WSR 97-16-053

EMERGENCY RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES

(Public Assistance)

[Filed July 31, 1997, 4:45 p.m., effective August 1, 1997]

Date of Adoption: July 31, 1997.

Purpose: To implement portions of federal and state legislation concerning welfare reform, implementation of TANF, and immigration reform as it impacts eligibility for medical programs.

Citation of Existing Rules Affected by this Order: Amending WAC 388-500-0005, 388-503-0310, 388-505-0520, 388-507-0740, 388-510-1020, and 388-523-2305.

Statutory Authority for Adoption: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, and ESB 6098 (1997).

Other Authority: Public Law 104-193, EHB 3901 (1997).

Under RCW 34.05.350 the agency for good cause finds that state or federal law or federal rule or a federal deadline for state receipt of federal funds requires immediate adoption of a rule.

Reasons for this Finding: The department is required to change rules by August 1, 1997, to implement, and comply with, state and federal welfare reform legislation.

Number of Sections Adopted in Order to Comply with Federal Statute: New 1, amended 6, repealed 0; Federal Rules or Standards: New 0, amended 0, repealed 0; or Recently Enacted State Statutes: New 1, amended 6, repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, amended 0, repealed 0.

Number of Sections Adopted on the Agency's own Initiative: New 0, amended 0, repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, amended 0, repealed 0.

Number of Sections Adopted using Negotiated Rule Making: New 0, amended 0, repealed 0; Pilot Rule Making: New 0, amended 0, repealed 0; or Other Alternative Rule Making: New 0, amended 0, repealed 0.

Effective Date of Rule: August 1, 1997.

July 31, 1997

Merry A. Kogut, Manager

Rules and Policies Assistance Unit

AMENDATORY SECTION (Amending Order 3913, filed 10/25/95, effective 10/28/95)

WAC 388-500-0005 Medical definitions. Unless defined in this chapter or specifically defined in other chapters of the Washington Administrative Code, the department shall use definitions found in the Webster's New World Dictionary. This section contains definitions of words and phrases the department uses in rules for medical programs. Definitions of words used for both medical and financial programs are defined under WAC 388-22-030.

"Application" for eligibility for medical programs means a written request to the department of social and health services (DSHS) on a department form, from the applicant, an authorized representative, or if the applicant is incompetent or incapacitated, someone acting responsibly for the applicant.

"Assignment Medicare" means the method by which the provider receives payment for services under Part B of Medicare.

"Assignment of rights" means the client gives the state the right to payment and support for medical care from a third party.

"Assistance unit" means a person or members of a family unit who are eligible for medical care.

"Authorization" means official approval for department action.

"Base period" means the time period used in the limited casualty program which corresponds with the months considered for eligibility.

"Beneficiary" means an eligible person who receives:

* A federal cash Title XVI benefit; and/or

* State supplement under Title XVI; or

* Benefits under Title XVIII of the Social Security Act.

"Benefit period" means the time period used in determining whether Medicare can pay for covered Part A services. A benefit period begins the first day a beneficiary is furnished inpatient hospital or extended care services by a qualified provider. The benefit period ends when the beneficiary has not been an inpatient of a hospital or other facility primarily providing skilled nursing or rehabilitation services for sixty consecutive days. There is no limit to the number of benefit periods a beneficiary may receive. Benefit period also means a "spell of illness" for Medicare payments.

"Cabulance" means a for-hire vehicle designed and used to transport a person confined to a wheelchair or persons otherwise physically restricted.

"Carrier" means an organization contracting with the federal government to process claims under Part B of Medicare.

"Categorical assistance unit (CAU)" means one or more family members whose eligibility for medical care is determined separately or together based on categorical relatedness.

"Categorically needy" means the status of a person who is eligible for medical care under Title XIX of the Social Security Act and is:

* A client receiving or eligible to receive cash assistance under:

* Temporary assistance for needy families (TANF). For the purpose of determining eligibility for a medical program, the department shall consider any reference to aid to families with dependent children (((AFDC))) as including TANF;

* Supplemental security income (SSI), including a grandfathered person and a person with an essential spouse:

* State supplement;

* Continuing state-funded cash assistance who is blind or disabled under SSI criteria, as described under WAC 388-511-1105; or

* Special categories.

* A financially eligible person under twenty-one years of age who would be eligible for ((AFDC)) TANF but does not qualify as a dependent child and who is in:

* Foster care;

* Subsidized adoption;

* A nursing facility or intermediate care facility for mentally retarded; or

* An approved inpatient psychiatric facility.

* A person who would be eligible for cash assistance except for the person's institutional status((.));

* A person who is SSI categorically related and would not be eligible for cash assistance if the person was not institutionalized and whose gross income does not exceed the three hundred percent SSI benefit cap((.));

* A qualified severely impaired disabled person under sixty-five years of age who works((.));

* A person ((during a temporary period)) who lost AFDC or TANF because of increased earnings, ((increased hours, loss of earned income disregards,)) or by receiving child or spousal support payments((.));

* A pregnant woman:

((* Who meets AFDC financial eligibility standards;

* Who would qualify for AFDC if the baby was already born;))

* Whose family income does not exceed one hundred eighty-five percent of the federal poverty level; or

* Who was eligible for and receiving Medicaid while pregnant continues to be eligible through a sixty-day postpartum period that extends through the month that contains the sixtieth day after birth.

