HEALTH CARE AUTHORITY

(Medicaid Program)

"Washington apple health" means the public health insurance programs for eligible Washington residents. Washington apple health is the name used in Washington state for medicaid, the children's health insurance program (CHIP), and state-only funded health care programs.

"Washington Healthplanfinder" is a marketplace for individuals, families, and small businesses in Washington state to compare and enroll in health insurance coverage and gain access to premium tax credits, reduced cost sharing, and public programs such as Washington apple health. Washington Healthplanfinder is administered by the Washington health benefit exchange.

(1) An individual applying for Washington apple health (WAH) (as defined in WAC 182-500-0120) is not required to have an in-person interview to determine eligibility.

(2) The agency or its designee may contact an individual by phone or in writing to gather any additional information that is needed to make an eligibility determination.

(3) A phone or in-person interview is required to determine initial financial eligibility for WAH long-term care services.

(4) The interview requirement described in subsection (3) of this section may be waived if the applicant is unable to comply:

(a) Due to his or her medical condition; or

(b) Because the applicant does not have a family member or another individual that is able to conduct the interview on his or her behalf.

(1) An individual may request an exception to a Washington apple health financial eligibility rule in Title 182 WAC. An individual must request an exception to rule (ETR) within ninety calendar days of the agency action with which the individual disagrees. The individual or the individual's representative may request an ETR orally or in writing. The request must:

(a) Identify the rule for which an exception is being requested;

(b) State what the individual is requesting; and

(c) Describe how the request meets subsection (2) of this section.

(2) The agency director or designee has the discretion to grant an ETR if he or she determines that the individual's circumstances satisfy the conditions below:

(a) The exception would not contradict a specific provision of federal or state law; and

(b) The individual's situation differs from the majority; and

(c) It is in the interest of the overall economy and the individual's welfare, and:

(i) It increases opportunity for the individual to function effectively; or

(ii) The individual has an impairment or limitation that significantly interferes with the usual procedures required to determine eligibility and payment.

(3) Individuals cannot appeal ETR decisions under chapter 182-526 WAC.

(4) An individual is mailed a decision in writing within ten calendar days when agency staff:

(a) Approve or deny an ETR request; or

(b) Request more information.

(5) If the ETR is approved, the notice includes information on the approval period.

(6) The agency designates staff at the aging and disability services administration (ADSA) to process all ETRs specifically relating to long-term care programs described in Title 182 WAC.

(7) This section does not apply to requests that the agency pay for noncovered medical or dental services or related equipment. WAC 182-501-0160 applies to such requests.

For the purposes of determining an individual's citizenship and alien status for health care coverage, the following definitions apply:

(1) Lawfully present are immigrants or noncitizens that have been inspected and admitted into the United States and not overstayed the period for which they were admitted, or have current permission from the U.S. Citizenship and Immigrant Services (CIS) to stay or live in the U.S.

(2) Qualified aliens are lawfully present immigrants defined in federal law as one of the following:

(a) Individuals lawfully admitted for permanent residence (LPRs).

(b) Individuals who are admitted to the U.S. as refugees under Immigration and Nationality Act (INA) Section 207. The following individuals are treated the same as refugees in their eligibility for public assistance:

(i) Hmong or Highland Lao are members of a Hmong or Highland Laotian tribe which rendered military assistance to the U.S. during the Vietnam era (August 5, 1964, to May 7, 1975), and are "lawfully present" in the U.S. This category also includes the spouse (including unremarried widow or widower) or unmarried dependent child of such tribal members.

(ii) Victims of trafficking, who according to federal law are:

(A) Individuals who have been certified or approved as victims of trafficking by the federal office of refugee resettlement.

(B) Immediate family members of trafficking victims. Immediate family members are the spouse or child of a victim of any age and the parent or minor sibling if the victim is under twenty-one years old.

(iii) Special immigrants from Iraq and Afghanistan are individuals granted special immigrant status under INA Section 101 (a)(27).

(c) Individuals who have been granted asylum under INA Section 208.

(d) Cuban/Haitian entrants. These are nationals of Cuba or Haiti who were paroled into the U.S. or given other special status.

(e) Abused spouses or children, parents of abused children, or children of abused spouses:

(i) When the alien no longer resides with the person who committed the abuse, and has one of the following:

(A) A pending or approved I-130 petition or application to immigrate as an immediate relative of a U.S. citizen or as the spouse of an unmarried child under age twenty-one of a lawful permanent resident (LPR);

(B) A notice of "prima facie" approval of a pending self-petition under the Violence Against Women Act (VAWA); or

(C) Proof of a pending application for suspension of deportation or cancellation of removal under VAWA.

(ii) Children of an abused spouse do not need their own separate pending or approved petition, but are included in their parent's petition if it was filed before they turned twenty-one years old. Children of abused persons who meet the conditions above retain their "qualified alien" status even after they turn twenty-one years old.

