WSR 14-10-057

PROPOSED RULES

HEALTH CARE AUTHORITY

(Medicaid Program)

[Filed May 2, 2014, 12:52 p.m.]

Original Notice.

Preproposal statement of inquiry was filed as WSR 12-19-092.

Title of Rule and Other Identifying Information: Phase 2 ACA WACs, WAC 182-500-0020 Medical assistance definitions—C, 182-500-0030 Medical assistance definitions—E, 182-503-0001 Insurance affordability programs—Overview, 182-503-0005 Washington apple health (WAH)—How to apply, 182-503-0010 WAH—Who can apply, 182-503-0060 WAH—Application processing times, 182-503-0070 WAH—When coverage begins, 182-503-0080 WAH—Application denials and withdrawals, 182-503-0505 WAH—General eligibility requirements, 182-503-0515 WAH—Social security number requirements, 182-503-0520 WAH—Residency requirements for noninstitutionalized medical programs, 182-503-0525 WAH—Residency requirements for an institutionalized individual, 182-503-0535 WAH—Citizenship and alien status, 182-503-0540 WAH—Assignment of rights and cooperation, 182-503-0565 WAH—Age requirements for medical programs based on MAGI, 182-504-0015 WAH—Certification periods for CN programs, 182-504-0035 WAH—Renewals, 182-504-0105 WAH—Changes that must be reported, 182-504-0110 WAH—When to report changes, 182-504-0120 WAH—Effective dates of changes, 182-504-0125 WAH—Effect of changes, 182-505-0100 WAH—Monthly income standards based on the FPL, 182-505-0115 WAH—Eligibility for pregnant women, 182-505-0210 WAH—Eligibility for children, 182-505-0215 WAH—Premium-based children's program—Purpose and scope, 182-505-0220 Definitions for premium-based health care coverage under programs included in apple health for kids, 182-505-0225 WAH—Premium-based children's program—Purpose and scope, 182-505-0230 Waiting period for premium-based health care coverage, 182-505-0235 WAH—Premium-based children's program—Order of payments, 182-505-0237 WAH—Premium-based children's program—Other rules that apply, 182-505-0240 WAH—Parents and caretaker relatives, 182-505-0245 Income and resources standards for family medical programs, 182-505-0250 WAH—MAGI-based adult medical, 182-505-0515 Medical coverage resulting from a cash grant, 182-518-0005 WAH—Notice requirements—General, 182-518-0010 WAH—Notice requirements—Approval and denial notices, 182-518-0015 WAH—Notice requirements—Verification requests, 182-518-0020 WAH—Notice requirements—Renewals, 182-518-0025 WAH—Notice requirements—Changes in and terminations of coverage, and 182-518-0030 WAH—Notice requirements—Electronic notices.

These rules were previously proposed in 2013 under WSR 13-11-141. At that time, there were so many substantive changes resulting from the public comments that the agency felt it best to repropose the rules.

Hearing Location(s): Health Care Authority (HCA), Cherry Street Plaza Building, Sue Crystal Conference Room 106A, 626 8th Avenue, Olympia, WA 98504 (metered public parking is available street side around building. A map is available at http://maa.dshs.wa.gov/pdf/CherryStreetDirectionsNMap.pdf, or directions can be obtained by calling (360) 725-1000), on June 10, 2014, at 10:00 a.m.

Date of Intended Adoption: Not sooner than June 10, 2014.

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 June 10, 2014.

Assistance for Persons with Disabilities: Contact Kelly Richters by June 2, 2014, TTY (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: HCA is implementing new regulations under the federal Patient Protection and Affordable Care Act in preparation for healthcare reform in Washington state. This includes the establishment of standalone rules for medical assistance programs, which are required under 2E2SHB 1738, Laws of 2011, which creates HCA as the single state agency responsible for the administrations and supervision of Washington's medicaid program (WAH).

Reasons Supporting Proposal: See Purpose statement.

Statutory Authority for Adoption: RCW 41.05.021.

Statute Being Implemented: Patient Protection and Affordable Care Act (Public Law 111-148); 42 C.F.R. § 431, 435, and 457; and 45 C.F.R. § 155.

Rule is necessary because of federal law, Patient Protection and Affordable Care Act (Public Law 111-148).

Name of Proponent: HCA, governmental.

Name of Agency Personnel Responsible for Drafting: Kevin Sullivan, P.O. Box 42716, Olympia, WA 98504-2716, (360) [725-]1344; Implementation and Enforcement: Jessie M. Dean, P.O. Box 45534, Olympia, WA 98504-5534, (360) [725-]1301.

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 HCA rules unless requested by the joint administrative rules review committee or applied voluntarily.

May 2, 2014

Kevin M. Sullivan

Rules Coordinator

AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)

WAC 182-500-0020 Medical assistance definitions—C.

"Caretaker relative" means a relative of a dependent child by blood, adoption, or marriage with whom the child is living, who assumes primary responsibility for the child's care, and who is one of the following:

(1) The child's father, mother, grandfather, grandmother, brother, sister, stepfather, stepmother, stepbrother, stepsister, uncle, aunt, first cousin, nephew, or niece.

(2) The spouse of such parent or relative (including same sex marriage or domestic partner), even after the marriage is terminated by death or divorce.

(3) Other relatives including relatives of half-blood, first cousins once removed, persons of earlier generations (as shown by the prefixes of great, great-great, or great-great-great), and natural parents whose parental rights were terminated by a court order.

"Carrier" means an organization that contracts with the federal government to process claims under medicare Part B.

"Categorically needy (CN) or categorically needy program (CNP)" is the state and federally funded health care program established under Title XIX of the Social Security Act for persons within medicaid-eligible categories, whose income and/or resources are at or below set standards.

"Categorically needy income level (CNIL)" is the standard used by the agency to determine eligibility under a categorically needy program.

"Categorically needy (CN) scope of care" is the range of health care services included within the scope of service categories described in WAC ((388-501-0060)) 182-501-0060 available to ((individuals)) persons eligible to receive benefits under a CN program. Some state-funded health care programs provide CN scope of care.

"Centers for Medicare and Medicaid Services (CMS)" means the agency within the federal department of health and human services (DHHS) with oversight responsibility for the medicare and medicaid programs.

"Children's health program or children's health care programs" See "Apple health for kids."

"Community spouse." See "spouse" in WAC ((388-500-0100)) 182-500-100.

"Cost-sharing" means any expenditure required by or on behalf of an enrollee with respect to essential health benefits; such term includes deductibles, coinsurance, copayments, or similar charges, but excludes premiums, balance billing amounts for nonnetwork providers, and spending for noncovered services.

"Cost-sharing reductions" means reductions in cost-sharing for an eligible person enrolled in a silver level plan in the health benefit exchange or for a person who is an American Indian or Alaska native enrolled in a qualified health plan (QHP) in the exchange.

"Couple." See "spouse" in WAC ((388-500-0100)) 182-500-0100.

"Covered service" is a health care service contained within a "service category" that is included in a medical assistance benefits package described in WAC ((388-501-0060)) 182-501-0060. For conditions of payment, see WAC ((388-501-0050)) 182-501-0050(5). A noncovered service is a specific health care service (for example, cosmetic surgery), contained within a service category that is included in a medical assistance benefits package, for which the agency or the agency's designee requires an approved exception to rule (ETR) (see WAC ((388-501-0160)) 182-501-0160). A noncovered service is not an excluded service (see WAC ((388-501-0060)) 182-501-0060).

"Creditable coverage" means most types of public and private health coverage, except Indian health services, that provide access to physicians, hospitals, laboratory services, and radiology services. This term applies to the coverage whether or not the coverage is equivalent to that offered under premium-based programs included in Washington apple health (WAH). Creditable coverage is described in 42 U.S.C. 300gg-3 (c)(1).

AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)

WAC 182-500-0030 Medical assistance definitions—E.

"Early and periodic screening, diagnosis and treatment (EPSDT)" is a comprehensive child health program that entitles infants, children, and youth to preventive care and treatment services. EPSDT is available to persons twenty years of age and younger who are eligible for any agency health care program. Access and services for EPSDT are governed by federal rules at 42 C.F.R., Part 441, Subpart B. See also chapter ((388-534)) 182-534 WAC.

"Emergency medical condition" means the sudden onset of a medical condition (including labor and delivery) manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:

(1) Placing the patient's health in serious jeopardy;

(2) Serious impairment to bodily functions; or

(3) Serious dysfunction of any bodily organ or part.

(("Emergency medical expense requirement (EMER)" see WAC 388-865-0217(3).))

"Employer-sponsored dependent coverage" means creditable health coverage for dependents offered by a family member's employer or union, for which the employer or union may contribute in whole or in part towards the premium. Extensions of such coverage (e.g., COBRA extensions) also qualify as employer-sponsored dependent coverage as long as there remains a contribution toward the premiums by the employer or union.

"Evidence-based medicine (EBM)" means the application of a set of principles and a method for the review of well-designed studies and objective clinical data to determine the level of evidence that proves to the greatest extent possible, that a health care service is safe, effective, and beneficial when making:

(1) Population-based health care coverage policies (WAC ((388-501-0055)) 182-501-0055 describes how the agency or ((the agency's)) its designee determines coverage of services for its health care programs by using evidence and criteria based on health technology assessments); and

(2) Individual medical necessity decisions (WAC ((388-501-0165)) 182-501-0165 describes how the agency or ((the agency's)) its designee uses the best evidence available to determine if a service is medically necessary as defined in WAC ((388-500-0030)) 182-500-0030).

"Exception to rule." See WAC ((388-501-0160)) 182-501-0160 for exceptions to noncovered health care services, supplies, and equipment. See WAC 182-503-0090 for exceptions to program eligibility.