* An infant until the infant's first birthday when the infant lives with the mother and the mother was Medicaid eligible at the time the infant was born;

* An infant under one year of age whose family income does not exceed one hundred eighty-five percent of the federal poverty level;

* A child under six years of age or until the child is no longer an inpatient if the inpatient stay began before six years of age and whose family income does not exceed one hundred thirty-three percent of the federal poverty level((.));

* A child born after September 30, 1983, who has attained six years of age or until the child is no longer an inpatient if the inpatient stay began before eighteen years of age, but not attained eighteen years of age whose family income does not exceed one hundred percent of the federal poverty level((.));

* A child up to eighteen years of age or until the child is no longer an inpatient if the inpatient stay began before eighteen years of age, born before September 30, 1983, with income allowed by AFDC((.));

* A certain widow, widower, and other qualified person who fails to meet SSI standards because of Social Security coverage or increase in Social Security coverage((.));

* A Medicare-eligible person whose income does not exceed one hundred percent of the federal poverty level and whose resources do not exceed twice the SSI resource eligibility level((.));

* A disabled working person entitled to enroll in Medicare Part A, whose income does not exceed two hundred percent of the federal poverty level and whose resources do not exceed twice the SSI resource eligibility level((.));

* An alien as defined under WAC 388-510-1020; or

* A person whose categorical eligibility is protected by statute.

"Children's health program" means a state-funded medical program for children under eighteen years of age:

* Whose family income does not exceed one hundred percent of the federal poverty level; and

* Who are not otherwise eligible under Title XIX of the Social Security Act.

"Client" means an applicant for or recipient of DSHS medical care programs.

"Coinsurance-Medicare" means the portion of reimbursable hospital and medical expenses, after subtraction of any deductible, which Medicare does not pay. Under Part A, coinsurance is a per day dollar amount. Under Part B, coinsurance is twenty percent of reasonable charges.

"Community services office (CSO)" means an office of the department which administers social and health services at the community level.

"Copayment" means a fixed dollar amount that is the responsibility of the client.

"Couple" means, for the purposes of an SSI-related client, an SSI-related client living with a person of the opposite sex and both presenting themselves to the community as husband and wife. The department shall consider the income and resources of such couple as if the couple were married.

"Deductible-Medicare" means an initial specified amount that is the responsibility of the client.

* "Part A of Medicare-inpatient hospital deductible" means an initial amount of the medical care cost in each benefit period which Medicare does not pay.

* "Part B of Medicare-physician deductible" means an initial amount of Medicare Part B covered expenses in each calendar year which Medicare does not pay.

"Delayed certification" means a department approval of a person's eligibility for medicaid made after the established application processing time limits.

"Department" means the state department of social and health services.

"Early and periodic screening, diagnosis and treatment (EPSDT)" also known as the "healthy kids" program, means a program providing early and periodic screening, diagnosis and treatment to persons under twenty-one years of age who are eligible for Medicaid or the children's health program.

"Electronic fund transfers" means automatic bank deposits to a client's account.

"Emergency medical condition" means a medical condition (including labor and delivery) manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:

* Placing the patient's health in serious jeopardy;

* Impairment to bodily functions; or

* Dysfunction of any bodily organ or part.

"Emergency medical expense requirement" means a specified amount of expenses for ambulance, emergency room or hospital services, including physician services in a hospital, incurred for an emergency medical condition that a client must incur prior to certification for the medically indigent program.

"Essential spouse" see "spouse."

"Extended care patient" means a recently hospitalized Medicare patient needing relatively short-term skilled nursing and rehabilitative care in a skilled nursing facility.

"Garnishment" means withholding an amount from earned or unearned income to satisfy a debt or legal obligation.

"Grandfathered client" means:

* A noninstitutionalized person who meets all current requirements for Medicaid eligibility except the criteria for blindness or disability; and

* Was eligible for Medicaid in December 1973 as blind or disabled whether or not the person was receiving cash assistance in December 1973; and

* Continues to meet the criteria for blindness or disability and other conditions of eligibility used under the Medicaid plan in December 1973; and

* An institutionalized person who was eligible for Medicaid in December 1973 or any part of that month, as an inpatient of a medical institution or resident of an intermediate care facility that was participating in the Medicaid program and for each consecutive month after December 1973 who:

* Continues to meet the requirements for Medicaid eligibility that were in effect under the state's plan in December 1973 for institutionalized persons; and

* Remains institutionalized.

"Health insuring organization (HIO)" means an entity that arranges and pays for medical services provided to an eligible enrolled client in exchange for a premium or subscription charge paid by the department on a prepaid capitation risk basis.

"Health maintenance organization (HMO)" means an entity that provides comprehensive medical services directly to an eligible enrolled client in exchange for a premium paid by the department on a prepaid capitation risk basis.

"Healthy kids," see "EPSDT."

"Home health agency" means an agency or organization certified under Medicare to provide comprehensive health care on a part-time or intermittent basis to a patient in the patient's place of residence.

"Hospital" means an institution licensed as a hospital by the official state licensing authority.

"Income" means, for an SSI-related client, the receipt by an individual of any property or service which the client can apply either directly, by sale, or conversion to meet the client's basic needs for food, clothing, and shelter.

