Original Notice.

     Preproposal statement of inquiry was filed as WSR 12-19-092.

     Title of Rule and Other Identifying Information: WAC 182-500-0020 Medical assistance definitions -- C, 182-500-0030 Medical assistance definitions -- E, 182-503-0001 Insurance affordability programs -- Overview, 182-503-0005 Washington apple health (WAH) -- How to apply, 182-503-0010 WAH -- Who can apply, 182-503-0060 WAH -- Application processing times, 182-503-0070 WAH -- When coverage begins, 182-503-0080 WAH -- Application denials and withdrawals, 182-503-0505 WAH -- General eligibility requirements, 182-503-0515 WAH -- Social security number requirements, 182-503-0520 WAH -- Residency requirements for noninstitutionalized medical programs, 182-503-0525 WAH -- Residency requirements for an institutionalized individual, 182-503-0535 WAH -- Citizenship and alien status, 182-503-0540 WAH -- Assignment of rights and cooperation, 182-503-0565 WAH -- Age requirements for medical programs based on MAGI, 182-504-0015 WAH -- Certification periods for CN programs, 182-504-0035 WAH -- Renewals, 182-504-0105 WAH -- Changes that must be reported, 182-504-0110 WAH -- When to report changes, 182-504-0120 WAH -- Effective dates of changes, 182-504-0125 WAH -- Effect of changes, 182-505-0100 WAH -- Monthly income standards based on the FPL, 182-505-0115 WAH -- Eligibility for pregnant women, 182-505-0210 WAH -- Eligibility for children, 182-505-0211 WAH -- Foster care, 182-505-0220 Definitions for premium-based health care coverage under programs included in apple health for kids, 182-505-0225 WAH -- Premium-based children's program -- Purpose and scope, 182-505-0230 Waiting period for premium-based health care coverage, 182-505-0235 WAH -- Premium-based children's program -- Order of payments, 182-505-0237 WAH -- Premium-based children's program -- Other rules that apply, 182-505-0240 WAH -- Parents and caretaker relatives, 182-505-0245 Income and resources standards for family medical programs, 182-505-0250 WAH -- MAGI-based adult medical, 182-505-0515 Medical coverage resulting from a cash grant, 182-518-0005 WAH -- Notice requirements -- General, 182-518-0010 WAH -- Notice requirements -- Approval and denial notices, 182-518-0015 WAH -- Notice requirements -- Verification requests, 182-518-0020 WAH -- Notice requirements -- Renewals, 182-518-0025 WAH -- Notice requirements -- Changes in and terminations of coverage, and 182-518-0030 WAH -- Notice requirements -- Electronic notices.

     Hearing Location(s): Health Care Authority (HCA), Cherry Street Plaza Building, Sue Crystal Conference Room 106A, 626 8th Avenue, Olympia, WA 98504 (metered public parking is available street side around building. A map is available at http://maa.dshs.wa.gov/pdf/CherryStreetDirectionsNMap.pdf or directions can be obtained by calling (360) 725-1000), on June 25, 2013, at 10:00 a.m.

     Date of Intended Adoption: Not sooner than June 26, 2013.

     Submit Written Comments to: HCA Rules Coordinator, P.O. Box 45504, Olympia, WA 98504-5504, delivery 626 8th Avenue, Olympia, WA 98504, e-mail arc@hca.wa.gov, fax (360) 586-9727, by 5:00 p.m. on June 25, 2013.

     Assistance for Persons with Disabilities: Contact Kelly Richters by June 17, 2013, TTY (800) 848-5429 or (360) 725-1307 or e-mail kelly.richters@hca.wa.gov.

     Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: HCA is implementing new regulations under the federal Patient Protection and Affordable Care Act in preparation for healthcare reform in Washington state. This includes the establishment of standalone rules for medical assistance programs, which are required under 2E2SHB 1738, Laws of 2011, which creates the HCA as the single state agency responsible for the administration and supervision of Washington's medicaid program (WAH).

     Reasons Supporting Proposal: See Purpose statement above.

     Statutory Authority for Adoption: RCW 41.05.021.

     Statute Being Implemented: Patient Protection and Affordable Care Act (Public Law 111-148); 42 C.F.R. § 431, 435, and 457; and 45 C.F.R. § 155.

     Rule is necessary because of federal law, Patient Protection and Affordable Care Act (Public Law 111-148).

     Name of Proponent: HCA, governmental.

     Name of Agency Personnel Responsible for Drafting: Kevin Sullivan, P.O. Box 42716, Olympia, WA 98504-2716, (360) 1344 [725-1344]; Implementation and Enforcement: Catherine Fisher, P.O. Box 45534, Olympia, WA 98504-5534, (360) 1357 [725-1357].

     No small business economic impact statement has been prepared under chapter 19.85 RCW. The joint administrative rules review committee has not requested the filing of a small business economic impact statement, and these rules do not impose a disproportionate cost impact on small businesses.

     A cost-benefit analysis is not required under RCW 34.05.328. RCW 34.05.328 does not apply to HCA rules unless requested by the joint administrative rules review committee or applied voluntarily.

May 22, 2013

Kevin M. Sullivan

Rules Coordinator

OTS-5459.2

AMENDATORY SECTION(Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)

WAC 182-500-0020   Medical assistance definitions -- C.   "Caretaker relative" means a relative of a dependent child by blood, adoption, or marriage with whom the child is living, who assumes primary responsibility for the child's care, and who is one of the following:

     (1) The child's father, mother, grandfather, grandmother, brother, sister, stepfather, stepmother, stepbrother, stepsister, uncle, aunt, first cousin, nephew, or niece.

     (2) The spouse of such parent or relative (including same sex marriage or domestic partner), even after the marriage is terminated by death or divorce.

     (3) Other relatives including relatives of half-blood, first cousins once removed, persons of earlier generations (as shown by the prefixes of great, great-great, or great-great-great), and natural parents whose parental rights were terminated by a court order.

     "Carrier" means an organization that contracts with the federal government to process claims under medicare Part B.

     "Categorically needy (CN) or categorically needy program (CNP)" is the state and federally funded health care program established under Title XIX of the Social Security Act for persons within medicaid-eligible categories, whose income and/or resources are at or below set standards.

     "Categorically needy income level (CNIL)" is the standard used by the agency to determine eligibility under a categorically needy program.

     "Categorically needy (CN) scope of care" is the range of health care services included within the scope of service categories described in WAC ((388-501-0060)) 182-501-0060 available to individuals eligible to receive benefits under a CN program. Some state-funded health care programs provide CN scope of care.

     "Centers for Medicare and Medicaid Services (CMS)" means the agency within the federal department of health and human services (DHHS) with oversight responsibility for the medicare and medicaid programs.

     "Children's health program or children's health care programs" See "Apple health for kids."

     "Community spouse." See "spouse" in WAC ((388-500-0100)) 182-500-0100.

     "Cost-sharing" means any expenditure required by or on behalf of an enrollee with respect to essential health benefits; such term includes deductibles, coinsurance, copayments, or similar charges, but excludes premiums, balance billing amounts for nonnetwork providers, and spending for noncovered services.

     "Cost-sharing reductions" means reductions in cost-sharing for an eligible individual enrolled in a silver level plan in the health benefit exchange or for an individual who is an American Indian or Alaska native enrolled in a qualified health plan (QHP) in the exchange.

     "Couple." See "spouse" in WAC ((388-500-0100)) 182-500-0100.

     "Covered service" is a health care service contained within a "service category" that is included in a medical assistance benefits package described in WAC ((388-501-0060)) 182-501-0060. For conditions of payment, see WAC ((388-501-0050)) 182-501-0050(5). A noncovered service is a specific health care service (for example, cosmetic surgery), contained within a service category that is included in a medical assistance benefits package, for which the agency or the agency's designee requires an approved exception to rule (ETR) (see WAC ((388-501-0160)) 182-501-0160). A noncovered service is not an excluded service (see WAC ((388-501-0060)) 182-501-0060).

     "Creditable coverage" means most types of public and private health coverage, except Indian health services, that provide access to physicians, hospitals, laboratory services, and radiology services. This term applies to the coverage whether or not the coverage is equivalent to that offered under premium-based programs included in Washington apple health (WAH). Creditable coverage is described in 42 U.S.C. 300gg-3 (c)(1).

[11-14-075, recodified as § 182-500-0020, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 2011 1st sp.s. c 15. 11-14-053, § 388-500-0020, filed 6/29/11, effective 7/30/11.]

     "Emergency medical condition" means the sudden onset of 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:

     (1) Placing the patient's health in serious jeopardy;

     (2) Serious impairment to bodily functions; or

     (3) Serious dysfunction of any bodily organ or part.

     "Emergency medical expense requirement (EMER)." See WAC 388-865-0217(3).

