-018, § 388-505-0210, filed 2/12/08, effective 3/14/08. 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.]

     (2) Payment of a premium is required as a condition of eligibility for premium-based coverage under programs included in apple health for kids, as described in WAC 388-505-0210(4), unless the child is:

     (a) Pregnant; or

     (b) An American Indian or Alaska native.

     (3) 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.

     (4) The premium amount for the assistance unit is based on the net countable income as described in WAC 388-450-0210 and the number of children in the assistance unit. If the household includes more than one assistance unit, the premium amount billed for the assistance units may be different amounts.

     (5) The premium amount for each eligible child shall be:

     (a) Twenty dollars per month per child for households with income above two hundred percent FPL, but not above two hundred and fifty percent FPL;

     (b) Thirty dollars per month per child for households with income above two hundred and fifty percent FPL, but not above three hundred percent FPL; and

     (c) Limited to a monthly maximum of two premiums for households with two or more children.

     (6) All children in an assistance unit are ineligible for healthcare coverage when the head of household fails to pay required premium payments for three consecutive months.

     (7) When the department terminates the medical coverage of a 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)) child's ineligibility is rescinded only when the:

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

     (b) The child becomes eligible for coverage under a nonpremium-based CN healthcare program. ((The department will not rescind the three-month period of ineligibility for reasons other than the criteria described in this subsection.))

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

     (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 premium-based coverage under a program included in apple health for kids)) If all past due premiums are paid after the certification period is over, then:

     (a) Ineligibility for prior months is not rescinded; and

     (b) Children are not eligible for premium-based coverage under apple health for kids until the month the premiums are paid or the department writes off the debt.

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

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

     (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 (7) of this section; or

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

[Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.402, 74.09.470, and 2008 session law. 09-07-086, § 388-505-0211, filed 3/17/09, effective 4/17/09. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, 74.09.700, and 2007 c 5. 08-05-018, § 388-505-0211, filed 2/12/08, effective 3/14/08. 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.]

     (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 (4) and (5), ((Children's healthcare)) apple health for kids program eligibility;

     (3) WAC 388-505-0211, Premium requirements for premium-based coverage under programs included in apple health for kids;

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

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

[Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.402, 74.09.470, and 2008 session law. 09-07-086, § 388-542-0020, filed 3/17/09, effective 4/17/09. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, 74.09.700, and 2007 c 5. 08-05-018, § 388-542-0020, filed 2/12/08, effective 3/14/08. 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.]

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