"Expedited prior authorization (EPA)" means the process for obtaining authorization for selected health care services in which providers use a set of numeric codes to indicate to the agency or the agency's designee which acceptable indications, conditions, or agency or agency's designee-defined criteria are applicable to a particular request for authorization. EPA is a form of "prior authorization."

"Extended care services" means nursing and rehabilitative care in a skilled nursing facility provided to a recently hospitalized medicare patient.

NEW SECTION

WAC 182-503-0001 Insurance affordability programs—Overview.

(1) For the purposes of this chapter, "we" refers to the agency or its designee and "you" refers to the applicant for, or recipient of, health care coverage.

(2) A person may apply for all of the insurance affordability programs offered through the health care authority (HCA) or the Washington Healthplanfinder (as defined in WAC 182-500-0015):

(a) Washington apple health (WAH) programs (defined in WAC 182-500-0120). WAH includes medicaid programs (defined in WAC 182-500-0070), the children's health insurance program (CHIP) (defined in WAC 182-500-0020), and state-only funded health care programs. These programs are provided free or at low cost on a sliding scale to eligible persons based on their income. WAH program regulations for the application process and eligibility determination are found in chapters 182-503 through 182-527 WAC.

(b) Health insurance premium tax credits (defined in WAC 182-500-0045). This federal refundable tax credit partially offsets the cost of monthly premiums for qualified health plan (QHP) (defined in WAC 182-500-0090) insurance that an eligible person purchases through the Washington Healthplanfinder. Any advance payments of the tax credit are reconciled annually by the Internal Revenue Service (IRS) when the person files his or her federal tax return.

(c) Cost-sharing reductions. Cost-sharing reductions (defined in WAC 182-500-0020) are available to eligible persons enrolled in a silver-level QHP and to American Indians/Alaska Natives enrolled in any QHP.

(3) A person may also apply for and enroll in unsubsidized insurance with a QHP. This unsubsidized insurance is not an insurance affordability program.

(4) Persons choose whether or not to apply for insurance affordability programs. All persons who apply for an insurance affordability program are treated as an applicant for WAH coverage and receive an approval or denial of WAH. Applicants who are denied WAH are reviewed for other insurance affordability programs.

NEW SECTION

WAC 182-503-0005 Washington apple health—How to apply.

(1) You may apply for Washington apple health (WAH) by giving us (the medicaid agency or its designee) an application as follows:

(a) For WAH for parents and caretaker relatives, adults, pregnant women, or kids (with or without premiums):

(i) Online via the Washington Healthplanfinder at http://www.wahealthplanfinder.org;

(ii) By calling the Washington Healthplanfinder customer support center number;

(iii) By mail to Washington Healthplanfinder, the agency or its designee; or

(iv) By fax to Washington Healthplanfinder.

(b) For WAH medical programs for persons age sixty-five or older, persons on medicare, persons applying for health care based on blindness or disability, or persons applying for long-term care services:

(i) Online via Washington Connection at http://www.waconnection.org;

(ii) By mail to community services division of the department of social and health services (DSHS); or

(iii) At a local DSHS office.

(c) For the breast and cervical cancer treatment program (see WAC 182-505-0120), the TAKE CHARGE program (see chapter 182-532 WAC), and the kidney disease program (chapter 182-540 WAC), complete a separate application directly with a program provider.

More information on how to give us an application may be found at the agency's web site: http://www.hca.wa.gov.

(2) You may start an application for WAH by giving us at least the following information:

(a) Name of the primary applicant or head of household;

(b) Birth dates; and

(3) To complete an application for WAH, you must also give us all of the other information requested on the application form.

(4) If you need help filing an application, you can:

(a) For WAH for parents and caretaker relatives, adults, pregnant women, or kids (with or without premiums):

(i) Contact the Washington Healthplanfinder customer support center number listed on the application form or medical eligibility determination services at the number provided on the agency's web site, http://www.hca.wa.gov; or

(ii) Contact an application assistor, certified application counselor or navigator.

(i) Visit a local DSHS office; or

(ii) Call the DSHS community services division customer service contact center.

(5) We will help you with the application or renewal process in a manner that is accessible to persons with disabilities as described in WAC 182-503-0120 and in a manner that is accessible to those who are limited-English proficient as described in WAC 182-503-0110.

NEW SECTION

WAC 182-503-0010 Washington apple health—Who can apply.

(1) You may apply for Washington apple health (WAH) for yourself.

(2) You can apply for WAH for another person if you are:

(a) A legal guardian;

(b) An authorized representative (as described in WAC 182-500-0010);

(d) A tax filer applying for a tax dependent less than nineteen years of age;

(e) A spouse; or

(f) A person applying for someone who is unable to apply on their own due to a medical condition and who is in need of long-term care services.

(3) If you reside in one of the following facilities and the facility has entered into a memorandum of understanding with the agency, the agency will coordinate with the facility to enroll you in WAH coverage for which you are determined eligible no later than the day you are released to:

(a) A correctional institution, as defined in RCW 9.94.049, including:

(i) Washington state department of corrections facilities;

(ii) City or county jails; and

(iii) Secure community transition facilities and total confinement facilities, as defined in RCW 71.09.020, including the special commitment center.

(b) An institution for mental disease (IMD).

(4) You are automatically enrolled in WAH and do not need to turn in an application if you are a:

(a) Supplemental security income (SSI) recipient;

(b) Person deemed to be an SSI recipient under 1619(b) of the SSA;

(d) Child in foster care placement as described in WAC 182-505-0211.

(5) You are the primary applicant on an application if you complete and sign the application on behalf of your household.

(6) If you are an SSI recipient, then you, your authorized representative as defined in WAC 182-500-0010, or another person applying on your behalf as described in subsection (2) of this section, must turn in a signed application to apply for long-term care services as described in WAC 182-513-1315.

NEW SECTION

WAC 182-503-0060 Washington apple health (WAH)—Application processing times.

(1) We process applications for Washington apple health (WAH) within forty-five calendar days, with the following exceptions:

(a) If you are pregnant, we process your application within fifteen calendar days;

(b) If you are applying for a program that requires a disability decision, we process your application within sixty calendar days; or

(c) The modified adjusted gross income (MAGI)-based WAH application process using Washington Healthplanfinder may provide faster or real-time determination of eligibility for medicaid.

(2) For calculating time limits, "day one" is the day we get an application from you that includes at least the information described in WAC 182-503-0005(2). If you give us your paper application during business hours, "day one" is the day you give us your application. If you give us your paper application outside of business hours, "day one" is the next business day. If you experience technical difficulties while attempting to give us your application in Washington Healthplanfinder, "day one" is the day we are able to determine, based on the evidence available, that you first tried to submit an application that included at least the information described in WAC 182-503-0005(2).

(3) We determine eligibility as quickly as possible and respond promptly to applications and information received. We do not delay a decision by using the time limits in this section as a waiting period.

(4) If we need more information to decide if you can get WAH coverage, we will send you a letter within twenty calendar days of your initial application that:

(a) Follows the rules in chapter 182-518 WAC;

(b) States the additional information we need; and

(c) Allows at least ten calendar days to provide it. We will allow you more time if you ask for more time or need an accommodation due to disability or limited-English proficiency.

(5) Good cause for a delay in processing the application exists when we acted as promptly as possible but:

(a) The delay was the result of an emergency beyond our control;

(b) The delay was the result of needing more information or documents that could not be readily obtained;

(6) Good cause for a delay in processing the application does NOT exist when:

(a) We caused the delay in processing by:

(i) Failing to ask you for information timely; or

(ii) Failing to act promptly on requested information when you provided it timely; or

(b) We did not document the good cause reason before missing a time frame specified in subsection (1) of this section.

NEW SECTION

WAC 182-503-0070 Washington apple health (WAH)—When coverage begins.

(1) Your Washington apple health (WAH) coverage starts on the first day of the month you applied for and we decided you are eligible to receive coverage, unless one of the exceptions in subsection (4) of this section applies to you.

(2) Sometimes we can start your coverage up to three months before the month you applied (see WAC 182-504-0005).

(3) If you are confined or incarcerated as described in WAC 182-503-0010, your coverage cannot start before the day you are discharged, except when:

(a) You are hospitalized during your confinement; and

(b) The hospital requires you to stay overnight.

(4) Your WAH coverage may not begin on the first day of the month if:

(a) Subsection (3) of this section applies to you. In that case, your coverage would start on the first day of your hospital stay;

(b) You must meet a medically needy spenddown liability (see WAC 182-519-0110). In that case, your coverage would start on the day your spenddown is met; or

(c) You are eligible under the WAH alien emergency medical program (see WAC 182-507-0115). In that case, your coverage would start on the day your emergent hospital stay begins.

(5) For long-term care, the date your services start is described in WAC 388-106-0045.

NEW SECTION

WAC 182-503-0080 Washington apple health—Application denials and withdrawals.

(1) We follow the rules about notices and letters in chapter 182-518 WAC. We follow the rules about timelines in WAC 182-503-0060.

(2) We deny your application for Washington apple health (WAH) coverage when:

(a) You tell us either orally or in writing to withdraw your request for coverage; or

(b) Based on all information we have received from you and other sources within the time frames stated in WAC 182-503-0060, including any extra time given at your request or to accommodate a disability or limited-English proficiency:

(i) We are unable to determine that you are eligible; or

(ii) We determine that you are not eligible.

(3) We send you a written notice explaining why we denied your application (per chapter 182-518 WAC).

(4) We reconsider our decision to deny your WAH coverage without a new application from you when:

(a) We receive the information that we need to decide if you are eligible within thirty days of the date on the denial notice; or

(b) You request a hearing within ninety days of the date on the denial letter and an administrative law judge (ALJ) or HCA review judge decides our denial was wrong (per chapter 182-526 WAC).

