HEALTH CARE AUTHORITY

(Medicaid Program)

"Third party" means an entity other than the agency or the agency's designee that is or may be liable to pay all or part of the cost of health care for a ((medical assistance)) Washington apple health client.

"Third party liability (TPL)" means the legal responsibility of an identified third party or parties to pay all or part of the cost of health care for a ((medical assistance)) Washington apple health (WAH) client. A ((medical assistance)) WAH client's obligation to help establish TPL is described in WAC ((388-505-0540)) 182-503-0540.

"Title XIX" is the portion of the federal Social Security Act, 42 U.S.C. 1396, that authorizes funding to states for ((medical assistance)) health care programs. Title XIX is also called medicaid.

"Title XXI" is the portion of the federal Social Security Act, 42 U.S.C. 1397 et seq, that authorizes funding to states for the children's health insurance program((. Title XXI is also called)) (CHIP).

"Transfer of assets" means changing ownership or title of an asset such as income, real property, or personal property by one of the following:

(1) An intentional act that changes ownership or title; or

(2) A failure to act that results in a change of ownership or title.

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

(1) If you are applying for or receiving health care coverage, you have the right to:

(a) Have your rights and responsibilities explained to you and given in writing;

(b) Be treated politely and fairly no matter what your race, color, political beliefs, national origin, religion, age, gender (gender identity and sex stereotyping), sexual orientation, disability, honorably discharged veteran or military status, or birthplace;

(c) Request health care coverage using any method listed under WAC 182-503-0010 (if you ask us for a receipt or confirmation, we will provide one to you);

(d) Get help completing your application if you ask for it;

(e) Have an application processed promptly and no later than the timelines described in WAC 182-503-0060;

(f) Have at least ten calendar days to give the agency or its designee information needed to determine eligibility and be given more time if requested;

(g) Have personal information kept confidential; we may share information with other state and federal agencies for purposes of verification and enrollment;

(h) Receive written notice, in most cases, at least ten calendar days before the agency or its designee denies, terminates, or changes coverage;

(i) Ask for an appeal if you disagree with a decision we make. You can also ask a supervisor or administrator to review our decision or action without affecting your right to a fair hearing;

(j) Request and receive interpreter or translator services at no cost and without delay;

(k) Request voter registration assistance;

(l) Refuse to speak to an investigator if we audit your case. You do not have to let an investigator into your home. You may ask the investigator to come back at another time. Such a request will not affect your eligibility for health care coverage; and

(m) Receive equal access services under WAC 182-503-0120 if you are eligible, in order to comply with the requirements of subsection (2) of this section.

(2) You are responsible to:

(a) Report changes in your household or family circumstances as required under WAC 182-504-0105 and 182-504-0110;

(b) Give us any information or proof needed to determine eligibility. If you have trouble getting proof, we help you get the proof or contact other persons or agencies for it;

(c) Assign the right to medical support as described in WAC 182-505-0540;

(d) Complete renewals when asked;

(e) Apply for and make a reasonable effort to get potential income from other sources when available;

(f) Give medical providers information needed to bill us for health care services; and

(g) Cooperate with quality assurance or post enrollment review staff when asked.

(1) The agency or its designee provides limited-English proficient (LEP) services free of charge to persons with limited ability to read, write, and/or speak English.

(2) The agency provides LEP services in the person's primary languages.

(a) The primary languages are the languages the person has indicated to the agency or its designee that they wish to use when communicating with the agency. A person may designate at least one primary language for oral communications and at least one primary language for written communications, and may designate a different primary language for oral and written communications.

(b) The agency or its designee notes the person's primary languages in a record available to the agency, its designee, and health benefit exchange employees.

(3) The agency or its designee can provide LEP services through bilingual workers and/or contracted interpreters and translators.

(4) The agency or its designee provides notice of the availability of LEP services. LEP services include:

(a) Interpreter (oral) services in person, over the telephone, or through other simultaneous audio or visual transmission (if available); and

(b) Translation of agency forms, letters, and other text-based materials, whether printed in hard-copy or stored and presented by computer. These include, but are not limited to:

(i) Agency pamphlets, brochures, and other informational material that describe agency services and health care rights and responsibilities;

(ii) Agency applications and other forms a person needs to complete and/or sign; and

(iii) Notices of agency actions affecting a person's eligibility for health care coverage.

