PERMANENT RULES
(Medicaid Program)
Effective Date of Rule: Thirty-one days after filing.
Purpose: The web link cited in WAC 182-519-0050 which connects the reader to the medically needy income level (MNIL) standards is obsolete. The agency has replaced the web link with a chart of the MNIL and reference to the annually updated federal benefit rate.
Citation of Existing Rules Affected by this Order: Repealing WAC 388-512-1210; amending WAC 182-512-0150, 182-512-0700, 182-512-0900, 182-512-0920, 182-512-0940, 182-519-0050, 388-519-0100, and 388-519-0110.
Statutory Authority for Adoption: RCW 41.05.021.
Adopted under notice filed as WSR 12-16-049 on July 27, 2012.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 8, Repealed 1.
Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 8, Repealed 1.
Date Adopted: September 19, 2012.
Kevin M. Sullivan
Rules Coordinator
OTS-4880.1
AMENDATORY SECTION(Amending WSR 11-24-018, filed 11/29/11,
effective 12/1/11)
WAC 182-512-0150
SSI-related medical -- Medically needy
(MN) medical eligibility.
(1) Medically needy (MN) medical
coverage is available for any of the following:
(a) ((A person)) An individual who is SSI-related and not
eligible for CN medical coverage because ((they have)) the
individual has countable income that is above the CN income
standard (or for long-term care (LTC) clients, above the
special income limit (SIL)):
(i) ((Their)) The individual's countable income is at or
below MN standards, leaving ((them with)) no spenddown
requirement; or
(ii) ((Their)) The individual's countable income is above
MN standards requiring ((them)) the individual to spenddown
their excess income (see subsection (4) ((below)) of this
section). See WAC ((388-475-0500)) 182-512-0500 through
((388-475-0800)) 182-512-0800 for rules on determining
countable income, and WAC ((388-478-0080)) 182-519-0050 for
program standards or chapter 388-513 WAC for institutional
standards.
(b) An SSI-related ineligible spouse of an SSI recipient;
(c) An ((adult)) individual who meets SSI program
criteria but is not eligible for the SSI cash grant due to
immigration status or sponsor deeming. See WAC 388-424-0010
for limits on eligibility for aliens;
(d) ((A person)) An individual who meets the MN LTC
services requirements of chapter 388-513 WAC ((and WAC 388-515-1540));
(e) ((A person)) An individual who lives in an alternate
living facility and meets the requirements of WAC 388-513-1305; or
(f) ((A person)) An individual who meets resource
requirements as described in chapter ((388-475)) 182-512 WAC,
elects and is certified for hospice services per chapter
((388-551)) 182-551 WAC.
(2) ((Clients)) Individuals whose countable resources are
above the SSI resource standards are not eligible for MN
noninstitutional medical benefits. See WAC ((388-475-0200))
182-512-0200 through ((388-475-0550)) 182-512-0550 to
determine countable resources.
(3) ((Clients)) Individuals who qualify for services
under long term care have different criteria and may spend
down excess resources to become eligible for LTC institutional
or waiver medical benefits. Refer to WAC 388-513-1315 and
388-513-1395.
(4) ((A client)) An individual with income over the
effective medically needy income limit (MNIL) described in WAC 182-519-0050 may become eligible for MN coverage when ((they
have)) the individual has incurred medical expenses that are
equal to the excess income. This is the process of meeting
spenddown. Refer to chapter ((388-519)) 182-519 WAC for
spenddown information.
(5) ((A client)) An individual may be eligible for
medical coverage for up to three months immediately prior to
the month of application, if the ((client)) individual:
(a) Met all eligibility requirements for the months being considered; and
(b) Received medical services covered by medicaid during that time.
(6) ((A client)) An individual eligible for MN without a
spenddown is certified for up to twelve months. For an ((MN
client with)) individual who must meet a spenddown, refer to
WAC ((388-519-0110)) 182-519-0110. For a long-term care MN
((client)) individual, refer to WAC 388-513-1305 and
388-513-1315.
(7) ((A client)) An individual must reapply for each
certification period. There is no continuous eligibility for
MN. Although each additional certification period requires a
new application, if the medical benefits have been closed less
than thirty days, an eligibility review form may be used to
reapply.
[11-24-018, recodified as WAC 182-512-0150, filed 11/29/11, effective 12/1/11. Statutory Authority: RCW 74.04.050, 74.08.090. 04-09-002, § 388-475-0150, filed 4/7/04, effective 6/1/04.]
(a) Annuities,
(b) Pensions,
(c) Unemployment compensation,
(d) Retirement, and
(e) Disability benefits; even if their receipt makes the
((client)) individual ineligible for ((department)) agency
services, unless the ((client)) individual can provide
evidence showing good reason for not obtaining the benefits.
((The department does not count this income until the
client begins to receive it.))
(2) The agency or its authorized representative does not count this income until the individual begins to receive it. Income is budgeted prospectively for all medical programs.
(3) Anticipated nonrecurring lump sum payments other than retroactive SSI/SSDI payments are considered income in the month received, subject to reporting requirements in WAC 388-418-0007(4). Any unspent portion is considered a resource the first of the following month.