(5) If you disagree with our decision, you can ask for a hearing. If we denied your application because we don't have enough information, the ALJ will consider the information we already have and anymore information you give us. The ALJ does not consider the previous absence of information or failure to respond in determining if you are eligible.

NEW SECTION

WAC 182-503-0515 Washington apple health—Social Security number requirements.

(1) To be eligible for Washington apple health (WAH), you must provide your valid Social Security number (SSN) or proof of application for an SSN, except as provided in subsections (5) and (6) of this section.

(2) If you are not able to provide your SSN, either because you do not know it or it has not been issued, you must provide:

(a) Proof from the Social Security Administration (SSA) that you turned in an application for an SSN; and

(b) The SSN when you receive it.

(3) Your WAH coverage will not be delayed, denied or terminated while waiting for SSA to send you your SSN.

(4) If you do not provide your SSN, then you will not receive WAH coverage except if you:

(a) Refused to apply for or provide your SSN for religious reasons;

(b) Claim good cause for not providing your SSN because of domestic violence;

(c) Have a newborn as described in WAC 182-505-0210(1). A newborn is eligible for WAH coverage until the baby's first birthday.

(5) There is no SSN requirement for the following:

(a) WAH refugee medical;

(b) WAH alien emergency medical;

(d) A household member who is not applying for WAH coverage.

(6) If you are a "qualified" or "nonqualified" alien as defined in WAC 182-503-0530 who is not authorized to work in the U.S., you do not have to apply for a nonwork SSN.

NEW SECTION

WAC 182-503-0525 Washington apple health—Residency requirements for an institutionalized person.

(1) An institutionalized person is a person who resides in an institution as defined in WAC 182-500-0050. The term "person" used in this section means an "institutionalized person" unless otherwise indicated. It does not include persons who receive services under a home and community-based waiver program. When a state is making a placement for a person in another state, the term institution also includes foster care homes, licensed as described in 45 C.F.R. 1355.20.

(2) The agency must determine whether a person is capable of indicating their intent to reside in Washington state when deciding whether that person is a resident of the state. The agency determines that persons who meet the following criteria are deemed incapable of indicating intent to reside in the state:

(a) The person is judged legally incompetent by a court of law;

(b) A physician, psychologist or licensed medical professional in the field of intellectual disabilities has determined that the person is incapable of indicating intent; or

(3) When a person is placed in an out-of-state institution by the agency, its designee or by a department of social and health services-contracted agency, the state arranging the placement is considered the person's state of residence, unless the person is capable of expressing intent and:

(a) Indicates a desire to change his or her state of residence; or

(b) Asks the current state of residence for help in relocating. This may include assistance in locating an institutional placement in the new state of residence.

(4) If another state has not authorized the placement in the institution, as described in subsection (3) of this section, the agency or its designee uses one of the following criteria to determine the state of residence for a person who is age twenty or younger:

(a) The state of residence is the state where the parent or legal guardian is a resident at the time of the placement in the institution. To determine a parent's or legal guardian's place of residence, follow rules described in WAC 182-503-0520 for a noninstitutionalized person.

(b) The state of residence is the state where the parent or legal guardian currently is a resident if the person resides in an institution in that state.

(c) If the parents of the person are separated and live in different states, the state of residence is that of the parent filing the application.

(d) If the parental rights are terminated and the person has a legal guardian, the state of residence is where the legal guardian is a resident.

(e) If the person has both a guardian of the estate and a guardian of the person, the state of residence is where the guardian of the person is a resident, unless the state has laws which delegate guardianship to a state official or agency for persons who are admitted to state institutions. In that case, the state of residence for the person is the state where the institution is located (unless another state has authorized the placement).

(f) If the person has been abandoned by the parents or legal guardian, and an application is filed on their behalf by another party, the state of residence is the state where the person is institutionalized. The term abandoned also includes situations where the parents or legal guardian are deceased.

(5) A person age twenty-one or older that is capable of indicating intent is considered a resident of the state where he or she is living and intends to reside.

(6) A person age twenty-one or older who became incapable of indicating intent at age twenty-one or older is considered a resident of the state where the person is physically residing, unless the person has been placed in the institution by another state.

(7) A person age twenty-one or older who became incapable of indicating intent before the age of twenty-one is considered a resident of the state where the parents or legal guardian were residents at the time of the placement in the institution.

(8) If a noninstitutionalized person moves directly from another state to an institution in Washington state, it is not necessary for the person to establish residency in Washington state prior to entering the facility. The person is considered a resident if he or she intends to reside in the state unless the placement was made by the other state.

(9) A person of any age who receives a state supplemental payment (SSP) is considered a resident of the state that is making the payment.

(10) In a dispute between states, the state of residence is the state in which the person is physically located.

NEW SECTION

WAC 182-503-0535 Washington apple health—Citizenship and alien status.

(1) To receive Washington apple health (WAH) coverage, you must meet all other eligibility requirements and be one of the following as defined in WAC 182-503-0530:

(a) A United States (U.S.) citizen;

(b) A U.S. national;

(d) A nonqualified alien and you are a:

(i) Pregnant woman;

(ii) Person who is otherwise eligible for medical care services (see WAC 182-508-0005);

(iii) Child under age nineteen; or

(iv) Child under age twenty-one who resides in an institution.

(2) If you are a nonqualified alien approved under deferred action childhood arrivals (DACA), then you are not eligible for WAH under subsection (1)(d) of this section. However, you may qualify under subsection (6) of this section.

(3) If you are a qualified alien as defined in WAC 182-503-0530, who physically entered the U.S. before August 22, 1996, you may receive WAH for nonpregnant adults if you:

(a) Became a qualified alien before August 22, 1996; or

(b) Became a qualified alien on or after August 22, 1996, and have continuously resided in the U.S. between your date of entry into the U.S. and the date on which you became a qualified alien.

(4) If you are a qualified alien who physically entered the U.S. on or after August 22, 1996, and you are a nonpregnant adult, you are not eligible to receive WAH for five years beginning on the day you most recently became a qualified alien, unless you meet one of the exemptions in subsection (5) of this section. This is called the five-year bar. The five-year bar starts on the day you obtain qualified alien status.

(5) You are exempt from the five-year bar if you are one of the following qualified aliens as defined in WAC 182-503-0530:

(a) Amerasian lawful permanent residents;

(b) Asylees;

(d) Persons granted withholding of deportation or removal;

(e) Refugees;

(f) Special immigrants from Iraq and Afghanistan;

(g) Victims of trafficking who have been certified or had their eligibility approved by the Office of Refugee Resettlement (ORR); and

(h) 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; and

(i) Lawful permanent residents, parolees, or battered aliens, who are also an armed services member or veteran, or a family member of an armed services member or veteran, as described below:

(i) On active duty in the U.S. military, other than active duty for training;

(ii) An honorably discharged U.S. veteran;

(iii) A veteran of the military forces of the Philippines who served prior to July 1st, 1946, as described in Title 38, Section 107 of the U.S. Code; or

(iv) The spouse, unremarried widow or widower, or unmarried dependent child of a veteran or active duty service member.

(6) If you are ineligible for WAH because of the five-year bar or because of your immigration status, including if you are approved under DACA, you may be eligible for:

(a) The WAH alien emergency medical program as described in WAC 182-507-0110 through 182-507-0125;

(b) WAH pregnancy medical for noncitizen women as described in WAC 182-505-0115;

(d) State-funded WAH for kids as described in WAC 182-505-0210; or

(e) The medical care services (MCS) program as described in chapter 182-508 WAC.

NEW SECTION

WAC 182-503-0565 Washington apple health—Age requirements for medical programs based on modified adjusted gross income (MAGI).

The following age requirements apply to persons whose eligibility for Washington apple health (WAH) is based on modified adjusted gross income (MAGI) methodology per WAC 182-509-0305.

(1) You must be age sixty-four or younger to be eligible for WAH MAGI-based adult coverage as described in WAC 182-505-0250.

(2) Your household must include an eligible dependent child age seventeen or younger to be eligible for WAH parent or caretaker relative coverage as described in WAC 182-505-0240. For purposes of this subsection, an "eligible dependent child" is a child related to you in one of the ways described in WAC 182-500-0020.

(3) A child must be age eighteen or younger to be eligible for WAH for kids as described in WAC 182-505-0210 with the following exceptions:

(a) An institutionalized child may still qualify under a children's health care program through the age of twenty-one (see WAC 182-514-0230);

(b) A foster care child may qualify for WAH foster care coverage through the age of twenty-six (see WAC 182-505-0211).

AMENDATORY SECTION (Amending WSR 12-13-056, filed 6/15/12, effective 7/1/12)

WAC 182-503-0505 Washington apple health—General eligibility requirements ((for medical programs)).

(1) Persons applying for ((benefits under the medical coverage)) Washington apple health (WAH) programs established under chapter 74.09 RCW must meet the eligibility criteria ((established by the department)) in chapters ((388-400)) 182-500 through ((388-555)) 182-527 WAC.

(2) Persons applying for ((medical coverage)) WAH are considered first for federally funded or federally matched programs. State-funded programs are considered after the person is determined ineligible for federally funded and federally matched programs ((are not available to the client except for brief periods when the state-funded programs offer a broad scope of care which meet a specific client need)).

(3) Unless otherwise specified in a program specific WAC, the eligibility criteria for each ((medical)) WAH program ((is)) are as follows:

(a) ((Verification of)) Age and identity (((chapters 388-404, 388-406, and 388-490)) WAC 182-503-0050); ((and))

(b) Residence in Washington state (((chapter 388-468)) WAC 182-503-0520 and 182-503-0525); ((and))

(d) Possession of a valid Social Security account number (((chapter 388-476)) WAC 182-503-0515); ((and))

(e) Assignment of medical support rights to the state of Washington (WAC ((388-505-0540)) 182-503-0540); ((and))

(f) ((Cooperation in securing medical support (chapter 388-422 WAC); and

(g))) Application for medicare and enrollment into medicare's prescription drug program if:

(i) It is likely that the ((individual)) person is entitled to medicare; and

(ii) The state has authority to pay medicare cost sharing as described in chapter ((388-517)) 182-517 WAC.