* "Earned income" means gross wages for services rendered and/or net earnings from self-employment. Earned income received at predictable intervals other than monthly or in unequal amounts will be converted to a monthly basis. If income is weekly, the amount is multiplied by 4.3 to arrive at a monthly figure.

* "Unearned income" means all other income.

"Institution" means an establishment which furnishes food, shelter, medically-related services, and medical care to four or more persons unrelated to the proprietor. This includes medical facilities, nursing facilities, and institutions for the mentally retarded, but does not include correctional institutions.

* "Institution-public" means an institution that is the responsibility of a governmental unit or over which a governmental unit exercises administrative control.

* "Institution for mental diseases" means an institution primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases including medical attention, nursing care, and related services.

* "Institution for the mentally retarded or a person with related conditions" means an institution that:

* Is primarily for the diagnosis, treatment or rehabilitation of the mentally retarded or a person with related conditions; and

* Provides, in a protected residential setting, on-going care, twenty-four hour supervision, evaluation, and planning to help each person function at the greatest ability.

* "Institution for tuberculosis" means an institution for the diagnosis, treatment, and care of a person with tuberculosis.

* "Medical institution" means an institution:

* Organized to provide medical care, including nursing and convalescent care;

* With the necessary professional personnel, equipment and facilities to manage the health needs of the patient on a continuing basis in accordance with acceptable standards;

* Authorized under state law to provide medical care; and

* Staffed by professional personnel. Services include adequate physician and nursing care.

"Intermediary" means an organization having an agreement with the federal government to process Medicare claims under Part A.

"Legal dependent" means a person whom another person is required by law to support.

"Limited casualty program (LCP)" means a medical care program for medically needy as defined under WAC 388-503-0320 and for medically indigent as defined under WAC 388-503-0370.

"Medicaid" means the federal aid Title XIX program under which medical care is provided to:

* Categorically needy as defined in WAC 388-503-0310 and ((388-503-1105)) 388-511-1105; or

* Medically needy as defined in WAC 388-503-0320.

"Medical assistance" means the federal aid Title XIX program under which medical care is provided to the categorically needy as defined in WAC 388-503-0310 and ((388-503-1105)) 388-511-1105.

"Medical assistance administration (MAA)" means the unit within the department of social and health services authorized to administer the Title XIX Medicaid and the state-funded medical care programs.

"Medical assistance unit (MAU)" means one or more family members whose eligibility for medical care is determined separately or together based on financial responsibility.

"Medical care services" means the limited scope of care financed by state funds and provided to general assistance (GAU) and ADATSA clients.

"Medical consultant" means a physician employed by the department.

"Medical facility" see "Institution."

"Medically indigent (MI)" means a state-funded medical program, part of the limited casualty program, for a person with limited income and resources who has an emergency medical condition requiring hospital-based services.

"Medically necessary" is a term for describing requested service which is reasonably calculated to prevent, diagnose, correct, cure, alleviate or prevent worsening of conditions in the client that endanger life, or cause suffering or pain, or result in an illness or infirmity, or threaten to cause or aggravate a handicap, or cause physical deformity or malfunction, and there is no other equally effective, more conservative or substantially less costly course of treatment available or suitable for the client requesting the service. For the purpose of this section, "course of treatment" may include mere observation or, where appropriate, no treatment at all.

"Medically needy (MN)" is the status of a person who is eligible for a federally matched medical program under Title XIX of the Social Security Act, who, but for income and/or resources above the categorically needy level, would be eligible as categorically needy. Effective January 1, 1996, an AFDC-related adult is not eligible for MN.

"Medicare" means the federal government health insurance program for certain aged or disabled clients under Titles II and XVIII of the Social Security Act. Medicare has two parts:

* "Part A" covers the Medicare inpatient hospital, post-hospital skilled nursing facility care, home health services, and hospice care.

* "Part B" is the supplementary medical insurance benefit (SMIB) covering the Medicare doctor's services, outpatient hospital care, outpatient physical therapy and speech pathology services, home health care, and other health services and supplies not covered under Part A of Medicare.

"Month of application" means the calendar month a person files the application for medical care unless the application is for the medically needy program, then, at the person's request and if the application is filed in the last ten days of that month, the month of application may be the following month.

"Nursing facility" means any institution or facility the department of health licenses as a nursing facility, or a nursing facility unit of a licensed hospital, that the:

* Department certifies; and

* Facility and the department agree the facility may provide skilled nursing facility care.

"Outpatient" means a nonhospitalized patient receiving care in a hospital outpatient or hospital emergency department, or away from a hospital such as in a physician's office, the patient's own home, or a nursing facility.

"Patient transportation" means client transportation to and from covered medical services under the federal Medicaid and state medical care programs.

"Physician" means a doctor of medicine, osteopathy, or podiatry who is legally authorized to perform the functions of the profession by the state in which the services are performed.

"Professional activity study (PAS)" means a compilation of inpatient hospital data by diagnosis and age, conducted by the commission of professional and hospital activities, to determine the average length of hospital stay for patients. These data were published in a book entitled, Length of Stay in PAS Hospitals, Western. The department has adopted this book as the basis for authorizing payment for the maximum number of inpatient hospital days for clients of state-funded programs, or where no memorandum of understanding with a professional review organization (PRO) exists.

"Professional review organization for Washington (PRO-W)" means the state level organization responsible for determining whether health care activities:

* Are medically necessary;

* Meet professionally acceptable standards of health care; and

* Are appropriately provided in an outpatient or institutional setting for beneficiaries of Medicare and clients of Medicaid and maternal and child health.