(c) Direct provision of services by bilingual employees.

(5) The agency or its designee provides interpreter services and translated documents in a prompt manner that allows the timely processing of a person's eligibility for health care coverage within time frames defined in WAC 182-503-0060, 182-503-0035, and 182-504-0125.

(1) The agency or its designee provides services to help a person apply for, maintain, and understand the health care coverage options available and eligibility decisions made by the agency or its designee when a person has a mental, neurological, physical or sensory impairment, or limitation that prevents a person from receiving health care coverage in the same way as an unimpaired or unlimited person. These services are called equal access (EA) services.

(2) The agency or its designee provides EA services on an ongoing basis to ensure that the person is able to maintain health care coverage and access to services provided by the agency. Accommodations include, but are not limited to:

(a) Arranging for or providing help to:

(i) Apply for or renew coverage;

(ii) Complete and submit forms;

(iii) Obtain information to determine or continue eligibility;

(iv) Request continued coverage; and

(v) Request a hearing.

(b) Allowing additional time, when needed, to provide information before health care coverage is reduced or stopped;

(c) Explaining the decision to stop or deny health care coverage; and

(d) Providing copies of notices and letters to the person's authorized representative.

(3) The agency or its designee informs a person of their right to EA services listed in subsection (2) of this section:

(a) On written notices;

(b) In the Rights and Responsibilities form; and

(c) During contact with the agency or its designee.

(4) The agency or its designee provides the services listed in subsection (2) of this section to persons who request EA services, persons who are receiving services through the aging and long-term support administration, or persons whom the agency determines would benefit from EA services. The agency or its designee identifies a person as benefiting from EA services if the person:

(a) Has or claims to have a mental impairment;

(b) Has a developmental disability;

(c) Is disabled by alcohol or drug addiction;

(d) Is unable to read or write in any language; or

(e) Is a minor not residing with his or her parents.

(5) For every person receiving EA services, the agency or its designee develops and documents an EA plan appropriate to the person's needs. The plan may be updated or changed at any time based on the person's request or a change in the person's needs.

(6) Even if the agency or its designee determines a person may benefit from EA services, the person may refuse the services offered.

(7) The agency provides a grace period to continue a person's coverage when:

(a) The agency stops coverage because it is unable to determine if a person continues to qualify; and

(b) The person provides proof he or she still qualifies for coverage within twenty calendar days from when the coverage stopped. We restore the coverage retroactive to the first of the month so there is no break in coverage.

(8) If a person believes that the agency or its designee has discriminated against them on the basis of a disability, the person may file a complaint with the United States Department of Health and Human Services (HHS) by:

(a) Writing to: HHS, Director, Office for Civil Rights, 200 Independence Ave. S.W., Room 509F HHH Bldg., Washington, D.C., 20201; or

(b) Calling HHS at 202-619-0403 (voice) or 202-619-3257 (TDD).

(4) Persons related to SSI or to TANF and who receive the related CN medical coverage have redetermination rights as described in WAC 388-503-0505(6).)) (1) The agency categorizes Washington apple health (WAH) programs into three groups based on the income methodology used to determine eligibility:

(1) A person who does not agree with a Washington apple health (WAH) decision made by the agency or its designee has the right to appeal under RCW 74.09.741. The hearing rules are found in chapter 182-526 WAC.

(2) If a person appeals a WAH decision on or before the tenth day after the date the person receives the written notice of the WAH decision, WAH coverage will continue or be reinstated until the appeals process ends, unless otherwise specified in this section. This is called continued coverage. The agency will treat the fifth day after the date on the notice as the date the person received the notice; however, if the person shows that he or she received the notice more than five days after the date on the notice, the agency will use the actual date the person received the notice for counting the ten-day appeal period for the purpose of providing continued coverage.

