WSR 14-20-094

PERMANENT RULES

HEALTH CARE AUTHORITY

(Washington Apple Health)

[Filed September 29, 2014, 3:36 p.m., effective October 30, 2014]

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

Purpose: WAC 182-504-0135 explains what a Washington apple health (WAH) client's rights are in getting his or her health care coverage reinstated while pending an appeal with the agency; and adding clarifying information to WAC 182-506-0015 that was inadvertently left out of the last revision.

Citation of Existing Rules Affected by this Order: Amending WAC 182-506-0015.

Statutory Authority for Adoption: RCW 41.05.021 and 41.05.160.

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

Adopted under notice filed as WSR 14-14-114 on July 1, 2014.

Changes Other than Editing from Proposed to Adopted Version: The following changes were made to the proposed rule text in WSR 14-14-114 filed on July 1, 2014:

WAC 182-504-0135(2)

If we end or change your WAH coverage without the advance notice required by WAC 182-518-0025(3) and you appeal on or before the tenth day after the date you receive the written notice of the WAH decision, we will reinstate (give back) your WAH coverage will be reinstated and continue until the appeals process ends, unless otherwise specified in this section back to the date we ended it. If our initial decision to end or change your WAH coverage was otherwise correct, we will send you a new notice that meets the requirements of chapter 182-518 WAC. This is called reinstated coverage.

WAC 182-504-0135 (3) and (4)

(3) We will treat the fifth day after the date on the notice as the date you received the notice; however, if you show that you received the notice more than five days after the date on the notice, we will use the actual date you received the notice for counting the ten-day appeal period for the purpose of providing continued coverage. If the tenth day falls on a weekend or holiday, you have until the next business day to appeal and still be able to receive continued coverage.

(4) You receive reinstated coverage through the end of the month an administrative hearing decision is sent to you unless:

(a) An administrative law judge or our presiding officer serves an order ending reinstated coverage; or

(b) You:

(i) Tell us in writing that you do not want reinstated coverage; or

(ii) Withdraw your appeal in writing or at an administrative proceeding.

WAC 182-504-0135(6)

A person receiving If you receive WAH medically needy coverage, is not eligible for you cannot receive reinstated coverage beyond past the end of the original certification period described in WAC 182-504-0020.

WAC 182-504-0135(7)

If we We may end your WAH coverage because if mail we sent to you was is returned to us with no forwarding address,. We will reinstate your WAH coverage will be reinstated if you continue to meet eligibility requirements and if we receive notification from you of we learn your new address and you still meet WAH eligibility requirements.

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

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

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

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

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

Date Adopted: September 29, 2014.

Kevin M. Sullivan

Rules Coordinator

NEW SECTION

WAC 182-504-0135 Washington apple health—Reinstated coverage pending an appeal.

(1) If you disagree with a Washington apple health (WAH) decision that we (the agency or its designee) made, you have the right to appeal under RCW 74.09.741. The appeal rules are found in chapter 182-526 WAC.

(2) If we end or change your WAH coverage without the advance notice required by WAC 182-518-0025(3), we will reinstate (give back) your WAH coverage back to the date we ended it. If our initial decision to end or change your WAH coverage was otherwise correct, we will send you a new notice that meets the requirements of chapter 182-518 WAC. This is called reinstated coverage.

(3) Generally, you cannot receive reinstated coverage when a change in your WAH coverage is the result of a mass change. A mass change is when rules change that impact coverage for a class of applicants and recipients or due to a legislative or statutory change.

(4) If you receive WAH medically needy coverage, you cannot receive reinstated coverage past the end of the certification period described in WAC 182-504-0020.

(5) We may end your WAH coverage if mail we sent you is returned to us with no forwarding address. We will reinstate your WAH coverage if we learn your new address and you still meet WAH eligibility requirements.

AMENDATORY SECTION (Amending WSR 14-01-021, filed 12/9/13, effective 1/9/14)

WAC 182-506-0015 Medical assistance units for non-MAGI-based Washington apple health programs.

This section explains how medical assistance units (MAUs) are constructed for programs not based on modified adjusted gross income (MAGI) methodologies. (MAGI-based programs are described in WAC 182-503-0510.)

(1) An MAU is a person or group of people who must be included together when determining eligibility. MAUs are established based on each person's relationship to other family members and the person's financial responsibility for the other family members. MAUs for non-MAGI-based programs include an applicant and persons financially responsible for the applicant as described in subsection (2) of this section (as limited by subsection (3) of this section).

(2) Financial responsibility applies only to spouses and to parents, as follows:

(a) Married persons, living together are financially responsible for each other;

(b) Natural, adoptive, or step-parents are financially responsible for their unmarried, minor children living in the same household;

(d) Married persons' financial responsibility for each other when not living together because one or both are residing in a medical institution is described in chapter 182-513 WAC.

(3) The number of persons in the MAU is increased by one for each verified unborn child for each pregnant woman already included in the MAU under this section.

(4) A separate SSI-related MAU is required for:

(a) SSI recipients;

(b) SSI-related persons;

(d) The purpose of applying medical income standards for an:

(i) SSI-related applicant whose spouse is not relatable to SSI or is not applying for SSI-related medical; and

(ii) Ineligible spouse of an SSI recipient.

(5) When determining eligibility for an SSI-related medical program, the agency determines how household income is allocated and deemed to the SSI-related person according to the rules described in WAC 182-512-0820 and 182-512-0900 through 182-512-0960.