WSR 02-10-018

PERMANENT RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)

[ Filed April 22, 2002, 3:33 p.m. ]

Date of Adoption: April 19, 2002.

Purpose: Amending WAC 388-523-0100 and adopting new WAC 388-523-0110, 388-523-0120, and 388-523-0130 on medical extensions. The proposed rules implement the establishment of premiums in the second six month period of medical extension benefits.

Citation of Existing Rules Affected by this Order: Amending WAC 388-523-0100.

Statutory Authority for Adoption: RCW 74.08.090.

Other Authority: ESSB 6153, Subsection 209.

Adopted under notice filed as WSR 02-06-097 on March 4, 2002.

Changes Other than Editing from Proposed to Adopted Version: WAC 388-523-0120 (6)(d), deleted "under" and replaced with "equal to or less than"; WAC 388-523-0120 (7), (8), and (9), changed the cross-reference from (6)(c) to (6)(d); and WAC 388-523-0130(2), deleted "significant."

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 3, Amended 1, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 3, Amended 1, Repealed 0.
Effective Date of Rule: Thirty-one days after filing.

April 19, 2002

Brian H. Lindgren, Manager

Rules and Policies Assistance Unit

2879.19
AMENDATORY SECTION(Amending WSR 98-16-044, filed 7/31/98, effective 9/1/98)

WAC 388-523-0100   Medical extensions -- Eligibility.   (1) A family who received temporary assistance for needy families (TANF) ((or)), state family assistance (SFA) cash ((or related medical assistance)), or family medical program in any three of the last six months in the state of Washington is eligible for extended medical benefits when they ((are)) become ineligible for ((TANF/SFA-related)) their current medical program because the family receives:

(a) ((They receive)) Child or spousal support, which exceeds the payment standard described in WAC ((388-478-0020)) 388-478-0065, and they are not eligible for any other categorically needy (CN) medical program; or

(b) ((Their earnings)) Increased earned income, resulting in income exceeding the ((TANF/SFA payment)) CN income standard described in ((subsection (1)(a))) WAC 388-478-0065.

(2) A family ((described in subsection (1)(a))) is eligible to receive ((four months of)) extended medical benefits beginning the month after termination from ((cash or TANF/SFA-related medical assistance, provided the family includes a child as defined in WAC 388-404-0005.

(3) A family described in subsection (1)(b) is eligible to receive six months of extended medical benefits when:

(a) They continue to meet the eligibility requirements of a TANF/SFA-related medical program, other than income; and

(b) The family includes a child.

(4) A family described in subsection (3) will not receive extended medical benefits for any family member who has been found ineligible for cash assistance because of fraud in any of the six months prior to the extended medical period.

(5) A family receiving extended medical benefits described in subsection (4) of this section is eligible for up to an additional six calendar months of extended medical benefits as long as:

(a) The family continues to include a child; and

(b) The family's gross earned income, after child care deductions in the preceding three months averages less than, one hundred eighty-five percent of the Federal Poverty Level (FPL), as described in WAC 388-478-0075; and

(c) A caretaker relative has had earnings in each of the three previous months, prior to the month of request for the second six month extension; and

(d) The family reports to the department family earnings and child care costs relating to employment by the twenty-first day of the:

(i) Fourth month of the initial six month extension period; and

(ii) First month of the second six month extension; and

(iii) Fourth month of the second six month extension.

(6) Certain circumstances may prevent a family from meeting the requirements in subsection (5)(b), (c) and (d) of this section. If that occurs, good cause may exist and the family remains eligible for the additional six month medical extension. Reasons for good cause include, but are not limited to:

(a) Illness, mental impairment, injury, trauma, or stress; or

(b) Lack of understanding the reporting requirement due to a language barrier; or

(c) Transportation problems; or

(d) Payment for work in each month of the reporting period was paid in a different month than it was earned; or

(e) The client expected to be able to meet the family medical needs, but could not; or

(f) The client was given incorrect information about the reporting requirements.

(7) Postpartum and family planning extensions are described in WAC 388-462-0015)) TANF/SFA cash or family medical program for:

(a) Four months for a family described in subsection (1)(a) of this section; or

(b) Up to twelve months, in two six-month segments, for a family described in subsection (1)(b) of this section. For the purposes of this chapter, months one through six are the initial six-month extension period. Months seven through twelve are the second six-month extension period.

(3) A family member is eligible to receive six months of medical extension benefits as described in subsection (2)(b) of this section unless:

(a) The individual family member:

(i) Moves out of state;

(ii) Dies;

(iii) Becomes an inmate of a public institution;

(iv) Leaves the household; or

(v) Does not cooperate, without good cause, with the division of child support or with third party liability requirements.

(b) The family:

(i) Moves out of state;

(ii) Loses contact with the department or the department does not know the whereabouts of the family; or

(iii) No longer includes a child as defined in WAC 388-404-0005(1).