(4) The ((department)) agency or its authorized
representative follows income and resource methodologies of
the supplemental security income (SSI) program defined in
federal law when determining eligibility for SSI-related
medical or medicare savings programs unless the ((department))
agency adopts rules that are less restrictive than those of
the SSI program.
(5) Exceptions to the SSI income methodology:
(a) Lump sum payments from a retroactive SSDI benefit, when reduced by the amount of SSI received during the period covered by the payment, are not counted as income;
(b) Unspent retroactive lump sum money from SSI or SSDI is excluded as a resource for nine months following receipt of the lump sum; and
(c) Both the principal and interest portions of payments
from a sales contract, that meet the definition in WAC
((388-475-0350)) 182-512-0350(10), are unearned income.
(6) To be eligible for categorically needy (CN)
SSI-related medical coverage, ((a client's)) an individual's
countable income cannot exceed the CN program standard
described in:
(a) WAC ((388-478-0065 through 388-478-0085))
182-512-0010 for noninstitutional medical unless living in an
alternate living facility; or
(b) WAC 388-513-1305(2) for noninstitutional CN benefits while living in an alternate living facility; or
(c) WAC 388-513-1315 for institutional and waiver services medical benefits.
(7) To be eligible for SSI-related medical coverage
provided under the medically needy (MN) program, ((a client))
an individual must:
(a) Have countable income at or below the effective MN
program standard as described in WAC ((388-478-0070))
182-519-0050; or
(b) Satisfy spenddown requirements described in WAC
((388-519-0110)) 182-519-0110;
(c) Meet the requirements for noninstitutional MN benefits while living in an alternate living facility (ALF). See WAC 388-513-1305(3); or
(d) Meet eligibility for ((the MN waiver program. See
WAC 388-515-1540 and 388-515-1550)) institutional MN benefits
described in WAC 388-513-1315.
[11-24-018, recodified as WAC 182-512-0700, filed 11/29/11, effective 12/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and 74.09.500, and Social Security Act as amended by P.L. 108-203. 06-04-046, § 388-475-0700, filed 1/26/06, effective 2/26/06. Statutory Authority: RCW 74.04.050, 74.08.090. 04-09-004, § 388-475-0700, filed 4/7/04, effective 6/1/04.]
(1) Deeming is the process of determining how much of another person's income is counted when determining eligibility of an SSI-related applicant. When income is deemed to the SSI-related applicant from other household members, that income is considered the applicant's income. Income is deemed only:
(a) From a nonapplying spouse who lives with the SSI-related applicant; or
(b) From a parent(s) residing with an SSI-related applicant child.
(2) An allocation is an amount deducted from income counted in the eligibility determination and considered to be set aside for the support of a person other than the SSI-related applicant. When income is allocated to other household members from the SSI-related applicant(s) or from the applicant's spouse, that income is not counted as income of the SSI applicant.
(3) An SSI-related ((person)) individual applying for
categorically needy (CN) medical coverage must have countable
income at or below the SSI categorically needy income level
(CNIL) described in WAC ((388-478-0080)) 182-512-0010 unless
the ((person)) individual is working and meets all
requirements for the healthcare for workers with disabilities
(HWD) program described in WAC ((388-475-1000)) 182-511-1000
through ((388-475-1250)) 182-511-1250.
(4) For institutional or home and community based waiver programs, use rules described in WAC 388-513-1315.
(5) The ((department)) agency or its authorized
representative follows rules described in WAC ((388-475-0600))
182-512-0600 through ((388-475-0880)) 182-512-0880 to
determine the countable income of an SSI-related applicant or
SSI-related couple.
(6) If countable income of the applicant exceeds the
one-person SSI CNIL prior to considering the income of a
nonapplying spouse or children, the applicant is not eligible
for CN medical coverage and the ((department)) agency or its
authorized representative determines eligibility for the
medically needy (MN) program. If the countable income does
not exceed the SSI CNIL, see WAC ((388-475-0920)) 182-512-0920
to determine if income is to be deemed to the applicant from
the nonapplying spouse.
(7) If countable income (after allowable deductions) of
an SSI-related couple both applying for medical coverage
exceeds the two-person SSI CNIL, the couple is not eligible
for CN medical coverage and the ((department)) agency or its
authorized representative determines eligibility for the
medically needy (MN) program.
(8) For CN medical coverage, allocations to children are
deducted from the nonapplying spouse's unearned income, then
from their earned income before income is deemed to the
SSI-related applicant. See WAC ((388-475-0820)) 182-512-0820.
(9) For MN medical coverage, allocations to children are deducted from the income of the SSI-related applicant or SSI-related applicant couple. See subsection (10) of this section to determine the amount of the allocation.
(10) An SSI-related individual or couple applying for MN
medical coverage is allowed an allocation to a nonapplying
spouse, their SSI recipient spouse or their dependent
child(ren) to reduce countable income before comparing income
to the effective medically needy income level (MNIL) described
in WAC ((388-478-0070)) 182-519-0050. The ((department))
agency or its authorized representative allocates income:
(a) Up to the effective one-person MNIL to a nonapplying spouse or SSI recipient spouse minus the spouse's countable income; and
(b) Up to one-half of the federal benefit rate (FBR) to
each dependent minus each dependent's countable income. See
WAC ((388-475-0820)) 182-512-0820 for child exclusions.
