PROPOSED RULES
(Medicaid Program)
Supplemental Notice to WSR 11-23-164.
Preproposal statement of inquiry was filed as WSR 11-16-104.
Title of Rule and Other Identifying Information: Incapacity-based medical care services program (new); repealing WAC 388-505-0110, 388-556-0500, 388-800-0020, 388-800-0025, 388-800-0030, 388-800-0035, 388-800-0048, 388-800-0110, 388-800-0115, 388-800-0130, 388-800-0135, 388-800-0140, 388-800-0145, 388-800-0150, 388-800-0155, 388-800-0160 and 388-800-0165; amending WAC 182-500-0070, 182-538-063 and 388-505-0270; and creating WAC 182-503-0520, 182-503-0532, 182-503-0555, 182-503-0560, 182-504-0030, 182-504-0040, 182-504-0100, 182-504-0125, 182-506-0020, 182-508-0001, 182-508-0005, 182-508-0010, 182-508-0015, 182-508-0020, 182-508-0030, 182-508-0035, 182-508-0040, 182-508-0050, 182-508-0060, 182-508-0070, 182-508-0080, 182-508-0090, 182-508-0100, 182-508-0110, 182-508-0120, 182-508-0130, 182-508-0150, 182-508-0160, 182-508-0220, 182-508-0230, 182-508-0305, 182-508-0310, 182-508-0315, 182-508-0320, 182-508-0375, 182-509-0005, 182-509-0015, 182-509-0025, 182-509-0030, 182-509-0035, 182-509-0045, 182-509-0055, 182-509-0065, 182-509-0080, 182-509-0085, 182-509-0095, 182-509-0100, 182-509-0110, 182-509-0135, 182-509-0155, 182-509-0165, 182-509-0175, 182-509-0200, 182-509-0205, and 182-509-0210.
Hearing Location(s): Office Building 2, Auditorium, 1115 Washington, Olympia, WA 98504 (public parking at 11th and Jefferson, a map is available at http://www1.dshs.wa.gov/msa/rpau/RPAU-OB-2directions.html or directions can be obtained by calling (360) 664-6094), on July 10, 2012, at 10:00 a.m.
Date of Intended Adoption: Not sooner than July 11, 2012.
Submit Written Comments to: HCA Rules Coordinator, P.O. Box 45504, Olympia, WA 98504-5504, delivery 626 8th Avenue, Olympia, WA 98504, e-mail arc@hca.wa.gov, fax (360) 586-9727, by 5:00 p.m. on July 10, 2012.
Assistance for Persons with Disabilities: Contact Kelly Richters by July 2, 2012, TTY/TDD (800) 848-5429 or (360) 725-1307 or e-mail kelly.richters@hca.wa.gov.
Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: In meeting the requirements of E2SHB [ESHB] 2082, the agency is amending, repealing, and creating new rules to: (1) Eliminate references to General assistance -- Unemployable and disability lifeline cash programs; and (2) establish the incapacity-based medical care services program.
Reasons Supporting Proposal: The agency is holding a second public hearing to allow interested stakeholders the opportunity to review the revised proposed rules as a result of the comments received from the first public hearing held on December 27, 2011.
Statutory Authority for Adoption: RCW 41.05.021, 74.09.035.
Statute Being Implemented: Chapter 36, Laws of 2011 (ESSHB [ESHB] 2082).
Rule is not necessitated by federal law, federal or state court decision.
Name of Proponent: Health care authority, governmental.
Name of Agency Personnel Responsible for Drafting: Kevin Sullivan, P.O. Box 45504, Olympia, WA 98504-5504, (360) 725-1344; Implementation and Enforcement: Dody McAlpine, P.O. Box 45504, Olympia, WA 98504-5534, (360) 725-9964.
No small business economic impact statement has been prepared under chapter 19.85 RCW. The joint administrative rules review committee has not requested the filing of a small business economic impact statement, and these rules do not impose a disproportionate cost impact on small businesses.
A cost-benefit analysis is not required under RCW 34.05.328. RCW 34.05.328 does not apply to health care authority rules unless requested by the joint administrative rules [review] committee or applied voluntarily.
June 5, 2012
Kevin M. Sullivan
Rules Coordinator
OTS-4390.1
AMENDATORY SECTION(Amending WSR 11-14-075, filed 6/30/11,
effective 7/1/11)
WAC 182-500-0070
Medical assistance definitions -- M.
"Medicaid" is the federal aid Title XIX program of the Social
Security Act under which medical care is provided to eligible
persons.
"Medical assistance" for the purposes of chapters 388-500 through 388-561 WAC, means the various healthcare programs administered by the agency or the agency's designee that provide federally funded and/or state-funded healthcare benefits to eligible clients.
"Medical assistance administration (MAA)" is the former organization within the department of social and health services authorized to administer the federally funded and/or state-funded healthcare programs that are now administered by the agency, formerly the medicaid purchasing administration (MPA), of the health and recovery services administration (HRSA).
"Medical care services (MCS)" means the limited scope of
care medical program financed by state funds ((and provided to
disability lifeline and alcohol and drug addiction services
clients)) for clients who meet the incapacity criteria defined
in chapter 182-508 WAC or who are eligible for the Alcohol and
Drug Addiction Treatment and Support Act (ADATSA) program.
"Medical consultant" means a physician employed or contracted by the agency or the agency's designee.
"Medical facility" means a medical institution or clinic that provides healthcare services.
"Medical institution" See "institution" in WAC 388-500-0050.
"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. 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 purposes of this section, "course of treatment" may include mere observation or, where appropriate, no medical treatment at all.
"Medically needy (MN) or medically needy program (MNP)" is the state- and federally funded healthcare program available to specific groups of persons who would be eligible as categorically needy (CN), except their monthly income is above the CN standard. Some long-term care clients with income and/or resources above the CN standard may also qualify for MN.
"Medicare" is the federal government health insurance program for certain aged or disabled persons under Titles II and XVIII of the Social Security Act. Medicare has four parts:
(1) "Part A" - Covers medicare inpatient hospital services, post-hospital skilled nursing facility care, home health services, and hospice care.
(2) "Part B" - The supplementary medical insurance benefit (SMIB) that covers medicare doctors' 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.
(3) "Part C" - Covers medicare benefits for clients enrolled in a medicare advantage plan.
(4) "Part D" - The medicare prescription drug insurance benefit.
"Medicare assignment" means the process by which a provider agrees to provide services to a medicare beneficiary and accept medicare's payment for the services.
"Medicare cost-sharing" means out-of-pocket medical expenses related to services provided by medicare. For medical assistance clients who are enrolled in medicare, cost-sharing may include Part A and Part B premiums, co-insurance, deductibles, and copayments for medicare services. See chapter 388-517 WAC for more information.
[11-14-075, recodified as § 182-500-0070, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 2011 1st sp. sess. c 15. 11-14-053, § 388-500-0070, filed 6/29/11, effective 7/30/11.]
OTS-4391.4
PERSONS ELIGIBLE FOR MEDICAL ASSISTANCE
(1) A resident is an individual who:
(a) Currently lives in Washington and intends to continue living here permanently or for an indefinite period of time; or
(b) Entered the state looking for a job; or
(c) Entered the state with a job commitment.
(2) An individual does not need to live in the state for a specific period of time to be considered a resident.
(3) An individual receiving MCS can temporarily be out of the state for more than one month. If so, the individual must provide the agency or the agency's designee with adequate information to demonstrate the intent to continue to reside in the state of Washington.
(4) An individual may not receive comparable benefits from another state for the MCS program.
(5) A former resident of the state can apply for MCS while living in another state if:
(a) The individual:
(i) Plans to return to this state;
(ii) Intends to maintain a residence in this state; and
(iii) Lives in the United States at the time of the application.
(b) In addition to the conditions in (a)(i), (ii), and (iii) of this subsection being met, the absence must be:
(i) Enforced and beyond the individual's control; or
(ii) Essential to the individual's welfare and is due to physical or social needs.
(c) See WAC 388-406-0035, 388-406-0040, and 388-406-0045 for time limits on processing applications.
(6) Residency is not a requirement for detoxification services.
(7) An individual is not a resident when the individual enters Washington state only for medical care. This individual is not eligible for any medical program. The only exception is described in subsection (8) of this section.
(8) It is not necessary for an individual moving from another state directly to a nursing facility in Washington state to establish residency before entering the facility. The individual is considered a resident if they intend to remain permanently or for an indefinite period unless placed in the nursing facility by another state.
(9) An individual's residence is the state:
(a) Where the parent or legal guardian resides, if appointed, for an institutionalized individual twenty-one years of age or older, who became incapable of determining residential intent before reaching age twenty-one;
(b) Where an individual is residing if the individual becomes incapable of determining residential intent after reaching twenty-one years of age;
(c) Making a placement in an out-of-state institution; or
(d) For any other institutionalized individual, the state of residence is the state where the individual is living with the intent to remain there permanently or for an indefinite period.
(10) In a dispute between states as to which is an individual's state of residence, the state of residence is the state in which the individual is physically located.
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(a) A U.S. citizen;
(b) A U.S. national;
(c) An American Indian born outside the U.S.;
(d) A "qualified alien" or similarly defined lawful immigrant such as victim of trafficking; or
(e) A nonqualified alien who meets the Washington state residency requirements as listed in WAC 182-503-0520.
(2) To receive ADATSA benefits, an individual must belong to one of the following groups as defined in WAC 388-424-0001:
(a) A U.S. citizen;
(b) A U.S. national;
(c) An American Indian born outside the U.S.;
(d) A "qualified alien" or similarly defined lawful immigrant such as victim of trafficking; or
(e) A nonqualified alien who meets the Washington state residency requirements as listed in WAC 182-503-0520.
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(1) Eighteen years of age or older; or
(2) For MCS only, if under eighteen years of age, a member of a married couple:
(a) Residing together; or
(b) Residing apart solely because a spouse is:
(i) On a visit of ninety days or less;
(ii) In a public or private institution;
(iii) Receiving care in a hospital, long-term care facility, or chemical dependency treatment facility; or
(iv) On active duty in the uniformed military services of the United States.
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(1) An individual is considered a fleeing felon if the individual is fleeing to avoid prosecution, custody, or confinement for a crime or an attempt to commit a crime that is considered a felony in the place from which the individual is fleeing.
(2) If the individual is a fleeing felon, or who is violating a condition of probation or parole as determined by an administrative body or court that has the authority to make this decision, is not eligible for MCS benefits.
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OTS-4392.3
NEW SECTION
WAC 182-504-0030
Medical certification periods for
recipients of medical care services (MCS).
(1) The
certification period for medical care services (MCS) begins:
(a) The date the agency or the agency's designee has enough information to make an eligibility decision; or
(b) No later than the forty-fifth day from the date the agency or the agency's designee received the application unless the applicant is confined in a Washington state public institution as defined in WAC 388-406-0005 (6)(a) on the forty-fifth day, in which case MCS coverage will start on the date of release from confinement.
(2) The certification period may or may not run concurrently with the incapacity review; and
(3) MCS coverage may end before the certification period ends when the incapacity review and financial review do not run concurrently.
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(2) A recipient of MCS must complete a midcertification review unless the review period is six months or less.
(3) The review form is sent in the fifth month of the MCS certification or review period and must be completed by the tenth day of month six.
(4) If the individual is required to complete a midcertification review, it can be completed in one of the following ways:
(a) Complete the form and return it to the DSHS office. The MCR will be considered complete if all of the following steps are taken:
(i) The form is completed in full and any changes in circumstances for the household are indicated;
(ii) The form is signed and dated;
(iii) Proof is provided of any changes that are reported; and
(iv) The form is returned to DSHS by mail or in person along with any required proof by the due date on the review.
