WSR 17-08-093 PROPOSED RULES HEALTH CARE AUTHORITY (Washington Apple Health) [Filed April 5, 2017, 9:12 a.m.]
Original Notice.
Preproposal statement of inquiry was filed as WSR 16-09-024.
Title of Rule and Other Identifying Information: WAC 182-505-0100 Washington apple health—Monthly income standards based on the federal poverty level, 182-505-0210 Washington apple health—Eligibility for children, 182-505-0215 Washington apple health—Premium-based children's program—Purpose and scope, 182-505-0225 Premium requirements for premium-based health care coverage under programs included in apple health for kids, 182-505-0235 Washington apple health—Premium-based children's program—Order of payments, 182-505-0237 Premium-based Washington apple health for kids—Other rules that apply, 182-505-0240 Washington apple health—Parents and caretaker relatives, and 182-505-0300 Washington apple health—Hospital presumptive eligibility.
Hearing Location(s): Health Care Authority (HCA), Cherry Street Plaza Building, Pear Conference Room 106A, 626 8th Avenue, Olympia, WA 98504 (metered public parking is available street side around building. A map is available at http://www.hca.wa.gov/documents/directions_to_csp.pdf or directions can be obtained by calling (360) 725-1000), on May 9, 2017, at 10:00 a.m.
Date of Intended Adoption: Not sooner than May 10, 2017.
Submit Written Comments to: HCA Rules Coordinator, P.O. Box 45504, Olympia, WA 98504-5504, delivery 626 8th Avenue, Olympia, WA 98504, email arc@hca.wa.gov, fax (360) 586-9727, by 5:00 p.m. on May 9, 2017.
Assistance for Persons with Disabilities: Contact Amber Lougheed by May 5, 2017, email amber.lougheed@hca.wa.gov, (360) 725-1349, or TTY (800) 848-5429 or 711.
Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The agency is updating these rules to correct the federal poverty level and to eliminate the contradiction between WAC 182-505-0210 and long-term care rules.
Reasons Supporting Proposal: See Purpose above.
Rule is not necessitated by federal law, federal or state court decision.
Name of Proponent: HCA, governmental.
Name of Agency Personnel Responsible for Drafting: Melinda Froud, P.O. Box 42716, Olympia, WA 98504-2716, (360) 725-1408; Implementation and Enforcement: Kevin Cornell, P.O. Box 45543 [45534], Olympia, WA 98504-5534, (360) 725-1423.
No small business economic impact statement has been prepared under chapter 19.85 RCW. The agency has determined that the proposed filing does not impose a disproportionate cost impact on small businesses or nonprofits.
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.
April 5, 2017
Wendy Barcus
Rules Coordinator
AMENDATORY SECTION (Amending WSR 14-16-052, filed 7/29/14, effective 8/29/14)
WAC 182-505-0100 ((Washington apple health—))Monthly income standards ((based on the federal poverty level (FPL))) for MAGI-based programs.
(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.
(a) The income standards for the following Washington apple health (((WAH))) programs change on the first day of April every year based on the new FPL((:
(a) WAH for)), except for subsections (2) and (3) of this section.
(b) The agency determines income eligibility by comparing countable income as determined under WAC 182-509-0300 to the person's medical assistance unit (MAU) as determined under WAC 182-506-0010 and 182-506-0012.
(2) Parents and caretaker relatives ((up to fifty-four percent of FPL (see)) under WAC 182-505-0240((). Persons enrolled in WAH for)) must have countable income equal to or below the following standards:
(3) Parents and caretaker relatives ((whose)) with earned income ((increases)) above ((this)) the limits in subsection (2) of this section are the only ((persons)) people who may be eligible for the ((WAH)) transitional medical program described in WAC 182-523-0100((;
(b) Modified adjusted gross income (MAGI)-based WAH for adults up to one hundred thirty-three percent of FPL;
(c) WAH for pregnant women up to)).