(11) A portion of a nonapplying spouse's income may be deemed to the SSI-related applicant:
(a) See WAC ((388-475-0920)) 182-512-0920(5) to determine
how much income is deemed from a nonapplying spouse to the
SSI-related applicant when determining CN eligibility; and
(b) See WAC ((388-475-0920)) 182-512-0920(10) to
determine how much income is deemed from a nonapplying spouse
to the SSI-related applicant when determining MN eligibility.
(12) A portion of the income of an ineligible parent or
parents is allocated to the needs of an SSI-related applicant
child. See WAC ((388-475-0940)) 182-512-0940 (4) through (7)
to determine how much income is allocated from ineligible
parent(s).
(13) Only income and resources actually contributed to an alien applicant from their sponsor are counted as income. For allocation of income from an alien sponsor, refer to WAC 388-450-0155.
[11-24-018, recodified as WAC 182-512-0900, filed 11/29/11, effective 12/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and 74.09.500. 11-15-023, § 388-475-0900, filed 7/8/11, effective 8/8/11. Statutory Authority: RCW 74.04.050, 74.08.090. 04-09-005, § 388-475-0900, filed 4/7/04, effective 6/1/04.]
(1) A portion of the income of a nonapplying spouse is considered available to meet the needs of an SSI-related applicant. A nonapplying spouse is defined as someone who is:
(a) Financially responsible for the SSI-related applicant
as described in WAC ((388-408-0055)) 182-506-0010 and
((388-475-0960)) 182-512-0960. For institutional and home and
community based waiver programs, see WAC 388-513-1315;
(b) Living in the same household with the SSI-related applicant;
(c) Not receiving a needs based payment such as temporary assistance to needy families (TANF), state funded cash assistance (SFA); or
(d) Not related to SSI, or is not applying for medical assistance including spouses receiving SSI.
(2) An ineligible spouse is the spouse of an SSI cash recipient and is either not eligible for SSI for themselves or who has elected to not receive SSI cash so that their spouse may be eligible. An SSI-related applicant who is the ineligible spouse of an SSI cash recipient is not eligible for categorically needy (CN) medical coverage and must be considered for medical coverage under the medically needy (MN) program.
(3) When determining whether a nonapplying spouse's
income is countable, the ((department)) agency or its
authorized representative:
(a) Follows the income rules described in WAC
((388-475-0600)) 182-512-0600 through ((388-475-0750))
182-512-0750;
(b) Excludes income described in WAC ((388-475-0800))
182-512-0800 (2) through (((11))) (10), and all income
excluded under federal statute or state law as described in
WAC ((388-475-0860)) 182-512-0860.
(c) Excludes work-related expenses described in WAC
((388-475-0840)) 182-512-0840, with the exception that the
sixty-five dollars plus one half earned income deduction
described in WAC ((388-475-0840)) 182-512-0840(2) does not
apply;
(d) Deducts any court ordered child support which the nonapplying spouse pays for a child outside of the home (current support or arrears); and
(e) Deducts any applicable child-related income
exclusions described in WAC ((388-475-0820)) 182-512-0820.
(4) The ((department)) agency or its authorized
representative allocates income of the nonapplying spouse to
nonapplying children who reside in the home as described in
WAC 388-475-0820. Allocations to children are deducted first
from the nonapplying spouse's unearned income, then from their
earned income.
(a) For CN medical determinations, allocations to children are not allowed out of the income of the SSI-related applicant, only from the income of the nonapplying spouse.
(b) For MN medical determinations, allocations to children are allowed from the income of the SSI-related applicant if the applicant is unmarried.
(5) For SSI-related CN medical determinations, a portion of the countable income of a nonapplying spouse remaining after the deductions and allocations described in subsections (3) and (4) of this section may be deemed to the SSI-related applicant. If the nonapplying spouse's countable income is:
(a) Less than or equal to one-half of the federal benefit
rate (FBR), no income is deemed to the applicant. Compare the
applicant's countable income to the one-person SSI
categorically needy income level (CNIL) described in WAC
((388-470-0040)) 182-512-0010. For healthcare for workers
with disabilities (HWD) applicants, compare to the one-person
HWD standard described in WAC ((388-478-0075)) 182-505-0100
(1)(c).
(b) Greater than one-half of the FBR, then the entire
nonapplying spouse's countable income is deemed to the
applicant. Compare the applicant's income to the two-person
SSI CNIL. For HWD applicants, compare to the two-person HWD
standard described in WAC ((388-478-0075)) 182-505-0100
(1)(c).
(6) When income is not deemed to the SSI-related applicant from the nonapplying spouse per subsection (5)(a):
(a) Allow all allowable income deductions and exclusions
as described in chapter ((388-475)) 182-512 WAC to the
SSI-related applicant's income; and
(b) Compare the net remaining income to the one-person SSI CNIL or the one-person HWD standard.