(b) Complete the midcertification review over the phone. The MCR will be considered complete over the phone if all of the following steps are taken:
(i) DSHS is contacted at the phone number on the review form and told about any changes in the household's circumstances;
(ii) Proof is provided of any changes that are reported, and DSHS may be able to verify some information over the phone; and
(iii) Required proof is returned to DSHS by the due date on the review.
(c) Complete the application process for another program. If the agency or the agency's designee approves an application for another program in the month the MCR is due, the application is used to complete the review when the same individual is head of household for the application and the midcertification review.
(5) If eligibility for medical coverage ends because of the information provided in the midcertification review, the change takes effect the next month even if this does not give ten days notice before the effective date of the termination.
(6) If the required midcertification review is not completed, medical coverage under the MCS program stops at the end of the month the review was due.
(7) Late reviews. If the midcertification review is completed after the last day of the month the review was due, the agency or the agency's designee will process the review as described below based on when the review is received:
(a) Midcertification reviews that are completed by the last day of the month after the month the review was due: The agency or the agency's designee determines the MCS recipient's eligibility for ongoing medical coverage. If the individual is determined to be eligible, coverage is reinstated based on the information in the review, unless there is a wait list due to an enrollment cap under WAC 182-508-0150;
(b) Midcertification reviews completed after the last day of the month after the month the review was due: The agency or the agency's designee treats the review as a request to send an application. In order to determine eligibility for ongoing MCS medical coverage, the application process as described in chapter 388-406 WAC must be completed.
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(a) A change in address;
(b) A change in who lives in the home with the individual;
(c) When the individual's total gross monthly income goes over the eligibility standards for MCS and ADATSA as listed in WAC 182-508-0230;
(d) When liquid resources are more than four thousand dollars;
(e) When the individual has a change in employment. The individual must notify the agency or the agency's designee if they:
(i) Get a job or change employers;
(ii) Change from part-time to full-time employment or from full-time to part-time employment;
(iii) Have a change in hourly wage rate or salary; or
(iv) Stop working.
(2) Changes listed in subsection (1) of this section must be reported to the agency or the agency's designee by the tenth day of the month following the month the change happened.
(3) When the change is a change in income, the date a change happened is the date the individual first received the income, e.g., the date of receipt of the first paycheck for a new job or the date of a paycheck showing a change in the amount of the individual's wage or salary.
(4) Changes that are reported late may result in receiving medical benefits to which the individual is not entitled.
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OTS-4493.1
NEW SECTION
WAC 182-504-0125
Effect of changes on medical program
eligibility.
(1) An individual continues to be eligible for
medical assistance until the agency or the agency's designee
completes a review of the individual's case record and
determines the individual is ineligible for medical assistance
or is eligible for another medical program. This applies to
all individuals who, during a certification period, become
ineligible for, or are terminated from, or request termination
from:
(a) A categorically needy (CN) medicaid program;
(b) A program included in apple health for kids; or
(c) Any of the following cash grants:
(i) Temporary assistance for needy families (TANF);
(ii) Supplemental Security Income (SSI); or
(iii) Aged, blind, disabled (ABD) cash assistance. See WAC 388-434-0005 for changes reported during eligibility review.
(2) If CN medical coverage ends under one program and the individual meets all the eligibility requirements to be eligible under a different CN medical program, coverage is approved under the new program. If the individual's income exceeds the standard for CN medical coverage, the agency or the agency's designee considers eligibility under the medically needy (MN) program where appropriate.
(3) If CN medical coverage ends and the individual does not meet the eligibility requirements to be eligible under a different medical program, the redetermination process is complete and medical assistance is terminated giving advance and adequate notice with the following exception:
(a) An individual who claims to have a disability is referred to the division of disability determination services for a disability determination if that is the only basis under which the individual is potentially eligible for medical assistance. Pending the outcome of the disability determination, medical eligibility is considered under the SSI-related medical program described in chapter 388-475 WAC.
(b) An individual with countable income in excess of the SSI-related CN medical standard is considered for medically needy (MN) coverage or medically needy (MN) with spenddown pending the final outcome of the disability determination.
(4) An individual who becomes ineligible for refugee cash assistance is eligible for continued refugee medical assistance through the eight-month limit, as described in WAC 388-400-0035(4).
(5) An individual who receives a TANF cash grant or family medical is eligible for a medical extension, as described under WAC 388-523-0100, when the cash grant or family medical program is terminated as a result of:
(a) An increase in earned income; or
(b) Collection of child or spousal support.
(6) Changes in income during a certification period affects eligibility for all medical programs except:
(a) Pregnant women's CN medical programs;
(b) A program included in apple health for kids, except as specified in subsection (5) of this section; or
(c) The first six months of the medical extension benefits described under chapter 388-523 WAC.
(7) A child who receives premium-based coverage under a program included in apple health for kids described in WAC 388-505-0210 and chapter 388-542 WAC must be redetermined for a nonpremium-based coverage when the family reports:
(a) Family income has decreased to less than two hundred percent federal poverty level (FPL);
(b) The child becomes pregnant;
(c) A change in family size; or
(d) The child receives SSI.
(8) An individual who receives SSI-related CN medical coverage and reports a change in earned income which exceeds the substantial gainful activity (SGA) limit set by Social Security Administration no longer meets the definition of a disabled individual as described in WAC 388-475-0050, unless the individual continues to receive a Title 2 cash benefit, e.g., SSDI, DAC, or DWB. The agency or the agency's designee redetermines eligibility for such an individual under the health care for workers with disabilities (HWD) program which waives the SGA income test. The HWD program is a premium-based program and the individual must approve the premium amount before the agency or the agency's designee can authorize ongoing CN medical benefits under this program.
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OTS-4393.3
NEW SECTION
WAC 182-506-0020
Assistance units for medical care
services (MCS).
(1) An adult who is incapacitated as defined
in WAC 182-508-0010 can be in a medical care services
assistance unit (AU).
(2) For an incapacitated adult who is married and lives with their spouse, the agency or the agency's designee decides who to include in the AU based on who is incapacitated:
(a) If both spouses are incapacitated as defined in WAC 182-508-0010, then the agency or the agency's designee includes both spouses in the AU.
(b) If only one spouse is incapacitated, then the agency or the agency's designee includes only the incapacitated spouse in the AU. Some of the income of the spouse not in the AU is counted as income to the AU as determined according to WAC 388-450-0135.
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OTS-4382.8
ADULT MEDICAL AND CHEMICAL DEPENDENCY ((ASSISTANCE PROGRAMS))
(a) Meets citizenship/immigrant, residency, and Social Security number requirements as described in WAC 388-503-0505; and
(b) Has CN countable income and resources that do not exceed the income and resource standards in WAC 388-478-0080; and
(c) Is sixty-five years of age or older, or meets the blind and/or disability criteria of the federal SSI program.
(2) An adult not meeting the conditions of subsection (1)(b) of this section is eligible for CN medical coverage if the individual:
(a) Is a current beneficiary of Title II of the Social Security Act (SSA) benefits who:
(i) Was a concurrent beneficiary of Title II and Supplemental Security Income (SSI) benefits;
(ii) Is ineligible for SSI benefits and/or state supplementary payments (SSP); and
(iii) Would be eligible for SSI benefits if certain cost-of-living (COLA) increases are deducted from the client's current Title II benefit amount:
(A) All Title II COLA increases under P.L. 94-566, section 503 received by the individual since their termination from SSI/SSP; and
(B) All Title II COLA increases received during the time period in (d)(iii)(A) of this subsection by the individual's spouse or other financially responsible family member living in the same household.
(b) Is an SSI beneficiary, no longer receiving a cash benefit due to employment, who meets the provisions of section 1619(b) of Title XVI of the SSA;
(c) Is a currently disabled individual receiving widow's or widower's benefits under section 202 (e) or (f) of the SSA if the disabled individual:
(i) Was entitled to a monthly insurance benefit under Title II of the SSA for December 1983;
(ii) Was entitled to and received a widow's or widower's benefit based on a disability under section 202 (e) or (f) of the SSA for January 1984;
(iii) 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 individual;
(iv) Has been continuously entitled to a widow's or widower's benefit under section 202 (e) or (f) of the SSA;
(v) Would be eligible for SSI/SSP benefits if the amount of that increase, and any subsequent COLA increases provided under section 215(i) of the SSA, were disregarded;
(vi) Is fifty through fifty-nine years of age; and
(vii) Filed an application for medicaid coverage before July 1, 1988.
(d) Was receiving, as of January 1, 1991, Title II disabled widow or widower benefits under section 202 (e) or (f) of the SSA if the individual:
(i) Is not eligible for the hospital insurance benefits under medicare Part A;
(ii) Received SSI/SSP payments in the month before receiving such Title II benefits;
(iii) Became ineligible for SSI/SSP due to receipt of or increase in such Title II benefits; and
(iv) 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 COLA increases provided under section 215(i) of the act were disregarded.
(e) Is a disabled or blind individual receiving Title II Disabled Adult Childhood (DAC) benefits under section 202(d) of the SSA if the individual:
(i) Is at least eighteen years old;
(ii) Lost SSI/SSP benefits on or after July 1, 1988, due to receipt of or increase in DAC benefits; and
(iii) Would be eligible for SSI/SSP if the amount of the DAC benefits or increase under section 202(d) of the DAC and any subsequent COLA increases provided under section 215(i) of the SSA were disregarded.
(f) Is an individual who:
(i) In August 1972, received:
(A) Old age assistance (OAA);
(B) Aid to blind (AB);
(C) Aid to families with dependent children (AFDC); or
(D) Aid to the permanently and totally disabled (APTD); and
(ii) Was entitled to or received retirement, survivors, and disability insurance (RSDI) benefits; or
(iii) Is eligible for OAA, AB, AFDC, SSI, or APTD solely because of the twenty percent increase in Social Security benefits under P.L. 92-336.
(3) An adult who does not meet the institutional status requirement as defined in WAC 388-513-1320 and who does not receive waiver services as described in chapter 388-515 WAC is considered for medically needy (MN) coverage under this chapter. Individuals excluded from this section have rules applied to eligibility from chapter 388-513 WAC. Under this section an individual is eligible for MN coverage when the individual:
(a) Meets citizenship/immigrant, residency, and Social Security number requirements as described in WAC 388-503-0505; and
(b) Has MN countable income that does not exceed the income standards in WAC 388-478-0080, or meets the excess income spenddown requirements in WAC 388-519-0110; and
(c) Meets the countable resource standards in WAC 388-478-0070; and
(d) Is sixty-five years of age or older or meets the blind and/or disability criteria of the federal SSI program.
(4) MN coverage is available for an aged, blind, or disabled ineligible spouse of an SSI recipient. See WAC 388-519-0100 for additional information.
(5) An adult may be eligible for the alien emergency medical program as described in WAC 388-438-0110.
(6) An adult is eligible for the aged, blind, disabled program when the individual:
(a) Meets the requirements of the aged, blind, disabled program in WAC 388-400-0060 and 388-478-0033; or
(b) Meets the SSI-related disability standards but cannot get the SSI cash grant due to immigration status or sponsor deeming issues. An adult may be eligible for aged, blind, disabled cash benefits and CN medical coverage due to different sponsor deeming requirements.
(7) An adult is eligible for the state-funded medical care services (MCS) program when the individual:
(a) Meets the requirements under WAC 182-508-0005; or
(b) Meets the aged, blind, or disabled requirements of WAC 388-400-0060 and is a qualified alien as defined in WAC 388-424-0001 who is subject to the five-year bar as described in WAC 388-424-0006(3); or a nonqualified alien as defined in WAC 388-424-0001; or
(c) Meets the requirements of the ADATSA program as described in WAC 182-508-0320 and 182-508-0375.
(8) An adult receiving MCS who resides in a county designated as a mandatory managed care plan county must enroll in a plan, pursuant to WAC 182-538-063.