     "Employer-sponsored dependent coverage" means creditable health coverage for dependents offered by a family member's employer or union, for which the employer or union may contribute in whole or in part towards the premium. Extensions of such coverage (e.g., COBRA extensions) also qualify as employer-sponsored dependent coverage as long as there remains a contribution toward the premiums by the employer or union.

     "Evidence-based medicine (EBM)" means the application of a set of principles and a method for the review of well-designed studies and objective clinical data to determine the level of evidence that proves to the greatest extent possible, that a health care service is safe, effective, and beneficial when making:

     (1) Population-based health care coverage policies (WAC ((388-501-0055)) 182-501-0055 describes how the agency or ((the agency's)) its designee determines coverage of services for its health care programs by using evidence and criteria based on health technology assessments); and

     (2) Individual medical necessity decisions (WAC ((388-501-0165)) 182-501-0165 describes how the agency or ((the agency's)) its designee uses the best evidence available to determine if a service is medically necessary as defined in WAC ((388-500-0030)) 182-500-0030).

     "Exception to rule." See WAC ((388-501-0160)) 182-501-0160 for exceptions to noncovered health care services, supplies, and equipment. See WAC 182-503-0090 for exceptions to program eligibility.

     "Expedited prior authorization (EPA)" means the process for obtaining authorization for selected health care services in which providers use a set of numeric codes to indicate to the agency or the agency's designee which acceptable indications, conditions, or agency or agency's designee-defined criteria are applicable to a particular request for authorization. EPA is a form of "prior authorization."

     "Extended care services" means nursing and rehabilitative care in a skilled nursing facility provided to a recently hospitalized medicare patient.

[11-14-075, recodified as § 182-500-0030, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 2011 1st sp.s. c 15. 11-14-053, § 388-500-0030, filed 6/29/11, effective 7/30/11.]

OTS-5460.2

NEW SECTION
WAC 182-503-0001   Insurance affordability programs -- Overview.   (1) A person may apply for all of the insurance affordability programs offered through the health care authority (HCA) or the Washington Healthplanfinder (as defined in WAC 182-500-0015):

     (a) Washington apple health (WAH) programs (defined in WAC 182-500-0120). WAH includes medicaid programs (defined in WAC 182-500-0070), the children's health insurance program (CHIP) (defined in WAC 182-500-0020), and state-only funded health care programs. These programs are provided free or at low cost on a sliding scale to eligible persons based on their income. WAH program regulations for the application process and eligibility determination are found in chapters 182-503 through 182-527 WAC.

     (b) Health insurance premium tax credits (defined in WAC 182-500-0045). This federal refundable tax credit partially offsets the cost of monthly premiums for qualified health plan (QHP) (defined in WAC 182-500-0090) insurance that an eligible person purchases through the Washington Healthplanfinder. These advance payments are reconciled annually by the Internal Revenue Service (IRS) at the time the person files his or her federal tax return.

     (c) Cost-sharing reductions. Cost-sharing reductions (defined in WAC 182-500-0020) are available to eligible persons enrolled in a silver-level QHP and to American Indians/Alaska natives enrolled in any QHP.    

     (2) A person may also apply for and enroll in unsubsidized insurance with a QHP. This unsubsidized insurance is not an insurance affordability program.

     (3) Persons choose whether or not to apply for insurance affordability programs. All persons who apply for an insurance affordability program are treated as an applicant for WAH coverage and receive an approval or denial of WAH. Applicants who are denied are reviewed for other insurance affordability programs.

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     (a) Online;

     (b) By calling the Healthplanfinder customer support center number;

     (c) By mail;

     (d) By fax; or

     (e) At a local department of social and health services (DSHS) office.

     (2) You may need to complete a supplemental form for WAH if you are:

     (a) Age sixty-five or older;

     (b) On medicare;

     (c) Applying for healthcare based on blindness or disability; or

     (d) Applying for long-term care services.

     (3) If you need help filing an application, you can:

     (a) Contact the Healthplanfinder customer support center number listed on the application form;

     (b) Contact an application assistor, certified application counselor or navigator; or

     (c) Have an authorized representative apply on your behalf as described in WAC 182-503-0010.

     (4) We will help you with the application or renewal process according to the equal access provisions described in WAC 182-503-0120 and the limited-English proficient provisions described in WAC 182-503-0110.

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     (2) You can apply for WAH for another person if you are:

     (a) A legal guardian;

     (b) An authorized representative;

     (c) A parent or caretaker relative of a child less than nineteen years of age;

     (d) A tax filer applying for a tax dependent less than nineteen years of age;

     (e) A spouse; or

     (f) A person applying for someone who is unable to apply on their own due to a medical condition and who is in need of long-term care services.

     (3) If you reside in one of the following public institutions, you may turn in an application up to forty-five days before you are released:

     (a) Washington state department of corrections;

     (b) City or county jails; or

     (c) An institution for mental disease (IMD).

     (4) You are automatically enrolled in WAH and do not need to turn in an application if you are a:

     (a) Supplemental security income (SSI) recipient;

     (b) Person deemed to be an SSI recipient under 1619(b) of the SSA;

     (c) Newborn as described in WAC 182-505-0210; or

     (d) Child in foster care placement as described in WAC 182-505-0211.

     (5) You are the primary applicant on an application if you complete and sign the application on behalf of your household.

     (6) If you are an SSI recipient, then you must turn in a signed application when applying for long-term care services per WAC 182-513-1315.

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     (a) Pregnant. We process these applications within fifteen calendar days; or

     (b) Applying for a program that requires a disability decision. We process these applications within sixty calendar days.

     (2) For calculating time limits, "day one" is the day we get a completed application from you, including at least your name, address, and signature.

     (3) If we need more information to decide if you can get WAH benefits, you will be given:

     (a) A letter asking for the additional information within twenty calendar days of your initial application; and

     (b) At least ten calendar days to provide the requested information.

     (4) Good cause for a delay in processing the application exists when we acted as promptly as possible but:

     (a) The delay was the result of an emergency beyond our control;

     (b) The delay was the result of needing more information or documents that could not be readily obtained;

     (c) You did not give us the information within the time frame specified in subsection (1) of this section.

     (5) Good cause for a delay in processing the application does NOT exist when:

     (a) We caused the delay in processing by:

     (i) Failing to ask you for information timely; or

     (ii) Failing to act on requested information when you provided it timely; or

     (b) We did not document the good cause reason when processing the application outside of the time frames specified in subsection (1) of this section.

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     (2) Sometimes we can start your coverage up to three months before the month you applied (see WAC 182-504-0005).

     (3) If you are confined or incarcerated as described in WAC 182-503-0010, your coverage cannot start before the day you are discharged, except when:

     (a) You are hospitalized during your confinement; and

     (b) The hospital requires you to stay overnight.

     (4) Your WAH coverage may not begin on the first day of the month if:

     (a) Subsection (3) of this section applies to you. In that case, your coverage would start on the first day of your hospital stay;

     (b) You must meet a medically needy spenddown liability (see WAC 182-519-0110). In that case, your coverage would start on the day your spenddown is met; or

     (c) You are eligible under the WAH alien emergency medical program (see WAC 182-507-0115). In that case, your coverage would start on the day your emergent hospital stay begins.

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     (2) We deny your application for Washington apple health (WAH) coverage when:

     (a) You tell us either verbally or in writing to withdraw your request for coverage;

     (b) You do not give us the information we ask for within the time frames stated in WAC 182-503-0060, including any extra time we allow based on your request, to accommodate a disability, or limited-English proficiency, and we need the information to decide whether you can receive coverage;

     (c) The information you provide shows you are not eligible.

     (3) We send you a written notice explaining why we denied your application (per chapter 182-518 WAC).

     (4) We reconsider our decision to deny your WAH coverage without a new application from you when you:

     (a) Give us the information we need to decide if you are eligible within thirty days of the date on the denial notice; or

     (b) Request a hearing within ninety days of the date on the denial letter and an administrative law judge (ALJ) decides our denial was wrong (per chapter 182-526 WAC).

     (5) If you disagree with our decision, you can ask for a hearing. If we denied your application because we don't have enough information, the ALJ will consider the information we already have and anymore information you give us. The ALJ does not consider the previous absence of information or failure to respond in determining if you are eligible.

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     (2) If you are not able to provide your SSN, either because you do not know it or it has not been issued, you must provide:

     (a) Proof from the Social Security Administration (SSA) that you turned in an application for an SSN; and

     (b) The SSN when you receive it.

     (3) Your WAH coverage will not be delayed, denied or terminated while waiting for SSA to send you your SSN.

     (4) If you do not provide your SSN, then you will not receive WAH coverage except if you:

     (a) Refused to apply for or provide your SSN for religious reasons;

     (b) Claim good cause for not providing your SSN because of domestic violence;

     (c) Have a newborn as described in WAC 182-505-0210(1). A newborn is eligible for WAH coverage until the baby's first birthday.