(7) When income is deemed to the SSI-related applicant from the nonapplying spouse per subsection (5)(b) of this section:
(a) Combine the applicant's unearned income with any unearned income deemed from the nonapplying spouse and allow one twenty dollar general income exclusion to the combined amount.
(b) Combine the applicant's earned income with any earned
income deemed from the nonapplying spouse and allow the
sixty-five dollar plus one half of the remainder earned income
deduction (described in WAC ((388-475-0840)) 182-512-0840(2))
to the combined amount.
(c) Add together the net unearned and net earned income
amounts and compare the total to the two-person SSI CNIL
described in WAC 182-512-0010 or the two-person HWD standard
described in WAC ((388-478-0075)) 182-505-0100 (1)(c). If the
income is equal to or below the applicable two-person
standard, the applicant is eligible for CN medical coverage.
(8) An SSI-related applicant under the age of sixty-five who is working at or below the substantial gainful activity (SGA) level but who is not eligible for CN coverage under the regular SSI-related program, may be considered for eligibility under the MN program or under the HWD program. The SGA level is determined annually by the Social Security Administration and is posted at: https://secure.ssa.gov/apps10/poms.nsf/lnx/0410501015.
(9) If the SSI-related applicant's countable income is
above the applicable SSI CNIL standard, the ((department))
agency or its authorized representative considers eligibility
under the MN program or under the HWD program if the
individual is under the age of sixty-five and working. An
SSI-related applicant who meets the following criteria is not
eligible for MN coverage and eligibility must be determined
under HWD:
(a) A blind or disabled individual who is under the age of sixty-five;
(b) Who has earned income over the SGA level; and
(c) Is not receiving a Title II Social Security cash benefit based on blindness or disability.
(10) For SSI-related MN medical determinations, a portion of the countable income of a nonapplying spouse remaining after the deductions and allocations described in subsections (3) and (4) of this section may be deemed to the SSI-related applicant. If the nonapplying spouse's countable income is:
(a) Less than or equal to the effective one-person MNIL
described in WAC ((388-478-0070)) 182-519-0050, no income is
deemed to the applicant and a portion of the applicant's
countable income is allocated to the nonapplying spouse's
income to raise it to the effective MNIL standard.
(b) Greater than the effective MNIL, then the amount in excess of the effective one-person MNIL is deemed to the applicant. Compare the applicant's income to the effective one-person MNIL.
(11) When income is not deemed to the SSI-related applicant from the nonapplying spouse per subsection (10)(a) of this section:
(a) Allocate income from the applicant to bring the income of the nonapplying spouse up to the effective one-person MNIL standard;
(b) Allow all allowable income deductions and exclusions
as described in chapter ((388-475)) 182-512 WAC to the
SSI-related applicant's remaining income;
(c) Allow a deduction for medical insurance premium expenses (if applicable); and
(d) Compare the net countable income to the effective one-person MNIL.
(12) When income is deemed to the SSI-related applicant from the nonapplying spouse per subsection (10)(b) of this section:
(a) Combine the applicant's unearned income with any unearned income deemed from the nonapplying spouse and allow one twenty dollar general income exclusion to the combined amount;
(b) Combine the applicant's earned income with any earned
income deemed from the nonapplying spouse and allow the
sixty-five dollar plus one half of the remainder earned income
deduction (described in WAC ((388-475-0840)) 182-512-0840(2))
to the combined amount;
(c) Add together the net unearned and net earned income amounts;
(d) Allow a deduction for medical insurance premium
expenses (if applicable) per WAC ((388-519-0100))
182-519-0100(5); and
(e) Compare the net countable income to the effective
one-person MNIL described in WAC ((388-478-0070))
182-519-0050. If the income is:
(i) Equal to or below the effective one-person MNIL, the applicant is eligible for MN medical coverage with no spenddown.
(ii) Greater than the effective MNIL, the applicant is
only eligible for MN medical coverage after meeting a
spenddown liability as described in WAC ((388-519-0110))
182-519-0110.
(13) The ineligible spouse of an SSI-cash recipient applying for MN coverage is eligible to receive the deductions and allocations described in subsection (10)(a) of this section.
[11-24-018, recodified as WAC 182-512-0920, filed 11/29/11, effective 12/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and 74.09.500. 11-15-023, § 388-475-0920, filed 7/8/11, effective 8/8/11.]
(1) A portion of the income of a parent(s) is considered available to the SSI-related applicant child when the child is age seventeen or younger and the parent(s) is:
(a) Financially responsible for the SSI-related child as
described in WAC ((388-408-0055)) 182-506-0010(2);
(b) The natural, adoptive, or step-parent of the child;
(c) Living in the same household with the child;
(d) Not receiving a needs-based payment such as TANF, SFA or SSI; and
(e) Not related to SSI or not applying for medical assistance.
(2) If an SSI-related applicant between the ages of eighteen to twenty-one lives with their parents, only consider the parent's income available to the applicant if it is actually contributed to the applicant. If income is not contributed, count only the applicant's own separate income.