(3) If the tenth day falls on a weekend or holiday, a person has until the next business day to appeal and still be able to receive continued coverage.

(4) Persons receive continued coverage through the end of the month an administrative hearing decision is sent to them unless:

(a) An administrative law judge or the agency's presiding officer serves an order ending continued coverage; or

(b) The person:

(i) Tells the agency or its designee in writing that he or she does not want continued coverage;

(ii) Withdraws the appeal in writing or at an administrative proceeding; or

(iii) Does not follow through with the appeals process.

(5) A person is not eligible for continued coverage when a change in WAH 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.

(6) A person receiving WAH medically needy is not eligible for continued coverage beyond the end of the original certification period described in WAC 182-504-0020.

(1) To qualify for an alien medical program (AMP) a person must:

(a) Be ineligible for ((medicaid or other medicaid agency medical)) federally funded Washington apple health (WAH) programs due to the citizenship/alien status requirements described in WAC ((388-424-0010)) 182-503-0535;

(b) Meet the requirements described in WAC 182-507-0115, 182-507-0120, or 182-507-0125; and

(c) Meet all categorical and financial eligibility criteria for one of the following programs, except for the Social Security number or citizenship/alien status requirements:

(i) ((WAC 388-475-0050, for)) An SSI-related ((person)) medical program described in chapters 182-511 and 182-512 WAC;

(ii) ((WAC 182-505-0240, for family medical programs;)) A MAGI-based program referred to in WAC 182-503-0510; or

(iii) ((WAC 182-505-0210, for a child under the age of nineteen;

(v) WAC 388-462-0020, for)) The breast and cervical cancer treatment program for women described in WAC 182-505-0120; or

(((vi) WAC 182-523-0100, for)) (iv) A medical extension((s)) described in WAC 182-523-0100.

(2) AMP medically needy (MN) health care coverage is available only for children, ((adults age sixty-five or over, or)) pregnant women and persons who meet ((SSI disability)) SSI-related criteria. See WAC ((388-519-0100)) 182-519-0100 for MN eligibility and ((388-519-0110)) WAC 182-519-0110 for spending down excess income under the MN program.

(3) The agency or its designee does not consider a person's date of arrival in the United States when determining eligibility for AMP.

(4) For non-MAGI-based programs, the agency or its designee does not consider a sponsor's income and resources when determining eligibility for AMP, unless the sponsor makes the income or resources available. Sponsor deeming does not apply to MAGI-based programs.

(5) A person is not eligible for AMP if that person entered the state specifically to obtain medical care.

(6) A person who the agency or its designee determines is eligible for AMP may be eligible for retroactive coverage as described in WAC ((388-416-0015)) 182-504-0005.

(7) Once the agency or its designee determines financial and categorical eligibility for AMP, the agency or its designee then determines whether a person meets the requirements described in WAC 182-507-0115, 182-507-0120, or 182-507-0125.

(1) The sections that follow describe the eligibility requirements for ((institutional medical benefits for parents and)) the Washington apple health (WAH) modified adjusted gross income (MAGI)-based long-term care program for children ((who are not aged, blind or disabled,)) and adults who are admitted for a long-term stay to a medical institution, an inpatient psychiatric facility or an institution for mental diseases (IMD):

(a) WAC ((388-505-0235)) 182-514-0235 Definitions;

(b) WAC ((388-505-0240)) 182-514-0240 General eligibility ((for family institutional medical coverage)) requirements for the WAH MAGI-based long-term care program;

(c) WAC ((388-505-0245)) 182-514-0245 Resource eligibility for ((family institutional medical coverage)) WAH MAGI-based long-term care program;

(d) WAC ((388-505-0250 Eligibility for family institutional medical for individuals)) 182-514-0250 WAH MAGI-based long-term care programs for adults twenty-one years of age or older;

(e) WAC ((388-505-0255 Eligibility for family institutional medical for individuals)) 182-514-0255 WAH MAGI-based long-term care program for young adults nineteen and twenty years of age;

(f) WAC ((388-505-0260 Eligibility for family institutional medical)) 182-514-0260 WAH MAGI-based long-term care program for children eighteen years of age or younger;

(g) WAC ((388-505-0265)) 182-514-0265 How the ((department)) agency or its designee determines how much of an institutionalized ((individual's)) person's income must be paid towards the cost of care for the WAH MAGI-based long-term care program; and

(h) WAC ((388-505-0270)) 182-514-0270 When an involuntary commitment to Eastern or Western State Hospital is covered by ((medicaid)) Washington apple health.