     (5) There is no SSN requirement for the following:

     (a) WAH refugee medical;

     (b) WAH alien emergency medical;

     (c) WAH programs for children and pregnant women who do not meet citizenship criteria described in WAC 182-503-0535;

     (d) A household member who is not applying for WAH coverage.

     (6) If you are a "qualified" or "nonqualified" alien as defined in WAC 182-503-0530 who is not authorized to work in the U.S., you do not have to apply for a nonwork SSN.

[]

     (2) The agency must determine whether an individual is capable of indicating their intent to reside in Washington state when deciding whether that individual is a resident of the state. The agency determines that individuals who meet the following criteria are deemed incapable of indicating intent to reside in the state:

     (a) The individual is judged legally incompetent by a court of law;

     (b) A physician, psychologist or licensed medical professional in the field of intellectual disabilities has determined that the individual is incapable of indicating intent; or

     (c) The individual is incapable of declaring intent due to a documented medical condition.

     (3) When an individual is placed in an out-of-state institution by the agency, its designee or by a department of social and health services-contracted agency, the state arranging the placement is considered the individual's state of residence, unless the individual is capable of expressing intent and:

     (a) Indicates a desire to change his or her state of residence; or

     (b) Asks the current state of residence for help in relocating. This may include assistance in locating an institutional placement in the new state of residence.

     (4) If another state has not authorized the placement in the institution, as described in subsection (3) of this section, the agency or its designee uses one of the following criteria to determine the state of residence for an individual who is age twenty or younger:

     (a) The state of residence is the state where the parent or legal guardian is a resident at the time of the placement in the institution. To determine a parent's or legal guardian's place of residence, follow rules described in WAC 182-503-0520 for a noninstitutionalized individual.

     (b) The state of residence is the state where the parent or legal guardian currently is a resident if the individual resides in an institution in that state.

     (c) If the parents of the individual are separated and live in different states, the state of residence is that of the parent filing the application.

     (d) If the parental rights are terminated and the individual has a legal guardian, the state of residence is where the legal guardian is a resident.

     (e) If the individual has both a guardian of the estate and a guardian of the person, the state of residence is where the guardian of the person is a resident, unless the state has laws which delegate guardianship to a state official or agency for individuals who are admitted to state institutions. In that case, the state of residence for the individual is the state where the institution is located (unless another state has authorized the placement).

     (f) If the individual has been abandoned by the parents or legal guardian, and an application is filed on their behalf by another party, the state of residence is the state where the individual is institutionalized. The term abandoned also includes situations where the parents or legal guardian are deceased.

     (5) An individual age twenty-one or older that is capable of indicating intent is considered a resident of the state where he or she is living and intends to reside.

     (6) An individual age twenty-one or older who became incapable of indicating intent at age twenty-one or older is considered a resident of the state where the individual is physically residing, unless the individual has been placed in the institution by another state.

     (7) An individual age twenty-one or older who became incapable of indicating intent before the age of twenty-one is considered a resident of the state where the parents or legal guardian were residents at the time of the placement in the institution.

     (8) If a noninstitutionalized individual moves directly from another state to an institution in Washington state, it is not necessary for the individual to establish residency in Washington state prior to entering the facility. The person is considered a resident if he or she intends to reside in the state unless the placement was made by the other state.

     (9) An individual of any age who receives a state supplemental payment (SSP) is considered a resident of the state that is making the payment.

     (10) In a dispute between states, the state of residence is the state in which the individual is physically located.

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     (a) A United States (U.S.) citizen;

     (b) A U.S. national;

     (c) A qualified alien; or

     (d) A nonqualified alien and you are a:

     (i) Pregnant woman;

     (ii) Child under age nineteen; or

     (iii) Child under age twenty-one who resides in an institution.

     (2) If you are a nonqualified alien approved under deferred action childhood arrivals (DACA), then you are not eligible for WAH under subsection (1)(d) of this section. However, you may qualify under subsection (6) of this section.

     (3) If you are a qualified alien as defined in WAC 182-503-0530, you may receive WAH for nonpregnant adults if you:

     (a) Physically entered the U.S. before August 22, 1996;

     (b) Have continuously resided in the U.S. before becoming a qualified alien; and

     (c) Are not subject to the five-year bar.

     (4) If you physically entered the U.S. on or after August 22, 1996, you are subject to the five-year bar for WAH for nonpregnant adults, unless you meet one of the exemptions in subsection (5) of this section. The five-year bar starts on the day you obtain qualified status.

     (5) You are exempt from the five-year bar if you are one of the following qualified aliens as defined in WAC 182-503-0530:

     (a) Amerasian lawful permanent residents;

     (b) Asylees;

     (c) Cuban/Haitian entrants;

     (d) Persons granted withholding of deportation or removal;

     (e) Refugees;

     (f) Special immigrants from Iraq and Afghanistan;

     (g) Victims of trafficking who have been certified or had their eligibility approved by the Office of Refugee Resettlement (ORR); and

     (h) Lawful permanent residents, parolees, or battered aliens, who are also an armed services member or veteran as described below:

     (i) On active duty in the U.S. military, other than active duty for training;

     (ii) An honorably discharged U.S. veteran;

     (iii) A veteran of the military forces of the Philippines who served prior to July 1st, 1946, as described in Title 38, Section 107 of the U.S. Code; or

     (iv) The spouse, unremarried widow or widower, or unmarried dependent child of a veteran or active duty service member.

     (6) If you are ineligible for WAH because of the five-year bar or because of your immigration status, including if you are approved under DACA, you may be eligible for:

     (a) The WAH alien emergency medical program as described in WAC 182-507-0110 through 182-507-0125;

     (b) WAH pregnancy medical for noncitizen women as described in WAC 182-505-0115;

     (c) State-funded WAH for kids as described in WAC 182-505-0210; or

     (d) The medical care services (MCS) program as described in chapter 182-508 WAC.

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     (1) You must be age sixty-four or younger to be eligible for WAH MAGI-based adult coverage as described in WAC 182-505-0250.

     (2) Your household must include an eligible dependent child age seventeen or younger to be eligible for WAH parent or caretaker relative coverage as described in WAC 182-505-0240. The child must be related to you in one of the ways described in WAC 182-500-0020 to be considered an eligible dependent child.

     (3) A child must be age eighteen or younger to be eligible for WAH for kids as described in WAC 182-505-0210 with the following exceptions:

     (a) An institutionalized child may still qualify under a children's health care program through the age of twenty-one (see WAC 182-514-0230);

     (b) A foster care child may qualify for WAH foster care coverage through the age of twenty-six (see WAC 182-505-0211).

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OTS-5461.1

AMENDATORY SECTION(Amending WSR 12-13-056, filed 6/15/12, effective 7/1/12)

WAC 182-503-0505   Washington apple health -- General eligibility requirements ((for medical programs)).   (1) ((Persons)) Individuals applying for ((benefits under the medical coverage)) Washington apple health (WAH) programs established under chapter 74.09 RCW must meet the eligibility criteria ((established by the department)) in chapters ((388-400)) 182-500 through ((388-555)) 182-527 WAC.

     (2) ((Persons)) Individuals applying for ((medical coverage)) WAH are considered first for federally funded or federally matched programs. State-funded programs are considered after the individual is determined ineligible for federally funded and federally matched programs ((are not available to the client except for brief periods when the state-funded programs offer a broad scope of care which meet a specific client need)).

     (3) Unless otherwise specified in program specific WAC, the eligibility criteria for each ((medical)) WAH program is as follows:

     (a) Verification of age and identity (((chapters 388-404, 388-406, and 388-490)) WAC 182-503-0050); ((and))

     (b) Residence in Washington state (((chapter 388-468)) WAC 182-503-0520 and 182-503-0525); ((and))

     (c) Citizenship or immigration status in the United States (((chapter 388-424)) WAC 182-503-0535); ((and))

     (d) Possession of a valid Social Security account number (((chapter 388-476)) WAC 182-503-0515); ((and))

     (e) Assignment of medical support rights to the state of Washington (WAC ((388-505-0540)) 182-503-0540); ((and))

     (f) ((Cooperation in securing medical support (chapter 388-422 WAC); and

     (g))) Application for medicare and enrollment into medicare's prescription drug program if:

     (i) It is likely that the individual is entitled to medicare; and

     (ii) The state has authority to pay medicare cost sharing as described in chapter ((388-517)) 182-517 WAC.

     (((h))) (g) For individuals whose eligibility is not on the basis of modified adjusted gross income (MAGI) methodology, countable resources must be within specific program limits (chapters ((388-470 and 388-478)) 182-512, 182-513, 182-515, 182-517, and 182-519 WAC); and

     (((i))) (h) Countable income within program limits (((chapters 388-450 and 388-478 WAC).)):

     (i) For MAGI-based WAH programs, see WAC 182-505-0100;

     (ii) For the WAH refugee program, see WAC 182-507-0110;

     (iii) For the WAH medical care services program, see WAC 182-508-0230;

     (iv) For WAH for workers with disabilities (HWD), see WAC 182-511-0060;

     (v) For the WAH SSI-related program, see WAC 182-512-0010;

     (vi) For WAH long-term care programs, see WAC 182-513-1300 and 182-515-1500;

     (vii) For WAH medicare savings programs, see WAC 182-517-0100; and

     (viii) For the WAH medically needy program, see WAC 182-519-0050.

