For the purposes of this chapter, "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 without regard to your race, color, political beliefs, national origin, religion, age, gender (including gender identity and sex stereotyping), sexual orientation, disability, honorably discharged veteran or military status, or birthplace;

(c) Ask for health care coverage using any method listed under WAC ((182-503-0010))182-503-0005 (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 10 calendar days to give the agency or its designee information needed to determine eligibility and be given more time if asked for;

(g) Have personal information kept confidential; we may share information with other state and federal agencies for purposes of eligibility and enrollment in Washington apple health;

(h) Get written notice, in most cases, at least 10 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) Ask for and get interpreter or translator services at no cost and without delay;

(k) Ask for 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;

(m) Get equal access services under WAC 182-503-0120 if you are eligible;

(n) Ask for support enforcement services through the division of child support; and

(o) Refuse to cooperate with us in identifying, using, or collecting third-party benefits (such as medical support) if you fear, and can verify, that your cooperating with us could result in serious physical or emotional harm to you, your children, or a child in your care. Verification may include one of the following:

(i) A statement you sign, outlining your fears and concerns;

(ii) Civil or criminal court orders (such as domestic violence protection orders, restraining orders, and no-contact orders);

(iii) Medical, police, or court reports; or

(iv) Written statement from clergy, friends, relatives, neighbors, or co-workers.

(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))182-503-0540, unless you can submit verification (which may include one of the items listed in subsection (1)(o) of this section) that your cooperating with us could result in serious physical or emotional harm to you, your children, or a child in your care;

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

This section describes how the medicaid agency calculates the premium amount a person must pay for apple health for workers with disabilities (HWD) coverage. This section also describes program requirements regarding the billing and payment of HWD premiums.

(1) When determining the HWD premium amount, the agency counts only the income of the person approved for the program. It does not count the income of another household member.

(2) When determining countable income used to calculate the HWD premium, the agency applies the following rules:

(a) Income is considered available and owned when it is:

(i) Received; and

(ii) Can be used to meet the person's needs for food, clothing, and shelter, except as described in WAC 182-512-0600(5)((,))and 182-512-0650((, and 182-512-0700(1))).

(b) Income is considered unavailable when it is:

(i) Described in 20 C.F.R. Sec. 416.1103.

(ii) Used to pay the fee described in WAC 182-512-0800(5).

(3) The HWD premium amount equals the lesser of the two following amounts:

(a) A total of the following (rounded down to the nearest whole dollar):

(i) Fifty percent of unearned income above the medically needy income level (MNIL) described in WAC 182-519-0050; plus

(ii) Five percent of total unearned income; plus

(iii) Two and one-half percent of earned income after first deducting $65; or

(b) Seven and one-half percent of countable income described in subsection (2) of this section, including both earned and unearned income.

(4) When determining the premium amount, the agency will use the currently verified income amount until a change in income is reported and processed, unless good cause for delay in verifying changes exists.

(5) A change in the premium amount is effective the month after the change in income is reported and processed.

(6) For current and ongoing coverage, the agency will bill for HWD premiums during the month following the benefit month.

(7) For retroactive coverage, the agency will bill the HWD premiums during the month following the month in which coverage is requested and necessary information that establishes eligibility is received by the agency.

(8) If initial coverage for the HWD program is approved in a month that follows the month of application, the first monthly premium includes the costs for both the month of application and any following months that have passed during determination of eligibility.

(9) As described in WAC 182-511-1050 (3)(b), the agency will close HWD coverage if premiums are not paid in full for four consecutive months.

(10) The person must pay the monthly premium in full to avoid losing HWD coverage. If a person makes a partial payment, the payment does not count as a full payment toward the premium.

(11) Payments received are applied to premiums owed in the following order:

(a) If retroactive coverage is requested, the retroactive coverage month(s);

(b) Past due months, beginning with the most delinquent month;

(d) Future coverage months.

(12) A person must pay a premium for any month that HWD coverage is provided. This includes months when a redetermination of coverage is made, and months when continued coverage that is requested, pending the outcome of an administrative hearing.

(1) Income is considered available to a person at the earliest of when it is:

(a) Received; or

(b) Credited to a person's account; or

(d) Used or can be used to meet the person's needs for shelter.

(2) Anticipated nonrecurring lump sum payments are treated as income in the month received, with the exception of those listed in WAC 182-512-0700(((5)))(4), and any remainder is considered a resource in the following month.

(3) Reoccurring income is considered available in the month of normal receipt, even if the financial institution posts it before or after the month of normal receipt.

(4) In-kind income received from anyone other than a legally responsible relative is considered available income only if it is earned income.