(2) ((Individuals who are already eligible for)) Recipients of a noninstitutional ((family or)) WAH children's ((medical)) program ((when they are admitted for long-term care)) as described in WAC 182-505-0210 or 182-505-0211 do not need to submit a new application for ((institutional medical)) long-term care coverage when admitted to an institution. The ((department)) agency or its designee treats ((their)) the admittance to the ((facility)) institution as a change of circumstances and determines ((their)) eligibility based upon the anticipated length of stay ((at the facility)).

The following terms are used in WAC ((388-505-0230)) 182-514-0230 through ((388-505-0270)) 182-514-0270:

"Categorically needy (CN) medical" - Full scope of care medical benefits. CN medical may be either federally funded under Title XIX of the Social Security Act or state-funded.

"Federal benefit rate (FBR)" - The payment standard set by the Social Security administration for recipients of supplemental security income (SSI). This standard is adjusted annually in January. Institutional standards and effective date can be found at: http://www.dshs.wa.gov/manuals/eaz/sections/LongTermCare/LTCstandardspna.shtml.

"Federal poverty level" - The income standards published annually by the federal government in the Federal Register found at http://aspe.hhs.gov/poverty/index.shtml. ((The income standards change on April first every year.

"Institutional status" - An individual meets institutional status when he or she is admitted to a medical institution, inpatient psychiatric facility, or IMD for a period of thirty days or longer. The time period is ninety days or longer for individuals seventeen years of age and younger who are admitted to an inpatient psychiatric facility or institution for mental diseases. Institutional status is described in WAC 388-513-1320.)) Institutional standards and effective date can be found at: http://www.dshs.wa.gov/manuals/eaz/sections/LongTermCare/LTCstandardspna.shtml.

"Legal dependent" - A minor child, seventeen years of age and younger, and an individual eighteen years of age and older claimed as a dependent for income tax purposes; or a parent of either the applicant or the applicant's spouse claimed as a dependent for income tax purposes; or the brother or sister (including half and adoptive siblings) claimed by either the applicant or the applicant's spouse as a dependent for income tax purposes.

"Medical institution" ((- A medical facility that provides twenty-four hour supervision and skilled nursing care. Facilities which meet this definition include:

(5) A residential habilitation center (RHC))) see WAC 182-500-0050.

"Medically needy income level (MNIL)" - The standard used by the ((department)) agency to determine eligibility under the medically needy medicaid program. The effective MNIL standards are described in WAC ((388-478-0070)) 182-519-0050.

"Medically needy (MN) ((medicaid))" ((- Federally funded medical coverage under Title XIX of the Social Security Act. MN coverage has a more limited scope of care than CN coverage)) see WAC 182-500-0070.

"Personal needs allowance (PNA)" - An amount designated to cover the expenses of an individual's clothing and personal incidentals while living in a medical institution, inpatient psychiatric facility, or institution for mental diseases. PNA standards are found at: http://www.dshs.wa.gov/manuals/eaz/sections/LongTermCare/ltcstandardsPNAchartsubfile.shtml.

"Spenddown" ((- The amount of medical expenses an individual is required to incur prior to medical benefits being authorized. Spenddown is described in WAC 388-519-0100 and 388-519-0110)) see WAC 182-500-0100.

"Title XIX" ((- The portion of the federal Social Security Act, 42 U.S.C. 1396, that authorizes grants to states for medical assistance programs. Title XIX is also called medicaid)) see WAC 182-500-0105.