(4) A family member is eligible to receive the second six months of medical extension benefits as described in subsection (2)(b) of this section unless:

(a) The family is no longer eligible for the reasons described in subsection (3)(a) or (b); or

(b) The individual family member is the caretaker adult who:

(i) Stops working or whose earned income stops;

(ii) Does not, without good cause, complete and return the completed medical extension report or otherwise provide the required income and child care information; or

(iii) Does not, without good cause, pay the billed premium amount for one month.

(5) A family described in subsection (3) will not receive medical extension benefits for any family member who has been found ineligible for TANF/SFA cash because of fraud in any of the six months prior to the medical extension period.

[Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. 98-16-044, 388-523-0100, filed 7/31/98, effective 9/1/98. Formerly WAC 388-522-2210, 388-523-2305 and 388-523-2320.]


NEW SECTION
WAC 388-523-0110   Medical extensions -- Reporting requirements.   (1) The family must report family income and employment-related child care costs the family pays by the twenty-first day of:

(a) Month four of the extension period, for months one, two, and three; and

(b) Month seven of the extension period, for months four, five, and six.

(2) Circumstances may prevent a family from meeting the reporting requirements in subsection (1) of this section. The family remains eligible for the medical extension when good cause exists. Reasons for good cause include, but are not limited to:

(a) Illness, mental impairment, injury, trauma, or stress;

(b) Lack of understanding the reporting requirement due to a language barrier;

(c) Transportation problems;

(d) Payment for work in each month of the reporting period was paid in a different month than it was earned;

(e) The client expected to be able to meet the family medical needs, but could not; or

(f) The client was given incorrect information about the reporting requirements. Refer to WAC 388-422-0020 (4) and (5).

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NEW SECTION
WAC 388-523-0120   Medical extensions -- Premiums.   (1) "Countable income" means, for the purposes of determining the premium amount described in this chapter, all earned and unearned income of the adult family members except SSI cash assistance, minus the amount of employment-related child care paid for by the family. The earned and unearned income of an adult, living in the household, who is financially responsible for other members of the assistance unit is included, whether or not the person is an eligible member of the assistance unit.

(2) For a family whose first month of medical extension benefits occurs on or after February 2002, the department requires the family pay premiums for medical coverage provided during the second six-month medical extension period. The premium amount is one percent of the family's countable income per person/per month. This amount is rounded down to the nearest whole dollar.

(3) The premiums for:

(a) Months seven, eight, and nine are based solely on the average countable income received in months one, two and three of the medical extension period; and

(b) Months ten, eleven, and twelve are based solely on the average countable income received in months four, five, and six of the medical extension period.

(4) A subsequent change in income does not effect the premium amount described in subsection (2) and (3) of this section.

(5) When a family's premium is one month in arrears, the family is ineligible for the balance of the medical extension period unless good cause exists. Reasons for good cause include, but are not limited to:

(a) Illness, mental impairment, injury, trauma, or stress;

(b) Lack of understanding the premium payment requirement due to a language barrier;

(c) Transportation problems;

(d) The client did not pay the premium because they expected to be able to meet the family medical needs, but could not; or

(e) The client was given incorrect information or did not receive advance and adequate notice about the premium payment requirements. Refer to WAC 388-422-0020 (4) and (5).

(6) The department exempts individual family members from the premium requirements, as follows:

(a) Children;

(b) Pregnant women;

(c) American Indians and Alaska Natives; and

(d) Caretaker adults in a family whose countable income is equal to or less than one hundred percent of the Federal Poverty Level based on family size as described in WAC 388-478-0075(2).

(7) When determining the exemption described in (6)(d), the department shall include in the household size an unborn child and a person who is financially responsible for other members of the assistance unit, whether or not the person is an eligible member of the assistance unit. A person receiving SSI cash assistance is not included when determining the household size.

(8) The department determines a family's exemption from the premium requirement as described in subsection (6)(d) for:

(a) Months seven, eight and nine based solely on information available to the department at the time the premium for these months is calculated; and

(b) Months ten, eleven, and twelve based solely on information available to the department at the time the premium for these months is calculated.

(9) Any income change resulting in an individual meeting the exemption criteria in subsection (6)(d) after the establishment of the premium amount for months seven, eight and nine is used to calculate the premium amount for months ten, eleven, and twelve.

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NEW SECTION
WAC 388-523-0130   Medical extension -- Redetermination.   (1) When the department determines the family or an individual family member is ineligible during the medical extension period, the department must determine if they are eligible for another medical program.

(2) When a family reports a reduction of income, the family may be eligible for a family medical program instead of medical extension benefits.

(3) Postpartum and family planning extensions are described in WAC 388-462-0015.

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Washington State Code Reviser's Office