(((h))) (g) For persons whose eligibility is not on the basis of modified adjusted gross income (MAGI) methodology, countable resources must be within specific program limits (chapters ((388-470 and 388-478)) 182-512, 182-513, 182-515, 182-517, and 182-519 WAC); and

(((i))) (h) Countable income within program limits (((chapters 388-450 and 388-478 WAC).)):

(i) For MAGI-based WAH programs, see WAC 182-505-0100;

(ii) For the WAH refugee program, see WAC 182-507-0110;

(iii) For the WAH medical care services program, see WAC 182-508-0150;

(iv) For WAH for workers with disabilities (HWD), see WAC 182-511-0060;

(v) For the WAH SSI-related program, see WAC 182-512-0010;

(vi) For WAH long-term care programs, see WAC 182-513-1300 and 182-515-1500;

(vii) For WAH medicare savings programs, see WAC 182-517-0100; and

(viii) For the WAH medically needy program, see WAC 182-519-0050.

(4) In addition to the general eligibility requirements in subsection (3) of this section, each program has specific eligibility requirements as described in applicable WAC.

(5) Persons ((living)) in a public institution, including a correctional facility, are not eligible for ((the department's medical coverage)) WAH programs((. For a person)), except in the following situations:

(a) The person is under age twenty or over age sixty-five ((who)) and is a patient in an institution for mental disease (see WAC ((388-513-1315(13) for exception.)) 182-513-1315(13)); or

(b) The person receives inpatient hospital services outside of the public institution or correctional facility.

(6) Persons terminated from SSI or ((TANF cash grants and those)) who lose eligibility for categorically needy (CN) ((medical)) coverage have their CN coverage continued while their eligibility for other ((medical)) health care programs is redetermined. ((This continuation of medical coverage is described in chapter 388-434 WAC)) See WAC 182-504-0125.

AMENDATORY SECTION (Amending WSR 12-19-051, filed 9/13/12, effective 10/14/12)

WAC 182-503-0520 Washington apple health—Residency requirements ((for medical care services (MCS)))—Persons who are not residing in an institution.

((This section applies to medical care services (MCS).))

(1) A resident is ((an individual who:

(a))) a person (including an emancipated person under age eighteen and a married person under age eighteen who is capable of indicating intent) who currently lives in Washington and:

(a) Intends to ((continue living here permanently or for an indefinite period of time)) reside here, including persons without a fixed address; or

(b) Entered the state looking for a job; or

(2) ((An individual)) A person does not need to live in the state for a specific period of time prior to ((be)) meeting the requirements in subsection (1) of this section before being considered a resident.

(3) ((An individual receiving MCS)) A child under age eighteen who is not covered by subsection (1) of this section, is a resident if:

(a) The child lives in the state, with or without a fixed address, including with a custodial parent or caretaker; or

(b) The child's parent or caretaker is a resident as defined in subsection (1) of this section.

(4) A resident applying for or receiving health care coverage 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.

(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;

(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)) without their health care coverage being denied or terminated, if the person:

(a) Intends to return to the state once the purpose of his or her absence has been accomplished and provides adequate information of this intent after a request by the agency or its designee; and

(b) Has not been determined eligible for medicaid or state-funded health care coverage in another state (other than coverage in another state for incidental or emergency health care).

(5) A person who enters Washington state only for health care is not a resident and is not eligible for any medical program. The only exception is for a person who moves from another state directly into an institution in Washington state. Residency rules for institutionalized persons are described in WAC 182-503-0525.

(6) A person of any age who receives a state supplemental payment (SSP) is considered a resident of the state that is making the payment.

(7) A person who receives federal payments for foster or adoption assistance is considered a resident of the state where the person physically resides even if:

(a) The person does not live in the state that is making the foster or adoption assistance payment; or

(b) The person does not live in the state where the adoption agreement was entered.

(8) In a dispute between states, the state of residence is the state in which the person is physically located.

AMENDATORY SECTION (Amending WSR 12-13-056, filed 6/15/12, effective 7/1/12)

WAC 182-503-0540 Assignment of rights and cooperation.

(1) When ((a person)) you become((s)) eligible for any of the ((department's medical)) agency's health care programs, ((they make assignment of)) you assign certain rights to the state of Washington. ((This assignment includes)) You assign all rights to any type of coverage or payment for ((medical)) health care ((which results)) that comes from:

(a) A court order;

(b) An administrative agency order; or

(c) Any third-party benefits or payment obligations for medical care which are the result of subrogation or contract (see WAC 388-501-0100).

(2) ((Subrogation is a legal term which describes the method by which the state acquires the rights of a client for whom or to whom the state has paid benefits. The subrogation rights of the state are limited to the recovery of its own costs.

(3) The person who)) When you sign((s)) the application ((makes the assignment of)) you assign the rights described in subsection (1) of this section to the state((. Assignment is made on their own behalf and on behalf of any eligible person for whom they can legally make such assignment.

(4) A person)) for:

(a) Yourself; and

(b) Any eligible person for whom you can legally make such assignment.

(3) You must cooperate with ((the department)) us in ((the identification, use or collection of)) identifying, using or collecting third-party benefits. ((Failure to)) If you do not cooperate ((results in a termination of eligibility for the responsible person. Other obligations for cooperation are located in chapters 388-14A and 388-422 WAC. The following clients are exempt from termination of eligibility for medical coverage as a result of noncooperation:

(a) A pregnant woman, and

(b) Minor children, and

(5) A person will not lose eligibility for medical assistance programs)), your health care coverage may end unless you can show good reason not to cooperate with us. Examples of good reason include, but are not limited to:

(a) Your reasonable belief that cooperating with us would result in serious physical or emotional harm to you or a child in your care; and

(b) Your being incapacitated without the physical ability to cooperate with us.

(4) Your WAH coverage will not end due solely to the noncooperation of any third party.

(((6) A person)) (5) You will ((be responsible for the costs of otherwise covered medical)) have to pay for your health care services if you:

(a) ((The person)) Received and kept the third-party payment for those services; or

(b) ((The person)) Refused to ((provide)) give to the provider of care ((their)) your legal signature on insurance forms.

(6) The state is limited to the recovery of its own costs for health care costs paid on behalf of a recipient of health care coverage. The legal term which describes the method by which the state acquires the rights of a person for whom the state has paid costs is called subrogation.

AMENDATORY SECTION (Amending WSR 11-24-018, filed 11/29/11, effective 12/1/11)

WAC 182-504-0015 Washington apple health—Certification periods for categorically needy (((CN) scope of care medical assistance)) programs.

(1) A certification period is the period of time a person is determined eligible for a categorically needy (CN) ((scope of care medical)) Washington apple health (WAH) program. Unless otherwise stated in this section, the certification period begins on the first day of the month of application and continues ((to)) through the last day of the last month of the certification period.

(2) For a ((child)) newborn eligible for ((the newborn medical program)) WAH, the certification period begins on the child's date of birth and continues through the end of the month of the child's first birthday.

(3) For a woman eligible for ((a medical program)) WAH based on pregnancy, the certification period ends the last day of the month that includes the sixtieth day from the day the pregnancy ends.

(4) For a person eligible for the WAH refugee program, the certification period ends at the end of the eighth month following the client's date of entry to the United States.

(5) For ((families the certification period is twelve months with a six-month report required as a condition of eligibility as described in WAC 388-418-0011)) all other WAH-CN coverage, the certification period is twelve months.

(((5))) (6) For children, ((the certification period is twelve months.)) eligibility is continuous ((without regard to changes in circumstances other than aging out of the program, moving out-of-state, failing to pay a required premium(s), incarceration or death.))

(6))) throughout the certification period regardless of a change in circumstances, unless a required premium (described in WAC 182-505-0225) is not paid for three consecutive months or the child:

(a) Turns age nineteen;

(b) Moves out of state;

(d) Dies.

(7) When the child turns nineteen, the certification period ends after the redetermination process described in WAC 182-504-0125 is completed, even if the twelve-month period is not over. The certification period may be extended past the end of the month the child turns nineteen when:

(a) The child is receiving inpatient services (((see)) described in WAC ((388-505-0230)) 182-514-0230) on the last day of the month the child turns nineteen;

(b) The inpatient stay continues into the following month or months; and

(((7) For an SSI-related person the certification period is twelve months.

(8) When the medical assistance unit is also receiving benefits under a cash or food assistance program, the medical certification period is updated to begin anew at each:

(a) Approved application for cash or food assistance; or

(b) Completed eligibility review.

(9))) (8) A retroactive certification period ((can begin up to three months immediately before the month of application when:

(a) The client would have been eligible for medical assistance if the client had applied; and

(b) The client received covered medical services as described in WAC 388-501-0060 and 388-501-0065.

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

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

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

(11) Any months of a retroactive certification period are added to the designated certification periods described in this section)) is described in WAC 182-504-0005.

(((12))) (9) Coverage under premium-based programs included in apple health for kids as described in ((WAC 388-505-0210 and)) chapter ((388-542)) 182-505 WAC begins no sooner than the month after creditable coverage ends.

NEW SECTION

WAC 182-504-0120 Washington apple health—Effective dates of changes.

(1) We (the agency or its designee) determine the date a change affects your Washington apple health (WAH) coverage based on:

(a) The date you report the change to us;

(b) The date you give us the requested verification; and

(2) When you report a change after you submit your application, but before your application is processed, the change is considered when processing your application.

(3) If another person, agency, or data source reports a change in circumstances, the information may be used in determining your eligibility. We will not rely on information received from a person, agency, or data source to terminate your WAH coverage without requesting additional information from you.