(1) This section applies to ((all individuals applying)) applicants for long-term care services under the ((family institutional medical)) Washington apple health (WAH) MAGI-based long-term care program. Additional rules may apply based upon ((an individual's)) a person's age at the time he or she applies for long-term care services and whether the facility the ((individual)) person is admitted to is a medical institution, inpatient psychiatric facility, or an institution for mental diseases (IMD). Additional rules are described in WAC ((388-505-0245)) 182-514-0245 through ((388-505-0265)) 182-514-0265.

(2) ((Individuals must meet)) The following requirements apply to ((qualify)) be eligible for ((family institutional)) WAH MAGI-based long-term care coverage under this section:

(a) Institutional status described in WAC ((388-513-1320)) 182-513-1320. ((An individual)) A person meets institutional status if he or she is admitted to:

(i) A medical institution and resides, or is likely to reside, there for thirty days or longer, regardless of age;

(ii) An inpatient psychiatric facility or IMD and resides, or is likely to reside, there for thirty days or longer and is eighteen through twenty years of age; or

(iii) An inpatient psychiatric facility or IMD and resides, or is likely to reside, there for ninety days or longer and is seventeen years of age or younger.

(b) General eligibility requirements described in WAC ((388-503-0505)) 182-503-0505 (with the exception that subsections (3)(c) and (d) of that section do not apply to ((individuals)) noncitizen applicants who are eligible under one of the WAH alien ((emergency)) medical (((AEM))) programs described in chapter 182-507 WAC) and the person meets one of the following:

(i) ((Be a parent of, or a relative caring for, an eligible dependent child and meet the program requirements under:

(ii))) Be a child and meet the program requirements under ((apple health)) WAH for kids as described in WAC ((388-505-0210)) 182-505-0210. For the purposes of this section, a person is considered a child through the age of twenty-one;

(ii) Be an adult nineteen through sixty-four years of age who meets the criteria in WAC 182-505-0250;

(iii) Be ((a)) pregnant ((woman)) and meet the program requirements for ((a)) the WAH pregnancy ((medical)) program as described in WAC ((388-462-0015)) 182-505-0115;

(iv) Meet the WAH alien ((emergency)) medical (((AEM))) program requirements as described in WAC ((388-438-0110)) 182-507-0110 (with the exception that for ((family)) MAGI-based long-term care services, ((AEM)) alien medical coverage may be authorized for children through twenty-one years of age) and:

(A) Have a qualifying emergency condition; and

(B) For payment for long-term care services and room and board costs in the institution, request prior authorization from the ((department's medical consultant)) aging and long-term support administration (ALTSA) if the ((individual)) person is admitted to a ((medical institution under hospice or is admitted to a)) nursing facility.

(d))) (c) Have countable income below the applicable standard described in WAC ((388-505-0250(4), 388-505-0255(3) or 388-505-0260(4))) 182-514-0250(4), 182-514-0255(3), or 182-514-0260(4);

(((e))) (d) Contribute income remaining after the post eligibility process described in WAC ((388-505-0265)) 182-514-0265 towards the cost of care in the facility, if applicable; and

(((f))) (e) Be assessed as needing nursing facility level of care as described in WAC 388-106-0355 if the admission is to a nursing facility. (This does not apply to nursing facility admissions under the hospice program.)

(3) Once the ((department)) agency or its designee determines ((an individual)) a person meets institutional status, it does not count the income of parent(s), a spouse, or dependent child(ren) when determining countable income. ((The department counts the following as the individual's income:

(5) Individuals)) Only income received by the person in his or her own name is counted for the initial eligibility determination.

(4) A person who ((are)) is not a United States citizen((s)) or a qualified alien((s do)) does not need to provide or apply for a Social Security number or meet the citizenship requirements under WAC ((388-424-0010 (1) or (2))) 182-503-0535 as long as the requirements in subsection (2) of this section are met.

(((6) Individuals who are)) (5) A person who meets the federal aged, blind or disabled ((under federal)) criteria may qualify for institutional benefits with income of up to three hundred percent of the federal benefit rate (FBR). Rules relating to institutional eligibility for an aged, blind or disabled ((individuals)) person are described in WAC ((388-513-1315)) 182-513-1315.