"Prosthetic devices" mean replacement, corrective, or supportive devices prescribed by a physician or other licensed practitioner of the healing arts within the scope of his or her practice as defined by state law to:

* Artificially replace a missing portion of the body;

* Prevent or correct physical deformity or malfunction; or

* Support a weak or deformed portion of the body.

"Provider" or "provider of service" means an institution, agency, or person:

* Having a signed agreement with the department to furnish medical care and goods and/or services to clients; and

* Eligible to receive payment from the department.

"Resources" mean, for an SSI-related client, cash or other liquid assets or any real or personal property that an individual or spouse, if any, owns and could convert to cash to be used for support or maintenance.

* If an individual can reduce a liquid asset to cash, it is a resource.

* If an individual cannot reduce an asset to cash, it is not considered an available resource.

* Liquid - Properties that are in cash or are financial instruments which are convertible to cash such as, but not limited to, cash in hand, stocks, savings, checking accounts, mutual fund shares, mortgage, promissory notes.

* Nonliquid - All other property both real and personal shall be evaluated according to the price the item can reasonably be expected to sell for on the open market in the particular geographical area involved.

"Retroactivity" means the period of no more than three calendar months before the application month of an otherwise eligible person under the Federal aid Title XIX program.

"Spell of illness" see "benefit period."

"Spenddown" means the process by which a person uses incurred medical expenses to offset income and/or resources to meet the financial standards established by the department.

"Spouse" means:

* "Community spouse" means a person living in the community and married to an institutionalized person or to a person receiving services from a home and community-based waivered program.

* "Eligible spouse" means an aged, blind or disabled husband or wife of an SSI-eligible person with whom such spouse lives.

* "Essential spouse" means, for the purposes of SSI, a spouse whose needs were taken into account in determining the need of an old age assistance (OAA), aid to the blind (AB), or disability assistance (DA) client for December 1973, who continues to live in the home and to be the spouse of such client.

* "Ineligible spouse" means the husband or wife of an SSI-eligible person, who lives with the SSI-eligible person and who has not applied or is not eligible to receive SSI.

* "Institutionalized spouse" means a married person in an institution or receiving services from a home or community-based waivered program.

* "Nonapplying spouse" means the husband or wife, who has not applied for assistance, of an SSI-eligible person.

"SSI-related" means an aged, blind or disabled person.

"State office or SO" means the medical assistance administration of the department of social and health services.

"Supplemental security income (SSI) program, Title XVI" means the federal grant program for aged, blind, and disabled established by section 301 of the Social Security amendments of 1972, and subsequent amendments, and administered by the Social Security Administration (SSA).

"Supplementary payment (SSP)" means the state money payment to persons receiving benefits under Title XVI, or who would, but for the person's income, be eligible for such benefits, as assistance based on need in supplementation of SSI benefits. This payment includes:

* "Mandatory state supplement" means the state money payment to a person who, for December 1973, was a client receiving cash assistance under the department's former programs of old age assistance, aid to the blind and disability assistance; and

* "Optional state supplement" means the elective state money payment to a person eligible for SSI benefits or who, except for the level of the person's income, would be eligible for SSI benefits.

"Third party" means any entity that is or may be liable to pay all or part of the medical cost of care of a federal Medicaid or state medical care client.

"Title XIX" is the portion of the federal Social Security Act that authorizes grants to states for medical assistance programs. Title XIX is also called Medicaid.

"Transfer" means any act or omission to act when title to or any interest in property is assigned, set over, or otherwise vested or allowed to vest in another person; including delivery of personal property, bills of sale, deeds, mortgages, pledges, or any other instrument conveying or relinquishing an interest in property. Transfer of title to a resource occurs by:

* An intentional act or transfer; or

* Failure to act to preserve title to the resource.

"Value-fair market" means, for SSI-related medical eligibility, the current value of a resource at the going price for which the resource can reasonably be expected to sell on the open market in the particular geographic area involved.

"Value of compensation received" means, for SSI-related medical eligibility, the gross amount paid or agreed to be paid by the purchaser.

"Value-uncompensated" means, for SSI-related medical eligibility, the fair market value of a resource minus the amount of compensation received in exchange for the resource.

[Statutory Authority: RCW 74.08.090. 95-22-039 (Order 3913, #100246), 388-500-0005, filed 10/25/95, effective 10/28/95; 94-10-065 (Order 3732), 388-500-0005, filed 5/3/94, effective 6/3/94. Formerly parts of WAC 388-80-005, 388-82-006, 388-92-005 and 388-93-005.]

AMENDATORY SECTION (Amending WSR 97-03-036, filed 1/9/97, effective 2/9/97)

WAC 388-503-0310 Categorically needy eligible persons. The department shall determine eligible for categorically needy medical assistance a client who is:

(1) Not eligible for or receiving temporary assistance for needy families (TANF) cash benefits who meets the eligibility criteria for aid to families with dependent children (AFDC) that were in effect on July 16, 1996 with the following changes:

(a) Consider earned income as described under WAC 388-507-0740; and

(b) Consider resources as described under WAC 388-505-0580.

This group shall include, but is not limited to, the special situations described under WAC 388-507-0740.

