PDFWAC 182-503-0510

Washington apple health—Program summary.

(1) The agency categorizes Washington apple health programs into three groups based on the income methodology used to determine eligibility:
(a) Those that use a modified adjusted gross income (MAGI)-based methodology described in WAC 182-509-0300, called MAGI-based apple health programs;
(b) Those that use an income methodology other than MAGI, called non-MAGI-based apple health programs, which include:
(i) Supplemental security income (SSI)-related apple health programs;
(ii) Temporary assistance for needy families (TANF)-related apple health programs; and
(iii) Other apple health programs not based on MAGI, SSI, or TANF methodologies.
(c) Those that provide coverage based on a specific status or entitlement in federal rule and not on countable income, called deemed eligible apple health programs.
(2) MAGI-based apple health programs include the following:
(a) Apple health parent and caretaker relative program described in WAC 182-505-0240;
(b) MAGI-based apple health adult medical program described in WAC 182-505-0250, for which the scope of coverage is called the alternative benefits plan (ABP) described in WAC 182-500-0010;
(c) Apple health for pregnant women program described in WAC 182-505-0115;
(d) Apple health for kids program described in WAC 182-505-0210 (3)(a);
(e) Premium-based apple health for kids described in WAC 182-505-0215;
(f) Apple health long-term care for children and adults described in chapter 182-514 WAC; and
(g) Apple health alien emergency medical program described in WAC 182-507-0110 through 182-507-0125 when the person is eligible based on criteria for a MAGI-based apple health program.
(3) Non-MAGI-based apple health programs include the following:
(a) SSI-related programs which use the income methodologies of the SSI program (except where the agency has adopted more liberal rules than SSI) described in chapter 182-512 WAC to determine eligibility:
(i) Apple health for workers with disabilities (HWD) described in chapter 182-511 WAC;
(ii) Apple health SSI-related programs described in chapters 182-512 and 182-519 WAC;
(iii) Apple health long-term care and hospice programs described in chapters 182-513 and 182-515 WAC;
(iv) Apple health medicare savings programs described in chapter 182-517 WAC; and
(v) Apple health alien emergency medical (AEM) programs described in WAC 182-507-0110 and 182-507-0125 when the person meets the age, blindness or disability criteria specified in WAC 182-512-0050.
(b) TANF-related programs which use the income methodologies based on the TANF cash program described in WAC 388-450-0170 to determine eligibility, with variations as specified in WAC 182-509-0001(5) and program specific rules:
(i) Refugee medical assistance (RMA) program described in WAC 182-507-0130; and
(ii) Apple health medically needy (MN) coverage for pregnant women and children who do not meet SSI-related criteria.
(c) Other programs:
(i) Breast and cervical cancer program described in WAC 182-505-0120;
(ii) Family planning only programs described in chapter 182-532 WAC;
(iii) Medical care services described in WAC 182-508-0005;
(iv) Apple health for pregnant minors described in WAC 182-505-0117;
(v) Kidney disease program described in chapter 182-540 WAC; and
(vi) Tailored supports for older adults described in WAC 182-513-1610.
(4) Deemed eligible apple health programs include:
(a) Apple health SSI medical program described in chapter 182-510 WAC, or a person who meets the medicaid eligibility criteria in 1619b of the Social Security Act;
(b) Newborn medical program described in WAC 182-505-0210(2);
(c) Foster care program described in WAC 182-505-0211;
(d) Medical extension program described in WAC 182-523-0100; and
(e) Family planning extension described in WAC 182-505-0115(5).
(5) A person is eligible for categorically needy (CN) health care coverage when the household's countable income is at or below the categorically needy income level (CNIL) for the specific program.
(6) If income is above the CNIL, a person is eligible for the MN program if the person is:
(a) A child;
(b) A pregnant woman; or
(c) SSI-related (aged 65, blind or disabled).
(7) MN health care coverage is not available to parents, caretaker relatives, or adults unless they are eligible under subsection (6) of this section.
(8) A person who is eligible for the apple health MAGI-based adult program listed in subsection (2)(b) of this section is eligible for ABP health care coverage as defined in WAC 182-500-0010. Such a person may apply for more comprehensive coverage through another apple health program at any time.
(9) For the other specific program requirements a person must meet to qualify for apple health, see chapters 182-503 through 182-527 WAC.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-11-007, § 182-503-0510, filed 5/4/23, effective 6/4/23. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 1st sp.s. c 36 § 213 (1)(e), section 1115 of the Social Security Act, and 42 C.F.R. §§ 431.400 through 431.428. WSR 17-12-019, § 182-503-0510, filed 5/30/17, effective 7/1/17. Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (P.L. 111-148), 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-06-068, § 182-503-0510, filed 2/28/14, effective 3/31/14. WSR 12-13-056, recodified as § 182-503-0510, filed 6/15/12, effective 7/1/12. WSR 12-02-034, recodified as § 182-505-0510, filed 12/29/11, effective 1/1/12. Statutory Authority: RCW 34.05.353 (2)(d), 74.08.090, and chapters 74.09, 74.04 RCW. WSR 08-11-047, § 388-503-0510, filed 5/15/08, effective 6/15/08. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and 74.09.530. WSR 05-07-097, § 388-503-0510, filed 3/17/05, effective 4/17/05. Statutory Authority: RCW 74.08.090, 74.08A.100, 74.09.080, and 74.09.415. WSR 02-17-030, § 388-503-0510, filed 8/12/02, effective 9/12/02. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. WSR 98-16-044, § 388-503-0510, filed 7/31/98, effective 9/1/98.]