(4) Adults described in WAC 182-505-0250 who are not eligible under subsection (2) or (3) of this section must have countable income equal to or below one hundred thirty-three percent of the FPL.
(5) Pregnant people described in WAC 182-505-0115 must have countable income equal to or below one hundred ninety-three percent of the FPL((;
(d) WAH for children up to)).
(6) Children with countable income:
(a) Equal to or below two hundred ten percent of the 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 agency uses the FPL income standards to determine the premium amount, if any, for a child.)) as described in WAC 182-505-0210 (3)(a)(i) receive coverage at no cost.
(b) Greater than two hundred ten percent but equal to or less than three hundred twelve percent as described in WAC 182-505-0210 (3)(a)(ii) receive premium-based coverage. Premium amounts are described in WAC 182-505-0225.
AMENDATORY SECTION (Amending WSR 16-01-034, filed 12/8/15, effective 1/8/16)
WAC 182-505-0210 ((Washington apple health—))Eligibility for children.
(((1) Unless otherwise stated in this section, a child is a person age eighteen or younger (including the month the child turns nineteen). To be eligible for one of the Washington apple health (WAH) for kids programs, a child must:
(a) Be a resident of Washington state under WAC 182-503-0520 and 182-503-0525;
(b) Provide a Social Security number (SSN) under WAC 182-503-0515 unless exempt; and
(c) Meet any additional requirements listed for the specific program.
(2) Children younger than age one 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 by 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) under 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 under WAC 182-505-0215 when they:
(a) Have countable family income that is not more than three hundred twelve percent of FPL under WAC 182-505-0100;
(b) Do not have other creditable health insurance under WAC 182-500-0020; and
(c) Pay the required monthly premiums under WAC 182-505-0225.
(5) Children are eligible for WAH home and community based waiver programs under chapter 182-515 WAC when they:
(a) Meet citizenship or immigration status under WAC 182-503-0535;
(b) Meet SSI-related eligibility requirements under chapter 182-512 WAC; and
(c) Meet program-specific age requirements.
(6) Children are eligible for the WAH long-term care program when they meet the institutional program rules under 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) (as defined in WAC 182-500-0050(1)) 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 under WAC 182-519-0100 when they:
(a) Meet citizenship or immigrant status under WAC 182-503-0535;
(b) Have countable family income that exceeds three hundred twelve percent of FPL under 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 under WAC 182-519-0110, if required.
(8) Children are eligible for WAH SSI-related programs under chapter 182-512 WAC when they:
(a) Meet citizenship or immigration status under WAC 182-503-0535;
(b) Meet SSI-related eligibility under chapter 182-512 WAC; and
(c) Meet an MN spenddown liability under WAC 182-519-0110, if required.
(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 under 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
(c) Meet a spenddown liability under WAC 182-519-0110, if required.
(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(4)) that is not an IMD, are not eligible for any WAH program unless they are receiving inpatient hospital services outside of the public institution.
(12) Children who reside in a public institution that is an IMD are eligible for WAH under this section but are not eligible to receive inpatient hospital services outside of the IMD unless they are unconditionally discharged from the IMD before receiving the services.)) (1) General eligibility. For purposes of this section, a child must:
(a) Be a Washington state resident under WAC 182-503-0520 and 182-503-0525;
(b) Provide a Social Security number under WAC 182-503-0515, unless exempt; and
(c) Meet program-specific requirements.
(2) Deemed eligibility groups. A child is automatically eligible for coverage without an application if the child meets the program-specific requirements in (a) through (c) of this subsection.
(a) Newborn coverage. A child under age one is eligible for categorically needy (CN) coverage if the birth parent was eligible for Washington apple health on the date of delivery:
(i) Including a retroactive eligibility determination; or
(ii) By meeting a medically needy (MN) spenddown liability with expenses incurred by the date of the newborn's birth:
(b) Washington apple health for supplemental security income (SSI) recipients. A child who is eligible for SSI is automatically eligible for CN coverage under WAC 182-510-0001.