(3) Income that is deemed to the child is considered as that child's income.
(4) When determining whether a parent's income is
countable, the ((department)) agency or its authorized
representative follows:
(a) The income rules described in WAC ((388-475-0600))
182-512-0600 through ((388-475-0750)) 182-512-0750; and
(b) Excludes income described in WAC ((388-475-0800))
182-512-0800 and ((388-475-0840)) 182-512-0840, and all income
excluded under a federal statute or state law as described in
WAC ((388-475-0860)) 182-512-0860.
(5) When determining the amount of income to be deemed
from a parent(s) to an SSI-related minor child for
categorically needy (CN) and medically needy (MN) coverage,
the ((department)) agency or its authorized representative
reduces the parent(s) countable income in the following order:
(a) Court ordered child support paid out for a child not in the home;
(b) An amount equal to one half of the federal benefit rate (FBR) for each SSI-eligible sibling living in the household, minus any countable income of that child. See WAC 388-478-0055 for FBR amount;
(c) A twenty dollar general income exclusion;
(d) A deduction equal to sixty-five dollars plus one-half of the remainder from any remaining earned income of the parent(s);
(e) An amount equal to the one-person SSI CNIL for a single parent or the two-person SSI CNIL for a two parent household;
(f) Any income remaining after these deductions is considered countable income to the SSI-related child and is added to the child's own income. If there is more than one child applying for SSI-related medical coverage, the deemed parental income is divided equally between the applicant children; and
(g) The deductions described in this section are deducted first from unearned income then from earned income unless they are specific to earned income.
(6) The SSI-related applicant child is also allowed all
applicable income exclusions and disregards described in
chapter ((388-475)) 182-475 WAC from their own income. After
determining the child's nonexcluded income, the ((department))
agency or its authorized representative:
(a) Allows the twenty dollar general income exclusion from any unearned income;
(b) Deducts sixty-five dollars plus one half of the
remainder from any earned income which has not already been
excluded under the student earned income exclusion (see WAC
((388-475-0820)) 182-512-0820).
(c) Adds the child's countable income to the amount deemed from their parent(s). If the combination of the child's countable income plus deemed parental income is equal to or less than the SSI CNIL, the child is eligible for SSI-related CN medical coverage.
(7) If the combination of the child's countable income
plus deemed parental income is greater than the SSI CNIL, the
((department)) agency or its authorized representative
considers the child for SSI-related medically needy (MN)
coverage. Any amount exceeding the effective medically needy
income level (MNIL) is used to calculate the amount of the
child's spenddown liability as described in WAC
((388-519-0110)) 182-519-0110. See WAC ((388-478-0070))
182-519-0050 for the current MNIL standards.
[11-24-018, recodified as WAC 182-512-0940, filed 11/29/11, effective 12/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and 74.09.500. 11-15-023, § 388-475-0940, filed 7/8/11, effective 8/8/11.]
OTS-4917.1
REPEALER
The following chapter of the Washington Administrative Code is repealed:
| WAC 388-512-1210 | Program description. |
OTS-4703.2
AMENDATORY SECTION(Amending WSR 11-23-091, filed 11/17/11,
effective 11/21/11)
WAC 182-519-0050
Monthly income and countable resource
standards for medically needy (MN).
(1) Changes to the
medically needy income level (MNIL) occur on January 1st of
each calendar year((. Current income standards can be found
at
http://www1.dshs.wa.gov/pdf/esa/manual/Standards_C_MedAsst_Chart.pdf)) when the Social Security Administration (SSA) issues
a cost-of-living adjustment for that year.
(2) Medically needy (MN) standards for persons who meet institutional status requirements are in WAC 388-513-1395. The standard for a client who lives in an alternate living facility can be found in WAC 388-513-1305.
(3) ((Find)) The resource standards for institutional
programs are found in WAC 388-513-1350. The institutional
standard chart can be found at
((http://www1.dshs.wa.gov/manuals/eaz/sections/LongTermCare/LTCstandardspna.shtml))
http://www.dshs.wa.gov/manuals/eaz/sections/LongTermCare/LTCstandardspna.shtml.
(4) Countable resource standards for the noninstitutional MN program are:
| (a) One person | $2,000 | |
| (b) A legally married couple | $3,000 | |
| (c) For each additional family member add | $50 |
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 |
| 467 | 592 | 667 | 742 | 858 | 975 | 1125 | 1242 | 1358 | 1483 |
[11-23-091, recodified as WAC 182-519-0050, filed 11/17/11, effective 11/21/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and 74.09.500. 08-11-098, § 388-478-0070, filed 5/20/08, effective 6/20/08. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, and Section 1924 of the Social Security Act (42 U.S.C. 1396r-5). 06-06-013, § 388-478-0070, filed 2/17/06, effective 3/20/06. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 42 U.S.C. 9902(2). 05-06-090, § 388-478-0070, filed 3/1/05, effective 4/1/05. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 42 U.S.C. 1396r-5. 02-10-116, § 388-478-0070, filed 4/30/02, effective 5/31/02. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and Section 1924 (42 U.S.C. 1396R-5). 01-12-073, § 388-478-0070, filed 6/4/01, effective 7/5/01. Statutory Authority: RCW 74.08.090, 74.04.050, 74.04.057, and 74.09.575. 00-10-095, § 388-478-0070, filed 5/2/00, effective 5/2/00; 99-11-054, § 388-478-0070, filed 5/17/99, effective 6/17/99. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. 98-16-044, § 388-478-0070, filed 7/31/98, effective 9/1/98. Formerly WAC 388-507-0710, 388-507-0720, 388-511-1115, 388-518-1820, 388-518-1830, 388-518-1840 and 388-518-1850.]