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(a) Completes an interview with the agency or its designee;
(b) Is incapacitated as required under WAC 182-508-0010 through 182-508-0120;
(c) Is at least eighteen years old or, if under eighteen, a member of a married couple;
(d) Is in financial need according to MCS' income and resource rules in chapter 182-509 WAC. The agency or the agency's designee determines who is in the individual's assistance unit according to WAC 182-506-0020;
(e) Meets the medical care services citizenship/alien status requirements under WAC 182-503-0532;
(f) Provides a Social Security number as required under WAC 388-476-0005;
(g) Resides in the state of Washington as required under WAC 182-503-0520;
(h) Reports changes of circumstances as required under WAC 182-504-0100; and
(i) Completes a midcertification review and provides proof of any changes as required under WAC 182-504-0040.
(2) An individual is not eligible for MCS benefits if the individual:
(a) Is eligible for temporary assistance for needy families (TANF) benefits.
(b) Refuses or fails to meet a TANF rule.
(c) Refuses to or fails to cooperate in obtaining federal aid assistance without good cause.
(d) Refuses or fails to participate in drug or alcohol treatment as required in WAC 182-508-0220.
(e) Is eligible for Supplemental Security Income (SSI) benefits.
(f) Is an ineligible spouse of an SSI recipient.
(g) Fails to follow a Social Security Administration (SSA) program rule or application requirement and SSA denied or terminated the individual's benefits.
(h) Is fleeing to avoid prosecution of, or to avoid custody or confinement for conviction of, a felony, or an attempt to commit a felony as described in WAC 182-503-0560.
(i) Is eligible for a categorically needy (CN) medicaid program.
(j) Refuses or fails to cooperate with CN medicaid program rules or requirements.
(3) An individual who resides in a public institution and meets all other requirements may be eligible for MCS depending on the type of institution. A "public institution" is an institution that is supported by public funds, and a governmental unit either is responsible for it or exercises administrative control over it.
(a) An individual may be eligible for MCS if the individual is:
(i) A patient in a public medical institution; or
(ii) A patient in a public mental institution and is sixty-five years of age or older.
(b) An individual is not eligible for MCS when the individual is in the custody of or confined in a public institution such as a state penitentiary or county jail, including placement:
(i) In a work release program; or
(ii) Outside of the institution including home detention.
(4) If an enrollment cap exists under WAC 182-508-0150, a waiting list of persons may be established.
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"Incapacitated" means that an individual cannot be gainfully employed as a result of a physical or mental impairment that is expected to continue for at least ninety days from the date the individual applies.
"Mental impairment" means a diagnosable mental disorder. The agency or the agency's designee excludes any diagnosis of or related to alcohol or drug abuse or addiction.
"Physical impairment" means a diagnosable physical illness.
(1) The agency or the agency's designee determines the individual is incapacitated if the individual is:
(a) Disabled based on Social Security Administration (SSA) disability criteria;
(b) Eligible for services from the division of developmental disabilities (DDD);
(c) Diagnosed as having mental retardation based on a full scale score of seventy or lower on the Wechsler adult intelligence scale (WAIS);
(d) At least sixty-four years and seven months old;
(e) Eligible for long-term care services from aging and disability services administration; or
(f) Approved through the progressive evaluation process (PEP).
(2) The agency or the agency's designee considers an individual to be incapacitated for ninety days after:
(a) The individual is released from inpatient treatment for a mental impairment if:
(i) The release from inpatient treatment was not against medical advice; and
(ii) There is no break in the individual's participation between inpatient and outpatient treatment of their mental impairment.
(b) The individual is released from a medical institution where the individual received long-term care services from the aging and disability services administration.
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If an individual is gainfully employed at the time of application for MCS, the agency or the agency's designee denies incapacity. "Gainful employment" means an individual is performing, in a regular and predictable manner, an activity usually done for pay or profit and earning more than the substantial gainful activity standard as defined by the Social Security Administration.
(1) The agency or the agency's designee doesn't consider work to be gainful employment when the individual is working:
(a) Under special conditions that go beyond the employer providing reasonable accommodation, such as in a sheltered workshop the agency or the agency's designee has approved; or
(b) Occasionally or part-time because the individual's impairment limits the hours the individual is able to work compared to unimpaired workers in the same job as verified by the individual's employer.
(2) The agency or the agency's designee determines if the individual is incapacitated when the individual:
(a) Applies for medical benefits;
(b) Becomes employed;
(c) Obtains work skills by completing a training program; or
(d) The agency or the agency's designee receives new information that indicates the individual may be employable.
(3) Unless the individual meets the other incapacity criteria in WAC 182-508-0010, the agency or the agency's designee decides incapacity by applying the progressive evaluation process (PEP) to the medical evidence that the individual provides that meets WAC 182-508-0030. The PEP is the sequence of eight steps described in WAC 182-508-0035 through 182-508-0110.
(4) If the individual has a physical or mental impairment and the individual is impaired by alcohol or drug addiction and does not meet the other incapacity criteria in WAC 182-508-0010, the agency or the agency's designee decides if the individual is eligible for MCS by applying the PEP described in WAC 182-508-0035 through 182-508-0110. The individual isn't eligible for MCS benefits if the individual is incapacitated primarily because of alcoholism or drug addiction.
(5) In determining incapacity, the agency or the agency's designee considers only the individual's ability to perform basic work-related activities. "Basic work-related activities" are activities that anyone would be required to perform in a work setting. They consist of: Sitting, standing, walking, lifting, carrying, handling; and other physical functions (including manipulative or postural functions such as pushing, pulling, reaching, handling, stooping, or crouching), seeing, hearing, communicating, remembering, understanding and following instructions, responding appropriately to supervisors and co-workers, tolerating the pressures of a work setting, maintaining appropriate behavior, and adapting to changes in a routine work setting.
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(1) For a physical impairment, a health professional licensed in Washington state or where the examination was performed:
(a) A physician, which for medical care services (MCS) program purposes, includes:
(i) Medical doctor (M.D.);
(ii) Doctor of osteopathy (D.O.);
(iii) Doctor of optometry (O.D.) to evaluate visual acuity impairments;
(iv) Doctor of podiatry (D.P.) for foot disorders; and
(v) Doctor of dental surgery (D.D.S.) or doctor of medical dentistry (D.M.D.) for tooth abscesses or temporomandibular joint (TMJ) disorders.
(b) An advanced registered nurse practitioner (ARNP) for physical impairments that are within the ARNP's area of certification to treat;
(c) The chief of medical administration of the Veterans' Administration, or their designee, as authorized in federal law; or
(d) A physician assistant when the report is cosigned by the supervising physician.
(2) For a mental impairment, professionals licensed in Washington state or where the examination was performed:
(a) A psychiatrist;
(b) A psychologist;
(c) An advanced registered nurse practitioner certified in psychiatric nursing; or
(d) At the agency's or the agency's designee's discretion:
(i) A person identified as a mental health professional within the regional support network mental health treatment system provided the person's training and qualifications at a minimum include having a master's degree and two years of mental health treatment experience; or
(ii) The physician who is currently treating the individual for a mental impairment.
(3) "Supplemental medical evidence" means information from a health professional not listed in subsection (1) or (2) of this section and who can provide supporting medical evidence for impairments identified by any of the professionals listed in subsection (1) or (2) of this section. The agency includes as supplemental medical evidence sources:
(a) A health professional who has conducted tests on or provides ongoing treatment to the individual, such as a physical therapist, chiropractor, nurse, physician assistant;
(b) Workers at state institutions and agencies who are not health professionals and are providing or have provided medical or health-related services to the individual; or
(c) Chemical dependency professionals (CDPs) when requesting information on the effects of alcohol or drug abuse.
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(1) Objective evidence for physical impairments means:
(a) Laboratory test results;
(b) Pathology reports;
(c) Radiology findings including results of X rays and computer imaging scans;
(d) Clinical finding including, but not limited to, ranges of joint motion, blood pressure, temperature or pulse; and documentation of a physical examination; or
(e) Hospital history and physical reports and admission and discharge summaries; or
(f) Other medical history and physical reports related to the individual's current impairments.
(2) Objective evidence for mental impairments means:
(a) Clinical interview observations, including objective mental status exam results and interpretation.
(b) Explanation of how examination findings meet the clinical and diagnostic criteria of the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM).
(c) Hospital, outpatient and other treatment records related to the individual's current impairments.
(d) Testing results, if any, including:
(i) Description and interpretation of tests of memory, concentration, cognition or intelligence; or
(ii) Interpretation of medical tests to identify or exclude a connection between the mental impairment and physical illness.
(3) Medical evidence sufficient for an incapacity determination must be from a medical professional described in WAC 182-508-0020 and must include:
(a) A diagnosis for the impairment, or impairments, based on an examination performed within twelve months of application;
(b) A clear description of how the impairment relates to the individual's ability to perform the work-related activities listed in WAC 182-508-0015(5);
(c) Documentation of how the impairment, or impairments, is currently limiting the individual's ability to work based on an examination performed within the ninety days of the date of application or the forty-five days before the month of incapacity review; and
(d) Facts in addition to objective evidence to support the medical provider's opinion that the individual is unable to be gainfully employed, such as proof of hospitalization.
(4) When making an incapacity decision, the agency or the agency's designee does not use the individual's report of symptoms as evidence unless objective evidence shows there is an impairment that could reasonably be expected to produce those symptoms.
(5) The agency or the agency's designee doesn't use symptoms related to substance abuse or a diagnosis of addiction or chemical dependency when determining incapacity when the only impairment supported by objective medical evidence is drug or alcohol addiction.
(6) The agency or the agency's designee considers diagnoses that are independent of addiction or chemical dependency when determining incapacity.
(7) The agency or the agency's designee determines the individual has a diagnosis that is independent of addiction or chemical dependency if the impairment will persist at least sixty days after the individual stops using drugs or alcohol.
(8) If the individual can't obtain medical evidence sufficient for the agency or its designee to determine if the individual is likely to be disabled without cost to the individual, and the individual meets other eligibility conditions in WAC 182-508-0005, the agency pays the costs to obtain objective evidence based on the agency's published payment limits and fee schedules.
(9) The agency or the agency's designee decides incapacity based solely on the objective information it receives. The agency or the agency's designee is not obligated to accept a decision that the individual is incapacitated or unemployable made by another agency or person.
(10) The agency or the agency's designee can't use a statement from a medical professional to determine that the individual is incapacitated unless the statement is supported by objective medical evidence.
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| Effect on Work Activities | Degree of Impairment | Numerical Value | ||
| (a) | There is no effect on performance of one or more basic work-related activities. | None | 1 | |
| (b) | There is no significant limit on performance of one or more basic work-related activities. | Mild | 2 | |
| (c) | There are significant limits on performance of one or more basic work-related activity. | Moderate | 3 | |
| (d) | There are very significant limits on the individual's performance of one or more basic work-related activities. | Marked | 4 | |
| (e) | The individual is unable to perform at least one basic work-related activity. | Severe | 5 | |
(3) A contracted doctor reviews the individual's medical evidence and the ratings assigned to the individual's impairment when there is at least a moderate severity rating and the individual's impairment has lasted, or is expected to last, twelve months or more.
(4) The contracted doctor reviews the individual's medical evidence, severity ratings, and functional assessment to determine whether:
(a) The medical evidence is objective and sufficient to support the findings of the provider;
(b) Description of impairments is supported by the medical evidence; and
(c) Severity rating and assessment of functional limitations assigned by the agency or the agency's designee are consistent with the medical evidence.