(2) Receiving or eligible to receive a cash assistance payment under:

(a) ((Aid to families with dependent children ()) TANF. For the purpose of determining eligibility for a medical program, the department shall consider any reference to AFDC(())) as including TANF; or

(b) Supplemental security income (SSI) including a grandfathered person and a person with an essential spouse; or

(c) State supplemental payment (SSP) to a person as assistance based on need in supplementation of SSI benefits. This payment includes mandatory state supplement or optional state supplement as defined under WAC 388-500-0005. The ineligible spouse of an SSI beneficiary receiving a state supplement payment for the ineligible spouse is not eligible for noninstitutional categorically needy medical assistance.

(((2))) (3) A person twenty years of age or younger who meets the:

(a) One-person ((AFDC)) TANF financial requirements and is in:

(i) Foster care; or

(ii) Subsidized adoption; or

(iii) A nursing facility or intermediate care facility for mentally retarded (ICF/MR); or

(iv) An approved inpatient psychiatric facility.

(b) Eligibility requirements under chapter 388-509 WAC.

(((3))) (4) A current client of Title II, Social Security Administration (SSA) benefits who:

(a) Was a concurrent client of Title II and SSI benefits;

(b) Is ineligible for SSI benefits and/or state supplementary payments; and

(c) Would be eligible for SSI benefits if the department deducts the following from the current Title II benefit amount:

(i) All Title II cost-of-living benefit increases under P.L. 94-566, Section 503 received by the client since termination from SSI/SSP; and

(ii) All Title II cost-of-living benefit increases received during the time period in subsection (3)(c)(i) of this section by the client's spouse and/or other financially responsible family member living in the same household.

(((4))) (5) An SSI client, after January 1, 1981, who continues to be eligible for medical assistance under P.L. 96-265 and 99-643;

(((5))) (6) A currently disabled client receiving widow's or widower's benefits under Section 202 (e) or (f) of the Social Security Act if the disabled client:

(a) Was entitled to a monthly insurance benefit under Title II of the Social Security Act for December 1983; and

(b) Was entitled to and received a widow's or widower's benefit based on a disability under Section 202 (e) or (f) of the Social Security Act for January 1984;

(c) Became ineligible for SSI/SSP in the first month in which the increase provided under Section 134 of P.L. 98-21 was paid to the client;

(d) Has been continuously entitled to a widow's or widower's benefit under Section 202 (e) or (f) of the act;

(e) Would be eligible for SSI/SSP benefits if the amount of that increase, and any subsequent cost-of-living increases provided under Section 215(i) of the act, were disregarded;

(f) Is fifty through fifty-nine years of age; and

(g) Filed an application for Medicaid coverage before July 1, 1988.

(((6))) (7) Effective January 1, 1991, any person receiving Title II disabled widow/widower benefits (DWB) under Section 202 (e) or (f) of the SSA, if the person:

(a) Is not eligible for the hospital insurance benefits under Medicare Part A of Title XVIII;

(b) Received SSI/SSP payments in the month before receiving such Title II benefits;

(c) Became ineligible for SSI/SSP due to receipt of or increase in such Title II benefits; and

(d) Would be eligible for SSI/SSP if the amount of such Title II benefits or increase in such Title II benefits under Section 202 (e) or (f) of the SSA, and any subsequent cost-of-living increases provided under Section 215(i) of the act were disregarded.

(((7))) (8) A disabled or blind client receiving Title II Disabled Adult Childhood (DAC) benefits under Section 202(d) of the SSA if the client:

(a) Has attained eighteen years of age;

(b) Lost SSI/SSP on or after July 1, 1988, due to receipt of or increase in DAC benefits; and

(c) Would be eligible for SSI/SSP if the amount of the DAC benefits or increase under Section 202(d) of the SSA and any subsequent cost-of-living increases provided under Section 215(i) of the SSA Act were disregarded.

(((8))) (9) A client who:

(a) In August 1972, received:

(i) Old age assistance (OAA);

(ii) Aid to blind (AB);

(iii) Aid to families with dependent children (AFDC); or

(iv) Aid to the permanently and totally disabled (APTD); and

(b) Was entitled to or received retirement, survivors, and disability insurance (RSDI) benefits; or

(c) Is ineligible for OAA, AB, AFDC, SSI or APTD solely because of the twenty percent increase in Social Security benefits under P.L. 92-336.

(((9))) (10) A pregnant woman whose family income is at or below one hundred eighty-five percent of the Federal Poverty Level (FPL), or postpartum woman as described under WAC 388-508-0830;

(((10))) (11) A child, born to a woman eligible for and receiving medical assistance on the date of the child's birth, from the date of birth for a period of one year when the child remains a member of the mother's household;

(((11))) (12) A child eighteen years of age or younger meeting residence, citizenship, and Social Security number requirements whose countable family income is at or under two hundred percent of the FPL.

(((12))) (13) In a family unit ineligible for ((AFDC)) TANF financial assistance as a result (wholly or in part) of the collection or increased collection of child or spousal support shall be eligible for medical assistance for four months beginning with the month of ineligibility, if the family unit received ((AFDC)) TANF financial assistance in at least three of the six months immediately preceding the month of ineligibility;

(((13) In a family unit which becomes ineligible for AFDC before April 1, 1990, solely because of increased hours or increased income from employment shall remain categorically eligible for medical assistance for four calendar months beginning with the month of ineligibility, provided:

(a) The family received AFDC in at least three of the six months immediately preceding the month of ineligibility; and

(b) A member of such family continues to be employed; and

(c) The department considers earned income tax credits (EITC) as income for the purposes of this subsection.))