(4) A change in income affects your ongoing eligibility only if it is expected to continue beyond the month when the change is reported, and only if it is expected to last more than two months.

(5) A change that results in termination of your WAH coverage takes effect the first of the month following the advance notice period.

(6) The advance notice period:

(a) Begins on the day we send the letter about the change to you; and

(b) Is determined according to the rules in WAC 182-518-0025.

(7) A change that results in a decreased scope of care takes effect on the first of the month following the advance notice period. Examples of a decreased scope of care are:

(a) Termination of WAH categorically needy (CN) medical and approval for other WAH coverage with a lesser scope of care such as WAH medically needy (MN) medical;

(b) WAH-MN recipient with a change that increases the spenddown liability amount;

(8) A change that results in an increased scope of care takes effect on the first of the month following the date the change was reported, when you provide the required verification:

(a) Within ten days of the date we requested the verification; or

(b) By the end of the month of your change report, whichever is later.

If you are a WAH-MN applicant with a spenddown liability that has not yet been met and you report a change that results in your becoming eligible for WAH-CN medical or WAH for adults, your change report will be treated as a new application for purposes of retroactive WAH coverage as described in WAC 182-504-0005.

(9) If you do not provide the required verification timely under subsection (8) of this section, we make the change effective the first of the month following the month in which you provide the verification. We may terminate your WAH coverage if you do not provide the required verification.

(10) When a law or regulation requires a change in WAH, the date specified by the law or regulation is the effective date of the change.

(11) When a change in income or allowable expenses is reported timely (within thirty days) and changes the amount you pay towards the cost of your care for institutional programs (residing in a medical institution), we calculate your new participation amount based on:

(a) Either actual income received in a month or allowable deductions incurred in a month, or both; or

(b) An estimate of your monthly or allowable expenses in a prospective period of six months or less, based on both actual income received in a preceding period of six months or less and income expected to be received during the prospective period. At the end of the prospective period or when any significant change occurs, we reconcile this estimate for the period with income received during the same period.

(12) When a change in income, or allowable expenses, changes the amount you pay towards the cost of your care for a home and community-based waiver or service, we calculate your new participation amount effective the first of the following month, except that the new participation amount will be effective the month the change occurs if the change is the loss of an income source that you report within thirty days of the change.

(13) We use the following rules to determine the effective date of change for the health care for workers with disabilities (HWD) program:

(a) HWD coverage begins the month after coverage in another medical program ends and the premium amount has been approved by the eligible person; and

(b) If a change in income increases or decreases the monthly premium, the change is effective the first of the month after the change is reported. For more information on premium requirements for this program, see WAC 182-511-1250.

AMENDATORY SECTION (Amending WSR 12-19-051, filed 9/13/12, effective 10/14/12)

WAC 182-504-0125 Washington apple health—Effect of reported changes ((on medical program eligibility)).

(1) ((An individual)) If you report a change required under WAC 182-504-0105 during a certification period, you continue((s)) to be eligible for ((medical assistance)) Washington apple health (WAH) coverage 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

(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)) we decide if you can keep getting WAH coverage under your current WAH program or a different WAH program.

(2) If ((CN medical)) your WAH categorically needy (CN) coverage ends ((under one program and the individual meets)) due to a reported change and you meet all the eligibility requirements ((to be eligible under)) for a different ((CN medical)) WAH-CN program, ((coverage is approved)) we will approve your coverage under the new WAH-CN 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)) you are not eligible for coverage under any WAH-CN ((medical coverage ends and the individual does not)) program but you 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)) for either WAH alternative benefits plan (ABP) coverage or WAH medically needy (MN) coverage, we will approve your coverage under the program you are eligible for. If you are not eligible for coverage under any WAH-CN program but you meet the eligibility requirements for both WAH-ABP coverage and WAH-MN coverage, we will approve the WAH-ABP coverage unless you notify us that you prefer WAH-MN coverage.

(3) If your WAH coverage ends and you are not eligible for a different WAH program, we stop your WAH coverage after giving you advance and adequate notice unless the exception in subsection (4) of this section applies to you.

(4) If you claim to have a disability ((is referred to the division of disability determination services for a disability determination if)) and that is the only basis ((under which the individual is)) for you to be potentially eligible for ((medical assistance)) WAH coverage, then we refer you to the division of disability determination services (within the department of social and health services) for a disability determination. Pending the outcome of the disability determination, ((medical eligibility is considered)) we also determine if you are eligible for WAH coverage under the SSI-related medical program described in chapter ((388-475)) 182-512 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))) If you have countable income in excess of the SSI-related categorically needy income level (CNIL), then we look to see if you can get coverage under WAH-MN with spenddown as described in chapter 182-519 WAC 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 182-507-0130.

(5) An individual who receives a TANF cash grant or family medical is eligible for a medical extension, as described under WAC 182-523-0100, 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))) (5) If you receive coverage under the WAH parent and caretaker relative program described in WAC 182-505-0240, you will be eligible for the WAH medical extension program described in WAC 182-523-0100, if your coverage ends as a result of an increase in your earned income.

(6) Changes in income during a certification period do not affect((s)) eligibility for ((all medical programs except)) the following programs:

(a) WAH for pregnant ((women's CN medical programs)) women;

(b) ((A program included in apple health for kids)) WAH for children, except as specified in subsection (((5))) (7) of this section; ((or))

(7) A child who receives)) WAH for SSI recipients;

(d) WAH refugee program; and

(e) WAH medical extension program.

(7) We redetermine eligibility for children receiving WAH for kids premium-based coverage ((under a program included in apple health for kids)) described in WAC 182-505-0210 ((and chapter 182-505 WAC must be redetermined for a nonpremium-based coverage)) when the ((family reports)):

(a) ((Family)) Household's countable income ((has decreased)) decreases to ((less than two hundred percent)) a percentage of the federal poverty level (FPL) that would result in either a change in premium for WAH for kids with premiums or the children becoming eligible for WAH for kids (without premiums);

(b) ((The)) Child becomes pregnant;

(d) ((The)) Child receives SSI.

(8) ((An individual who receives)) If you get SSI-related WAH-CN ((medical)) coverage and report((s)) a change in work or earned income which ((exceeds the substantial gainful activity (SGA) limit set by Social Security Administration)) results in a determination by the division of disability determination services that you no longer meet((s)) the definition of a disabled ((individual)) person as described in WAC 182-512-0050((, unless the individual continues to receive a Title 2 cash benefit, e.g., SSDI, DAC, or DWB. The agency or the agency's designee)) due to work or earnings at the level of substantial gainful activity (SGA), we redetermine((s)) your eligibility for ((such an individual)) coverage under the health care for workers with disabilities (HWD) program ((which waives the SGA income test)). The HWD program is a premium-based program that waives the SGA work or earnings test, and ((the individual)) you must approve the premium amount before ((the agency or the agency's designee)) we can authorize ((ongoing CN medical benefits)) coverage under this program. For HWD program rules, see chapter 182-511 WAC.

(9) Prior to a scheduled renewal or March 31, 2014, whichever is later, your WAH coverage will not end and you will not pay more for your WAH coverage as a result of an eligibility determination if:

(a) You are enrolled in WAH at the time of the eligibility determination;

(b) You were enrolled in WAH prior to October 1, 2013; and

NEW SECTION

WAC 182-504-0035 Washington apple health—Renewals.

(1) For all Washington apple health (WAH) programs, the following applies:

(a) You are required to complete a renewal of eligibility at least every twelve months with the following exceptions:

(i) If you are eligible for WAH medically needy with spenddown, then you must complete a new application at the end of each three- or six-month base period;

(ii) If you are eligible for WAH alien emergency medical, then you are certified for a specific period of time to cover emergency inpatient hospitalization costs only (see WAC 182-507-0115(8)); or

(iii) If you are eligible for WAH refugee coverage, you must complete a renewal of eligibility after eight months.

(b) You may complete renewals online, by phone, or mailed or faxed to us (the agency or its designee).

(d) We review all eligibility factors subject to change during the renewal process.

(e) We redetermine eligibility as described in WAC 182-504-0125 and send you written notice as described in WAC 182-518-0005 before WAH is terminated.

(f) If you need help meeting the requirements of this section, we provide equal access services as described in WAC 182-503-0120.

(2) For programs based on modified adjusted gross income (MAGI) as described in WAC 182-503-0510:

(a) Sixty days prior to the end of the certification period:

(i) When information from electronic sources shows income is reasonably compatible (as defined in WAC 182-500-0095), we administratively renew your coverage (as defined in WAC 182-500-0010) for a new certification period and send you a notice of renewal with the information used. You are required to inform us if any of the information we used is wrong.

(ii) If we are unable to complete an administrative renewal (as defined in WAC 182-500-0010), you must give us a signed renewal in order for us to decide if you will continue to get WAH coverage beyond the current certification period.

(iii) We follow the requirements described in WAC 182-518-0015 to request any additional information needed to complete the renewal process or to terminate coverage for failure to renew.

(b) If your WAH coverage is terminated because you didn't renew, you have ninety days from the termination date to give us a completed renewal. If we decide you are still eligible to get WAH coverage, we will restore your WAH without a gap in coverage.

(3) For non-MAGI based programs (as described in WAC 182-503-0510):

(a) Forty-five days prior to the end of the certification period, we send notice with a renewal form to be completed, signed, and returned by the end of the certification period.

(b) We follow the requirements in WAC 182-518-0015 to request any additional information needed to complete the renewal process or to terminate coverage for failure to renew.

(c) If you are terminated for failure to renew, you have thirty days from the termination date to submit a completed renewal. If still eligible, we will restore your WAH without a gap in coverage.