OTS-4704.4
AMENDATORY SECTION(Amending WSR 09-08-003, filed 3/19/09,
effective 4/19/09)
WAC 388-519-0100
Eligibility for the medically needy
program.
(1) An individual who meets the following conditions
may be eligible for medically needy (MN) coverage under the
special rules in chapters 388-513 WAC and 388-515 WAC:
(a) Meets the institutional status requirements of WAC 388-513-1320;
(b) Resides in a medical institution as described in WAC 388-513-1395; or
(c) Receives waiver services under a medically needy in-home waiver (MNIW) according to WAC 388-515-1550 or a medically needy residential waiver (MNRW) according to WAC 388-515-1540.
(2) An SSI-related individual who lives in a department contracted alternate living facility may be eligible for MN coverage under the rules described in WAC 388-513-1305.
(3) An individual may be eligible for MN coverage under this chapter when he or she is:
(a) Not covered under subsection (1) and (2) of this section; and
(b) Eligible for categorically needy (CN) medical coverage in all other respects except that his or her CN countable income is above the CN income standard.
(4) MN coverage may be available if the individual is:
(a) A child;
(b) A pregnant woman;
(c) A refugee;
(d) An SSI-related individual including an aged, blind or disabled individual with countable income under the CN income standard, who is an ineligible spouse of an SSI recipient; or
(e) A hospice client with countable income which is above the special income level (SIL).
(5) An individual who is not eligible for CN medical and who is applying for MN coverage has the right to income deductions in addition to, or instead of, those used to arrive at CN countable income. Deductions to income are applied to each month of the base period to determine MN countable income. The following deductions are used to calculate countable income for MN:
(a) The agency disregards the difference between the MNIL described in WAC 182-519-0050 and the federal benefit rate (FBR) established by the Social Security Administration each year. The FBR is the one person Supplemental Security Income (SSI) payment standard;
(b) All health insurance premiums, with the exception of medicare Part A, Part B, Part C and Part D premiums expected to be paid by the individual or family member during the base period(s);
(((b))) (c) Any allocations to a spouse or to dependents
for an SSI-related individual who is married or who has
dependent children. Rules for allocating income are described
in WAC ((388-475-0900)) 182-512-0900 through 182-512-0960;
(((c))) (d) For an SSI-related individual who is married
and lives in the same home as his or her spouse who receives
home and community based waiver services under chapter 388-515 WAC, an income deduction equal to the medically needy income
level (MNIL) minus the nonapplying spouse's income; and
(((d))) (e) A child or pregnant woman who is applying for
MN coverage is eligible for income deductions allowed under
TANF/SFA rules and not under the rules for CN programs based
on the federal poverty level. See WAC ((388-450-0210(4)))
182-109-0001(4) for exceptions to the TANF/SFA rules which
apply to medical programs and not to the cash assistance
program.
(6) The MNIL for individuals who qualify for MN coverage under subsection (1) of this section is based on rules in chapter 388-513 and 388-515 WAC.
(7) The MNIL for all other individuals is described in
WAC ((388-478-0070)) 182-519-0050. If an individual has
countable income which is at or below the MNIL, he or she is
certified as eligible for up to twelve months of MN medical
coverage.
(8) If an individual has countable income which is over
the MNIL, the countable income that exceeds the
((department's)) agency's MNIL standards is called "excess
income."
(9) When individuals have "excess income" they are not
eligible for MN coverage until they provide evidence to the
((department)) agency or its designee of medical expenses
incurred by themselves, their spouse or family members who
live in the home for whom they are financially responsible. See WAC ((388-519-0110(8))) 182-519-0110(8). An expense has
been incurred when:
(a) The individual has received the medical treatment or medical supplies, is financially liable for the medical expense but has not yet paid the bill; or
(b) The individual has paid for the expense within the
current or retroactive base period described in WAC
((388-519-0110)) 182-519-0110.
(10) Incurred medical expenses or obligations may be used to offset any portion of countable income that is over the MNIL. This is the process of meeting "spenddown."
(11) The ((department)) agency or its designee calculates
the amount of an individual's spenddown by multiplying the
monthly excess income amount by the number of months in the
certification period as described in WAC ((388-519-0110))
182-519-0110. The qualifying medical expenses must be greater
than or equal to the total calculated spenddown amount.