     (4) In addition to the general eligibility requirements in subsection (3) of this section, each program has specific eligibility requirements as described in applicable WAC.

     (5) ((Persons living)) Individuals in a public institution, including a correctional facility, are not eligible for ((the department's medical coverage)) WAH programs((. For a person)), except in the following situations:

     (a) The individual is under age twenty or over age sixty-five ((who)) and is a patient in an institution for mental disease (see WAC ((388-513-1315(13) for exception.)) 182-513-1315(13)); or

     (b) The individual receives inpatient hospital services outside of the public institution or correctional facility.

     (6) ((Persons)) Individuals terminated from SSI or ((TANF cash grants and those)) who lose eligibility for categorically needy (CN) ((medical)) coverage have their CN coverage continued while their eligibility for other ((medical)) health care programs is redetermined. ((This continuation of medical coverage is described in chapter 388-434 WAC)) See WAC 182-504-0125.

[12-13-056, recodified as WAC 182-503-0505, filed 6/15/12, effective 7/1/12. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and 74.09.530, 42 U.S.C., Section 1396a. 07-21-005, § 388-503-0505, filed 10/4/07, effective 11/4/07. Statutory Authority: RCW 74.08.090, 74.09.530, and 2003 1st sp.s. c 25. 04-07-141, § 388-503-0505, filed 3/22/04, effective 4/22/04. Statutory Authority: RCW 74.08.090, 74.08A.100, 74.09.080, and 74.09.415. 02-17-030, § 388-503-0505, filed 8/12/02, effective 9/12/02. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. 98-16-044, § 388-503-0505, filed 7/31/98, effective 9/1/98. Formerly WAC 388-501-0110, 388-503-0305 and 388-505-0501.]

     (1) A resident is an individual who((:

     (a))) currently lives in Washington and:

     (a) Intends to ((continue living here permanently or for an indefinite period of time)) reside here, including individuals without a fixed address; or

     (b) Entered the state looking for a job; or

     (c) Entered the state with a job commitment.

     (2) An individual does not need to live in the state for a specific period of time prior to ((be)) meeting the requirements in subsection (1) of this section before being considered a resident.

     (3) ((An individual receiving MCS)) A child under age eighteen is a resident of the state where the child's primary custodian lives.

     (4) A resident applying for or receiving health care benefits can temporarily be out of the state for more than one month((. If so, the individual must provide the agency or the agency's designee with adequate information to demonstrate the intent to continue to reside in the state of Washington.

     (4) An individual may not receive comparable benefits from another state for the MCS program.

     (5) A former resident of the state can apply for MCS while living in another state if:

     (a) The individual:

     (i) Plans to return to this state;

     (ii) Intends to maintain a residence in this state; and

     (iii) Lives in the United States at the time of the application.

     (b) In addition to the conditions in (a)(i), (ii), and (iii) of this subsection being met, the absence must be:

     (i) Enforced and beyond the individual's control; or

     (ii) Essential to the individual's welfare and is due to physical or social needs.

     (c) See WAC 388-406-0035, 388-406-0040, and 388-406-0045 for time limits on processing applications.

     (6) Residency is not a requirement for detoxification services.

     (7) An individual is not a resident when the individual enters Washington state only for medical care. This individual is not eligible for any medical program. The only exception is described in subsection (8) of this section.

     (8) It is not necessary for an individual moving from another state directly to a nursing facility in Washington state to establish residency before entering the facility. The individual is considered a resident if they intend to remain permanently or for an indefinite period unless placed in the nursing facility by another state.

     (9) An individual's residence is the state:

     (a) Where the parent or legal guardian resides, if appointed, for an institutionalized individual twenty-one years of age or older, who became incapable of determining residential intent before reaching age twenty-one;

     (b) Where an individual is residing if the individual becomes incapable of determining residential intent after reaching twenty-one years of age;

     (c) Making a placement in an out-of-state institution; or

     (d) For any other institutionalized individual, the state of residence is the state where the individual is living with the intent to remain there permanently or for an indefinite period.

     (10) In a dispute between states as to which is an individual's state of residence, the state of residence is the state in which the individual is physically located)) without their health care benefits being denied or terminated, if the individual:

     (a) Provides the agency or its designee with adequate information to determine that the individual intends to return to the state once the purpose of his or her absence has been accomplished; and

     (b) Has not been determined eligible for medicaid or state-funded health care benefits in another state.

     (5) An individual who enters Washington state only for health care is not a resident and is not eligible for any medical program. The only exception is for an individual who moves from another state directly into an institution in Washington state. Residency rules for institutionalized individuals are described in WAC 182-503-0525.

     (6) An individual of any age who receives a state supplemental payment (SSP) is considered a resident of the state that is making the payment.

     (7) An individual who receives federal payments for foster or adoption assistance is considered a resident of the state where the person physically resides even if:

     (a) The individual does not live in the state that is making the foster or adoption assistance payment; or

     (b) The individual does not live in the state where the adoption agreement was entered.

     (8) In a dispute between states, the state of residence is the state in which the individual is physically located.

[Statutory Authority: RCW 41.05.021, 74.09.035, and 2011 1st sp.s. c 36. 12-19-051, § 182-503-0520, filed 9/13/12, effective 10/14/12.]

OTS-5462.2

AMENDATORY SECTION(Amending WSR 12-13-056, filed 6/15/12, effective 7/1/12)

WAC 182-503-0540   Assignment of rights and cooperation.   (1) When ((a person)) you become((s)) eligible for any of the ((department's medical)) agency's health care programs, ((they make assignment of)) you assign certain rights to the state of Washington. ((This assignment includes)) You assign all rights to any type of coverage or payment for ((medical)) health care ((which results)) that comes from:

     (a) A court order;

     (b) An administrative agency order; or

     (c) Any third-party benefits or payment obligations for medical care which are the result of subrogation or contract (see WAC 388-501-0100).

     (2) ((Subrogation is a legal term which describes the method by which the state acquires the rights of a client for whom or to whom the state has paid benefits. The subrogation rights of the state are limited to the recovery of its own costs.

     (3) The person who)) When you sign((s)) the application ((makes the assignment of)) you assign the rights described in subsection (1) of this section to the state((. Assignment is made on their own behalf and on behalf of any eligible person for whom they can legally make such assignment.

     (4) A person)) for:

     (a) Yourself; and

     (b) Any eligible person for whom you can legally make such assignment.

     (3) You must cooperate with ((the department)) us (the agency) in ((the identification, use or collection of)) identifying, using or collecting third-party benefits. ((Failure to)) If you do not cooperate ((results in a termination of eligibility for the responsible person. Other obligations for cooperation are located in chapters 388-14A and 388-422 WAC. The following clients are exempt from termination of eligibility for medical coverage as a result of noncooperation:

     (a) A pregnant woman, and

     (b) Minor children, and

     (c) A person who has been determined to have "good cause" for noncooperation (see WAC 388-422-0015))), your health care benefits may end.

     (((5) A person will not lose eligibility for medical assistance programs)) (4) Your WAH coverage will not end due solely to the noncooperation of any third party.

     (((6) A person)) (5) You will ((be responsible for the costs of otherwise covered medical)) have to pay for your health care services if you:

     (a) ((The person)) Received and kept the third-party payment for those services; or

     (b) ((The person)) Refused to ((provide)) give to the provider of care ((their)) your legal signature on insurance forms.

     (6) The state is limited to the recovery of its own costs for health care costs paid on behalf of a recipient of health care coverage. The legal term which describes the method by which the state acquires the rights of a person for whom the state has paid costs is called subrogation.

[12-13-056, recodified as WAC 182-503-0540, filed 6/15/12, effective 7/1/12. Statutory Authority: RCW 74.08.090. 01-02-076, § 388-505-0540, filed 12/29/00, effective 1/29/01. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. 98-16-044, § 388-505-0540, filed 7/31/98, effective 9/1/98. Statutory Authority: RCW 74.08.090 and 74.09.522. 97-04-005, § 388-505-0540, filed 1/24/97, effective 2/24/97. Statutory Authority: RCW 74.08.090. 94-10-065 (Order 3732), § 388-505-0540, filed 5/3/94, effective 6/3/94. Formerly WAC 388-83-012, 388-501-0170 and 388-505-0560.]