(f) Individuals who have been granted parole into the U.S. for at least a period of one year (or indefinitely) under INA Section 212 (d)(5), including "public interest" parolees.

(g) Individuals granted withholding of deportation or removal under INA Section 243(h) or 241 (b)(3).

(h) Individuals who were admitted into the U.S. as conditional entrants under INA Section 203 (a)(7) prior to April 1, 1980.

(i) Amerasians who were born to U.S. citizen armed services members in Southeast Asia during the Vietnam War.

(3) Nonqualified aliens are noncitizens who are lawfully present in the U.S. and who are not included in the definition of qualified aliens in subsection (2) of this section. Nonqualified aliens include, but are not limited to:

(a) Citizens of Marshall Islands, Micronesia or Palau;

(b) Immigrants paroled into the U.S. for a period of one year or less;

(c) Immigrants granted temporary protected status;

(d) Abused aliens who are a relative of a U.S. citizen with an approved I-130 petition but not meeting the other requirements of battered immigrants, as described in WAC 182-503-0530;

(e) Abused aliens who have self-petitioned under VAWA but not yet received "Notice of Prima Facie" eligibility as described in WAC 182-503-0530;

(f) Applicants for adjustment of status, asylum, cancellation of removal, suspension of deportation or withholding of deportation or removal;

(g) Deferred action, cancellation of removal, or suspension of deportation granted:

(i) Deferred Action Childhood Arrivals (DACA) are not eligible for federal Washington apple health programs with the exception of the Alien Emergency Medical program.

(ii) If a person is granted cancellation of removal or suspension of deportation based on having been abused or granted deferred action based on an approved self-petition as an abused alien they are a "qualified alien");

(h) Deferred enforced departure granted;

(i) Family Unity granted;

(j) K, S, U, or V statuses, designated on a person's visa, allow holders to work and eventually adjust to lawful permanent resident (LPR) status;

(k) Lawful temporary residents under the amnesty program of the Immigration Reform and Control Act (IRCA), including those admitted under INA Sections 210 (special agricultural workers) and 245(a);

(l) Order of supervision granted;

(m) Residing in the U.S. since prior to January 1, 1972;

(n) Eligible to petition as special immigrant juveniles. These are juveniles who have been declared a "dependent of the state" and eligible for long-term foster care due to abuse, neglect, or abandonment;

(o) Stay of deportation granted;

(p) Voluntary departure granted − Definite or indefinite time; or

(q) Nonimmigrants who are allowed entry into the U.S. for a specific purpose usually for a limited time are also nonqualified. Examples include:

(i) Business visitors;

(ii) Students; and

(iii) Tourists.

(4) Undocumented aliens are noncitizens without a lawful immigration status as defined in subsection (2) or (3) of this section, and who:

(a) Entered the U.S. illegally; or

(b) Were lawfully admitted but whose status expired or was revoked per United States Citizenship and Immigration Services (USCIS).

(5) U.S. citizens are one of the following:

(a) Individuals born in the United States or its territories (Guam, Puerto Rico, and the U.S. Virgin Islands; also residents of the Northern Mariana Islands who elected to become U.S. citizens).

(b) American Indians born outside the U.S. without regard to immigration status or date of entry if:

(i) They were born in Canada and are fifty percent American Indian blood (but need not belong to a federally recognized tribe); or

(ii) They are members of a federally recognized Indian tribe or Alaskan Native village or corporation.

(c) Individuals who have become naturalized U.S. citizens.

(d) Individuals born abroad to at least one U.S. citizen parent depending on conditions at the time of their birth, per Title 8, Subchapter III, Section 1401 of the United States Code.

(e) Individuals who turn eighteen years of age on or after February 27, 2001, automatically become U.S. citizens if the following conditions are met while the individual is under age eighteen per INA Section 320.

(i) The individual is granted lawful permanent resident (LPR) status;

(ii) At least one of the individual's parents is a U.S. citizen by birth or naturalization; and

(iii) The individual:

(A) Resides in the U.S. in the legal and physical custody of the citizen parent; or

(B) Was adopted according to the requirements of INA Section 101 and resides in the U.S. in the legal and physical custody of the citizen parent.

(f) Individuals who turned eighteen before February 27, 2001, would have automatically become a citizen if, while the individual was still under eighteen, he or she became a lawful permanent resident and both his or her parents naturalized. Such individuals also may have derived citizenship when only one parent naturalized, if the other parent was dead or a U.S. citizen by birth, or the individual's parents were separated and the naturalized parent had custody.

(6) U.S. nationals are persons who owe permanent allegiance to the U.S. and may enter and work in the U.S. without restriction. The following are the only persons classified as U.S. nationals:

(a) Persons born in American Samoa or Swain's Island after December 24, 1952; and

(b) Residents of the Northern Mariana Islands who did not elect to become U.S. citizens.