(c) Foster care coverage. A child age twenty and younger is eligible for CN coverage under WAC 182-505-0211 when the child is in foster care or receives subsidized adoption services. For children who age out of the foster care program, see WAC 182-505-0211(3).
(3) MAGI-based eligibility groups. A child age eighteen and younger is eligible for CN coverage based on modified adjusted gross income (MAGI):
(a) At no cost when the child's countable income does not exceed the standard in WAC 182-505-0100 (6)(a);
(b) With payment of a premium when the child's countable income does not exceed the standard in WAC 182-505-0100 (6)(b), and the child meets additional eligibility criteria in WAC 182-505-0215;
(c) MAGI-based long-term care coverage. Under chapter 182-514 WAC, if the child needs long-term care services because the child resides or is expected to reside in an institution, as defined in WAC 182-500-0050, for thirty days or longer. An institutionalized child is eligible for coverage under the medically needy program if income exceeds the CN income standard for a person in an institution (special income level).
(4) Non-MAGI-based children's programs. The agency determines eligibility for the:
(a) Medically needy (MN) program according to WAC 182-510-0001(6) and 182-519-0100. A child age eighteen and younger is eligible if the child:
(i) Is not eligible for MAGI-based coverage under subsection (3) of this section;
(ii) Meets citizenship or immigration requirements under WAC 182-503-0535 (2)(a), (b), (c), or (d); and
(iii) Meets any spenddown liability required under WAC 182-519-0110.
(b) SSI-related program. A child age eighteen and younger is eligible for CN or MN SSI-related coverage if the child meets:
(i) SSI-related eligibility under chapter 182-512 WAC;
(ii) Citizenship or immigration requirements under WAC 182-503-0535 (2)(a), (b), (c), or (d); and
(iii) Any MN spenddown liability under WAC 182-519-0110.
(c) SSI-related long-term care program.
(i) A child age eighteen and younger is eligible for home and community based (HCB) waiver programs under chapter 182-515 WAC if the child meets:
(A) SSI-related eligibility under chapter 182-512 WAC;
(B) Citizenship or immigration requirements under WAC 182-503-0535 (2)(a), (b), (c), or (d); and
(C) Program-specific age and functional requirements under chapters 388-106 and 388-845 WAC.
(ii) A child age eighteen and younger who resides or is expected to reside in a medical institution as defined in WAC 182-500-0050 is eligible for institutional medical under chapter 182-513 WAC if the child meets:
(A) Citizenship or immigration requirements under WAC 182-503-0535 (2)(a), (b), (c), or (d);
(B) Blindness or disability criteria under WAC 182-512-0050; and
(C) Nursing facility level of care under chapter 388-106 WAC.
(5) Alien emergency medical program. A child age twenty and younger who does not meet the eligibility requirements for a program described under subsections (2) through (4) of this section is eligible for the alien emergency medical (AEM) program if the child meets:
(a) The eligibility requirements of WAC 182-507-0110; and
(b) MN spenddown liability, if any, under WAC 182-519-0110.
(6) Other provisions.
(a) A child residing in an institution for mental disease (IMD) as defined in WAC 182-500-0050(1) is not eligible for inpatient hospital services, unless the child is unconditionally discharged from the IMD before receiving the services.
(b) A child incarcerated in a public institution as defined in WAC 182-500-0050(4) is only eligible for inpatient hospital services.
AMENDATORY SECTION (Amending WSR 14-16-052, filed 7/29/14, effective 8/29/14)
WAC 182-505-0215 Children's Washington apple health((—Premium-based children's program—Purpose and scope)) with premiums.