(4) If we determine that you are not eligible for renewal of your WAH coverage, we:

(a) Consider your eligibility for all other WAH programs before ending your WAH coverage; and

(b) Coordinate with the health benefit exchange any request for information that is necessary to determine your eligibility for:

(i) Other WAH programs; and

(ii) With respect to qualified health plans, health insurance premium tax credits (as defined in WAC 182-500-0045) and cost-sharing reductions (as defined in WAC 182-500-0020).

NEW SECTION

WAC 182-504-0105 Washington apple health—Changes that must be reported.

(1) You must report changes in your household and family circumstances to us (the agency or its designee) timely according to WAC 182-504-0110.

(2) We tell you what you are required to report at the time you are approved for WAH coverage. We also will tell you if the reporting requirements change.

(3) You must report the following:

(a) Change in residential address;

(b) Change in mailing address;

(d) When family members or dependents move in or out of the residence;

(e) Pregnancy;

(f) Incarceration;

(g) Change in institutional status;

(h) Change in health insurance coverage including medicare eligibility; and

(i) Change in immigration or citizenship status.

(4) If you are eligible for a WAH long-term care program described in chapter 182-513 or 182-515 WAC, you must also report changes to the following:

(a) Income;

(b) Resources;

(d) Spouse or dependent changes in income or shelter cost when expenses are allowed for either.

(5) If you get WAH parent or caretaker (as described in WAC 182-505-0240) or WAH modified adjusted gross income (MAGI)-based adult coverage (as described in WAC 182-505-0250), you must also report changes to the following:

(a) When total income increases or total deductions decrease by one hundred fifty dollars or more a month and the change will continue for at least two months;

(b) Your federal income tax filing status that you expect to use when you file your taxes for the current tax filing year (such as changing from "married filing separately" to "married filing jointly"); and

(6) If you get WAH based on age, blindness, or disability (SSI-related medical), then you must also report changes to the following:

(a) Income; and

(b) Resources.

NEW SECTION

WAC 182-504-0110 Washington apple health—When to report changes.

(1) All changes you report to us (the agency or its designee), as required by WAC 182-504-0105, are used to decide if you can receive or keep receiving Washington apple health (WAH) coverage.

(2) You must report changes during your certification period within thirty days of when the change happened.

(3) You must report all changes during application, renewal, or redetermination of your WAH eligibility, regardless of when the change happened.

(4) For a change in income, the date a change happened is the first date you received income based on the change. For example, the date you receive your first paycheck for a new job or the date you got a paycheck with a wage increase is the date the change happened.

(5) If you don't report a change or you report a change late, we will decide if you can receive or keep receiving WAH coverage based on the date the change was required to be reported.

(6) If you don't report a change or you report a change late, and if it affects the amount you must pay toward your cost of care as described in WAC 182-513-1380 or chapter 182-515 WAC, you may become liable for overpayments we make on your behalf and you may need to pay more to your care provider.

(7) If you don't report a change or you report a change late, it may result in us overpaying you and you having to pay us back for the health care costs we overpaid. See chapter 182-520 WAC.

AMENDATORY SECTION (Amending WSR 11-23-091, filed 11/17/11, effective 11/21/11)

WAC 182-505-0100 ((Medical programs)) Washington apple health—Monthly income standards based on the federal poverty level (FPL).

(1) Each year, the federal government publishes new federal poverty level (FPL) income standards in the Federal Register found at http://aspe.hhs.gov/poverty/index.shtml. The income standards for the following ((medical)) Washington apple health (WAH) programs change on the first day of April every year based on the new FPL:

(a) ((Pregnant women's program up to one hundred eighty-five)) WAH for parents and caretaker relatives up to fifty-four percent of FPL (see WAC 182-505-0240). Persons enrolled in WAH for parents and caretaker relatives whose earned income increases above this limit are the only persons who may be eligible for the WAH transitional medical program described in WAC 182-523-0100;

(b) ((A program included in apple health for kids up to two hundred)) Modified adjusted gross income (MAGI)-based WAH for adults up to one hundred thirty-three percent of FPL;

(c) ((Health care for workers with disabilities (HWD) up to two hundred twenty)) WAH for pregnant women up to one hundred ninety-three percent of FPL; ((and))

(d) ((Premium-based coverage under a program included in apple health for kids over two hundred percent of FPL, but not over three hundred)) WAH for children up to two hundred ten percent of FPL; and

(e) Premium-based coverage under WAH for children over two hundred ten percent of FPL, but not over three hundred twelve percent of FPL.

(2) The ((department)) agency uses the FPL income standards to determine((:

(a) The mandatory or optional medicaid status of an individual; and

(b) Premium amount, if any, for a child.

(3) There are no resource limits for the programs under this section)) the premium amount, if any, for a child.

AMENDATORY SECTION (Amending WSR 12-13-056, filed 6/15/12, effective 7/1/12)

WAC 182-505-0115 ((Medical)) Washington apple health—Eligibility for pregnant women.

((Eligibility requirements for pregnancy medical are described below.)) (1) A pregnant woman is eligible for ((categorically needy (CN) scope of care)) the Washington apple health (WAH) for pregnant women program if she ((meets the following requirements)):

(a) Meets citizenship or immigration status (((chapter 388-424 WAC))) under WAC 182-503-0535; ((and))

(b) Meets Social Security ((account)) number (((chapter 388-474 WAC))) requirements under WAC 182-503-0115; ((and))

(c) ((Is a)) Meets Washington state ((resident (chapter 388-468 WAC))) residency requirements under WAC 182-503-0520 and 182-503-0525; and

(d) Has countable income ((as described in)) at or below the limit described in:

(i) WAC ((388-478-0075)) 182-505-0100 to be eligible for categorically needy (CN) coverage; or

(ii) WAC 182-505-0100 to be eligible for medically needy (MN) coverage. MN coverage begins when the pregnant woman meets any required spenddown liability as described in WAC 182-519-0110.

(2) ((A pregnant woman is considered for medically needy (MN) scope of care if she meets the requirements in subsection (1)(a) through (c) of this section and:

(a) Has countable income that exceeds the standard in subsection (1)(d) of this section; and

(b) Has countable resources that do not exceed the standard in WAC 388-478-0070.

(3) A pregnant woman may be eligible for noncitizen pregnancy medical if she is not eligible for medical described in subsections (1) and (2) of this section due to citizenship, immigrant status, or social security number requirements.

(4) A pregnant woman meeting the eligibility criteria in subsection (3) is eligible for:

(a) CN scope of care when the countable income is at or below the income standard described in subsection (1)(d); or

(b) MN scope of care when:

(i) The countable income exceeds the standard in subsection (1)(d); and

(ii) The resources do not exceed the standard described in WAC 388-478-0070.

(5) Consider as income to the pregnant woman the amount that is actually contributed to her by the father of her unborn child when the pregnant woman is not married to the father.

(6))) A noncitizen pregnant woman who does not need to meet the requirements in subsection (1)(a) or (b) of this section to be eligible for WAH and receives either CN or MN coverage based upon her countable income as described in subsection (1)(d) of this section.

(3) The assignment of ((child support and)) medical support rights as described in ((chapter 388-422)) WAC ((do)) 182-503-0540 do not apply to pregnant women.

(((7))) (4) A woman who was eligible for and received ((medical)) coverage under any WAH program on the last day of pregnancy is eligible for extended medical ((benefits)) coverage for postpartum care for a minimum of sixty days from the end of her pregnancy. This includes women who meet an MN spenddown liability with expenses incurred no later than the date the pregnancy ends. This extension continues through the end of the month in which the sixtieth day falls.

(((8) A woman who was eligible for medical coverage on the last day of pregnancy is)) (5) All women approved for WAH pregnancy coverage at any time are eligible for family planning services for twelve months ((from the end of)) after the pregnancy ((even when eligibility for pregnancy was determined after the pregnancy ended)) ends.

AMENDATORY SECTION (Amending WSR 12-13-056, filed 6/15/12, effective 7/1/12)

WAC 182-505-0210 Washington apple health ((for kids and other children's medical assistance programs))—Eligibility for children.

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

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

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

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

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

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

(2) Children under the age of nineteen who are U.S. citizens, U.S. nationals, or lawfully present qualified or nonqualified aliens as described in WAC 388-424-0001, 388-424-0010(4), and 388-424-0006 (1), (4), and (5) are eligible for free federally matched CN coverage when they meet the following criteria:

(a) State residence as described in chapter 388-468 WAC;

(b) A Social Security number or application as described in chapter 388-476 WAC;

(d) Family income is at or below two hundred percent of federal poverty level (FPL), as described in WAC 388-478-0075 at each application or review; or

(e) They received supplemental security income (SSI) cash payments in August 1996 and would continue to be eligible for those payments except for the August 1996 passage of amendments to federal disability definitions; or

(f) They are currently eligible for SSI.

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

(a) State residence as described in chapter 388-468 WAC; and

(b) Family income is at or below two hundred percent FPL at each application or review.

(4) Children under the age of nineteen who are U.S. citizens, U.S. nationals, or lawfully present qualified or nonqualified aliens as described in WAC 388-424-0001, 388-424-0010(4), and 388-424-0006 (1), (4), and (5) are eligible for premium-based federally matched CN coverage as described in chapter 388-542 WAC when they meet the following criteria:

(a) State residence as described in chapter 388-468 WAC;

(b) Proof of citizenship or immigrant status and identity as required by WAC 388-490-0005(11);

(c) Family income is over two hundred percent FPL, as described in WAC 388-478-0075, but not over three hundred percent FPL at each application or review;

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

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

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

(a) State residence as described in chapter 388-468 WAC;

(b) Family income is over two hundred percent FPL, as described in WAC 388-478-0075, but not over three hundred percent FPL at each application or review;

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

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

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

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

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

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

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

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

(a) Eighteenth birthday;

(b) Twenty-first birthday if the children's administration determines they remain eligible for continued foster care services; or

(c) Twenty-first birthday if they were in foster care on their eighteenth birthday and that birthday was on or after July 22, 2007.