(14) Denied ((AFDC)) TANF cash payments solely because of a departmental recovery of an overpayment;

(15) In a medical facility and:

(a) Who would be eligible for cash assistance if the person was not institutionalized; or

(b) Is an SSI-related institutionalized person and has gross income above the cash assistance level but below three hundred percent of the Federal Benefit Rate.

(16) Sixty-five years of age or older, a patient in an institution for mental diseases (IMD), and is resource and income eligible as described under subsection (((15))) (14)(a) or (b) of this section;

(17) A person eligible for and accepting hospice services as described under WAC 388-86-047 and who shall be:

(a) SSI categorically related with gross income less than three hundred percent of the SSI Federal Benefit Rate; or

(b) AFDC or TANF categorically related.

(18) Blind or presumptively disabled under SSI criteria, as described under WAC 388-511-1105, and the person receives continuing general assistance (GA-X) cash assistance;

(19) An alien ineligible for AFDC or SSI cash assistance because of deeming of income of the alien's sponsors;

(20) Not an inmate of a public institution;

(21) ((Not receiving cash assistance because of special situations as defined under WAC 388-507-0740)); or

(22))) A client who:

(a) Was entitled to RSDI benefits in August 1972; and

(b) Is ineligible for ((AFDC)) TANF or SSI solely because of the twenty percent increase in Social Security benefits under PL 92-336.

[Statutory Authority: RCW 74.08.090 and 74.04.050. 97-03-036, 388-503-0310, filed 1/9/97, effective 2/9/97. Statutory Authority: RCW 74.08.090 and SPA 95-11. 96-12-001 (Order 3981), 388-503-0310, filed 5/22/96, effective 6/22/96. Statutory Authority: RCW 74.08.090. 94-17-036 (Order 3769), 388-503-0310, filed 8/10/94, effective 9/10/94; 94-10-065 (Order 3732), 388-503-0310, filed 5/3/94, effective 6/3/94. Formerly parts of WAC 388-82-010 and 388-82-115.]

Reviser's note: The typographical error in the above section occurred in the copy filed by the agency and appears in the Register pursuant to the requirements of RCW 34.08.040.

AMENDATORY SECTION (Amending Order 3983, filed 6/6/96, effective 7/7/96)

WAC 388-505-0520 Citizenship ((and alien status)). (1) The department shall provide Medicaid to an otherwise eligible person who is((:

(a))) a citizen of the United States((; or

(b) A North American Indian born in Canada claiming fifty percent:

(i) Indian blood; or

(ii) Or less Indian blood and who has maintained United States residency since before December 25, 1952.

(((c) An alien lawfully admitted for permanent residence or otherwise permanently residing under color of law (PRUCOL) in the United States; or

(d) An alien lawfully present in the United States according to sections 203 (a)(7), 207(c), 208, and 212 (d)(5) of the Immigration and Nationality Act (INA); or

(e) An alien granted lawful temporary residence, or permanent residence according to sections 245(a), 210, 210(f), and 210A of INA and sections 202 and 302 of the Immigration Reform and Control Act (IRCA), unless five years from the date Immigration and Naturalization Service (INS) grants lawful temporary resident status has not passed; or

(f) An alien approved by the INS under the family unity program, unless five years from the date INS grants lawful temporary resident status for the petitioning relative has not passed.

(2) When an alien as described under subsection (1)(e) or (f) of this section has not passed the five-year disqualification period, the department shall provide Medicaid to an otherwise eligible person when the alien is:

(a) Aged, blind, or disabled; or

(b) Seventeen years of age or under; or

(c) Pregnant; or

(d) A Cuban/Haitian entrant as defined in sections 501 (e)(1) and (2)(A) of P.L. 96-422.

(3) When an alien as described under subsection (1)(e) or (f) of this section is still under the five-year disqualification period, and is not described under subsection (2) of this section, the department shall provide medical care and services as necessary for treatment of the alien's emergency medical condition as defined under WAC 388-500-0005.

(4) For any other alien, when such alien meets the eligibility requirements of a Medicaid program other than citizenship or alien status requirements, the department shall provide Medicaid as follows:

(a) Full scope medical services for a pregnant woman; or

(b) Medical care and services as necessary for treatment of the alien's emergency medical condition as defined under WAC 388-500-0005.

(5) Medical care services and children's health programs do not require citizenship/alien status)).

(2) The department shall provide Medicaid to noncitizens who are otherwise eligible who meet immigrant provisions as described under chapter 388-510 WAC.

[Statutory Authority: RCW 74.08.090. 96-13-002 (Order 3983), 388-505-0520, filed 6/6/96, effective 7/7/96. Statutory Authority: RCW 74.08.090 and 1995 2nd sp.s. c 18. 95-24-016 (Order 3923), 388-505-0520, filed 11/22/95, effective 12/23/95. Statutory Authority: RCW 74.08.090. 94-10-065 (Order 3732), 388-505-0520, filed 5/3/94, effective 6/3/94. Formerly WAC 388-83-015.]