((The 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 (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 federally matched health care coverage due to immigration status.)) (1) A child is eligible for Washington apple health with premiums if the child:
(a) Meets the requirements in WAC 182-505-0210(1);
(b) Has countable income below the standard in WAC 182-505-0100 (6)(b); and
(c) Pays the required premium under WAC 182-505-0225, unless the child is exempt under WAC 182-505-0225 (2)(c).
(2) A child is not eligible for Washington apple health with premiums if the child:
(a) Is eligible for no-cost Washington apple health;
(b) Has creditable health insurance coverage as defined in WAC 182-500-0020; or
(c) Is eligible for public employees benefits board health insurance coverage based on a family member's employment with a Washington state agency, or a Washington state university, community, or technical college.
AMENDATORY SECTION (Amending WSR 12-13-056, filed 6/15/12, effective 7/1/12)
WAC 182-505-0225 ((Premium requirements for premium-based health care coverage under programs included in apple health for kids.)) Children's Washington apple health with premiums—Calculation and determination of premium amount.
(1) For the purposes of this chapter, "premium" means an amount paid for health care coverage under ((programs included in apple health for kids as described in WAC 388-505-0210 (4) and (5).
(2) Payment of a premium is required as a condition of eligibility for premium-based coverage under programs included in apple health for kids, as described in WAC 388-505-0210 (4) and (5), unless the child is:
(a) Pregnant; or
(b) An American Indian or Alaska native.
(3) The premium requirement begins the first of)) WAC 182-505-0215.
(2) Premium requirement. Eligibility for Washington apple health premium-based program under WAC 182-505-0215 requires payment of a monthly premium.
(a) The first monthly premium is due in the month following the determination of eligibility.
(b) There is no premium requirement for ((medical)) health care coverage received in ((a)) the month ((or months before the determination of)) eligibility is determined or in any prior month.
(c) A child who is American Indian or Alaska native is exempt from the monthly premium requirement.
(3) Monthly premium amount.
(((4))) (a) The premium amount for the medical assistance unit (((AU))) (MAU) is based on ((the net)) countable income ((as described in WAC 388-450-0210)) under chapter 182-509 WAC and the number of ((children)) people in the ((AU. If the household includes more than one AU, the premium amount billed for the AUs may be different amounts)) MAU under chapter 182-506 WAC.
(((5))) (b) The premium amount is ((limited to a monthly maximum of two premiums for households with two or more children.
(6) 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 with income above two hundred percent FPL, but not above two hundred and fifty percent FPL; or
(b) Thirty dollars per month per child for households with income above two hundred and fifty percent FPL, but not above three hundred 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) All children in an AU are ineligible for health care coverage when the head of household fails to pay required premium payments for three consecutive months.
(9) When the agency or the agency's designee terminates the medical 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.
(10))) as follows:
(i) If the MAU's countable income exceeds two hundred ten percent of the federal poverty level (FPL) but does not exceed two hundred sixty percent of the FPL, the monthly premium for each child is $20.
(ii) If the MAU's countable income exceeds two hundred sixty percent of the FPL but does not exceed three hundred twelve percent of the FPL, the monthly premium for each child is $30.
(iii) The medicaid agency charges a monthly premium for no more than two children per household.
(iv) Payment of the full premium is required. Partial payments cannot be designated for a specific child or month.
(v) Any third party may pay the premium on behalf of the household. Failure of a third party to pay the premium does not eliminate the obligation of the household to pay past due premiums.
(c) A change that affects the premium amount takes effect the month after the change is reported.
(4) Nonpayment of premiums.
(a) Premium-based coverage ends for all children in the household if the required premiums are not paid for three consecutive months.
(b) Premium-based coverage is restored back to the month coverage ended if the unpaid premiums are fully paid before the certification period ends.
(c) The household may reapply for premium-based coverage ninety days after the coverage ended for nonpayment.
(d) The agency ((or the agency's designee)) writes off past-due premiums after twelve months.
(((11) 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 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) 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) A change that affects the premium amount is effective the month after the change is reported and processed.