(((7))) (6) If ((an individual)) a person does not meet institutional status, the ((department)) agency or its designee determines his or her eligibility for a noninstitutional WAH medical program. ((An individual)) A person who is determined eligible for CN or medically needy (MN) coverage under a noninstitutional program who is admitted to a nursing facility for less than thirty days is approved for coverage for the nursing facility room and board costs, as long as the ((individual)) person is assessed by ((the department)) ALTSA as meeting nursing home level of care as described in WAC 388-106-0355.

(iv) If countable income is over the CN income standard, but the combination of countable income plus excess resources is higher than the monthly cost of care at the institution's private rate plus the amount of any recurring medical expenses for institutional services, the individual is not eligible for family institutional coverage under the MN program. (MN coverage applies only to individuals twenty years of age or younger.))) (1) There is no resource test for applicants or recipients of the Washington apple health (WAH) modified adjusted gross income (MAGI)-based long-term care program.

(1) ((Individuals)) A person twenty-one years of age or older must meet the requirements in WAC ((388-505-0240)) 182-505-0250 to qualify for ((family institutional medical)) Washington apple health (WAH) modified adjusted gross income (MAGI)-based long-term coverage under this section.

(2) ((Individuals, twenty-one through sixty-four years of age who are admitted to an institution for mental diseases (IMD) are not eligible for coverage under this section. Individuals who are voluntarily admitted to a psychiatric hospital may be eligible for coverage under the psychiatric indigent inpatient program described in WAC 388-865-0217.

(4))) The categorically needy income level (CNIL) for ((individuals who qualify for family institutional medical)) health care coverage under this section is ((the temporary assistance for needy families (TANF) one person payment standard based on the requirement to pay shelter costs described in WAC 388-478-0020. An individual's)) one hundred thirty-three percent of federal poverty level. A person's countable income (after a standard five percentage point income disregard) must be at or below this amount to be eligible.

(((5))) (3) Countable income for categorically needy (CN) coverage under this section is determined using the MAGI methodologies described in chapter 182-509 WAC.

(4) If the ((individual's)) person's income exceeds the standards to be eligible under ((a categorically needy (CN) medicaid family)) the WAH MAGI-based CN long-term care program, he or she is not eligible for ((coverage under the)) medically needy (((MN) medicaid program.

(6) Individuals eligible under the provisions of this section may be required to contribute a portion of their income towards the cost of care as described in WAC 388-505-0265)) coverage under this section.

(5) A person, age twenty-one through sixty-four years of age who is admitted to an institution for mental diseases (IMD) is not eligible for coverage under this section.

(1) ((Individuals)) Persons nineteen and twenty years of age must meet the requirements in WAC ((388-505-0240)) 182-505-0210 to qualify for ((family institutional medical coverage)) the Washington apple health (WAH) modified adjusted gross income (MAGI)-based long-term care program.

(2) ((Rules governing resources are described in WAC 388-505-0245. However, if an applicant has countable resources over the standard described in WAC 388-505-0245, he or she may spend down any excess resources over the standard by applying the excess amount towards his or her cost of care as described in WAC 388-505-0265(6).

(3))) The categorically needy income level (CNIL) ((for individuals who qualify for family institutional medical coverage under this section is the temporary assistance for needy families (TANF) one person payment standard based on the requirement to pay shelter costs described in WAC 388-478-0020. An individual's countable income must be at or below this amount to be eligible.

(4))) is two hundred ten percent of the federal poverty level. A person's countable income (after a standard five percentage point income disregard) must be at or below this amount to be eligible.

(5) If ((an individual's)) a person's countable income exceeds the standard described in subsection (3) of this section, the ((department)) agency or its designee determines whether ((he or she)) the person is eligible for coverage under the WAH institutional medically needy (MN) ((medicaid)) program.