OTS-5465.3

AMENDATORY SECTION(Amending WSR 11-24-018, filed 11/29/11, effective 12/1/11)

WAC 182-504-0015   Washington apple health -- Certification periods for categorically needy (((CN) scope of care medical assistance)) programs.   (1) A certification period is the period of time a person is determined eligible for a categorically needy (CN) ((scope of care medical)) Washington apple health (WAH) program. Unless otherwise stated in this section, the certification period begins on the first day of the month of application and continues to the last day of the last month of the certification period.

     (2) For a ((child)) newborn eligible for ((the newborn medical program)) WAH, the certification period begins on the child's date of birth and continues through the end of the month of the child's first birthday.

     (3) For a woman eligible for ((a medical program)) WAH based on pregnancy, the certification period ends the last day of the month that includes the sixtieth day from the day the pregnancy ends.

     (4) For a person eligible for the WAH refugee program, the certification period ends at the end of the eighth month following the client's date of entry to the United States.

     (5) For ((families the certification period is twelve months with a six-month report required as a condition of eligibility as described in WAC 388-418-0011)) all other WAH-CN coverage, the certification period is twelve months.

     (((5))) (6) For children, ((the certification period is twelve months.)) eligibility is continuous ((without regard to changes in circumstances other than aging out of the program, moving out-of-state, failing to pay a required premium(s), incarceration or death.

     (6))) throughout the certification period regardless of a change in circumstances, unless a required premium (described in WAC 182-505-0225) is not paid for three consecutive months or the child:

     (a) Turns age nineteen;

     (b) Moves out of state;

     (c) Is incarcerated; or

     (d) Dies.

     (7) When the child turns nineteen, the certification period ends after the redetermination process described in WAC 182-504-0125 is completed, even if the twelve-month period is not over. The certification period may be extended past the end of the month the child turns nineteen when:

     (a) The child is receiving inpatient services (((see)) described in WAC ((388-505-0230)) 182-514-0230) on the last day of the month the child turns nineteen;

     (b) The inpatient stay continues into the following month or months; and

     (c) The child remains eligible except for ((exceeding)) turning age nineteen.

     (((7) For an SSI-related person the certification period is twelve months.

     (8) When the medical assistance unit is also receiving benefits under a cash or food assistance program, the medical certification period is updated to begin anew at each:

     (a) Approved application for cash or food assistance; or

     (b) Completed eligibility review.

     (9))) (8) A retroactive certification period ((can begin up to three months immediately before the month of application when:

     (a) The client would have been eligible for medical assistance if the client had applied; and

     (b) The client received covered medical services as described in WAC 388-501-0060 and 388-501-0065.

     (10) If the client is eligible only during the three-month retroactive period, that period is the only period of certification, except when:

     (a) A pregnant woman is eligible in one of the three months preceding the month of application, but no earlier than the month of conception. Eligibility continues as described in subsection (3);

     (b) A child is eligible for a CN medical program as described in WAC 388-505-0210 (1) through (5) and (7) in one of the three months preceding the month of application. Eligibility continues for twelve months from the earliest month that the child is determined eligible.

     (11) Any months of a retroactive certification period are added to the designated certification periods described in this section)) is described in WAC 182-504-0005.

     (((12))) (9) Coverage under premium-based programs included in apple health for kids as described in ((WAC 388-505-0210 and)) chapter ((388-542)) 182-505 WAC begins no sooner than the month after creditable coverage ends.

[11-24-018, recodified as WAC 182-504-0015, filed 11/29/11, effective 12/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, and 74.08.090, and Apple Health for Kids Act (ESHB 2128); 42 U.S.C. 1305; Public Law 111-3 (Children's Health Insurance Program Reauthorization Act of 2009). 11-03-001, § 388-416-0015, filed 1/5/11, effective 2/5/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.402, 74.09.470, and 2008 session law. 09-07-086, § 388-416-0015, filed 3/17/09, effective 4/17/09. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, 74.09.700, and 2007 c 5. 08-05-018, § 388-416-0015, filed 2/12/08, effective 3/14/08. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. 06-24-036, § 388-416-0015, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090, 74.09.530, and 74.09.415. 05-19-031, § 388-416-0015, filed 9/12/05, effective 10/13/05. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.04.510, and 2004 c 54. 04-21-064, § 388-416-0015, filed 10/18/04, effective 11/18/04. Statutory Authority: RCW 74.08.090, 74.09.530, and 2003 c 10. 04-03-019, § 388-416-0015, filed 1/12/04, effective 2/12/04. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.08.090 and 74.09.450. 00-08-002, § 388-416-0015, filed 3/22/00, effective 5/1/00. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. 98-16-044, § 388-416-0015, filed 7/31/98, effective 9/1/98. Formerly 388-509-0970, 388-521-2105, 388-522-2210 and 388-522-2230.]

     (a) The date you report the change to us;

     (b) The date you give us the requested verification; and

     (c) The type of WAH you or your family is receiving.

     (2) When you report a change after you submit your application, but before your application is processed, the change is considered when processing your application.

     (3) If another person, agency, or data source reports a change in circumstances, the information may be used in determining your eligibility. We will not rely on information received from a data source to terminate your WAH coverage without requesting additional information from you.

     (4) A change in income affects your ongoing eligibility only if it is expected to continue beyond the month when the change is reported, and only if it is expected to last more than two months.

     (5) A change that results in termination of your WAH coverage takes effect the first of the month following the advance notice period.

     (6) The advance notice period:

     (a) Begins on the day we send the letter about the change to you; and

     (b) Is determined according to the rules in WAC 182-518-0025.

     (7) A change that results in a decreased scope of care takes effect on the first of the month following the advance notice period. Examples of a decreased scope of care are:

     (a) Termination of WAH categorically needy (CN) medical and approval for other WAH coverage with a lesser scope of care such as WAH medically needy (MN) medical;

     (b) WAH-MN recipient with a change that increases the spenddown liability amount;

     (c) WAH-MN recipient with no spenddown liability with a change that results in WAH-MN with a spenddown liability.

     (8) A change that results in an increased scope of care takes effect on the first of the month following the date the change was reported, when you provide the required verification:

     (a) Within ten days of the date we requested the verification; or

     (b) By the end of the month of report, whichever is later.

     (9) If you do not provide the required verification timely under subsection (8) of this section, we make the change effective the first of the month following the month in which you provide the verification. We may terminate your WAH coverage if you do not provide the required verification.

     (10) When a law or regulation requires a change in WAH, the date specified by the law or regulation is the effective date of the change.

     (11) When a change in income or allowable expenses changes the amount you pay towards the cost of your care for institutional programs, we calculate your new participation amount beginning with the month your income or allowable expenses changed.

     (12) We use the following rules to determine the effective date of change for the health care for workers with disabilities (HWD) program:

     (a) HWD coverage begins the month after coverage in another medical program ends and the premium amount has been approved by the eligible person; and

     (b) If a change in income increases or decreases the monthly premium, the change is effective the first of the month after the change is reported. For more information on premium requirements for this program, see WAC 182-511-1250.

[]

     (iii) Aged, blind, disabled (ABD) cash assistance. See WAC 388-434-0005 for changes reported during eligibility review)) a determination of eligibility or ineligibility for other WAH programs is completed.

     (2) If a person is no longer eligible for WAH due to a change, then the agency or its designee is responsible to ensure eligibility for other insurance affordability programs (as described in WAC 182-503-0001) is coordinated and that information necessary to determine eligibility is securely provided to the health benefits exchange making the determination.

     (3) If WAH-CN ((medical)) or ABP coverage ends under one program and the ((individual)) person meets all the eligibility requirements to be eligible under a different ((CN medical)) WAH program, ((coverage)) WAH is approved under the new program. If the ((individual's)) person's income exceeds the standard for WAH-CN ((medical)) coverage, the agency or ((the agency's)) its designee ((considers)) determines eligibility under:

     (a) The medically needy (MN) program described in chapter 182-519 WAC where appropriate; and

     (b) The person is referred for an eligibility determination under another insurance affordability program, if not excluded from coverage under these programs on the basis of age, immigration status, medicare, or other minimum essential coverage.

     (((3))) (4) If WAH-CN ((medical)) or ABP coverage ends and the ((individual)) person does not meet the eligibility requirements to be eligible under a different ((medical)) WAH program, the redetermination process for WAH is complete and ((medical assistance)) WAH coverage is terminated giving advance and adequate notice, with the following exception:

     (a) ((An individual)) A person who claims to have a disability is referred to the division of disability determination services for a disability determination if that is the only basis under which the ((individual)) person is potentially eligible for ((medical assistance)) WAH. Pending the outcome of the disability determination, ((medical eligibility is considered)) coverage is continued under the SSI-related medical program described in chapter ((388-475)) 182-512 WAC if countable income is below the SSI categorically needy income level (CNIL).

     (b) ((An individual)) A person with countable income in excess of the SSI-related ((CN medical standard is considered for medically needy (MN) coverage or medically needy ())CNIL, is eligible for WAH or WAH-MN(())) with spenddown as described in chapter 182-519 WAC pending the final outcome of the disability determination.