(1) The medicaid agency approves a retroactive Washington apple health (WAH) certification period for the three months immediately before the month of application when an individual:

(a) Requests retroactive WAH on his or her application, within the certification period following the retroactive period, or before the determination of benefits and any appeal process is final;

(b) Would have been eligible for WAH for any or all of the three months if he or she had applied during the retroactive period; and

(c) The individual received covered medical services as described in WAC 182-501-0060 and 182-501-0065.

(2) When an individual is eligible only during the three-month retroactive certification period, that period is the only period of certification, except when:

(a) A pregnant woman is eligible in one of the three months immediately before the month of application, but no earlier than the month of conception. Eligibility continues as described in WAC 182-504-0015(3).

(b) A child is eligible for categorically needy (CN) WAH as described in WAC 182-505-0210 (1) through (5) and (7) in at least one of the three months immediately before the month of application. Eligibility after the retroactive period continues as described in WAC 182-504-0015(11).

(3) An individual applying for the medically needy (MN) spenddown program may be eligible for a retroactive certification period as described in WAC 182-504-0020.

(4) An individual applying for a medicare savings program may be eligible for a retroactive certification period as described in WAC 182-504-0025.

(1) Supplemental security income (SSI) is a federal cash benefit administered by the Social Security Administration (SSA) under Title XVI of the Social Security Act. The SSI program replaces state programs for the aged, blind and disabled individuals beginning January 1974. An individual who received state assistance in December 1973 who became eligible for SSI in January 1974 is considered a grandfathered client by the medicaid agency, and a mandatory income level (MIL) client by SSI. The individual must continue to meet the definition of blind or disabled that was in effect under the state plan in December 1973. These definitions can be found in the SSA program operations manual system (POMS), see https://secure.ssa.gov/apps10/poms.nsf/aboutpoms. Other definitions related to SSI eligibility are described in WAC 182-500-0100.

(2) An essential person is an individual who is needed in the home to care for an SSI recipient. An essential person is eligible for categorically needy (CN) Washington apple health (WAH) as long as he or she has lived continuously with the eligible person since January 1974.

(3) An ineligible spouse is not eligible for SSI-related CN WAH. An ineligible spouse must have his or her eligibility for WAH determined separately in accordance with SSI-related medically needy (MN) rules in WAC 182-519-0100.

(4) When an individual receives SSI, the agency accepts SSA's determination of medicaid entitlement. The individual is eligible for CN WAH without submitting an additional application as long as he or she:

(a) Remains entitled to an SSI cash payment;

(b) Is no longer entitled to an SSI cash payment, but SSA is in the process of determining eligibility under Section 1619(b) of the Social Security Act; or

(c) Currently has 1619(b) status as described in WAC 182-512-0880(3).

(5) An SSI recipient may be terminated from CN WAH when he or she:

(a) Does not provide the agency with information necessary for the agency to determine if he or she has other medical insurance; or

(b) Does not assign the right to recover insurance funds to the agency as required in WAC 182-503-0540.

(6) When SSA stops an individual's SSI cash payment for one of the reasons listed in (a), (b), or (c) of this subsection, CN WAH eligibility continues.

(a) The individual's countable income exceeds the SSI income standard due solely to the annual cost-of-living adjustment (COLA) as described in WAC 182-512-0880(1);

(b) The individual is a "deemed" eligible SSI recipient on the basis of eligibility for a special income disregard described in WAC 182-512-0880; or

(c) The individual has an appeal of an SSA termination pending which has not yet resulted in a final determination.

(7) If an individual's SSI cash payment stops due to an SSA determination that the individual is no longer disabled, and any appeal of this determination has resulted in a final decision, the agency:

(a) Redetermines eligibility for all other WAH programs that are not based on receipt of SSI; and

(b) Continues CN WAH until the agency completes the redetermination process described in WAC 182-504-0125.

(8) If an individual's SSI cash payment stops for a reason not addressed elsewhere in this section, the agency considers the individual to meet disability requirements through the SSA's original disability review date. The agency:

(a) Redetermines eligibility for other WAH programs, which may or may not be based on disability; and

(b) Continues CN WAH until the agency completes the redetermination process described in WAC 182-504-0125.

(1) The federal poverty levels (FPL) amounts, also known as poverty guidelines, are issued by the federal Department of Health and Human Services each year in the Federal Register and are generally found at http://aspe.hhs.gov/poverty/index.shtml.

(2) If the FPL amounts change from one calendar year to the next, the net income standard for the Washington apple health for workers with disabilities (HWD) program changes on the first of April each year based on that calendar year's poverty guidelines.

(3) The net income standard for HWD is two hundred twenty percent of the poverty guideline.

(4) There is no test for resources for the HWD program.