(5))) (6) If ((an individual)) the person is a medicaid applicant or ((current medical assistance client)) recipient in the month of his or her twenty-first birthday and receives active inpatient psychiatric or inpatient chemical dependency treatment which extends beyond his or her twenty-first birthday, the ((department)) agency or its designee approves or continues WAH CN or MN ((medicaid)) health care coverage until the date the ((individual)) person is discharged from the facility or until his or her twenty-second birthday, whichever occurs first.

(((6) Individuals)) (7) Young adults eligible under the provisions of this section may be required to contribute a portion of their income towards the cost of care as described in WAC ((388-505-0265)) 182-514-0265.

(1) ((Individuals)) Children eighteen years of age or younger must meet the requirements in WAC ((388-505-0240)) 182-514-0240 to qualify for ((family institutional medical coverage)) the Washington apple health (WAH) modified adjusted gross income (MAGI)-based long-term care program.

(2) When ((an individual)) a child eighteen years of age or younger is eligible for the premium-based ((categorically needy (CN) coverage under apple health)) WAH for kids program as described in WAC ((388-505-0210(4))) 182-505-0210, the ((department)) agency or its designee redetermines his or her eligibility using the provisions of this section so that the ((individual)) child's family is not required to pay the premium.

(3) ((The department does not restrict or limit the resources available to individuals eighteen years of age or younger when determining eligibility for family institutional medical coverage. The department does not consider, or count towards eligibility any resources owned by the individual in this age category, or any resources owned by the individual's parent(s), spouse, or child(ren), if applicable.

(4))) The categorically needy income level (CNIL) for ((individuals who qualify for family institutional medical)) WAH long-term care coverage under this section is two hundred ten percent of the federal poverty level ((income standard. Once the department determines an individual meets institutional status, it does not count the income of a parent(s), spouse, or dependent children (if applicable) when determining the individual's countable income)) (after a standard five percentage point income disregard).

(4) Countable income for categorically needy (CN) coverage under this section is determined using the MAGI methodologies described in chapter 182-509 WAC.

(5) The ((department)) agency or its designee approves CN ((medical)) health care coverage under this section for twelve calendar months. If ((an individual)) the child is discharged from the facility before the end of his or her certification period, ((he or she)) the child remains continuously eligible for CN ((medical)) health care coverage through the end of the original certification date, unless he or she ages out of the program, moves out of state, is incarcerated, or dies.

(6) If ((an individual)) a child is not eligible for CN ((medical)) health care coverage under this section, the ((department)) agency or its designee determines ((his or her)) the child's eligibility for health care coverage under the WAH institutional medically needy (MN) program described in WAC 182-513-1395.

(((a))) (7) MN coverage is only available for ((an individual)) a child who meets the citizenship requirements under WAC ((388-424-0010 (1) or (2))) 182-503-0535.

(7))) (8) The facility where the ((individual)) child resides may submit an application on the ((individual's)) child's behalf and may act as an authorized representative ((for the individual)) if the ((individual)) child is:

(a) In a court ordered, out-of-home placement under chapter 13.34 RCW; or

(b) Involuntarily committed to an inpatient treatment program by a court order under chapter 71.34 RCW.

(((8) Individuals)) (9) Children who are eligible for ((family institutional medical)) WAH MAGI-based long-term care coverage under the provisions of this section may be required to contribute a portion of their income towards the cost of care as described in WAC ((388-505-0265)) 182-514-0265.

(1) ((Individuals)) A person who resides in a medical institution, inpatient psychiatric facility, or an institution for mental diseases (IMD) may be required to pay a portion of their income towards the cost of care. This section explains how the ((department)) agency or its designee calculates how much ((an individual is required to)) a person pays to the facility under the Washington apple health (WAH) modified adjusted gross income (MAGI)-based long-term care program. This process is known as the post-eligibility process. If ((an individual)) a person does not have income, he or she does not have to pay.

(2) The ((department)) agency or its designee determines available income by considering ((an individual's)) a person's total gross income before any mandatory deductions from earnings. Income that was not counted in the initial eligibility process under the MAGI methodology is counted for the post-eligibility process unless the income is excluded under ((federal or state law. See WAC 388-450-0015 for examples of excluded income types)) WAC 182-513-1340.