     (((4) An individual who becomes ineligible for refugee cash assistance is eligible for continued refugee medical assistance through the eight-month limit, as described in WAC 182-507-0130.

     (5) An individual who receives a TANF cash grant or family medical is eligible for a medical extension, as described under WAC 182-523-0100, when the cash grant or family medical program is terminated as a result of:

     (a) An increase in earned income; or

     (b) Collection of child or spousal support.

     (6))) (5) A person who receives coverage under the WAH parent and caretaker relative program described in WAC 182-505-0240 is eligible for the WAH health care extension program, as described under WAC 182-523-0100, when the coverage ends as a result of an increase in earned income.

     (6) Changes in income during a certification period do not affect((s)) eligibility for ((all medical programs except)) the following programs:

     (a) WAH for pregnant ((women's CN medical programs)) women;

     (b) ((A program included in apple health for kids)) WAH for children, except as specified in subsection (((5))) (7) of this section; ((or))

     (c) ((The first six months of the medical extension benefits described under chapter 182-523 WAC.

     (7) A child who receives)) WAH for SSI recipients;

     (d) WAH refugee program; and

     (e) WAH health care extension.

     (7) The agency or its designee redetermines eligibility for children receiving WAH for kids premium-based coverage ((under a program included in apple health for kids)) described in WAC 182-505-0210 ((and chapter 182-505 WAC must be redetermined for a nonpremium-based coverage)) when the ((family reports)):

     (a) ((Family)) Household's income ((has decreased)) decreases to less than two hundred percent federal poverty level (FPL);

     (b) ((The)) Child becomes pregnant;

     (c) ((A change in)) Family size changes; or

     (d) ((The)) Child receives SSI.

     (8) ((An individual)) A person who receives SSI-related CN ((medical)) coverage ((and reports)) who has a change in earned income which exceeds the substantial gainful activity (SGA) limit set by the Social Security Administration, no longer meets the definition of a disabled ((individual)) person as described in WAC 182-512-0050, unless the ((individual)) person continues to receive a Title 2 cash benefit, ((e.g.,)) such as Social Security disability income (SSDI), disabled adult child (DAC), or disabled widow's benefits (DWB). This does not apply to SSI cash recipients, SSI-deemed eligible clients, as described in WAC 182-512-0880, or persons who meet the medicaid eligibility criteria in section 1619(b) of the Social Security Act.

     (9) The agency or ((the agency's)) its designee redetermines eligibility for ((such an individual)) a person described in subsection (8) of this section under the ((health care)) WAH for workers with disabilities (HWD) program which waives the SGA income test. The HWD program is a premium-based program and the ((individual)) person must approve the premium amount before the agency or ((the agency's)) its designee can authorize ongoing CN ((medical benefits)) coverage under this program.

     (10) Prior to a scheduled renewal or March 31, 2014, whichever is later, eligibility determinations using modified adjusted gross income (MAGI) methodologies will not cause a person to become ineligible for WAH, to receive less benefits, or to pay a premium when:

     (a) The person is enrolled in WAH coverage at the time of the eligibility decision;

     (b) The person was enrolled prior to October 1, 2013; and

     (c) At the time of the eligibility determination, the person's enrollment in WAH is not already based on MAGI methodologies.

[Statutory Authority: RCW 41.05.021, 74.09.035, and 2011 1st sp.s. c 36. 12-19-051, § 182-504-0125, filed 9/13/12, effective 10/14/12.]

OTS-5464.2

NEW SECTION
WAC 182-504-0035   Washington apple health -- Renewals.   (1) For all Washington apple health (WAH) programs, the following applies:

     (a) You are required to complete a renewal of eligibility at least every twelve months with the following exceptions:

     (i) If you are eligible for WAH medically needy with spenddown, then you must complete a new application at the end of each three- or six-month base period;

     (ii) If you are eligible for WAH alien emergency medical, then you are certified for a specific period of time to cover emergency inpatient hospitalization costs only (see WAC 182-507-0115(8)); or

     (iii) If you are eligible for WAH refugee coverage, you must complete a renewal of eligibility after eight months.

     (b) You may complete renewals online, by phone, or mailed or faxed to us (the agency or its designee).

     (c) If your WAH is renewed, we decide the certification period according to WAC 182-504-0015.

     (d) We review all eligibility factors subject to change during the renewal process.

     (e) We redetermine eligibility as described in WAC 182-504-0125 and send you written notice as described in WAC 182-518-0005 before WAH is terminated.

     (f) If you need help meeting the requirements of this section, we provide equal access services as described in WAC 182-503-0120.

     (2) For programs based on modified adjusted gross income (MAGI) as described in WAC 182-503-0510:

     (a) Sixty days prior to the end of the certification period:

     (i) When information from electronic sources shows income is reasonably compatible (as defined in WAC 182-500-0095), we administratively renew your coverage (as defined in WAC 182-500-0010) for a new certification period and send you a letter letting you know.

     (ii) You are sent a notice of renewal with the information used and you are required to inform us if any of the information we used is wrong.

     (iii) If we are unable to complete an administrative renewal (as defined in WAC 182-500-0010), you must give us a signed renewal in order for us to decide if you will continue to get WAH coverage beyond the current certification period.

     (iv) We follow the requirements described in WAC 182-518-0015 to request any additional information needed to complete the renewal process or to terminate coverage for failure to renew.

     (b) If your WAH coverage is terminated because you didn't renew, you have ninety days from the termination date to give us a completed renewal. If we decide you are still eligible to get WAH coverage, we will restore your WAH without a gap in coverage.

     (3) For non-MAGI based programs (as described in WAC 182-503-0510):

     (a) Forty-five days prior to the end of the certification period, we send notice with a renewal form to be completed, signed, and returned by the end of the certification period.

     (b) We follow the requirements in WAC 182-518-0015 to request any additional information needed to complete the renewal process or to terminate coverage for failure to renew.

     (c) If you are terminated for failure to renew, you have thirty days from the termination date to submit a completed renewal. If still eligible, we will restore your WAH without a gap in coverage.

[]

     (2) We tell you what you are required to report at the time you are approved for WAH coverage. We also will tell you if the reporting requirements change.

     (3) You must report the following:

     (a) Change in residential address;

     (b) Change in mailing address;

     (c) Change in marital status;

     (d) When family members or dependents move in or out of the residence;

     (e) Pregnancy;

     (f) Incarceration;

     (g) Change in institutional status;

     (h) Change in health insurance coverage including medicare eligibility; and

     (i) Change in immigration or citizenship status.

     (4) If you are eligible for a WAH long-term care program described in chapter 182-513 or 182-515 WAC, you must also report changes to the following:

     (a) Income;

     (b) Resources;

     (c) Medical expenses; and

     (d) Spouse or dependent changes in income or shelter cost when expenses are allowed for either.

     (5) If you get WAH parent or caretaker or WAH modified adjusted gross income (MAGI)-based adult coverage, you must also report changes to the following:

     (a) When income increases by one hundred fifty dollars or more a month and the change will continue for at least two months;

     (b) Anticipated federal income tax filing status; and

     (c) The number of tax dependents you intend to claim on your federal income taxes.

     (6) If you get WAH based on age, blindness, or disability (SSI-related medical), then you must also report changes to the following:

     (a) Income; and

     (b) Resources.

[]

     (2) You must report changes during your certification period within thirty days of when the change happened.

     (3) You must report all changes during application, renewal, or redetermination of your WAH eligibility, regardless of when the change happened.

     (4) For a change in income, the date a change happened is the first date you received income based on the change. For example, the date you receive your first paycheck for a new job or the date you got a paycheck with a wage increase is the date the change happened.

     (5) If you don't report a change or you report a change late, we will decide if you can receive or keep receiving WAH coverage based on the date the change was required to be reported.

     (6) If you don't report a change or you report a change late, it may result in us overpaying you and you having to pay us back for the health care costs we overpaid. See chapter 182-520 WAC.

[]

OTS-5244.4

AMENDATORY SECTION(Amending WSR 11-23-091, filed 11/17/11, effective 11/21/11)

WAC 182-505-0100   ((Medical programs)) Washington apple health--Monthly income standards based on the federal poverty level (FPL).   (1) Each year, the federal government publishes new federal poverty level (FPL) income standards in the Federal Register found at http://aspe.hhs.gov/poverty/index.shtml. The income standards for the following ((medical)) Washington apple health (WAH) programs change on the first day of April every year based on the new FPL:

     (a) ((Pregnant women's program up to one hundred eighty-five)) WAH for parents and caretaker relatives up to thirty-five percent of FPL (see WAC 182-505-0540). Parents and caretaker relatives whose earned income exceeds this limit may be eligible for the WAH transitional medical program as described in WAC 182-523-0100;

     (b) ((A program included in apple health for kids up to two hundred)) Modified adjusted gross income (MAGI)-based WAH for adults up to one hundred thirty-three percent of FPL;

     (c) ((Health care for workers with disabilities (HWD) up to two hundred twenty)) WAH for pregnant women up to one hundred eighty-five percent of FPL; and

     (d) ((Premium-based coverage under a program included in apple health for kids over two hundred percent of FPL, but not over three hundred)) WAH for children up to two hundred percent of FPL; and

     (e) Premium-based coverage under WAH for children over two hundred percent of FPL, but not over three hundred percent of FPL.

