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

     Purpose: Eliminating the Social Security number requirement for premium-based apple health [for] kids medical coverage is necessary to comply with federal "maintenance of effort" requirements under Patient Protection and Affordable Care Act (PPACA); adding description of lawfully present aliens to comply with Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA); and creating new WAC section identifying the order of Title XXI payments under the premium-based apple health for kids program.

     Citation of Existing Rules Affected by this Order: Amending WAC 388-505-0210 and 388-505-0211.

     Statutory Authority for Adoption: RCW 41.05.021, 74.04.050, 74.04.057, and 74.09.500.

     Other Authority: PPACA; §2102 (b)(1)(A) of the Social Security Act; and Public Law 111-3 (CHIPRA).

      Adopted under notice filed as WSR 11-20-052 on September 29, 2011.

     Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 1, Amended 2, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0;      Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 1, Amended 2, Repealed 0.

     Date Adopted: November 15, 2011.

Kevin M. Sullivan

Rules Coordinator

OTS-4320.1

AMENDATORY SECTION(Amending WSR 11-03-001, filed 1/5/11, effective 2/5/11)

WAC 388-505-0210   Apple health for kids and other children's medical assistance programs.   Funding for coverage under the apple health for kids programs may come through Title XIX (medicaid), Title XXI (CHIP), or through state-funded programs. There are no resource limits for the apple health for kids programs. Apple health for kids coverage is free to children in households with incomes of no more than two-hundred percent of the federal poverty level (FPL), and available on a premium basis to children in households with incomes of no more than three-hundred percent FPL.

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

     (a) The newborn is a resident of the state of Washington.

     (b) The newborn's mother is eligible for medical assistance:

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

     (2) Children under the age of nineteen who are U.S. citizens, U.S. nationals, or lawfully present qualified or nonqualified aliens as described in WAC 388-424-0001, 388-424-0010(4), 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 currently eligible for SSI.

     (3) Noncitizen children under the age of nineteen, who are not lawfully present qualified or nonqualified aliens as described in WAC 388-424-0001, 388-424-0010(4), and 388-424-0006 (1), (4), and (5), are eligible for free state-funded coverage 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 lawfully present qualified or nonqualified aliens as described in WAC 388-424-0001, 388-424-0010(4), 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))) (c) 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;

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

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

     (5) Noncitizen children under the age of nineteen, who are not lawfully present qualified or nonqualified aliens as described in WAC 388-424-0001, 388-424-0010(4), and 388-424-0006 (1), (4), and (5), are eligible for premium-based state-funded CN coverage 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) of this section;

     (b) Are ineligible for other federally matched CN programs;

     (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 liability as described in WAC 388-519-0100 and 388-519-0110.

     (7) Children under the age of 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.

     (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) of this section 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.

     (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 coverage.

     (11) Children under the age of nineteen not eligible for apple health for kids programs listed above may 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;

     (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) of this section; and

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

     (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 child described in subsection (7) of this section, an inmate of a public institution, as defined in WAC 388-500-0005, is not eligible for any apple health for kids program.

[Statutory Authority: RCW 74.04.050, 74.04.057, and 74.08.090, and Apple Health for Kids Act (ESHB 2128); 42 U.S.C. 1305; Public Law 111-3 (Children's Health Insurance Program Reauthorization Act of 2009). 11-03-001, § 388-505-0210, filed 1/5/11, effective 2/5/11. 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) and (5), 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 (AU) is based on the net countable income as described in WAC 388-450-0210 and the number of children in the ((assistance unit)) AU. If the household includes more than one ((assistance unit)) AU, the premium amount billed for the ((assistance units)) AUs may be different amounts.

     (5) The premium amount is limited to a monthly maximum of two premiums for households with two or more children.

     (6) The premium amount for each ((eligible)) U.S. citizen or lawfully present alien child ((shall be)) described in WAC 388-505-0210(4) is:

     (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; or

     (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))) (7) The premium amount for each noncitizen child described in WAC 388-505-0210(5) who is not a lawfully present qualified or nonqualified alien is no greater than the average of the state-share of the per capita cost for state-funded children's health coverage. The premium amount is set every two years, based on the forecasted per capita costs for that period.

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

     (((7))) (9) When the ((department)) agency or the agency's designee terminates the medical coverage of a child due to nonpayment of premiums, the child's eligibility is restored only when the:

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

     (b) The child becomes eligible for coverage under a nonpremium-based CN healthcare program.

     (((8))) (10) The ((department)) agency or the agency's designee writes off past-due premiums after twelve months.

     (((9))) (11) If all past due premiums are paid after the certification period is over:

     (a) Eligibility for prior months is not restored; and

     (b) Children are not eligible for premium-based coverage under apple health for kids until:

     (i) The month the premiums are paid or the ((department)) agency writes off the debt; ((or)) and

     (ii) The family reapplies and is found eligible.

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

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

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

[Statutory Authority: RCW 74.04.050, 74.04.057, and 74.08.090, and Apple Health for Kids Act (ESHB 2128); 42 U.S.C. 1305; Public Law 111-3 (Children's Health Insurance Program Reauthorization Act of 2009). 11-03-001, § 388-505-0211, filed 1/5/11, effective 2/5/11. 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.]

OTS-4289.1

NEW SECTION
WAC 182-505-0235   Order of payments under the premium-based apple health for kids program as funded by Title XXI of the Social Security Act.   The agency administers the programs included in apple health for kids that provide premium-based coverage through a combination of state and federal funding sources. For expenditures funded by Title XXI of the Social Security Act, also known as the children's health insurance program (CHIP), federal financial participation will be sought in compliance with section 2105 of the act in the following order:

     (1) For medical assistance for targeted low-income children from birth through age eighteen, as described in section 4 of the Title XXI state plan.

     (2) For medical assistance for unborn children, as described in section 4.1.2.1 of the Title XXI state plan.

     (3) For medical assistance for medicaid-eligible children, as described in CHIPRA, section 214.

     (4) For medical assistance for medicaid-eligible children, as described in section 2105 (g)(4)(A) and (B) of the act.

     (5) For allowable administrative expenditures under the ten percent cap, as defined in section 2105 (a)(1)(D) of the act in the following order:

     (a) First, for reasonable expenditures necessary to administer the plan, including staffing for eligibility determinations, plan administration, quality assurance, and similar costs.

     (b) Second, for a toll-free 800 telephone number providing information regarding the Washington apple health for kids program.

     (c) Third, for health services initiatives, such as the funding of the Washington poison center, to the extent that state funds are appropriated by the legislature.

     (d) Fourth, for translation or interpretation services in connection with the enrollment, retention, or use of services under this title by individuals for whom English is not their primary language, but only to the extent that state-matching funds are made available.

     (e) Fifth, for outreach services for the Washington apple health for kids program, to the extent that appropriated state-matching funds are available.

     (f) Sixth, for other CMS-approved activities to the extent that federal matching funds are available, and where such activities do not duplicate efforts conducted under this subsection.

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