(5) If the medical evidence provider's description of the individual's impairments is not consistent with other objective evidence the agency or the agency's designee has obtained, the agency or the agency's designee takes the following action:
(a) If the individual's limitations are more severe than the impairments described, the agency or the agency's designee assigns a higher severity rating; or
(b) If the individual's limitations are less severe than the impairments described, the agency or the agency's designee assigns a lower severity rating; and
(c) The agency or the agency's designee gives clear and convincing reasons for rejecting the medical evidence provider's opinion.
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(1) The agency or the agency's designee requires a written medical report to determine incapacity. The report must:
(a) Contain sufficient information as described under WAC 182-508-0030;
(b) Be written by an authorized medical professional described in WAC 182-508-0020;
(c) Document the existence of a potentially incapacitating condition; and
(d) Indicate an impairment is expected to last ninety days or more from the application date.
(2) If the information received isn't clear, the agency or the agency's designee may require more information before the agency or the agency's designee decides the individual's ability to be gainfully employed. As examples, the agency or the agency's designee may require the individual to get more medical tests or be examined by a medical specialist.
(3) The agency or the agency's designee denies incapacity if:
(a) There is only one impairment and the severity rating is less than three;
(b) A reported impairment isn't expected to last ninety days or more from the date of application;
(c) The only impairment supported by objective medical evidence is drug or alcohol addiction; or
(d) The agency or the agency's designee doesn't have clear and objective medical evidence to approve incapacity.
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(1) The agency or the agency's designee reviews the following psychological evidence to determine the severity of the individual's mental impairment:
(a) Psychosocial and treatment history records;
(b) Clinical findings of specific abnormalities of behavior, mood, thought, orientation, or perception;
(c) Results of psychological tests; and
(d) Symptoms observed by the examining practitioner that show how the individual's impairment affects their ability to perform basic work-related activities.
(2) The agency or the agency's designee excludes diagnosis and related symptoms of alcohol or substance abuse or addiction when the only impairment supported by objective medical evidence is drug or alcohol addiction.
(3) If the individual is diagnosed with mental retardation, the diagnosis must be based on the Wechsler adult intelligence scale (WAIS). The following test results determine the severity rating:
| Intelligence Quotient (IQ) Score | Severity Rating |
| 85 or above | 1 |
| 71 to 84 | 3 |
| 70 or lower | 5 |
(a) Short term memory impairment;
(b) Perceptual or thinking disturbances;
(c) Disorientation to time and place; or
(d) Labile, shallow, or coarse affect.
(5) The agency or the agency's designee bases the severity of an impairment diagnosed as a mood, anxiety, thought, memory, personality, or cognitive disorder on a clinical assessment of the intensity and frequency of symptoms that:
(a) Affect the individual's ability to perform basic work-related activities; and
(b) Are consistent with a diagnosis of a mental impairment as listed in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM).
(6) The agency or the agency's designee bases the severity rating for a functional mental impairment on accumulated severity ratings for the symptoms in subsection (5)(a) of this section as follows:
| Symptom Ratings or Condition | Severity Rating | ||
| (a) | The individual is diagnosed with a functional disorder with psychotic features; | Moderate | (3) |
| (b) | The individual has had two or more hospitalizations for psychiatric reasons in the past two years; | ||
| (c) | The individual has had more than six months of continuous psychiatric inpatient or residential treatment in the past two years; | ||
| (d) | The objective evidence and global assessment of functioning score are consistent with a significant limitation on performing one or more basic work activities. | ||
| (e) | The objective evidence and global assessment of functioning score are consistent with very significant limitations on ability to perform one or more basic work activities. | Marked | (4) |
| (f) | The objective evidence and global assessment of functioning score are consistent with the absence of ability to perform one or more basic work activities. | Severe | (5) |
| Condition | Severity Rating | ||
| (a) | Two or more disorders with moderate severity (3) ratings; or | Marked | (4) |
| (b) | One or more disorders rated moderate severity (3), and one rated marked severity (4). | ||
| (c) | Two or more disorders rated marked severity (4). | Severe | (5) |
(9) The agency or the agency's designee approves incapacity when the individual has an overall mental severity rating of severe (5).
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(1) The agency or the agency's designee assigns to each physical impairment a severity rating that is supported by medical evidence.
(2) If the individual's physical impairment is rated two, and there is no mental impairment or a mental impairment that is rated one, the agency or the agency's designee denies incapacity.
(3) If the individual's physical impairment is consistent with a severity rating of five, the agency or the agency's designee approves incapacity.
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(a) Musculo-skeletal;
(b) Special senses and speech;
(c) Respiratory;
(d) Cardiovascular;
(e) Digestive;
(f) Genito-urinary;
(g) Hemic and lymphatic;
(h) Skin;
(i) Endocrine and obesity;
(j) Neurological;
(k) Mental disorders;
(l) Neoplastic; and
(m) Immune systems.
(2) The agency or the agency's designee follows these rules when there are multiple impairments:
(a) The agency or the agency's designee groups each diagnosis by body system.
(b) When an individual has two or more diagnosed impairments that limit work activities, the agency or the agency's designee assigns an overall severity rating as follows:
| Client Condition | Severity Rating | |
| (i) | All impairments are in the same body system, are rated two and there is no cumulative effect on one or more basic work activities. | 2 |
| (ii) | All impairments are in the same body system, are rated two and there is a cumulative effect on one or more basic work activities. | 3 |
| (iii) | All impairments are in different body systems, are rated two and there is a cumulative effect on basic work activities. | |
| (iv) | Two or more impairments are in different body systems and are rated three. | 4 |
| (v) | Two or more impairments are in different body systems; one is rated three and one is rated four. | |
| (vi) | Two or more impairments in different body systems are rated four. | 5 |
(d) The agency or the agency's designee approves incapacity when the overall severity rating is five.
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(1) The agency or the agency's designee evaluates cognitive and social functioning by assessing the individual's ability to:
(a) Understand, remember, and persist in tasks by following very short and simple instructions.
(b) Understand, remember, and persist in tasks by following detailed instructions.
(c) Perform activities within a schedule, maintain regular attendance, and be punctual within customary tolerances without special supervision.
(d) Learn new tasks.
(e) Perform routine tasks without special supervision.
(f) Adapt to changes in a routine work setting.
(g) Make simple work-related decisions.
(h) Be aware of normal hazards and take appropriate precautions.
(i) Ask simple questions or request assistance.
(j) Communicate and perform effectively in a work setting.
(k) Complete a normal workday and workweek without interruptions from psychologically based symptoms.
(l) Set realistic goals and plan independently.
(m) Maintain appropriate behavior in a work setting.
(2) The agency or the agency's designee approves incapacity when it has objective medical evidence, including a mental status exam (MSE) per WAC 182-508-0050, that demonstrates the individual is:
(a) At least moderately impaired in their ability to understand, remember, and persist in tasks following simple instructions, and at least moderately limited in their ability to:
(i) Learn new tasks;
(ii) Be aware of normal hazards and take appropriate precautions; and
(iii) Perform routine tasks without undue supervision; or
(b) At least moderately impaired in the ability to understand, remember, and persist in tasks following complex instructions; and at least markedly limited in the ability to:
(i) Learn new tasks;
(ii) Be aware of normal hazards and take appropriate precautions; and
(iii) Perform routine tasks without undue supervision.
(3) The agency or the agency's designee approves incapacity when the individual is moderately (rated three) impaired in their ability to:
(a) Communicate and perform effectively in a work setting; and
(b) Markedly (rated four) impaired in their ability to maintain appropriate behavior in a work setting.
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(1) "Exertion level" means having strength, flexibility, and mobility to lift, carry, stand or walk as needed to fulfill job duties in the following work levels. For this section, "occasionally" means less than one third of the time and "frequently" means one third to two thirds of the time.
The following table is used to determine an individual's exertion level. Included in this table is a strength factor, which is an individual's ability to perform physical activities, as defined in Appendix C of the Dictionary of Occupational Titles (DOT), Revised Edition, published by the U.S. Department of Labor as posted on the Occupational Information Network (O.*NET).
| If an individual is able to: | Then the individual is assigned this exertion level | |
| (a) | Lift no more than two pounds or unable to stand or walk. | Severely limited |
| (b) | Lift ten pounds maximum and frequently lift or carry lightweight articles. Walking or standing only for brief periods. | Sedentary |
| (c) | Lift twenty pounds maximum and frequently lift or carry objects weighing up to ten pounds. Walk six out of eight hours per day or stand during a significant portion of the workday. Sitting and using pushing or pulling arm or leg movements most of the day. | Light |
| (d) | Lift fifty pounds maximum and frequently lift or carry up to twenty-five pounds. | Medium |
| (e) | Lift one hundred pounds maximum and frequently lift or carry up to fifty pounds. | Heavy |
(3) "Functional physical capacity" means the degree of strength, agility, flexibility, and mobility an individual can apply to work-related activities. The agency or the agency's designee considers the effect of the physical impairment on the ability to perform work-related activities when the physical impairment is assigned an overall severity rating of three or four. The agency or the agency's designee determines functional physical capacity based on the individual's exertional, exertionally related and nonexertional limitations. All limitations must be substantiated by the medical evidence and directly related to the diagnosed impairment(s).
(4) "Nonexertional physical limitation" means a restriction on work activities that does not affect strength, mobility, agility, or flexibility. Examples are:
(a) Environmental restrictions which could include, among other things, an individual's inability to work in an area where they would be exposed to chemicals; and
(b) Workplace restrictions, such as impaired hearing or speech, which would limit the types of work environments an individual could work in.
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(1) The agency or the agency's designee evaluates education in terms of formal schooling or other training that would enable the individual to meet job requirements. Education is classified as:
| If the individual: | Then the individual's education level is | |
| (a) | Can't read or write a simple communication, such as two sentences or a list of items. | Illiterate |
| (b) | Has no formal schooling or vocational training beyond the eleventh grade; or | Limited education |
| (c) | Has participated in special education in basic academic classes of reading, writing, or mathematics in high school. | |
| (d) | Has received a high school diploma or general equivalency degree (GED); or | High school and above level of education |
| (e) | Has received skills training and was awarded a certificate, degree or license. | |
(a) Is defined as gainful employment per WAC 182-508-0015;
(b) Has been performed in the past five years; and
(c) The individual performed long enough to acquire the knowledge and skills to continue performing the job. The individual must meet the specific vocational preparation level as defined in Appendix C of the Dictionary of Occupational Titles.
(3) For each relevant past work situation that the individual had, the agency or the agency's designee determines:
(a) The exertion or skill requirements of the job; and
(b) Current cognitive, social, or nonexertion factors that significantly limit the individual's ability to perform past work.
(4) After considering vocational factors, the agency or the agency's designee denies incapacity when the individual has:
(a) The physical and mental ability to perform past work, and there is no significant cognitive, social or exertion limitation that would prevent the individual from performing past work; or
(b) Recently acquired specific work skills through completion of schooling or training, for jobs within the individual's current physical or mental capacities.
(5) The agency or the agency's designee approves incapacity when the individual is fifty-five years of age or older and doesn't have the physical or mental ability to perform past work.
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(1) The agency or the agency's designee approves incapacity if the individual has a physical impairment and meets the vocational factors below:
| Highest Work Level Assigned by the Practitioner | Age | Education Level | Other Vocational Factors |
| Sedentary | Any age | Any level | Does not apply |
| Light | 50 and older | Any level | Does not apply |
| Light | 35 and older | Illiterate or LEP | Does not apply |
| Light | 18 and older | Limited Education | Does not have any past work |
| Medium | 50 and older | Limited Education | Does not have any past work |
| Social Limitation | Age | ||
| (a) | Moderately impaired (rated three) in the individual's ability to: | 50 years and older | |
| (i) | Communicate and perform effectively in a work setting; and | ||
| (ii) | Maintain appropriate behavior in a work setting. | ||
| (b) | The individual has a severe (five) impairment in their ability to communicate and perform effectively in a work setting. | Any age | |
| (c) | A mental disorder of marked severity (rated four): | Any age | |
| (i) | One or more severe (rated five) mental impairment symptoms; and | ||
| (ii) | Moderately impaired (rated three) in the ability to communicate and perform effectively in a work setting. | ||
| Age | Education | Other Restrictions | |
| Any age | Any level | The individual is moderately impaired in their ability to communicate and perform effectively in a work setting. | |
| 50 or older | Limited education | Restricted to medium work level or less. | |
| Any age | Limited education | Restricted to light work level. | |
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(2) The agency does not cover medical services received outside the state of Washington unless the medical services are provided in a border city listed in WAC 182-501-0175.