(12) An individual who is considered for MN coverage
under this chapter may not spenddown excess resources to
become eligible for the MN program. Under this chapter
individuals are ineligible for MN coverage if their resources
exceed the program standard in WAC ((388-478-0070))
182-519-0050. An individual who is considered for MN coverage
under WAC 388-513-1395, ((388-505-0250)) 182-514-0250 or
((388-505-0255)) 182-514-0255 is allowed to spenddown excess
resources.
(13) There is no automatic redetermination process for MN coverage. An individual must submit an application for each eligibility period under the MN program.
(14) An individual who requests a timely administrative
hearing under WAC 388-458-0040 is not eligible for continued
benefits beyond the end of the original certification date
under the ((medically needy)) MN program.
[Statutory Authority: RCW 74.04.055, 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 42 C.F.R. 435.831 (3)(e) and (f). 09-08-003, § 388-519-0100, filed 3/19/09, effective 4/19/09. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. 98-16-044, § 388-519-0100, filed 7/31/98, effective 9/1/98. Formerly WAC 388-503-0320, 388-518-1840, 388-519-1930 and 388-522-2230.]
(2) A base period begins on the first day of the month, in which an individual applies for medical assistance, subject to the exceptions in subsection (4) of this section.
(3) An individual may request a separate base period to cover the time period up to three calendar months immediately prior to the month of application. This is called a retroactive base period.
(4) A base period may vary from the terms in subsections (1), (2), or (3) of this section if:
(a) A three month base period would overlap a previous eligibility period; or
(b) The individual has countable resources that are over the applicable standard for any part of the required base period; or
(c) The ((client)) individual is not or will not be able
to meet the TANF-related or SSI-related requirement for the
required base period; or
(d) The individual is eligible for categorically needy (CN) coverage for part of the required base period; or
(e) The ((client)) individual was not otherwise eligible
for MN coverage for each of the months of the retroactive base
period.
(5) An individual's spenddown liability is calculated by
the ((department)) agency or its designee. The MN countable
income from each month of the base period is compared to the
effective medically needy income level (MNIL) described in WAC 182-519-0050. Income which is over the effective MNIL
standard (based on the individual's household size) in each
month in the base period is added together to determine the
total spenddown amount. ((The MNIL standard is found at
http://www.dshs.wa.gov/pdf/esa/manual/standards_C_MedAsstChart.pdf and is updated annually in January.))
(6) If household income varies and an individual's MN
countable income falls below the effective MNIL for one or
more months, the difference is used to offset the excess
income in other months of the base period. If this results in
a spenddown amount of zero dollars and cents, see WAC
((388-519-0100(7))) 182-519-0100(7).
(7) If an individual's income decreases, the
((department)) agency or its designee approves CN coverage for
each month in the base period when the individual's countable
income and resources are equal to or below the applicable CN
standards. Children under the age of nineteen and pregnant
women who become CN eligible in any month of the base period
remain continuously eligible for CN coverage for the remainder
of the certification even if there is a subsequent increase in
income.
(8) Once an individual's spenddown amount has been determined, qualifying medical expenses are deducted. To be considered a qualifying medical expense, the expense must:
(a) Be an expense for which the individual is financially liable;
(b) Not have been used to meet another spenddown;
(c) Not be the confirmed responsibility of a third party.
The ((department)) agency or its designee allows the entire
expense if the third party has not confirmed its coverage of
the expense within:
(i) Forty-five days of the date of service; or
(ii) Thirty days after the base period ends.
(d) Be an incurred expense for the individual:
(i) The individual's spouse;
(ii) A family member, residing in the home of the individual, for whom the individual is financially responsible; or
(iii) A relative, residing in the home of the individual, who is financially responsible for the individual.
(e) Meet one of the following conditions:
(i) Be an unpaid liability at the beginning of the base period;
(ii) Be for medical services either paid or unpaid and incurred during the base period;
(iii) Be for medical services incurred and paid during the three month retroactive base period if eligibility for medical assistance was not established in that base period. Paid expenses that meet this requirement may be applied towards the current base period; or
(iv) Be for medical services incurred during a previous base period and either unpaid or paid for, if it was necessary for the individual to make a payment due to delays in the certification for that base period.
(9) An exception to the provisions in subsection (8) of
this section exists for qualifying medical expenses that have
been paid on behalf of the individual by a publicly
administered program during the current or the retroactive
base period. The ((department)) agency or its designee uses
the qualifying medical expenses to meet the spenddown
liability. To qualify for this exception the program must:
(a) Not be federally funded or make the payments from federally matched funds;
(b) Not pay the expenses prior to the first day of the retroactive base period; and
(c) Provide proof of the expenses paid on behalf of the individual.