(1) ((In order to be eligible, a person is required to do everything necessary to obtain any income to which he or she is entitled including (but not limited to):

(a) Annuities;

(b) Pensions;

(d) Retirement; and

(e) Disability benefits; even if their receipt makes the person ineligible for agency services, unless the person can provide evidence showing good reason for not obtaining the benefits.

(2))) The agency does not count ((this)) income until the person begins to receive it. Income is budgeted prospectively for all Washington apple health (((WAH))) health care programs.

(((3)))(2) Anticipated nonrecurring lump sum payments other than retroactive SSI/SSDI payments are considered income in the month received, subject to reporting requirements in WAC 182-504-0110. Any unspent portion is considered a resource the first of the following month.

(((4)))(3) The agency follows income and resource methodologies of the supplemental security income (SSI) program defined in federal law when determining eligibility for ((WAH))apple health SSI-related medical or medicare savings programs unless the agency adopts rules that are less restrictive than those of the SSI program.

(((5)))(4) Exceptions to the SSI income methodology:

(a) Lump sum payments from a retroactive old age, survivors, and disability insurance (OASDI) benefit, when reduced by the amount of SSI received during the period covered by the payment, are not counted as income;

(b) Unspent retroactive lump sum money from SSI or OASDI is excluded as a resource for nine months following receipt of the lump sum; and

(c) Both the principal and interest portions of payments from a sales contract, that meet the definition in WAC 182-512-0350(10), are unearned income.

(((6)))(5) To be eligible for ((WAH))apple health categorically needy (CN) SSI-related health care coverage, a person's countable income cannot exceed the ((WAH))apple health CN program standard described in:

(a) WAC 182-512-0010 for noninstitutional ((WAH))apple health coverage unless living in an alternate living facility; or

(b) WAC 182-513-1205 for noninstitutional ((WAH))apple health CN coverage while living in an alternate living facility; or

(((7)))(6) To be eligible for SSI-related health care coverage provided under the ((WAH))apple health medically needy (MN) program, a person must:

(a) Have countable income at or below the effective ((WAH))apple health MN program standard as described in WAC 182-519-0050;

(b) Satisfy spenddown requirements described in WAC 182-519-0110;

(c) Meet the requirements for noninstitutional ((WAH))apple health MN coverage while living in an alternate living facility (ALF). See WAC 182-513-1205; or

(d) Meet eligibility for institutional ((WAH))apple health MN coverage described in WAC 182-513-1315.

(1) The person receiving care must meet the financial eligibility criteria for tailored supports for older adults (TSOA).

(2) To be eligible for the TSOA program, the person receiving care must:

(a) Be age 55 or older;

(b) Be assessed as meeting nursing facility level of care under WAC 388-106-0355;

(d) Live at home and not in a residential or institutional setting;

(e) Have an eligible unpaid caregiver under WAC 388-106-1905, or meet the criteria under WAC 388-106-1910 if the person does not have an eligible unpaid caregiver;

(f) Meet citizenship or immigration status requirements under WAC 182-503-0535. To be eligible for TSOA, a person must be a:

(i) U.S. citizen under WAC 182-503-0535 (1)(c);

(ii) U.S. national under WAC 182-503-0535 (1)(d);

(iii) Qualifying American Indian born abroad under WAC 182-503-0535 (1)(f); or

(iv) Qualified alien under WAC 182-503-0535 (1)(b) and have either met or is exempt from the five-year bar requirement for medicaid.

(g) Provide a valid Social Security number under WAC 182-503-0515;

(h) Have countable resources within specific program limits under WAC 182-513-1640; and

(i) Meet income requirements under WAC 182-513-1635.

(3) TSOA applicants who receive coverage under Washington apple health programs are not eligible for TSOA, unless their enrollment is limited to the:

(a) Medically needy program under WAC 182-519-0100;

(b) Medicare savings programs under WAC 182-517-0300;

(d) Family planning only programs under chapter 182-532 WAC; or

(e) Kidney disease program under chapter 182-540 WAC.

(4) A person who receives apple health coverage under a categorically needy (CN) or alternative benefit plan (ABP) program is not eligible for TSOA but may qualify for:

(a) Caregiver supports under medicaid alternative care (MAC) under WAC 182-513-1605; or

(b) Other long-term services and supports under chapter 182-513 or 182-515 WAC.

(5) The following rules do not apply to services provided under the TSOA benefit:

(a) Transfer of asset penalties under WAC 182-513-1363;

(b) Excess home equity under WAC 182-513-1350;

(d) Estate recovery under chapter 182-527 WAC;

(e) Disability requirements under WAC 182-512-0050; and

(f) ((Requirement to do anything necessary to obtain income under WAC 182-512-0700(1); and

(g))) Assignment of rights and cooperation under WAC 182-503-0540.