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(2) The agency may limit enrollment into MCS coverage by implementing an enrollment cap and waiting list.
(3) If an individual is denied MCS coverage due to an enrollment cap:
(a) The individual is added to the MCS waiting list based on the date the individual applied.
(b) Applicants with the oldest application date will be the first to receive an opportunity for enrollment when MCS coverage is available.
(4) An individual is exempted from the enrollment cap and wait list rules when:
(a) MCS was terminated due to agency error;
(b) The individual is in the thirty-day reconsideration period for incapacity reviews under WAC 182-508-0160(4); or
(c) The individual is being terminated from a CN medical program and was receiving and eligible for CN coverage prior to the date a wait list was implemented and the following conditions are met:
(i) The individual met financial and program eligibility criteria for MCS at the time their CN coverage ended; and
(ii) The individual met the incapacity criteria for MCS at the time their CN coverage ended.
(d) The individual applied for medical coverage and an eligibility decision was not completed prior to the enrollment cap effective date.
(5) If the individual is sent an offer for MCS enrollment, the individual must submit a completed application no later than the last day of the month following the month of enrollment offer. The individual must reapply within this time period and subsequently be determined eligible before MCS coverage can begin. The individual must reapply and requalify even if the individual was previously determined eligible for MCS.
(6) The individual is removed from the MCS wait list if the individual:
(a) Is not a Washington resident;
(b) Is deceased;
(c) Requests removal from the wait list;
(d) Fails to submit an application after an enrollment offer is sent as described in subsection (5) of this section;
(e) Reapplies as described in subsection (5) of this section, but does not qualify for MCS; or
(f) Is found eligible for categorically or medically needy coverage.
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(2) The individual's benefits stop at the end of the individual's incapacity period unless the individual provides additional medical evidence that demonstrates during the current incapacity period that there was no material improvement in the individual's impairment. No material improvement means that the individual's impairment continues to meet the progressive evaluation process criteria in WAC 182-508-0015 through 182-508-0110, excluding the requirement that the individual's impairment(s) prevent employment for ninety days.
(3) The medical evidence must meet all of the criteria defined in WAC 182-508-0030.
(4) The agency or the agency's designee uses medical evidence received after the individual's incapacity period had ended when:
(a) The delay was not due to the individual's failure to cooperate; and
(b) The agency or the agency's designee receives the evidence within thirty days of the end of the individual's incapacity period; and
(c) The evidence meets the progressive evaluation process criteria in WAC 182-508-0015 through 182-508-0110.
(5) Even if the individual's condition has not improved, the individual isn't eligible for MCS when:
(a) The agency or the agency's designee receives current medical evidence that doesn't meet the progressive evaluation process criteria in WAC 182-508-0035 through 182-508-0110; and
(b) The agency's or the agency designee's prior decision that the individual's incapacity met the requirements was incorrect because:
(i) The information the agency or the agency's designee had was incorrect or not enough to show incapacity; or
(ii) The agency or the agency's designee didn't apply the rules correctly to the information it had at that time.
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(2) An individual must accept an assessment referral and participate in drug or alcohol treatment if a certified chemical dependency counselor indicates a need for treatment, unless the individual meets one of the following good cause reasons:
(a) The agency or the agency's designee determines that the individual's physical or mental health impairment prevents them from participating in treatment.
(b) The outpatient chemical dependency treatment the individual needs isn't available in the county they live in.
(c) The individual needs inpatient chemical dependency treatment at a location that they can't reasonably access.
(3) If an individual refuses or fails to complete an assessment or treatment without good cause, the individual's MCS coverage will end following advance notification rules under WAC 388-458-0030.
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| Assistance Unit Size | Eligibility Standard |
| 1 | $339 |
| 2 | $428 |
| Assistance Unit Size | Eligibility Standard |
| 1 | $206 |
| 2 | $261 |
| Facility Type | Assistance Unit Size | Eligibility Standard | |
| Medical institutions (includes nursing homes and hospitals) | 1 | 41.62 | |
| Adult family homes | 1 | 339.00 | |
| Boarding homes (includes assisted living, enhanced residential centers (EARC), and adult residential centers (ARC)) | 1 | 38.84 | |
| DDD group home | 1 | 38.84 | |
| Mental Health adult residential treatment facilities (ARTF) | 1 | 38.84 | |
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(a) Provided to eligible individuals as described in subsection (5) of this section;
(b) Directly related to detoxification; and
(c) Performed by a certified detoxification center or by a general hospital that has a contract with the department of social and health services to provide detoxification services.
(2) The agency limits on paying for detoxification services are:
(a) Three days for an acute alcoholic condition; or
(b) Five days for acute drug addiction.
(3) The agency only pays for detoxification services when notified within ten working days of the date detoxification began and all eligibility factors are met.
(4) To apply for detoxification services, an individual must complete an application for benefits. An interview is not required when applying for medical assistance. However, additional documentation may be needed to prove or confirm the information provided in the application form.
(5) An individual is eligible for detoxification services if the individual receives benefits under one of the following programs:
(a) Temporary assistance for needy families (TANF);
(b) Aged, blind, disabled cash assistance program (ABD);
(c) Supplemental Security Income (SSI);
(d) Medical care services program (MCS);
(e) Alcohol and Drug Addiction Treatment and Support Act (ADATSA); or
(f) A medical assistance program.
(6) An individual who is not eligible for one of the programs listed in subsection (5) of this section is eligible for the detoxification program if they meet the following criteria:
(a) Nonexempt countable income does not exceed the eligibility standards for MCS and ADATSA as described in WAC 182-508-0230; and
(b) Nonexempt countable resources do not exceed one thousand dollars.
(7) The following expenses are deducted from income when determining countable income:
(a) Mandatory expenses of employment;
(b) Support payments paid under a court order; and
(c) Payments to a wage earner specified by a court in bankruptcy proceedings, or previously contracted major household repairs, when failure to make such payments will result in garnishment of wages or loss of employment.
(8) The following resources are not counted when determining countable resources:
(a) A home;
(b) Household furnishings and personal clothing essential for daily living;
(c) Other personal property used to reduce need for assistance or for rehabilitation;
(d) A used and useful automobile; and
(e) All income and resources of a noninstitutionalized SSI beneficiary.
(9) The following resources are counted when determining countable resources:
(a) Cash and other liquid assets;
(b) Marketable securities; and
(c) Any other resource not specifically exempted that can be converted to cash.
(10) If an individual receives detoxification services, the individual will not incur a deductible as a factor of eligibility for the covered period of detoxification.
(11) Once an individual has been determined eligible for detoxification services, the individual is eligible from the date detoxification begins through the end of the month in which the detoxification is completed.
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(2) ADATSA provides eligible individuals with treatment if they are chemically dependent and would benefit from it.
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(1) Alcohol/drug treatment services and support based on an individual assessment of alcohol/drug involvement and treatment needs in accordance with RCW 70.96A.100.
(2) Medical care services (MCS) as described under WAC 182-508-0005, 182-501-0060, and 182-501-0065.
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(a) Be eighteen years of age or older;
(b) Be a resident of Washington as defined in WAC 182-503-0520;
(c) Meet citizenship requirements as described in WAC 182-503-0532;
(d) Provide their Social Security number; and
(e) Meet the same income and resource criteria for the medical care services (MCS) program (unless subsection (3) of this section applies), or receive federal assistance under Supplemental Security Income (SSI) or temporary assistance for needy families (TANF).
(2) An individual is not eligible for the ADATSA program if the individual is otherwise eligible for TANF and loses their eligibility for medical coverage due to:
(a) Noncooperation with the division of child support requirements; or
(b) Failure to cooperate with third-party liability (TPL) requirements to identify any potential third-party payors for medical coverage.
(3) An individual with nonexcluded countable income higher than the MCS eligibility standard described in WAC 182-508-0230 may qualify for inpatient only residential treatment if total countable income is below the projected monthly cost of care in the treatment center based on the state daily reimbursement rate.
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(1) The individual meets the requirements in WAC 182-508-0320 and be waiting to receive the Alcohol and Drug Addiction Treatment and Support Act (ADATSA) services;
(2) The individual is participating in ADATSA residential or outpatient treatment; or
(3) The individual has chosen opiate dependency (methadone maintenance) chemical dependency treatment services instead of other ADATSA treatment, but only if these treatment services are from a state-approved, publicly funded opiate dependency/methadone maintenance program.
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OTS-4394.5
INCOME AND RESOURCES ((FOR MEDICAL PROGRAMS))
(1) The agency or the agency's designee counts all available income owned or held by persons in the assistance unit under WAC 182-506-0020 to decide if the individual is eligible for benefits when:
(a) The individual gets or expects to get income in the month.
(b) The agency or the agency's designee must count the income based on rules under this chapter.
(c) The individual owns the income. The agency or the agency's designee uses state and federal laws about who owns property to decide if the individual actually owns the income. If the individual is married, the agency or the agency's designee decides if the income is separate or community income according to chapter 26.16 RCW.
(d) The individual has control over the income, which means the income is actually available to the individual. If the individual has a representative payee, protective payee, or other person who manages the individual's income, the agency or the agency's designee considers this as the individual having control over this income.
(e) The individual can use the income to meet their current needs. The agency or the agency's designee counts the gross amount of available income in the month the individual's assistance unit gets it. If the individual normally gets the income:
(i) On a specific day, the agency or the agency's designee counts it as available on that date.
(ii) Monthly or twice monthly and the pay date changes due to a reason beyond the individual's control, such as a weekend or holiday, the agency or the agency's designee counts it in the month the individual would normally get it.
(iii) Weekly or every other week and the pay date changes due to a reason beyond the individual's control, the agency or the agency's designee counts it in the month the individual would normally get it.
(2) If income is legally the individual's designee, the agency or the agency's designee considers the income as available to the individual even if it is paid to someone else for the individual.
(3) The agency or the agency's designee:
(a) May count the income of certain people who live in the individual's home, even if they are not getting or applying for benefits. Their income counts as part of the individual's income.
(b) Counts the income of ineligible, disqualified, or financially responsible people as defined in WAC 182-509-0100.
(4) If the individual has a joint bank account with someone who is not in the individual's assistance unit (AU), the agency or the agency's designee counts any money deposited into that account as the individual's income unless:
(a) The individual can show that all or part of the funds belong only to the other account holder and are held or used only for the benefit of that holder; or
(b) Social Security Administration (SSA) used that money to determine the other account holder's eligibility for SSI benefits.
(5) Potential income is income the individual may be able to get that can be used to lower their need for assistance. If the agency or the agency's designee determines that the individual has a potential source of income, the individual must make a reasonable effort to make the income available in order to get MCS. The agency or the agency's designee does not count that income until the individual actually gets it.
(6) If the individual's AU includes a sponsored immigrant, the agency or the agency's designee considers the income of the immigrant's sponsor as available to the immigrant under the rules of this chapter. The agency or the agency's designee uses this income when deciding if the individual's AU is eligible for benefits and to calculate the individual's monthly benefits.
(7) The individual may give the agency or the agency's designee proof about a type of income at anytime, including when the agency or the agency's designee asks for it or if the individual disagrees with a decision the agency or the agency's designee made, about:
(a) Who owns the income;
(b) Who has legal control of the income;
(c) The amount of the income; or
(d) If the income is available.