     (2) The ((department)) agency uses the FPL income standards to determine((:

     (a) The mandatory or optional medicaid status of an individual; and

     (b) Premium amount, if any, for a child.

     (3) There are no resource limits for the programs under this section)) the premium amount, if any, for a child.

[11-23-091, recodified as WAC 182-505-0100, filed 11/17/11, effective 11/21/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.402, 74.09.470, and 2008 session law. 09-07-086, § 388-478-0075, filed 3/17/09, effective 4/17/09. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, 74.09.700, and 2007 c 5. 08-05-018, § 388-478-0075, filed 2/12/08, effective 3/14/08. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500 and 42 U.S.C. 9902(2). 06-16-026, § 388-478-0075, filed 7/24/06, effective 8/24/06. Statutory Authority: RCW 74.08.090, 74.09.415, 74.09.530 and 2005 c 279. 06-03-080, § 388-478-0075, filed 1/12/06, effective 2/12/06. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 42 U.S.C. 9902(2). 05-17-157, § 388-478-0075, filed 8/22/05, effective 9/22/05. Statutory Authority: RCW 74.08.090, 74.04.057, 74.04.050, and 74.09.530. 04-15-092, § 388-478-0075, filed 7/16/04, effective 8/16/04. Statutory Authority: RCW 74.08.090, 74.04.050, 74.04.057, 74.09.530, and 42 U.S.C. 9902(2). 03-15-088, § 388-478-0075, filed 7/17/03, effective 7/17/03. Statutory Authority: RCW 74.08.090, 74.08A.100, 74.09.080, and 74.09.415. 02-17-030, § 388-478-0075, filed 8/12/02, effective 9/12/02. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.500, 74.09.510, and Section 1902 (a)(10)(A)(ii)(XV) and (XVI) of the Social Security Act. 02-07-090, § 388-478-0075, filed 3/19/02, effective 4/1/02. Statutory Authority: RCW 74.08.090, 74.04.050, 74.04.057, 74.09.530, and Section 673(2) (42 U.S.C. 9902(2)). 01-18-056, § 388-478-0075, filed 8/30/01, effective 9/30/01; 00-17-085, § 388-478-0075, filed 8/14/00, effective 9/14/00; 99-19-005, § 388-478-0075, filed 9/3/99, effective 10/4/99. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. 98-16-044, § 388-478-0075, filed 7/31/98, effective 9/1/98. Formerly WAC 388-507-0805, 388-508-0810, 388-509-0910, 388-509-0920, 388-509-0940 and 388-509-0960.]

     (1) A pregnant woman is eligible for ((categorically needy (CN) scope of care)) the Washington apple health (WAH) for pregnant women program if she ((meets the following requirements)):

     (a) Meets citizenship or immigration status (((chapter 388-424 WAC))) under WAC 182-503-0535; ((and))

     (b) Meets Social Security ((account)) number (((chapter 388-474 WAC))) requirements under WAC 182-503-0115; ((and))

     (c) ((Is a)) Meets Washington state ((resident (chapter 388-468 WAC))) residency requirements under WAC 182-503-0520 and 182-503-0525; and

     (d) Has countable income ((as described in)) at or below the limit described in:

     (i) WAC ((388-478-0075)) 182-505-0100 to be eligible for categorically needy (CN) coverage; or

     (ii) WAC 182-505-0100 to be eligible for medically needy (MN) coverage. MN coverage begins when the pregnant woman meets any required spenddown liability as described in WAC 182-519-0110.

     (2) ((A pregnant woman is considered for medically needy (MN) scope of care if she meets the requirements in subsection (1)(a) through (c) of this section and:

     (a) Has countable income that exceeds the standard in subsection (1)(d) of this section; and

     (b) Has countable resources that do not exceed the standard in WAC 388-478-0070.

     (3) A pregnant woman may be eligible for noncitizen pregnancy medical if she is not eligible for medical described in subsections (1) and (2) of this section due to citizenship, immigrant status, or social security number requirements.

     (4) A pregnant woman meeting the eligibility criteria in subsection (3) is eligible for:

     (a) CN scope of care when the countable income is at or below the income standard described in subsection (1)(d); or

     (b) MN scope of care when:

     (i) The countable income exceeds the standard in subsection (1)(d); and

     (ii) The resources do not exceed the standard described in WAC 388-478-0070.

     (5) Consider as income to the pregnant woman the amount that is actually contributed to her by the father of her unborn child when the pregnant woman is not married to the father.

     (6))) A noncitizen pregnant woman who does not need to meet the requirements in subsection (1)(a) or (b) of this section to be eligible for WAH and receives either CN or MN coverage based upon her countable income as described in subsection (1)(d) of this section.

     (3) The assignment of child support and medical support rights as described in ((chapter 388-422)) WAC ((do)) 182-503-0540 and 182-503-0545 does not apply to pregnant women.

     (((7))) (4) A woman who was eligible for and received ((medical)) coverage under any WAH program on the last day of pregnancy is eligible for extended medical ((benefits)) coverage for postpartum care for a minimum of sixty days from the end of her pregnancy. This includes women who meet an MN spenddown liability with expenses incurred no later than the date the pregnancy ends. This extension continues through the end of the month in which the sixtieth day falls.

     (((8) A woman who was eligible for medical coverage on the last day of pregnancy is)) (5) All women approved for WAH pregnancy coverage at any time are eligible for family planning services for twelve months ((from the end of)) after the pregnancy ((even when eligibility for pregnancy was determined after the pregnancy ended)) ends.

[12-13-056, recodified as WAC 182-505-0115, filed 6/15/12, effective 7/1/12. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 42 U.S.C. 9902(2). 05-07-032, § 388-462-0015, filed 3/9/05, effective 4/9/05. Statutory Authority: RCW 74.08.090, 74.08A.100, 74.09.080, and 74.09.415. 02-17-030, § 388-462-0015, filed 8/12/02, effective 9/12/02. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. 98-16-044, § 388-462-0015, filed 7/31/98, effective 9/1/98. Formerly WAC 388-508-0820, 388-508-0830, 388-522-2230 and 388-508-0835.]

     (12) Except for a child described in subsection (7) of this section, an inmate of a public institution, as defined in WAC 388-500-0005, is not eligible for any apple health for kids program.)) (1) Unless otherwise stated in this section, a child is a person who is under nineteen years of age (including the month the person turns nineteen). To be eligible for one of the Washington apple health (WAH) for kids programs described below, a child must:

     (a) Be a resident of Washington state, as described in WAC 182-503-0520 and 182-503-0525;

     (b) Provide a Social Security number (SSN) as described in WAC 182-503-0515 unless exempt; and

     (c) Meet any additional requirements listed for the specific program.

     (2) Children under one year of age are eligible for WAH categorically needy (CN) coverage when they are born to a mother who is eligible for WAH:

     (a) On the date of the newborn's birth, including a retroactive eligibility determination; or

     (b) Based on meeting a medically needy (MN) spenddown liability with expenses incurred no later than the date of the newborn's birth.

     (3) Children are eligible for WAH at no cost when they:

     (a) Have countable family income that is no more than two hundred percent of the federal poverty level (FPL) as described in WAC 182-505-0100;

     (b) Are currently eligible for supplemental security income (SSI); or

     (c) Received SSI payments in August 1996 and would continue to be eligible for those payments except for the August 1996 passage of amendments to federal disability definitions.

     (4) Children are eligible for premium-based WAH as described in WAC 182-505-0215 when they:

     (a) Have countable family income that is not more than three hundred percent of FPL as described in WAC 182-505-0100;

     (b) Do not have other creditable health insurance as described in WAC 182-505-0220; and

     (c) Pay the required monthly premiums as described in WAC 182-505-0225.

     (5) Children are eligible for WAH home and community based waiver programs as described in chapter 182-515 WAC when they:

     (a) Meet citizenship or immigration status as described in WAC 182-503-0525;

     (b) Meet SSI-related eligibility requirements as described in chapter 182-512 WAC; and

     (c) Meet program specific age requirements.

     (6) Children are eligible for the WAH long-term care program when they meet the institutional program rules as described in chapter 182-513 or 182-514 WAC, and either:

     (a) Reside or are expected to reside in a medical institution, intermediate care facility for the intellectually disabled (ICF/ID), hospice care center, or nursing home for thirty days or longer; or

     (b) Reside or are expected to reside in an institution for mental diseases (IMD) or inpatient psychiatric facility:

     (i) For ninety days or longer and are age seventeen or younger; or

     (ii) For thirty days or longer and are age eighteen through twenty-one.