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

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

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

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

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

(a) Family medical as described in WAC 388-505-0220;

(b) Medical extensions as described in WAC 388-523-0100;

(i) Meet the blind and/or disability criteria of the federal SSI program, or the condition of subsection (2)(e) of this section; and

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

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

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

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

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

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

(12) Except for a child described in subsection (7) of this section, an inmate of a public institution, as defined in WAC 388-500-0005, is not eligible for any apple health for kids program.)) (1) Unless otherwise stated in this section, a child is a person who is under nineteen years of age (including the month the person turns nineteen). To be eligible for one of the Washington apple health (WAH) for kids programs described below, a child must:

(a) Be a resident of Washington state, as described in WAC 182-503-0520 and 182-503-0525;

(b) Provide a Social Security number (SSN) as described in WAC 182-503-0515 unless exempt; and

(2) Children under one year of age are eligible for WAH categorically needy (CN) coverage, without a new application, when they are born to a mother who is eligible for WAH:

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

(b) Based on meeting a medically needy (MN) spenddown liability with expenses incurred no later than the date of the newborn's birth.

(3) Children are eligible for WAH at no cost when they:

(a) Have countable family income that is no more than two hundred ten percent of the federal poverty level (FPL) as described in WAC 182-505-0100;

(b) Are currently eligible for supplemental security income (SSI); or

(c) Received SSI payments in August 1996 and would continue to be eligible for those payments except for the August 1996 passage of amendments to federal disability definitions.

(4) Children are eligible for premium-based WAH as described in WAC 182-505-0215 when they:

(a) Have countable family income that is not more than three hundred twelve percent of FPL as described in WAC 182-505-0100;

(b) Do not have other creditable health insurance as described in WAC 182-505-0220; and

(5) Children are eligible for WAH home and community based waiver programs as described in chapter 182-515 WAC when they:

(a) Meet citizenship or immigration status as described in WAC 182-503-0525;

(b) Meet SSI-related eligibility requirements as described in chapter 182-512 WAC; and

(6) Children are eligible for the WAH long-term care program when they meet the institutional program rules as described in chapter 182-513 or 182-514 WAC, and either:

(a) Reside or are expected to reside in a medical institution, intermediate care facility for the intellectually disabled (ICF/ID), hospice care center, or nursing home for thirty days or longer; or

(b) Reside or are expected to reside in an institution for mental diseases (IMD)or inpatient psychiatric facility:

(i) For ninety days or longer and are age seventeen or younger; or

(ii) For thirty days or longer and are age eighteen through twenty-one.

(7) Children are eligible for the WAH-MN program as described in WAC 182-519-0100 when they:

(a) Meet citizenship or immigrant status as described in WAC 182-503-0535;

(b) Have countable family income that exceeds three hundred twelve percent of FPL as described in WAC 182-505-0100; or

(c) Have countable family income that is more than two hundred ten percent of FPL, but are not eligible for premium-based WAH as described in subsection (4) of this section because of creditable coverage; and

(d) Meet a spenddown liability as described in WAC 182-519-0110, if required.

(8) Children are eligible for WAH SSI-related programs as described in chapter 182-512 WAC when they:

(a) Meet citizenship or immigration status as described in WAC 182-503-0535;

(b) Meet SSI-related eligibility as described in chapter 182-512 WAC; and

(9) Children who are not eligible for WAH under subsections (5) through (8) of this section because of their immigration status, are eligible for the WAH alien emergency medical program if they:

(a) Meet the eligibility requirements of WAC 182-507-0110;

(b) Have countable family income:

(i) That exceeds three hundred twelve percent of FPL as described in WAC 182-505-0100; or

(ii) That is more than two hundred ten percent of FPL, but they are not eligible for premium-based WAH, as described in subsection (4) of this section because of creditable coverage; and

(10) Children who are in foster care or receive subsidized adoption services are eligible for coverage under the WAH foster care program described in WAC 182-505-0211.

(11) Children who are incarcerated in a public institution (as defined in WAC 182-500-0050), or a city or county jail, are not eligible for any WAH program, with the following exceptions:

(a) Children who reside in an IMD as described in subsection (6) of this section; or

(b) Children who are released from a public institution or city or county jail to a hospital for inpatient treatment. Children who are released from an IMD to a hospital setting must be unconditionally discharged from the IMD to qualify for coverage under this provision.

AMENDATORY SECTION (Amending WSR 12-13-056, filed 6/15/12, effective 7/1/12)

WAC 182-505-0215 Washington apple health—Premium-based children's program—Purpose and scope ((of premium-based health care coverage under programs included in apple health for kids)).

The ((department)) medicaid agency administers the programs included in Washington apple health (WAH) for kids that provide premium-based coverage through a combination of state and federal funding sources as described below:

(1) Federally matched health care coverage as authorized by Title XXI of the Social Security Act state children's health insurance program (((SCHIP))) (CHIP) and RCW 74.09.450 for citizen and federally qualified immigrant children whose family income is above two hundred ten percent of the federal poverty level (FPL) but is not above three hundred twelve percent FPL.

(2) State funded health care coverage for children with family income above two hundred ten percent FPL, but not above three hundred twelve percent FPL, who are ineligible for ((Title XXI)) federally matched health care coverage due to immigration ((issues)) status.

AMENDATORY SECTION (Amending WSR 12-13-056, filed 6/15/12, effective 7/1/12)

WAC 182-505-0225 Premium-based Washington apple health for kids—Premium requirements ((for premium-based health care coverage under programs included in apple health for kids)).

(1) For the purposes of this chapter, "premium" means an amount paid for ((health care)) Washington apple health (WAH) coverage ((under programs included in apple health)) for kids as described in WAC ((388-505-0210 (4) and (5))) 182-505-0210(4).

(2) Payment of a premium is required as a condition of eligibility for premium-based WAH coverage ((under programs included in apple health)) for kids, as described in WAC ((388-505-0210 (4) and (5))) 182-505-0210(4), unless the child is:

(a) Pregnant; or

(b) An American Indian or Alaska Native.

(3) The premium requirement begins the first of the month following the determination of eligibility. There is no premium requirement for ((medical)) WAH coverage received in a month or months before the determination of eligibility.

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

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

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

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

(b) Thirty dollars per month per child for ((households)) families with countable income above two hundred ((and fifty)) sixty percent FPL, but not above three hundred twelve percent FPL.

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

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

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

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

(b) The child becomes eligible for coverage under ((a nonpremium-based CN health care program)) WAH without a premium.

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

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

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

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

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

(ii) The family reapplies and is found eligible.

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

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

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

AMENDATORY SECTION (Amending WSR 11-23-077, filed 11/15/11, effective 12/16/11)

WAC 182-505-0235 Washington apple health—Premium-based children's program—Order of payments ((under the premium-based apple health for kids program as funded by Title XXI of the Social Security Act)).

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

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

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

(3) For ((medical assistance)) health care coverage for medicaid-eligible children, as described in the Children's Health Insurance Program Reauthorization Act (CHIPRA), section 214.

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

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

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

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

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

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

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

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

AMENDATORY SECTION (Amending WSR 12-13-056, filed 6/15/12, effective 7/1/12)

WAC 182-505-0237 Premium-based Washington apple health for kids—Other rules that apply ((to premium-based health care coverage under programs included in apple health for kids)).

In addition to the rules of this chapter, children receiving premium-based ((coverage under)) Washington apple health (WAH) for kids are subject to the following rules:

(1) Chapter ((388-538)) 182-538 WAC, Managed care (except WAC ((388-538-061)) 182-538-061, ((388-538-063)) 182-538-063, and ((388-538-065)) 182-538-065) if the child is covered under federally matched CN coverage;

(2) WAC ((388-505-0210 (4) and (5), apple health for kids program eligibility;

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

(4) WAC 388-416-0015(12))) 182-504-0015, Certification periods for categorically needy (CN) scope of care medical assistance programs; and

(((5))) (3) WAC ((388-418-0025)) 182-504-0125, Effect of changes on medical program eligibility.

AMENDATORY SECTION (Amending WSR 12-13-056, filed 6/15/12, effective 7/1/12)

WAC 182-505-0240 ((Family medical eligibility.)) Washington apple health—Parents and caretaker relatives.

(1) A person is eligible for Washington apple health (WAH) categorically needy (CN) ((medical assistance)) coverage when ((they are)) he or she:

(a) ((Receiving temporary assistance for needy families (TANF) cash benefits;

(b) Receiving Tribal TANF;

(d) Eligible for TANF cash benefits but choose not to receive;

(e) Over the TANF cash payment standard but under the family medical payment standard as described in WAC 388-478-0065; or

(f) Not eligible for or receiving TANF cash assistance, but meet the eligibility criteria for aid to families with dependent children (AFDC) in effect on July 16, 1996 except that:

(i) Earned income is treated as described in WAC 388-450-0210; and

(ii) Resources are treated as described in WAC 388-470-0005 for applicants and 388-470-0026 for recipients.

(2) An adult cannot receive a family medicaid program unless the household includes a child who is eligible for:

(a) Family medicaid;

(b) SSI; or

(3) A person is eligible for CN family medical coverage when the person is not eligible for or receiving cash benefits solely because the person:

(a) Received sixty months of TANF cash benefits or is a member of an assistance unit which has received sixty months of TANF cash benefits;

(b) Failed to meet the school attendance requirement in chapter 388-400 WAC;

(d) Is a parent or caretaker relative who fails to notify the department within five days of the date the child leaves the home and the child's absence will exceed one hundred eighty days;

(e) Is a fleeing felon or fleeing to avoid prosecution for a felony charge, or is a probation and parole violator;

(f) Was convicted of a drug related felony;

(g) Was convicted of receiving benefits unlawfully;

(h) Was convicted of misrepresenting residence to obtain assistance in two or more states;

(i) Has gross earnings exceeding the TANF gross income level; or

(j) Is not cooperating with WorkFirst requirements.

