HEALTH CARE AUTHORITY

(Washington Apple Health)

(1) The certification period for the noninstitutional medically needy (MN) program for clients with countable income equal to or below the medically needy income level (MNIL):

(a) Begins on the first day of the month in which eligibility is established; and

(b) Is approved for twelve calendar months.

(2) The certification period for the noninstitutional MN program for clients with countable income above the MNIL:

(a) Begins on the day that spenddown is met; and

(b) Continues through the last day of the final month of the base period as described in WAC ((388-519-0110)) 182-519-0110.

(3) A retroactive MN certification period may be established for ((any or all of the)) up to three months ((immediately prior to)) preceding the month of application.

(4) Expenses used to meet the spenddown liability for the current or the retroactive certification periods are the responsibility of the client. The ((department)) agency is not responsible ((to pay)) for paying any expense or portion of an expense which has been used to meet the spenddown liability. See WAC ((388-519-0110)) 182-519-0110.

(5) A new application must be submitted for each subsequent certification period for which medically needy coverage is requested.

(1) Supplemental security income (SSI) is a federal cash benefit administered by the Social Security Administration (SSA) under ((Title XVI of)) the Social Security Act, 42 U.S.C. Sec. 1381-1383f. The SSI program replaces state programs for the aged, blind and disabled individuals beginning January 1974. An individual who received state assistance in December 1973 who became eligible for SSI in January 1974 is considered a grandfathered client by the medicaid agency, and a mandatory income level (MIL) client by SSI. The individual must continue to meet the definition of blind or disabled that was in effect under the state plan in December 1973. ((These definitions can be found in the SSA program operations manual system (POMS), see https://secure.ssa.gov/apps10/poms.nsf/aboutpoms. Other definitions related to SSI eligibility are described in WAC 182-500-0100)) See chapter 182-500 WAC for additional definitions.

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

(3) An ineligible spouse is the spouse of an SSI recipient who is not eligible for SSI-related CN ((WAH)) coverage. An ineligible spouse must have his or her eligibility for Washington apple health (WAH) determined separately ((in accordance with SSI-related medically needy (MN) rules in)) under WAC 182-519-0100.

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

(a) Remains entitled to ((an)) SSI ((cash payment));

(b) Is no longer entitled to ((an)) SSI ((cash payment)), but the SSA is in the process of determining eligibility under ((Section 1619(b) of)) the Social Security Act, 42 U.S.C. Sec. 1619(b); or

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(1) If you are ((an SSI client)) a supplemental security income (SSI) recipient, you automatically get categorically needy (CN) ((medical)) coverage (WAC ((388-505-0110)) 182-512-0100) unless you:

(a) Refuse to provide private medical insurance information; or

(b) Refuse to assign the right to recover insurance funds to the ((department (WAC 388-505-0540))) agency (WAC 182-503-0540).

(2) If you are an essential person as described in WAC ((388-474-0001)) 182-510-0001 you get CN ((medical)) coverage as long as you continue to live with the SSI ((client)) recipient.

(3) If you are an ineligible spouse you are not considered an SSI recipient. You must have your ((medical assistance)) Washington apple health eligibility determined separately.

(1) Your ((CN medical)) categorically needy (CN) coverage (WAC ((388-505-0110)) 182-512-0100) continues after ((an SSI cash payment ends when)) supplemental security income (SSI) ends if:

(a) Countable income exceeds the SSI income standard due solely to the annual cost-of-living adjustment (COLA); or

(b) A timely request for a hearing has been filed. CN ((medical)) coverage is continued until the Social Security Administration (SSA) makes a final decision on the hearing request and on any subsequent timely appeals.

(2) If your SSI ends, your CN ((medical)) coverage continues for a period of up to one hundred twenty days while the ((department)) agency reviews your eligibility for other cash or medical programs.

(3) If you are a terminated SSI or SSI-related ((client)) recipient, the ((department)) agency will review your disability status when:

(a) You present new medical evidence;

(b) Your medical condition changes significantly; or

(c) Your termination from SSI was not based on a review of current medical evidence.

(4) Children terminated from SSI due to loss of disabled status may be eligible for medical benefits under WAC ((388-505-0210)) 182-505-0210.