AMENDATORY SECTION (Amending Order 3954, filed 3/13/96, effective 4/13/96 WAC 388-507-0740 Special situations. (1) The department shall ((not)) allow ((the AFDC thirty dollars plus one-third earned income exemption for clients applying solely for medical assistance, unless the conditions under subsection (2) of this section apply)) a fifty percent family earned-income exemption and the actual dependent care amount deduction, described in WAC 388-505-0590 when the client:

(a) Applies for or receives temporary assistance for needy families (TANF) cash benefits;

(b) Applies for or receives TANF-related medical only benefits; or

(c) Is not eligible for or receiving TANF benefits but who meets the eligibility criteria for AFDC that were in effect on July 16, 1996.

This subsection does not apply to a client described in subsection (2) of this section.

(2) The department shall allow ((the exemption in subsection (1) of this section when the family has:

(a) Received AFDC cash assistance in one of the four preceding months; and

(b) Not already received the exemption for a maximum of four consecutive months; or

(c) Already received the exemption for the maximum period, but has subsequently not received AFDC cash assistance for at least twelve consecutive months)) a ninety dollar earned-income exemption and the actual dependent care amount deduction when a client applies for or receives noncash medical only benefits described under chapter 388-508 WAC, Pregnant women medical eligibility and chapter 388-509 WAC, Children medical eligibility.

(3) The department shall consider ((an AFDC client terminated from cash assistance)) as eligible for Medicaid ((when termination was solely due to an AFDC client:

(a) Ceasing to attend school; or

(b) Refusing)) a person who:

(a) Would be eligible for, but chooses not to receive, TANF; or

(b) Is not eligible for or receiving TANF solely because the person:

(i) Has received sixty months of financial assistance or is a member of an assistance unit which has received sixty months of financial assistance;

(ii) Is not attending, or ceased to attend school;

(iii) Refuses to participate in the ((job opportunities and basic skills (jobs))) workfirst training program;

(iv) Is an unmarried minor parent and is not in a department-approved living situation as described under WAC 388-215-1660;

(v) Is a parent or caretaker relative who fails to notify the department within five days of the date the child leaves the home and the child's absence will exceed ninety days as described under WAC 388-215-1115;

(vi) Is a fleeing felon or fleeing to avoid prosecution for a felony charge, or a probation and parole violator;

(vii) Is convicted of a drug-related felony as described under WAC 388-215-1570;

(viii) Is convicted of receiving benefits unlawfully as described under WAC 388-46-110;

(ix) Is convicted of misrepresenting residence to obtain assistance in two or more states as described under WAC 388-46-120; or

(x) Has gross earnings exceeding the TANF gross income standard.

(4) The department shall not consider the transfer of a resource when determining medical program eligibility for a person who is not institutionalized. For an institutionalized client, refer to WAC 388-513-1365.

[Statutory Authority: RCW 74.08.090. 96-07-023 (Order 3954), 388-507-0740, filed 3/13/96, effective 4/13/96; 94-10-065 (Order 3732), 388-507-0740, filed 5/3/94, effective 6/3/94.]

NEW SECTION

WAC 388-510-1005 Definitions--Aliens. "Legal immigrant" means an alien residing in the United States who is lawfully present with intent to remain. A legal immigrant includes, but is not limited to, an alien meeting PRUCOL criteria.

"Nonimmigrant" means an alien legally residing in the country but without an intent to remain permanently or who is not lawfully present.

"Nonqualified alien" means any alien or noncitizen not meeting the definition of qualified alien as described under "qualified alien" of this section.

"PRUCOL" means a person residing under color of law.

"Qualified alien" means an alien:

(1) Who is lawfully admitted for permanent residence under the Immigration and Nationality Act (8 U.S.C. 12), including but not limited to an American Indian born in Canada who resides in the United States and who:

(a) Has at least fifty percent American Indian blood; or

(b) Has less than fifty percent Indian blood and who has maintained United States residency since before December 25, 1952.

(2) Who is a refugee admitted to the United States under section 207 of such Act;

(3) Who is granted asylum under section 208 of Act;

(4) Whose deportation is being withheld under section 243(h) of such Act;

(5) Who is paroled into the United States under section 212(d)(5) of such Act for a period of at least one year;

(6) Who is granted conditional entry under section 203(a)(7) of such Act as in effect prior to April 1, 1980; or

(7) Who is an immigrant that is a victim of domestic violence or an immigrant child that has been battered or subjected to extreme cruelty when:

(a) The immigrant petitions for legal status under the Illegal Immigration Reform and Immigrant Responsibility Act P.L. 104-208 section 501; and

(b) The person responsible for the battery no longer resides with the immigrant.

[]

AMENDATORY SECTION (Amending Order 3732, filed 5/3/94, effective 6/3/94)

WAC 388-510-1020 Alien--Eligibility. (1) For the purpose of determining eligibility for a medical program, the department shall ((provide Medicaid to an otherwise eligible person who meets the criteria as described under WAC 388-505-0520)) consider the terms "qualified alien" or "nonqualified alien" as indicating the Immigration and Naturalization Services (INS) status of the alien, not as an indication of eligibility status for medical programs.

(2) The department shall consider as eligible for Medicaid an alien receiving temporary assistance for needy families (TANF) or Supplemental Security Income (SSI).

(3) The department shall determine eligible for categorically needy (CN) Medicaid a qualified alien who:

(a) Arrived in the United States on or before August 21, 1996;

(b) Is otherwise eligible for or related to a Medicaid program; and

(c) Meets one of the qualified alien categories described under WAC 388-510-1005.