(4) An adult must cooperate with the division of child support in the identification, use, and collection of medical support from responsible third parties, unless the person meets the medical exemption criteria described in WAC 388-505-0540 or the medical good cause criteria described in chapter 388-422 WAC.

(5) Except for a client described in WAC 388-505-0210(6), a person who is an inmate of a public institution, as defined in WAC 388-500-0005, is not eligible for CN or MN medical coverage.)) Is a parent or caretaker relative of a dependent child who meets the criteria described in WAC 182-503-0565(2);

(b) Meets citizenship and immigration status requirements described in WAC 182-503-0505;

(d) Has countable income below fifty-four percent of the federal poverty level (FPL).

(2) To be eligible for WAH coverage as a caretaker relative, a person must be related to a dependent child who meets the criteria described in WAC 182-503-0565(2).

(3) A person must cooperate with the state of Washington in the identification, use and collection of medical support from responsible third parties as described in WAC 182-503-0540.

(4) A person who does not cooperate with the requirements in subsection (3) of this section is not eligible for WAH coverage.

REPEALER

The following sections of the Washington Administrative Code are repealed:


WAC 182-505-0220	Definitions for premium-based health care coverage under programs included in apple health for kids.
WAC 182-505-0230	Waiting period for premium-based health care coverage under programs included in apple health for kids following employer coverage.
WAC 182-505-0245	Income and resource standards for family medical programs.
WAC 182-505-0515	Medical coverage resulting from a cash grant.

NEW SECTION

WAC 182-505-0250 Washington apple health—MAGI-based adult medical.

(1) Effective on or after January 1, 2014, a person is eligible for Washington apple health (WAH) modified adjusted gross income (MAGI)-based adult coverage when he or she meets the following requirements:

(a) Is age nineteen or older and under the age of sixty-five;

(b) Is not entitled to, or enrolled in, medicare benefits under Part A or B of Title XVIII of the Social Security Act;

(i) WAH SSI-related categorically needy (CN);

(ii) WAH foster care program; or

(iii) WAH adoption support program;

(d) Meets citizenship and immigration status requirements described in WAC 182-503-0535;

(e) Meets general eligibility requirements described in WAC 182-503-0505; and

(f) Has net countable income that is at or below one hundred thirty-three percent of the federal poverty level for a household of the applicable size.

(2) Parents or caretaker relatives of an eligible dependent child as described in WAC 182-503-0565 are first considered for WAH for families as described in WAC 182-505-0240. A person whose countable income exceeds the standard to qualify for family coverage is considered for coverage under this section.

(3) Persons who are eligible under this section are eligible for WAH alternative benefit plan as defined in WAC 182-500-0010 coverage. A person described in this section is not eligible for medically needy WAH.

(4) Other coverage options for adults not eligible under this section are described in WAC 182-508-0001.

Chapter 182-518 WAC

WASHINGTON APPLE HEALTH—LETTERS AND NOTICES

NEW SECTION

WAC 182-518-0005 Washington apple health—Notice requirements—General.

(1) For the purposes of this chapter, "we" refers to the agency or its designee and "you" refers to the applicant for, or recipient of, health care coverage.

(2) This section applies only to notices and letters that we send about eligibility for Washington apple health (WAH) programs. WAC 182-501-0165 applies to notices and letters regarding prior authorization or other action on requests to cover specific fee-for-service health care services.

(3) We send you written notices (letters) when we:

(a) Approve you for health care coverage for any program;

(b) Reconsider your application for other types of health care coverage based on new information;

(c) Deny you health care coverage (including because you withdrew your application) for any program (according to rules in WAC 182-503-0080);

(d) Ask you for more information to decide if you can start or renew health care coverage;

(e) Renew your health care coverage; or

(f) Change or terminate your health care coverage, even if we approve you for another kind of coverage.

(4) If you are receiving limited-English proficient services, we send notices to you in your primary language according to the rules in WAC 182-503-0110. If you are receiving equal access services, we follow the equal access rules described in WAC 182-503-0120.

(5) All WAH notices we send you include the following information:

(a) The date of the notice;

(b) Specific contact information for you if you have questions or need help with the notice;

(d) Other information required by state or federal law.

NEW SECTION

WAC 182-518-0010 Washington apple health—Notice requirements approval and denial notices.

(1) We send written notice when we approve, reopen, reinstate, or deny coverage for any Washington apple health (WAH) program. The notice includes the information described in WAC 182-518-0005(4) and all of the following:

(a) The WAH coverage for each person approved, reopened or reinstated;

(b) The date that each person's coverage begins (the effective date); and

(2) Denial and withdrawal notices include:

(a) The date of denial;

(b) Specific facts and reason(s) supporting the decision; and

(3) If we deny your request for health care coverage or consider it withdrawn because you failed to give us requested information, the denial notice also includes:

(a) A list of the information you did not give us;

(b) The date we asked you for the information and the date it was due;

(c) Notice that we will reconsider your eligibility if we receive any information related to determining your eligibility, including any changes to information we have, within thirty days of the date of the notice; and

(d) Information described in subsection (1) of this section.

NEW SECTION

WAC 182-518-0015 Washington apple health—Notice requirements verification requests.

(1) We send you written notice when we need more information as described in WAC 182-503-0050 to decide if you are eligible to receive or continue receiving Washington apple health (WAH) coverage. The notice includes:

(a) A description or list of the information that we need;

(b) When we must have the information (see WAC 182-503-0060 for applications and WAC 182-504-0035 for renewals);

(d) Information required in WAC 182-518-0005(4).

(2) If we have received conflicting information about facts we need to determine your coverage, the notice will also include:

(a) The information we received that does not match what you gave us and the source; and

(b) A request that you send us a statement explaining the difference(s) between the information from you and the information from the other source.

(3) We allow you at least ten days to return the information. If you ask, we may allow you more time to get us the information. If the tenth day falls on a weekend or holiday, the due date is the next business day.

(4) If the information we ask for costs money, we will pay for it or help you get the information in another way.

NEW SECTION

WAC 182-518-0020 Washington apple health—Notice requirements—Renewals.

(1) We send you written notice before we stop your WAH coverage at the end of your certification period as described in WAC 182-504-0035.

(2) When we can administratively renew your coverage (as defined in WAC 182-500-0010), the notice includes:

(a) Your new certification period;

(b) The information we used to renew your coverage; and

(3) When we cannot administratively renew your coverage, the notice includes:

(a) Information we currently have on record;

(b) How to complete the renewal using any of the methods described in WAC 182-504-0035 (1)(b);

(d) That we follow the rules in WAC 182-518-0015.

(4) We send your renewal notice following the timeline in:

(a) WAC 182-504-0035(2) for programs based on modified adjusted gross income (MAGI); or

(b) WAC 182-504-0035(3) for non-MAGI based programs.

NEW SECTION

WAC 182-518-0025 Washington apple health—Notice requirements—Changes in and terminations of coverage.

(1) We send you written notice before your Washington apple health (WAH) coverage changes or ends. The notice includes:

(a) The change in coverage;

(b) The date your coverage will change or end;

(d) Specific rules the decision is based on; and

(e) Information found in WAC 182-518-0005(4).

(2) Before we send any notices to end your WAH coverage because your income is more than the modified adjusted gross income (MAGI) standard, we determine if you are eligible for other health care coverage as described in WAC 182-504-0125.

(3) We notify you at least ten days before we change or end your health care coverage. The ten days start on the day we send you the notice and end on the tenth day. We are not required to give ten days' notice if:

(a) You asked us to change or end your coverage;

(b) We are changing or ending your coverage due only to a change in law;

(c) We are ending your coverage because everyone in your household either died or has been accepted to receive medicaid coverage somewhere else (another local jurisdiction, state, territory, or commonwealth);

(d) We are ending your coverage because mail we sent you was returned to us with no forwarding address; or

(e) You are incarcerated and it is expected to last more than thirty days.

(4) If we do not have to give ten days' advance notice, we send the notice right away after getting the information that caused the change, but no later than the date we took the action the notice is about.

(5) You may request an appeal if you disagree with our decision to change or end your health care coverage and you may request continued coverage as described in WAC 182-504-0130.

NEW SECTION

WAC 182-518-0030 Washington apple health—Notice requirements—Electronic notices.

(1) We send you letters (notices) to inform you about your eligibility for Washington apple health (WAH) programs as described in WAC 182-518-0005 through 182-518-0025.

(2) For programs based on modified adjusted gross income (MAGI), you have the right to choose to get WAH eligibility notices by regular mail, in an electronic format, or both.

(3) To receive electronic notices you must:

(a) Have an account with Washington Healthplanfinder. (There is no charge to create an account); and

(b) Provide us with the following information: A valid e-mail address, your name, and your application identification number.

(4) You may ask to receive WAH notices electronically by:

(a) Mailing, delivering, or giving us a written letter to the address listed on our web site;

(b) Sending a facsimile letter to us as directed on our web site;

(d) Logging on to your Healthplanfinder account online and selecting the "I would prefer to receive written communications by e-mail" check box on the contact information page; or

(e) Calling the Healthplanfinder customer support center.

(5) When you have asked for electronic notification, we:

(a) Send the notice to your Healthplanfinder account no later than one business day after creating the notice.

(b) Send you an e-mail message to notify you when a new WAH notice has been sent electronically to your Healthplanfinder account.

(i) The e-mail message will not include the notice, information about the content of the notice, or other confidential information; and

(ii) You must log on to your Healthplanfinder account to get the notice.

(6) We will stop sending WAH notices electronically to you if you ask us. You must notify us if your e-mail address changes.