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(1) Bona fide loans as defined in WAC 388-470-0045, except certain student loans as specified under WAC 182-509-0035;
(2) Federal earned income tax refunds and earned income tax credit (EITC) payments for up to twelve months from the date of receipt;
(3) Federal economic stimulus payments that are excluded for federal and federally assisted state programs;
(4) Federal twenty-five dollar supplemental weekly unemployment compensation payment authorized by the American Recovery and Reinvestment Act of 2009;
(5) Title IV-E and state foster care maintenance payments if the individual chooses not to include the foster child in the assistance unit;
(6) Energy assistance payments;
(7) Educational assistance that is not counted under WAC 182-509-0035;
(8) Native American benefits and payments that are not counted under WAC 388-450-0040;
(9) Income from employment and training programs that is not counted under WAC 182-509-0045;
(10) Money withheld from a benefit to repay an overpayment from the same income source;
(11) One-time payments issued under the Department of State or Department of Justice Reception and Replacement Programs, such as voluntary agency (VOLAG) payments;
(12) Payments we are directly told to exclude as income under state or federal law; and
(13) Payments made to someone outside of the household for the benefits of the assistance unit using funds that are not owed to the household.
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(1) Unearned income is income an individual gets from a source other than employment or self-employment. Some examples of unearned income are:
(a) Railroad retirement;
(b) Unemployment compensation;
(c) Social Security benefits (including retirement benefits, disability benefits, and benefits for survivors);
(d) Time loss benefits as described in WAC 388-450-0010, such as benefits from the department of labor and industries (L&I); or
(e) Veteran Administration benefits.
(2) The agency or the agency's designee counts unearned income before any taxes are taken out.
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(1) Earned income money received from working. This includes:
(a) Wages;
(b) Tips;
(c) Commissions;
(d) Profits from self-employment activities as described in WAC 182-509-0080; and
(e) One-time payments for work performed over a period of time.
(2) Income received for work performed for something other than money, such as rent, is considered earned income. The amount that is counted when determining the individual's eligibility for MCS is the amount received before any taxes are taken out (gross income).
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(1) Educational benefits that do not count are:
(a) Educational assistance in the form of grants, loans or work study, issued from Title IV of the Higher Education Amendments (Title IV - HEA) and Bureau of Indian Affairs (BIA) education assistance programs. Examples of Title IV - HEA and BIA educational assistance include, but are not limited to:
(i) College work study (federal and state);
(ii) Pell grants; and
(iii) BIA higher education grants.
(b) Educational assistance in the form of grants, loans or work study made available under any program administered by the Department of Education (DOE) to an undergraduate student. Examples of programs administered by DOE include, but are not limited to:
(i) Christa McAuliffe Fellowship Program;
(ii) Jacob K. Javits Fellowship Program; and
(iii) Library Career Training Program.
(2) For assistance in the form of grants, loans or work study under the Carl D. Perkins Vocational and Applied Technology Education Act, P.L. 101-391:
(a) If the individual is attending school half time or more, the following expenses are subtracted:
(i) Tuition;
(ii) Fees;
(iii) Costs for purchase or rental of equipment, materials, or supplies required of all students in the same course of study;
(iv) Books;
(v) Supplies;
(vi) Transportation;
(vii) Dependent care; and
(viii) Miscellaneous personal expenses.
(b) If the individual is attending school less than half time, the following expenses are subtracted:
(i) Tuition;
(ii) Fees; and
(iii) Costs for purchase or rental of equipment, materials, or supplies required of all students in the same course of study.
(c) The MCS eligibility standard based on one person is also subtracted.
(d) Any remaining income is unearned income and budgeted using the appropriate budgeting method for the assistance unit.
(3) If the individual is participating in a work study that is not excluded in subsection (1) of this section, that work study income is counted as earned income under the following conditions:
(a) The individual is allowed the earned income work incentive deduction described in WAC 182-509-0175; and
(b) The remaining income is budgeted using the appropriate budgeting method for the assistance unit.
(4) If the individual receives Veteran's Administration Educational Assistance:
(a) All applicable attendance costs are subtracted; and
(b) The remaining unearned income is budgeted using the appropriate budgeting method for the assistance unit.
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(1) All payments issued under the Workforce Investment Act (WIA) are excluded.
(2) All payments issued under the National and Community Service Trust Act of 1993 are excluded. This includes payments made through the AmeriCorps program.
(3) All payments issued under Title I of the Domestic Volunteer Act of 1973, such as VISTA, AmeriCorps Vista, university year for action, and urban crime prevention program are excluded.
(4) All payments issued under Title II of the Domestic Volunteer Act of 1973 are excluded. These include:
(a) Retired senior volunteer program (RSVP);
(b) Foster grandparents program; and
(c) Senior companion program.
(5) Training allowances from vocational and rehabilitative programs are counted as earned income when:
(a) The program is recognized by federal, state, or local governments; and
(b) The allowance is not a reimbursement.
(6) When an MCS client receives training allowances, the following is allowed:
(a) The earned income incentive and work expense deduction specified under WAC 182-509-0175, when applicable; and
(b) The actual cost of uniforms or special clothing required for the course as a deduction, if enrolled in a remedial education or vocational training course.
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(a) Clothing;
(b) Food;
(c) Household supplies;
(d) Medical supplies (nonprescription);
(e) Personal care items;
(f) Shelter;
(g) Transportation; and
(h) Utilities (e.g., lights, cooking fuel, the cost of heating or heating fuel).
(2) "Needs-based" means eligibility is based on an asset test of income and resources relative to the federal poverty level (FPL). This definition excludes such incomes as retirement benefits or unemployment compensation which are not needs-based.
(3) If the needs-based assistance is countable, it is treated as unearned income under WAC 182-509-0025.
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(1) A cash gift is a gift that is furnished as money, cash, checks or any other readily negotiable form. Cash gifts totaling no more than thirty dollars per calendar quarter for each assistance unit member are disregarded as income.
(2) A noncash gift is treated as a resource.
(a) If the gift is a countable resource, its value is added to the value of the individual's existing countable resources and a determination is made on the impact to continue the individual's eligibility for MCS, per WAC 182-509-0005.
(b) If the gift is an excluded or noncountable resource, it does not affect the individual's eligibility or benefit level.
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(1) Self-employment income is income that is earned by an individual from running a business, performing a service, selling items that are made by the individual or by reselling items to make a profit.
(2) An individual is self-employed if the individual earns income without having an employer/employee relationship with the person who pays for the goods or services. This includes, but is not limited to, when:
(a) The individual has primary control of the way they do their work; or
(b) Income is reported by the individual using IRS Schedule C, Schedule C-EZ, Schedule K-1, or Schedule SE.
(3) An individual usually is considered to have an employer/employee relationship when:
(a) The person the individual provides services for has primary control of how the individual does their work; or
(b) The individual gets an IRS form W-2 to report their income.
(4) Self-employment does not have to be a licensed business for the individual's business or activity to qualify as self-employment. Some examples of self-employment include:
(a) Childcare that requires a license under chapter 74.15 RCW;
(b) Driving a taxi cab;
(c) Farming/fishing;
(d) Odd jobs such as mowing lawns, house painting, gutter cleaning, or car care;
(e) Running a lodging for roomers and/or boarders. Roomer income includes money paid to the individual for shelter costs by someone not in your assistance unit who lives with the individual when:
(i) The individual owns or is buying their own residence; or
(ii) The individual rents all or a part of their residence and the total rent charges to all others living in the home is more than the individual's total rent.
(f) Running an adult family home;
(g) Providing services such as a massage therapist or a professional escort;
(h) Retainer fees to reserve a bed for a foster child;
(i) Selling items that are home-made or items that are supplied to the individual;
(j) Selling or donating biological products such as providing blood or reproductive material for profit;
(k) Working as an independent contractor; and
(l) Running a business or trade either as a sole proprietorship or in a partnership.
(5) If the individual is an employee of a company or person who does the activities listed in subsection (2) of this section as a part of their job, the agency or the agency's designee does not count the work that is performed by the individual as self-employment.
(6) Self-employment income is counted as earned income as described in WAC 182-509-0030 except as described in subsection (7) of this section.
(7) There are special rules about renting or leasing out property or real estate that is owned by the individual. If the individual does not spend at least twenty hours per week managing the property, the income is counted as unearned income.
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(1) Counting actual income in the month of application. This is done by:
(a) Adding together the individual's gross self-employment income and any profit the individual made from selling their business property or equipment;
(b) Subtracting the individual's business expenses as described in subsection (2) of this section; and
(c) Dividing the remaining amount of self-employment income by the number of months over which the income will be averaged.
(2) Subtracting one hundred dollars as a business expense even if the individual's costs are less than this. If the individual's costs are more than one hundred dollars, the agency or the agency's designee may subtract the individual's actual costs if the individual provides proof of their expenses. The following expenses are never allowed:
(a) Federal, state, and local income taxes;
(b) Money set aside for retirement purposes;
(c) Personal work-related expenses (such as travel to and from work);
(d) Net losses from previous periods;
(e) Depreciation; or
(f) Any amount that is more than the payment the individual gets from a boarder for lodging and meals.
(3) If the individual has worked at their business for less than a year, figuring the individual's gross self-employment income by averaging:
(a) The income over the period of time the business has been in operation; and
(b) The monthly amount is estimated to be the amount the individual will get for the coming year.
(4) If the individual's self-employment expenses are more than their self-employment income, not using this "loss" to reduce income from other self-employment businesses or other sources of income to the assistance unit.
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(1) Allocation is the process of determining how much of a financially responsible person's income is considered available to meet the needs of legal dependents within or outside of an assistance unit (AU).
(2) "In-bound allocation" means income possessed by a financially responsible person outside the AU which is considered available to meet the needs of legal dependents in the AU.
(3) "Out-bound allocation" means income possessed by a financially responsible AU member which is set aside to meet the needs of a legal dependent outside the AU.
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(1) "Dependent" means a person who:
(a) Is or could be claimed for federal income tax purposes by the financially responsible person; or
(b) The financially responsible person is legally obligated to support.
(2) "Financially responsible person" means a parent, stepparent, adoptive parent, spouse or caretaker relative.
(3) "Ineligible assistance unit member" means a person who is:
(a) Ineligible for MCS due to the citizenship/alien status requirements in WAC 182-503-0532;
(b) Ineligible to receive MCS under WAC 182-503-0560 for fleeing to avoid prosecution or custody or confinement after conviction for a crime or attempt to commit a crime; or
(c) Ineligible to receive MCS under WAC 182-503-0560 for violating a condition of probation or parole which was imposed under federal or state law as determined by an administrative body or court of competent jurisdiction.
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(1) The income of an individual is reduced by the following:
(a) The MCS earned income work incentive deduction as specified in WAC 182-509-0175; and
(b) An amount not to exceed the ordered amount paid for court or administratively ordered current or back support for legal dependents living outside the home.
(2) When an individual resides in a medical institution, alcohol or drug treatment center, boarding home, or adult family home and has income, the individual retains an amount equal to:
(a) The eligibility standard amount for the nonapplying spouse living in the home; and
(b) The eligibility standard or personal needs allowance the individual is eligible for based upon their living arrangement.
(3) An individual with countable income remaining after the allocation in subsection (2)(a) and (b) of this section is not eligible for medical care services (MCS).
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(1) The remainder of the individual's wages, retirement benefits or separate property after reducing the income by:
(a) The MCS earned income work incentive deduction as specified in WAC 182-509-0175; and
(b) An amount not to exceed the ordered amount paid for court or administratively ordered current or back support for legal dependents living outside the home.