(14) 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 14-16-052, filed 7/29/14, effective 8/29/14)
WAC 182-505-0240 ((Washington apple health—))Parents and caretaker relatives.
(1) A person is eligible for Washington apple health (((WAH))) categorically needy (CN) coverage when ((he or she)) the person:
(a) 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 182-503-0535;
(c) Meets general eligibility requirements described in WAC 182-503-0505; and
(d) Has countable income below ((fifty-four percent of the federal poverty level (FPL))) the standard in WAC 182-505-0100(2).
(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.
AMENDATORY SECTION (Amending WSR 15-06-039, filed 2/26/15, effective 3/29/15)
WAC 182-505-0300 ((Washington apple health—))Hospital presumptive eligibility.
(1) Purpose. The hospital presumptive eligibility (HPE) program provides temporary Washington apple health (((WAH))) coverage to HPE-eligible persons who enroll through an HPE-qualified hospital.
(2) HPE-eligible persons. To be HPE-eligible:
(a) A person must:
(i) Be younger than age sixty-five; and
(ii) Meet the eligibility requirements for one or more of the following programs:
(A) ((WAH)) Washington apple health for pregnant women (chapter 182-505 WAC);
(B) ((WAH)) Washington apple health for kids (chapter 182-505 WAC);
(C) ((WAH)) Washington apple health for foster care (chapter 182-505 WAC);
(D) ((WAH)) Washington apple health for parents and caretaker relatives (chapter 182-505 WAC);
(E) ((WAH)) Washington apple health for adults (chapter 182-505 WAC); or
(F) TAKE CHARGE for family planning services (chapter 182-532 WAC).
(b) A person must not:
(i) Be ((a WAH)) an apple health beneficiary;
(ii) Be a supplemental security income beneficiary; or
(iii) Have received HPE coverage within the preceding twenty-four months.
(3) HPE-qualified hospitals. To be HPE-qualified, a hospital must:
(a) Operate in Washington state;
(b) Submit a signed core provider agreement (CPA) to the agency;
(c) Submit a signed HPE agreement to the agency;
(d) Comply with the terms of the CPA and HPE agreements;
(e) Determine HPE eligibility using only those employees who have successfully completed the agency's HPE training;
(f) Agree to provide HPE-application assistance to anyone who requests it; and
(g) Agree to be listed on the agency's web site as an HPE-application assistance provider.
(4) Limitations.
(a) An HPE-qualified hospital must attempt to help the person complete a regular ((WAH)) apple health application before filing an HPE application. If the person cannot indicate whether ((he or she)) they expect((s)) to file a federal tax return or be claimed as a tax dependent, the HPE-qualified hospital may treat the person as a nonfiler under WAC 182-506-0010 (5)(c) for HPE purposes.
(b) HPE coverage begins on the earlier of:
(i) The day the HPE-qualified hospital determines the person is eligible; or
(ii) The day the HPE-qualified hospital provides a covered medical service to the person, but only if the hospital determines the person is eligible and submits the decision to the agency no later than five calendar days after the date of service.
(c) HPE coverage ends on the earlier of:
(i) The last day of the month following the month in which HPE coverage began; or
(ii) The day the agency determines the person is eligible for other ((WAH)) apple health coverage.
(d) HPE coverage does not qualify a person for continuous eligibility under WAC 182-504-0015.
(e) If HPE coverage is based on pregnancy, the pregnant ((woman)) person is eligible for HPE coverage only once for that pregnancy.
(f) The HPE program covers only those services included in the programs listed in subsection (2)(e) of this section, except that pregnancy-related services are limited to ambulatory prenatal care.
(g) A child born to a ((woman)) person with HPE coverage is ineligible for ((WAH)) apple health under WAC 182-505-0210(2). An HPE-qualified hospital must complete a separate HPE determination for the newborn child.
REPEALER
The following sections of the Washington Administrative Code are repealed:
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