(10) Once the ((department)) agency or its designee has
determined that the expenses meet the definition of a
qualified expense as defined in subsection (8) or (9) of this
section, the expenses are subtracted from the spenddown
liability to determine the date the individual is eligible for
medical coverage to begin. Qualifying medical expenses are
deducted in the following order:
(a) First, medicare and other health insurance
deductibles, coinsurance charges, enrollment fees, copayments
and premiums that are the individual's responsibility under
medicare Part A, Part B, Part C and Part D. (Health insurance
premiums are income deductions under WAC ((388-519-0100(5)))
182-519-0100(5));
(b) Second, medical expenses incurred and paid by the individual during the three month retroactive base period if eligibility for medical assistance was not established in that base period;
(c) Third, current payments on, or unpaid balance of,
medical expenses incurred prior to the current base period
which have not been used to establish eligibility for medical
coverage in any other base period. The ((department)) agency
or its designee sets no limit on the age of an unpaid expense;
however, the expense must still be a current liability and be
unpaid at the beginning of the base period;
(d) Fourth, other medical expenses that would not be
covered by the ((department's)) agency's or its designee's
medical programs, minus any third party payments which apply
to the charges. The items or services allowed as a medical
expense must have been provided or prescribed by a licensed
health care provider;
(e) Fifth, other medical expenses which have been
incurred by the individual during the base period that are
potentially payable by the MN program (minus any confirmed
third party payments that apply to the charges), even if
payment is denied for these services because they exceed the
((department)) agency's or its designee's limits on amount,
duration or scope of care. Scope of care is described in WAC
((388-501-0060)) 182-501-0060 and ((388-501-0065))
182-501-0065; and
(f) Sixth, other medical expenses that have been incurred
by the individual during the base period that are potentially
payable by the MN program (minus any confirmed third party
payments that apply to the charges) and that are within the
((department)) agency's or its designee's limits on amount,
duration or scope of care.
(11) If an individual submits verification of qualifying
medical expenses with his or her application that meets or
exceeds the spenddown liability, he or she is eligible for MN
medical coverage for the remainder of the base period unless
their circumstances change. See WAC 388-418-0005 to determine
which changes must be reported to the ((department)) agency or
its designee. The beginning of eligibility is determined as
described in WAC ((388-416-0020)) 182-504-0020.
(12) If an individual cannot meet the spenddown amount at the time the application is submitted, the individual is not eligible until he or she provides proof of additional qualifying expenses that meet the spenddown liability.
(13) Each dollar of a qualifying medical expense may count once against a spenddown period that leads to eligibility for MN coverage. However, medical expenses may be used more than once under the following circumstances:
(a) The individual did not meet his or her total spenddown liability and become eligible in a previous base period and the bill remains unpaid; or
(b) The medical expense was a bill incurred and paid
within three months of the current application and the
((department)) agency or its designee could not establish
eligibility for medical assistance for the individual in the
retroactive base period.
(14) The individual must provide the proof of qualifying
medical expenses to the ((department)) agency or its designee.
The deadline for providing medical expense information is
thirty days after the base period ends unless there is a good
reason for delay.
(15) Once an individual meets the spenddown requirement
and the certification begin date has been established, newly
identified expenses cannot be considered toward that spenddown
unless there is a good reason for the delay in submitting the
expense or there was ((a department)) an error by the agency
or its designee in determining the correct begin date.
(16) Good reasons for delay in providing medical expense
information to the ((department)) agency or its designee
include, but are not limited to:
(a) The individual did not receive a timely bill from his or her medical provider or insurance company;
(b) The individual has medical issues that prevents him or her from submitting proof in a timely manner; or
(c) The individual meets the criteria for needing a supplemental accommodation under chapter 388-472 WAC.
(17) The ((department)) agency or its designee is not
responsible to pay for any expense or portion of an expense
that has been used to meet an individual's spenddown
liability. If an expense is potentially payable under the MN
program, and only a portion of the medical expense has been
assigned to meet spenddown, the medical provider may not bill
the individual for more than the amount which was assigned to
the remaining spenddown liability, or accept or retain any
additional amount for the covered service from the individual.
Any additional amount may be billed to the ((department))
agency or its designee. See WAC ((388-502-0160))
182-502-0160, Billing a client.
(18) The ((department)) agency or its designee determines
whether any payment is due to the medical provider on medical
expenses that have been partially assigned to meet a spenddown
liability, according to WAC ((388-502-0100)) 182-502-0100.
(19) If the medical expense assigned to spenddown was
incurred outside of a period of MN eligibility, or if the
expense is not the type that is covered by the
((department's)) agency's or its designee's medical assistance
programs, the ((department)) agency or its designee is not
responsible for any portion of the bill.
[Statutory Authority: RCW 74.04.055, 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 42 C.F.R. 435.831 (3)(e) and (f). 09-08-003, § 388-519-0110, filed 3/19/09, effective 4/19/09. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. 06-24-036, § 388-519-0110, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 71.05.560, 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530. 06-13-042, § 388-519-0110, filed 6/15/06, effective 7/16/06. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, and 74.08.090. 05-08-093, § 388-519-0110, filed 4/1/05, effective 5/2/05; 98-16-044, § 388-519-0110, filed 7/31/98, effective 9/1/98. Formerly WAC 388-518-1830, 388-518-1840, 388-519-1905, 388-519-1910, 388-519-1930 and 388-522-2230.]
The following sections of the Washington Administrative
Code is decodified as follows:
| Old WAC Number | New WAC Number |
| 388-519-0100 | 182-519-0100 |
| 388-519-0110 | 182-519-0110 |