(2) The remainder of the nonapplying spouse's wages, retirement benefits and separate property after reducing the income by:
(a) An amount not to exceed the ordered amount paid for court or administratively ordered current or back support for legal dependents living outside the home, when the order is a separate order from the applying individual's order; and
(b) The one-person eligibility standard amount as specified under WAC 182-508-0230 which includes ineligible assistance unit members.
(3) One-half of all other community income, as provided in WAC 182-509-0005.
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(1) An individual who meets any of the following conditions is permanently exempt from deeming and none of a sponsor's income or resources are counted when determining eligibility for MCS:
(a) The Immigration and Nationality Act (INA) does not require the individual to have a sponsor. Immigrants who are not required to have a sponsor include those with the following status with United States Citizenship and Immigration Services (USCIS):
(i) Refugee;
(ii) Parolee;
(iii) Asylee;
(iv) Cuban/Haitian entrant; or
(v) Special immigrant from Iraq or Afghanistan.
(b) The sponsor is an organization or group as opposed to an individual;
(c) The individual does not meet the alien status requirements to be eligible for benefits under WAC 182-503-0532;
(d) The individual has worked or can get credit for forty qualifying quarters of work under Title II of the Social Security Act. If the individual worked during a quarter in which they received TANF, Basic Food, SSI, CHIP, or nonemergency medicaid benefits, a quarter of work is not counted towards the forty quarters. A quarter of work by the following people is also counted toward the forty qualifying quarters:
(i) The individual;
(ii) The individual's parents for the time they worked before the individual turned eighteen years old (including the time they worked before the individual was born); and
(iii) The individual's spouse if still married or if the spouse is deceased.
(e) The individual becomes a United States (U.S.) citizen;
(f) The individual's sponsor is dead; or
(g) If USCIS or a court decides that the individual, their child, or their parent was a victim of domestic violence from the sponsor and:
(i) The individual no longer lives with the sponsor; and
(ii) Leaving the sponsor caused the need for benefits.
(2) While the individual is in the same assistance unit (AU) as their sponsor, they are exempt from the deeming process. An individual is also exempt from the deeming process if:
(a) The sponsor signed the affidavit of support more than five years ago;
(b) The sponsor becomes permanently incapacitated; or
(c) The individual is a qualified alien according to WAC 388-424-0001 and:
(i) Is on active duty with the U.S. armed forces or the individual is the spouse or unmarried dependent child of someone on active duty;
(ii) Is an honorably discharged veteran of the U.S. armed forces or the individual is the spouse or unmarried dependent child of an honorably discharged veteran;
(iii) Was employed by an agency of the U.S. government or served in the armed forces of an allied country during a military conflict between the U.S. and a military opponent; or
(iv) Is a victim of domestic violence and the individual has petitioned for legal status under the Violence Against Women Act.
(3) If the individual, their child, or their parent was a victim of domestic violence, the individual is exempt from the deeming process for twelve months if:
(a) The individual no longer lives with the person who committed the violence; and
(b) Leaving this person caused the need for benefits.
(4) If the AU has income at or below one hundred thirty percent of the federal poverty level (FPL), the individual is exempt from the deeming process for twelve months. This is called the "indigence exemption." For this rule, the following is counted as income to the AU:
(a) Earned and unearned income the AU receives from any source; and
(b) Any noncash items of value such as free rent, commodities, goods, or services that are received from an individual or organization.
(5) If the individual chooses to use the indigence exemption, and is eligible for a state program, this information is not reported to the United States Attorney General.
(6) If the individual chooses not to use the indigence exemption:
(a) The individual could be found ineligible for benefits for not verifying the income and resources of the sponsor; or
(b) The individual will be subject to regular deeming rules under this section.
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(1) Countable income is all income that is available to the assistance unit (AU) after the following is subtracted:
(a) Excluded or disregarded income under WAC 182-509-0015;
(b) The earned income work incentive deduction under WAC 182-509-0175;
(c) Income that is allocated to someone outside of the AU under WAC 182-509-0110 through 182-509-0135.
(2) Countable income includes all income that must be counted because it is deemed or allocated from financially responsible persons who are not members of the AU under WAC 182-509-0110 through 182-509-0165.
(3) Countable income is compared to the eligibility standards under WAC 182-508-0230.
(4) If countable income available to the AU is equal to or greater than the eligibility standard, the individual is not eligible for medical care services (MCS).
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(1) When determining eligibility for MCS, the agency or the agency's designee allows an earned income work incentive deduction of fifty percent of an individual's gross earned income.
(2) This deduction is used to reduce countable income before comparing the income to the eligibility standard for the program.
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(1) The following definitions apply to this chapter:
(a) "Equity value" means the fair market value (FMV) minus any amount you owe on the resource.
(b) "Community property" means a resource in the name of the husband, wife, or both.
(c) "Separate property" means a resource of a married person that one of the spouses:
(i) Had possession of and paid for before they were married;
(ii) Acquired and paid for entirely out of income from separate property; or
(iii) Received as a gift or inheritance.
(2) A resource is counted towards the resource limit described in subsection (6) of this section when:
(a) It is a resource that must be counted under WAC 182-509-0205;
(b) The individual owns the resource. Ownership means:
(i) The individual's name is on the title to the property; or
(ii) The individual has property that doesn't have a title; and
(c) The individual has control over the resource, which means the resource is actually available to the individual; and
(d) The individual could legally sell the resource or convert it into cash within twenty days.
(3) The individual must try to make their resources available even if it will take more than twenty days to do so, unless:
(a) There is a legal barrier; or
(b) A court must be petitioned to release part or all of a resource.
(4) Resources are counted as of the date of application for MCS coverage.
(5) If total countable resources are over the resource limit in subsection (6) of this section, the individual is not eligible for MCS.
(6) Countable resources must be below the standards listed below based on the equity value of all countable resources.
(a) Applicants can have countable resources up to one thousand dollars.
(b) Recipients can have an additional three thousand dollars in a savings account.
(7) If the individual owns a countable resource with someone who is not included in the assistance unit (AU), only the portion of the resource that is owned by the individual is counted. If ownership of the funds cannot be determined, an equal portion of the resource is presumed to be owned by the individual and all other joint owners.
(8) It is assumed an individual has control of community property and is legally able to sell the property or convert it to cash unless evidence is provided to show the individual does not have control of the property.
(9) An item may not be considered separate property if the individual used both separate and community funds to buy or improve it.
(10) The resources of victims of family violence are not counted when:
(a) The resource is owned jointly with member of the former household;
(b) Availability of the resource depends on an agreement of the joint owner; or
(c) Making the resource available would place the individual at risk of harm.
(11) An individual may provide proof about a resource anytime, including when asked for proof by the agency or the agency's designee, or if the individual disagrees with a decision made about:
(a) Who owns a resource;
(b) Who has legal control of the resource;
(c) The value of a resource;
(d) The availability of a resource; or
(e) The portion of a property owned by the individual or another person(s).
(12) Resources of certain people who live in the home with the individual are countable, even if they are not getting assistance. Resources that count toward the resource limit in subsection (6) of this section include the resources of ineligible or financially responsible people as defined in WAC 182-509-0100.
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(1) The following resources count toward the resource limit described in WAC 182-509-0200:
(a) Liquid resources not specifically excluded in subsection (2) of this section. These are resources that are easily changed into cash. Some examples of liquid resources are:
(i) Cash on hand;
(ii) Money in checking or savings accounts;
(iii) Money market accounts or certificates of deposit (CDs) less any withdrawal penalty;
(iv) Available retirement funds or pension benefits, less any withdrawal penalty;
(v) Stocks, bonds, annuities, or mutual funds less any early withdrawal penalty;
(vi) Available trusts or trust accounts;
(vii) Lump sum payments as described in chapter 388-455 WAC; or
(viii) Any funds retained beyond the month of receipt from conversion of federally protected rights or extraction of exempt resources by members of a federally recognized tribe that are in the form of countable resources.
(b) The cash surrender value (CSV) of whole life insurance policies.
(c) The CSV over fifteen hundred dollars of revocable burial insurance policies or funeral agreements.
(d) Funds withdrawn from an individual development account (IDA) if they were removed for a purpose other than those specified in RCW 74.08A.220.
(e) Any real property like a home, land, or buildings not specifically excluded in subsection (3) of this section.
(f) The equity value of vehicles as described in WAC 182-509-0210.
(g) Personal property that is not:
(i) A household good;
(ii) Needed for self-employment; or
(iii) Of "great sentimental value," due to personal attachment or hobby interest.
(h) Resources of a sponsor as described in WAC 388-470-0060.
(i) Sales contracts.
(2) The following types of liquid resources are not counted toward the resource limit described in WAC 182-509-0200 when determining eligibility for MCS:
(a) Bona fide loans, including student loans;
(b) Basic food benefits;
(c) Income tax refunds for twelve months from the date of receipt;
(d) Earned income tax credit (EITC) in the month received and for up to twelve months;
(e) Advance earned income tax credit payments;
(f) Federal economic stimulus payments that are excluded for federal and federally assisted state programs;
(g) Individual development accounts (IDAs) established under RCW 74.08A.220;
(h) Retroactive cash benefits or TANF/SFA benefits resulting from a court order modifying a decision of the department;
(i) Underpayments received under chapter 388-410 WAC;
(j) Educational benefits that are excluded as income under WAC 182-509-0035;
(k) The income and resources of an SSI recipient;
(l) A bank account jointly owned with an SSI recipient if SSA already counted the money for SSI purposes;
(m) Foster care payments provided under Title IV-E and/or state foster care maintenance payments;
(n) Adoption support payments;
(o) Self-employment accounts receivable that the individual has billed to the customer but has been unable to collect;
(p) Resources specifically excluded by federal law; and
(q) Receipts from exercising federally protected rights or extracted exempt resources (fishing, shell fishing, timber sales, etc.) during the month of receipt for a member of a federally recognized tribe.
(3) The following types of real property are not counted when determining eligibility for MCS coverage:
(a) A home where the individual, their spouse, or their dependents live, including the surrounding property;
(b) A house the individual does not live in but plans to return to, and the individual is out of the home because of:
(i) Employment;
(ii) Training for future employment;
(iii) Illness; or
(iv) Natural disaster or casualty.
(c) Property that:
(i) The individual is making a good faith effort to sell;
(ii) The individual intends to build a home on, if they do not already own a home;
(iii) Produces income consistent with its fair market value (FMV), even if used only on a seasonal basis; or
(iv) A household member needs for employment or self-employment. Property excluded under this section and used by a self-employed farmer or fisher retains its exclusion for one year after the household member stops farming or fishing.
(d) Indian lands held jointly with the tribe, or land that can be sold only with the approval of the Bureau of Indian Affairs.
(4) If the individual deposits excluded liquid resources into a bank account with countable liquid resources, the excluded liquid resources are not counted for six months from the date of deposit.
(5) If the individual sells their home, the individual has ninety days to reinvest the proceeds from the sale of a home into an exempt resource.
(a) If the individual does not reinvest within ninety days, the agency or the agency's designee will determine whether there is good cause to allow more time. Some examples of good cause are:
(i) Closing on a new home is taking longer than anticipated;
(ii) The individual is unable to find a new home that is affordable;
(iii) Someone in the household is receiving emergent medical care; or
(iv) The individual has children or dependents that are in school and moving would require them to change schools.
(b) If good cause is determined, more time will be allowed based on the individual's circumstances.
(c) If good cause is not determined, the money received from the sale of the home is considered a countable resource.
[]
(1) A vehicle is any device for carrying persons and objects by land, water, or air.
(2) The entire value of a licensed vehicle needed to transport a physically disabled assistance unit (AU) member is excluded.
(3) The equity value of one vehicle up to five thousand dollars is excluded when the vehicle is used by the AU or household as a means of transportation.