(4) The department shall determine eligible for state-funded CN scope of care a legal immigrant who:

(a) Arrived in the United States on or before August 21, 1996;

(b) Is otherwise eligible for or related to a Medicaid program; and

(c) Does not meet qualified alien criteria.

(5) The department shall determine eligible for CN Medicaid an alien who:

(a) Arrived in the United States on or after August 22, 1996;

(b) Is otherwise eligible for or related to a Medicaid program; and

(c) Meets at least one of the following qualified alien categories:

(i) A refugee;

(ii) An asylee;

(iii) An alien who has had deportation withheld; or

(iv) An honorably discharged veteran or alien on active duty in the United States armed forces, the spouse or unmarried dependent child of such person; or

(d) Is a qualified alien who has resided in the United States for five years.

(6) The department shall determine eligible for state-funded CN scope of care a family with child(ren) who:

(a) Arrived in the United States on or after August 22, 1996;

(b) Has resided in Washington for twelve-consecutive months as described under WAC 388-215-1210;

(c) Is determined eligible for or receiving state-funded TANF; and

(d) Is a legal immigrant not meeting the alien criteria described under subsection (5)(c) of this section.

(7) The department shall determine eligible for state-funded medical care services, as described under WAC 388-529-2930, an alien who:

(a) Arrived in the United States on or after August 22, 1996;

(b) Is determined eligible for and is receiving financial assistance under the GA-U program; and

(c) Is a legal immigrant who does not meet the alien criteria described under subsection (5)(c) of this section.

(8) The department shall determine eligible for state-funded CN scope of care an alien pregnant woman:

(a) Who is not eligible for coverage under a CN Medicaid program;

(b) Regardless of date of arrival into the United States; and

(c) Who would be eligible under chapter 388-508 WAC.

(9) The department shall determine eligible for state-funded CN scope of care an alien child under the Children's Health Program:

(a) Who is not eligible for coverage under a CN Medicaid program;

(b) Regardless of date of arrival into the United States; and

(c) Who would be eligible under WAC 388-509-0920.

(10) The department shall provide emergency medical care and services:

(a) Regardless of date of arrival into the United States;

(b) For any alien meeting Medicaid eligibility requirements as described in WAC 388-503-0310 and 0320, other than citizenship; and

(c) Only for the necessary treatment of an alien's emergency medical condition as defined under WAC 388-500-0005, with the exception of:

(i) Organ transplants as described under WAC 388-87-115(2) and related medical care services; or

(ii) Routine prenatal or postpartum care.

(11) Refer to chapter 388-518 WAC, Limited casualty program--Medically indigent for an alien who:

(a) Is not eligible for or related to a Medicaid program;

(b) Has an emergency medical condition; or

(c) Requires an organ transplant.

[Statutory Authority: RCW 74.08.090. 94-10-065 (Order 3732), 388-510-1020, filed 5/3/94, effective 6/3/94.]

AMENDATORY SECTION (Amending Order 3732, filed 5/3/94, effective 6/3/94)

WAC 388-523-2305 Medical extensions. (1) Refer to:

(a) WAC 388-508-0830 for extensions for a pregnant woman; and

(b) WAC 388-508-0835 for the family planning extension.

(2) A family unit ineligible for AFDC or temporary assistance for needy families (TANF) cash assistance because of the collection or increased collection of child or spousal support shall be eligible for medical assistance for four months beginning with the month of ineligibility provided the family unit:

(a) Is eligible for and received AFDC or TANF cash assistance in three or more of the six months immediately preceding the month of ineligibility; and

(b) Continues to meet all AFDC or TANF eligibility criteria except income.

(3) The department shall find eligible for medical assistance, an AFDC or TANF family unit which becomes ineligible for or requests termination from cash assistance because of:

(a) Income from((,)); or

(b) Hours of, employment of the caretaker relative; ((or

(b) The loss of the thirty dollars plus one-third earned income deduction; or

(c) The loss of the thirty-dollar earned income deduction)). Such ((AFDC)) family unit as described under (a)((,)) and (b)((, or (c))) of this subsection shall remain eligible for medical assistance for six calendar months when the family unit:

(i) Received AFDC or TANF in three or more of the six months immediately preceding the month of ineligibility; and

(ii) Includes a child.

(4) The ((AFDC)) family unit, under subsection (3) of this section, shall be:

(a) Eligible for six additional calendar months of medical assistance provided the family unit:

(i) Continues to include a child; and

(ii) Received medical assistance for the entire six-month extension under subsection (3) of this section; and

(iii) Reports any family earnings and child care costs related to the employment of the caretaker relative for the preceding three-month period. The client shall report by the twenty-first day of the fourth month of the initial extension, unless good cause is established.

(b) Terminated from the six additional calendar months of medical assistance when the:

(i) Family's average gross monthly earned income, less the cost of child care related to employment of the caretaker relative, exceeds one hundred eighty-five percent of the Federal Poverty Level when averaged over the immediately preceding three-month period; or

(ii) Caretaker relative has no earnings in one or more of the three previous months, unless lack of earnings is due to good cause.

(5) An AFDC or TANF family member shall not be eligible for the extensions in subsections (3) and (4) of this section when the department finds the person ineligible for AFDC or TANF in any of the last six months before the extension because of fraud.