(3) The following income allocations and exemptions are deducted from ((an individual's)) the person's total gross income to determine his or her available income. The ((department)) agency or its designee uses the rules described in WAC ((388-513-1380)) 182-513-1380 to calculate the amount of these allocations and exemptions, with the exception that ((under the family institutional medical program, there is no deduction for earned income in the post-eligibility process)) the deduction of wages stated in WAC 182-513-1380 (4)(c) is not allowed.

(a) A personal needs allowance (PNA) and maintenance allocation. The combined totals of all of the following deductions cannot exceed the medically needy income level (MNIL):

(i) PNA as allowed under WAC ((388-478-0040)) 182-513-1300;

(ii) Mandatory federal, state, or local income taxes owed by the ((client)) person; and

(iii) Court ordered guardianship fees and administrative costs, including attorney fees, as described in chapter 388-79 WAC.

(b) Income garnished to comply with a court order for child support.

(c) Community spouse allocation.

(d) Family maintenance allocation if married with dependents.

(e) Legal dependent allocation for an unmarried ((client)) person with dependents. The maximum allocation is based upon the MNIL standard for the number of dependents minus the dependent's income.

(f) Medical expense allocation. The ((department)) agency or its designee allows a deduction for unpaid medical expenses for which the individual is still liable. Medical expenses allowed for this allocation are described in WAC ((388-513-1350)) 182-513-1350.

(g) Housing maintenance exemption:

(i) ((For an individual)) A person who is financially responsible for the costs of maintaining a home while he or she is in an institution((, the department allows)) is allowed a deduction, limited to a six-month period, of up to one hundred percent of the one-person poverty level per month, when a physician has certified that the ((individual)) person is likely to return to the home within the six-month period.

(ii) ((An individual)) A person eighteen years of age or younger is not eligible for the housing maintenance exemption unless the housing expense is the ((individual's)) person's financial responsibility. Children are not financially responsible for the housing expenses incurred by their parents.

(4) ((Individuals)) A person may keep a personal needs allowance of up to the ((one person temporary assistance for needy families (TANF) payment standard (based upon the requirement to pay shelter costs))) effective MNIL in the month ((they are)) he or she admitted and in the month ((they are)) the person discharged from the facility. See WAC 182-519-0050 for the effective MNIL standards.

(5) Any income ((which remains)) remaining is called the person's responsibility toward the cost of care and must be paid to the facility ((towards the cost of care.

(6) Individuals nineteen years of age or older who qualify for categorically needy (CN) or medically needy (MN) coverage but have countable resources in excess of the resource limits as described in WAC 388-505-0245 must pay an amount equal to the excess amount to the facility towards the cost of their care in the month of application. This amount is in addition to the amount calculated under subsections (2) through (4) of this section (if any))). This amount is also called the person's participation.

(1) ((Individuals)) A person who is admitted to Eastern or Western State Hospital for inpatient psychiatric treatment ((may qualify)) is eligible for categorically needy (CN) ((medicaid)) health care coverage ((and aged, blind, disabled (ABD) cash benefits to cover their personal needs allowance (PNA))) in limited circumstances.

(2) To be eligible under this program, ((individuals)) a person must:

(a) Be ((eighteen through)) twenty years of age or younger, or sixty-five years of age or older;

(b) Meet institutional status under WAC ((388-513-1320)) 182-513-1320;

(c) Be involuntarily committed to an inpatient treatment program by a court order under chapter 71.34 RCW;

(d) ((Meet the general eligibility requirements for the ABD cash program as described in WAC 388-400-0060;

(e))) Have countable income below ((the payment standard described in WAC 388-478-0040; and

(ii) The SSI-related CN income level if age sixty-five years or older and have countable resources below the standard described in WAC 182-512-0010.

(3) ((ABD clients)) A person who receives active psychiatric treatment in Eastern or Western State Hospital at the time of ((their)) his or her twenty-first birthday continues to be eligible for ((medicaid)) CN health care coverage until the date ((they are)) he or she is discharged from the facility or until ((their)) the person's twenty-second birthday, whichever occurs first.