[]
OTS-4473.1
AMENDATORY SECTION(Amending WSR 11-14-075, filed 6/30/11,
effective 7/1/11)
WAC 182-538-063
((GAU)) MCS clients residing in a
designated mandatory managed care plan county.
(1) In Laws of
2007, chapter 522, section 209 (13) and (14), the legislature
authorized the department to provide coverage of certain
medical and mental health benefits to clients who:
(a) ((Receive)) Are eligible for medical care services
(MCS) under ((the general assistance unemployable (GAU)
program)) WAC 182-508-0005; and
(b) Reside in a county designated by the ((department))
agency as a mandatory managed care plan county.
(2) The only sections of chapter ((388-538)) 182-538 WAC
that apply to ((GAU)) MCS clients described in this section
are incorporated by reference into this section.
(3) ((GAU)) MCS clients who reside in a county designated
by the department as a mandatory managed care plan county must
enroll in a managed care plan as required by WAC
((388-505-0110(7))) 182-508-0001 to receive
((department-paid)) agency-paid medical care. ((A GAU)) An
MCS client enrolled in an MCO plan under this section is
defined as ((a GAU)) an MCS enrollee.
(4) ((GAU)) MCS clients are exempt from mandatory
enrollment in managed care if they are American Indian or
Alaska Native (AI/AN) and meet the provisions of 25 U.S.C.
1603 (c)-(d) for federally recognized tribal members and their
descendants.
(5) The ((department)) agency exempts ((a GAU)) an MCS
client from mandatory enrollment in managed care:
(a) If the ((GAU)) MCS client resides in a county that is
not designated by the ((department)) agency as a mandatory MCO
plan county; or
(b) In accordance with WAC ((388-538-130))
182-538-130(3).
(6) The ((department)) agency ends ((a GAU)) an MCS
enrollee's enrollment in managed care in accordance with WAC
((388-538-130)) 182-538-130(4).
(7) On a case-by-case basis, the ((department)) agency
may grant ((a GAU)) an MCS client's request for exemption from
managed care or ((a GAU)) an MCS enrollee's request to end
enrollment when, in the ((department's)) agency's judgment:
(a) The client or enrollee has a documented and verifiable medical condition; and
(b) Enrollment in managed care could cause an interruption of treatment that could jeopardize the client's or enrollee's life or health or ability to attain, maintain, or regain maximum function.
(8) The ((department)) agency enrolls ((GAU)) MCS clients
in managed care effective on the earliest possible date, given
the requirements of the enrollment system. The ((department))
agency does not enroll clients in managed care on a
retroactive basis.
(9) Managed care organizations (MCOs) that contract with
the ((department)) agency to provide services to ((GAU)) MCS
clients must meet the qualifications and requirements in WAC
((388-538-067)) 182-538-067 and ((388-538-095)) 182-538-095
(3)(a), (b), (c), and (d).
(10) The ((department)) agency pays MCOs capitated
premiums for ((GAU)) MCS enrollees based on legislative
allocations for the ((GAU)) MCS program.
(11) ((GAU)) MCS enrollees are eligible for the scope of
care as described in WAC ((388-501-0060)) 182-501-0060 for
medical care services (MCS) programs.
(a) ((A GAU)) An MCS enrollee is entitled to timely
access to medically necessary services as defined in WAC
((388-500-0005)) 182-500-0070;
(b) MCOs cover the services included in the managed care
contract for ((GAU)) MCS enrollees. MCOs may, at their
discretion, cover services not required under the MCO's
contract for ((GAU)) MCS enrollees;
(c) The ((department)) agency pays providers on a
fee-for-service basis for the medically necessary, covered
medical care services not covered under the MCO's contract for
((GAU)) MCS enrollees;
(d) ((A GAU)) An MCS enrollee may obtain:
(i) Emergency services in accordance with WAC
((388-538-100)) 182-538-100; and
(ii) Mental health services in accordance with this section.
(12) The ((department)) agency does not pay providers on
a fee-for-service basis for services covered under the MCO's
contract for ((GAU)) MCS enrollees, even if the MCO has not
paid for the service, regardless of the reason. The MCO is
solely responsible for payment of MCO-contracted healthcare
services that are:
(a) Provided by an MCO-contracted provider; or
(b) Authorized by the MCO and provided by nonparticipating providers.
(13) The following services are not covered for ((GAU))
MCS enrollees unless the MCO chooses to cover these services
at no additional cost to the ((department)) agency:
(a) Services that are not medically necessary;
(b) Services not included in the medical care services scope of care, unless otherwise specified in this section;
(c) Services, other than a screening exam as described in
WAC ((388-538-100)) 182-538-100(3), received in a hospital
emergency department for nonemergency medical conditions; and
(d) Services received from a nonparticipating provider requiring prior authorization from the MCO that were not authorized by the MCO.
(14) A provider may bill ((a GAU)) an MCS enrollee for
noncovered services described in subsection (12) of this
section, if the requirements of WAC ((388-502-0160))
182-502-0160 and ((388-538-095)) 182-538-095(5) are met.
(15) Mental health services and care coordination are
available to ((GAU)) MCS enrollees on a limited basis, subject
to available funding from the legislature and an appropriate
delivery system.
(16) A care coordinator (a person employed by the MCO or
one of the MCO's subcontractors) provides care coordination to
((a GAU)) an MCS enrollee in order to improve access to mental
health services. Care coordination may include brief,
evidenced-based mental health services.
(17) To ensure ((a GAU)) an MCS enrollee receives
appropriate mental health services and care coordination, the
((department)) agency requires the enrollee to complete at
least one of the following assessments:
(a) A physical evaluation;
(b) A psychological evaluation;
(c) A mental health assessment completed through the client's local community mental health agency (CMHA) and/or other mental health agencies;
(d) A brief evaluation completed through the appropriate care coordinator located at a participating community health center (CHC);
(e) An evaluation by the client's primary care provider (PCP); or
(f) An evaluation completed by medical staff during an emergency room visit.
(18) ((A GAU)) An MCS enrollee who is screened positive
for a mental health condition after completing one or more of
the assessments described in subsection (17) of this section
may receive one of the following levels of care:
(a) Level 1. Care provided by a care coordinator when it
is determined that the ((GAU)) MCS enrollee does not require
Level 2 services. The care coordinator will provide the
following, as determined appropriate and available:
(i) Evidenced-based behavioral health services and care coordination to facilitate receipt of other needed services.
(ii) Coordination with the PCP to provide medication management.
(iii) Referrals to other services as needed.
(iv) Coordination with consulting psychiatrist as necessary.
(b) Level 2. Care provided by a contracted provider when
it is determined that the ((GAU)) MCS enrollee requires
services beyond Level 1 services. A care coordinator refers
the ((GAU)) MCS enrollee to the appropriate provider for
services:
(i) A regional support network (RSN) contracted provider; or
(ii) A contractor-designated entity.
(19) Billing and reporting requirements and payment
amounts for mental health services and care coordination
provided to ((GAU)) MCS enrollees are described in the
contract between the MCO and the ((department)) agency.
(20) The total amount the ((department)) agency pays in
any biennium for services provided pursuant to this section
cannot exceed the amount appropriated by the legislature for
that biennium. The ((department)) agency has the authority to
take whatever actions necessary to ensure the ((department))
agency stays within the appropriation.
(21) Nothing in this section shall be construed as
creating a legal entitlement to any ((GAU)) MCS client for the
receipt of any medical or mental health service by or through
the ((department)) agency.
(22) An MCO may refer enrollees to the ((department's))
agency's patient review and coordination (PRC) program
according to WAC ((388-501-0135)) 182-501-0135.
(23) The grievance and appeal process found in WAC
((388-538-110)) 182-538-110 applies to ((GAU)) MCS enrollees
described in this section.
(24) The hearing process found in chapter ((388-02))
182-526 WAC and WAC ((388-538-112)) 182-538-112 applies to
((GAU)) MCS enrollees described in this section.
[11-14-075, recodified as § 182-538-063, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 2007 c 522 § 209 (13)-(14). 08-10-048, § 388-538-063, filed 5/1/08, effective 6/1/08. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. 06-24-036, § 388-538-063, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090 and 74.09.522. 06-03-081, § 388-538-063, filed 1/12/06, effective 2/12/06. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.522, and 2003 1st sp.s. c 25 § 209(15). 04-15-003, § 388-538-063, filed 7/7/04, effective 8/7/04.]
OTS-4395.1
REPEALER
The following section of the Washington Administrative Code is repealed:
| WAC 182-556-0500 | Medical care services under state-administered cash programs. |
OTS-4433.2
AMENDATORY SECTION(Amending WSR 09-06-029, filed 2/24/09,
effective 3/27/09)
WAC 388-505-0270
When an involuntary commitment to
Eastern or Western State Hospital is covered by medicaid.
(1)
Individuals admitted to Eastern or Western State Hospital for
inpatient psychiatric treatment may qualify for categorically
needy (CN) medicaid coverage and ((general assistance (GA)))
aged, blind, disabled (ABD) cash benefits to cover their
personal needs allowance (PNA).
(2) To be eligible under this program, individuals must:
(a) Be eighteen through twenty years of age or sixty-five years of age or older;
(b) Meet institutional status under WAC 388-513-1320;
(c) Be involuntarily committed to an inpatient treatment program by a court order under chapter 71.34 RCW;
(d) Meet the general eligibility requirements for the
((GA)) ABD cash program as described in WAC ((388-400-0025))
388-400-0060;
(e) Have countable income below the payment standard described in WAC 388-478-0040; and
(f) Have countable resources below one thousand dollars. Individuals eligible under the provisions of this section may not apply excess resources towards the cost of care to become eligible. An individual with resources over the standard is not eligible for assistance under this section.
(3) ((GA)) ABD clients who receive active psychiatric
treatment in Eastern or Western State Hospital at the time of
their twenty-first birthday continue to be eligible for
medicaid coverage until the date they are discharged from the
facility or until their twenty-second birthday, whichever
occurs first.
[Statutory Authority: RCW 74.04.055, 74.04.057, 74.08.090, 74.09.530, and 42 C.F.R. 441.151. 09-06-029, § 388-505-0270, filed 2/24/09, effective 3/27/09.]
The following section of the Washington Administrative
Code is decodified as follows:
| Old WAC Number | New WAC Number |
| 388-505-0270 | 182-514-0270 |
OTS-4384.1
REPEALER
The following section of the Washington Administrative Code is repealed:
| WAC 388-505-0110 | Medical assistance coverage for adults not covered under family medical programs. |
OTS-4386.1
REPEALER
The following sections of the Washington Administrative Code are repealed:
| WAC 388-800-0020 | What detoxification services will the department pay for? |
| WAC 388-800-0025 | What information does the department use to decide if I am eligible for the detoxification program? |
| WAC 388-800-0030 | Who is eligible for detoxification services? |
| WAC 388-800-0035 | How long am I eligible to receive detoxification services? |
| WAC 388-800-0048 | Who is eligible for ADATSA? |
| WAC 388-800-0110 | What cash benefits am I eligible for through ADATSA if I am in residential treatment? |
| WAC 388-800-0115 | What cash benefits can I receive through ADATSA if I am in outpatient treatment? |
| WAC 388-800-0130 | What are ADATSA shelter services? |
| WAC 388-800-0135 | When am I eligible for ADATSA shelter services? |
| WAC 388-800-0140 | What incapacity criteria must I meet to be eligible for ADATSA shelter services? |
| WAC 388-800-0145 | How does the department review my eligibility for ADATSA shelter services? |
| WAC 388-800-0150 | Who is my protective payee? |
| WAC 388-800-0155 | What are the responsibilities of my protective payee? |
| WAC 388-800-0160 | What are the responsibilities of an intensive protective payee? |
| WAC 388-800-0165 | What happens if my relationship with my protective payee ends? |