     (7) Children are eligible for the WAH medically needy (MN) program as described in WAC 182-519-0100 when they:

     (a) Meet citizenship or immigrant status as described in WAC 182-503-0535;

     (b) Have countable family income that exceeds three hundred percent of FPL as described in WAC 182-505-0100; or

     (c) Have countable family income that is more than two hundred percent of FPL, but are not eligible for premium-based WAH as described in subsection (4) of this section because of creditable coverage; and

     (d) Meet a spenddown liability as described in WAC 182-515-0110, if required.

     (8) Children are eligible for WAH SSI-related programs as described in chapter 182-512 WAC when they:

     (a) Meet citizenship or immigration status as described in WAC 182-503-0535;

     (b) Meet SSI-related eligibility as described in chapter 182-512 WAC; and

     (c) Meet an MN spenddown liability as described in WAC 182-519-0110, if required.

     (9) Children who are not eligible for WAH under subsections (5) through (8) of this section because of their immigration status, may be eligible for the WAH alien emergency medical program if they:

     (a) Meet the eligibility requirements of WAC 182-507-0110;

     (b) Have countable family income less than three hundred percent of FPL, but do not qualify for premium-based WAH, as described in subsection (4) of this section because of creditable coverage; and

     (c) Meet a spenddown liability as described in WAC 182-519-0110, if required.

     (10) Children who are in foster care or receive subsidized adoption services are eligible for coverage under the WAH foster care program described in WAC 182-505-0211.

     (11) Children who are incarcerated in a public institution (as defined in WAC 182-500-0050), or a city or county jail, are not eligible for any WAH program, with the following exceptions:

     (a) Children who reside in an IMD as described in subsection (6) of this section; or

     (b) Children who are released from a public institution or city or county jail to a hospital for inpatient treatment. Children who are released from an IMD to a hospital setting must be unconditionally discharged from the IMD to qualify for coverage under this provision.

[12-13-056, recodified as WAC 182-505-0210, filed 6/15/12, effective 7/1/12. Statutory Authority: RCW 41.05.021, 74.04.050, 74.04.057, 74.09.500, and PPACA, § 2102 (b)(1)(A) of the Social Security Act, and Public Law 111-3 (CHIPRA). 11-23-077, § 388-505-0210, filed 11/15/11, effective 12/16/11. Statutory Authority: RCW 74.04.050, 74.04.057, and 74.08.090, and Apple Health for Kids Act (ESHB 2128); 42 U.S.C. 1305; Public Law 111-3 (Children's Health Insurance Program Reauthorization Act of 2009). 11-03-001, § 388-505-0210, filed 1/5/11, effective 2/5/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.402, 74.09.470, and 2008 session law. 09-07-086, § 388-505-0210, filed 3/17/09, effective 4/17/09. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, 74.09.700, and 2007 c 5. 08-05-018, § 388-505-0210, filed 2/12/08, effective 3/14/08. Statutory Authority: RCW 74.08.090, 74.09.530, and 74.09.415. 05-23-013, § 388-505-0210, filed 11/4/05, effective 1/1/06. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.08.090. 04-15-057, § 388-505-0210, filed 7/13/04, effective 8/13/04. Statutory Authority: RCW 74.08.090 and 74.04.050. 03-14-107, § 388-505-0210, filed 6/30/03, effective 7/31/03. Statutory Authority: RCW 74.08.090, 74.08A.100, 74.09.080, and 74.09.415. 02-17-030, § 388-505-0210, filed 8/12/02, effective 9/12/02. Statutory Authority: RCW 74.08.090, 74.04.050, [74.04.]055, and [74.04.]057. 01-11-110, § 388-505-0210, filed 5/21/01, effective 6/21/01. Statutory Authority: RCW 74.08.090 and 74.08A.100. 99-17-023, § 388-505-0210, filed 8/10/99, effective 9/10/99. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. 98-16-044, § 388-505-0210, filed 7/31/98, effective 9/1/98. Formerly WAC 388-509-0905, 388-509-0910 and 388-509-0920.]

     (1) Federally matched health care coverage as authorized by Title XXI of the Social Security Act state children's health insurance program (((SCHIP))) (CHIP) and RCW 74.09.450 for citizen and federally qualified immigrant children whose family income is above two hundred percent of the federal poverty level (FPL) but is not above three hundred percent FPL.

     (2) State funded health care coverage for children with family income above two hundred percent FPL, but not above three hundred percent FPL, who are ineligible for ((Title XXI)) federally matched health care coverage due to immigration ((issues)) status.

[12-13-056, recodified as WAC 182-505-0215, filed 6/15/12, effective 7/1/12. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.402, 74.09.470, and 2008 session law. 09-07-086, § 388-542-0010, filed 3/17/09, effective 4/17/09. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, 74.09.700, and 2007 c 5. 08-05-018, § 388-542-0010, filed 2/12/08, effective 3/14/08. Statutory Authority: RCW 74.08.090, 74.09.050, and Title XXI of the Social Security Act. 06-15-134, § 388-542-0010, filed 7/19/06, effective 8/19/06. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.522, 74.09.450, and 2004 c 276. 04-16-064, § 388-542-0010, filed 7/30/04, effective 8/30/04.]

     (2) Payment of a premium is required as a condition of eligibility for premium-based WAH coverage ((under programs included in apple health)) for kids, as described in WAC ((388-505-0210 (4) and (5))) 182-505-0210(4), unless the child is:

     (a) Pregnant; or

     (b) An American Indian or Alaska native.

     (3) The premium requirement begins the first of the month following the determination of eligibility. There is no premium requirement for ((medical)) WAH coverage received in a month or months before the determination of eligibility.

     (4) ((The premium amount for the assistance unit (AU) is based on the net countable income as described in WAC 388-450-0210 and the number of children in the AU. If the household includes more than one AU, the premium amount billed for the AUs may be different amounts.

     (5))) The premium amount is limited to a monthly maximum of two premiums for ((households)) families with two or more children.

     (((6))) (5) The premium amount for each U.S. citizen or lawfully present alien child described in WAC ((388-505-0210)) 182-505-0210(4) is:

     (a) Twenty dollars per month per child for ((households)) families with countable income above two hundred percent FPL, but not above two hundred and fifty percent FPL; or

     (b) Thirty dollars per month per child for ((households)) families with countable income above two hundred and fifty percent FPL, but not above three hundred percent FPL.

     (((7))) (6) The premium amount for each noncitizen child described in WAC ((388-505-0210(5))) 182-505-0210(4) who is not a lawfully present qualified or nonqualified alien is no greater than the average of the state-share of the per capita cost for state-funded children's health coverage. The premium amount is set every two years, based on the forecasted per capita costs for that period.

     (((8))) (7) All children in an assistance unit (AU) are ineligible for ((health care)) WAH coverage when the ((head of household)) family fails to pay required premium payments for three consecutive months.

     (((9))) (8) When the agency or ((the agency's)) its designee terminates the ((medical)) WAH coverage ((of a child)) due to nonpayment of premiums, the child's eligibility is restored ((only)) when the:

     (a) Past due premiums are paid in full prior to the end of the certification period; or

     (b) The child becomes eligible for coverage under ((a nonpremium-based CN health care program)) WAH without a premium.

     (((10))) (9) The agency or ((the agency's)) its designee writes off past-due premiums after twelve months.

     (((11))) (10) If all past due premiums are paid after the certification period is over:

     (a) Eligibility for prior months is not restored; and

     (b) Children are not eligible for premium-based ((coverage under apple health)) WAH for kids until:

     (i) The month the premiums are paid or the agency writes off the debt; and

     (ii) The family reapplies and is found eligible.

     (((12))) (11) A family cannot designate partial payment of the billed premium amount as payment for a specific child in the AU. The full premium amount is the obligation of the head of household of the AU. A family can decide to request health care coverage only for certain children in the AU, if they want to reduce premium obligation.

     (((13))) (12) A change that affects the premium amount is effective the month after the change is reported and processed.

     (((14))) (13) A sponsor or other third party may pay the premium on behalf of the child or children in the AU. The premium payment requirement remains the obligation of head of household of the AU. The failure of a sponsor or other third party to pay the premium does not eliminate the obligation of the head of household to pay past due premiums.

[12-13-056, recodified as WAC 182-505-0225, filed 6/15/12, effective 7/1/12. Statutory Authority: RCW 41.05.021, 74.04.050, 74.04.057, 74.09.500, and PPACA, § 2102 (b)(1)(A) of the Social Security Act, and Public Law 111-3 (CHIPRA). 11-23-077, § 388-505-0211, filed 11/15/11, effective 12/16/11. Statutory Authority: RCW 74.04.050, 74.04.057, and 74.08.090, and Apple Health for Kids Act (ESHB 2128); 42 U.S.C. 1305; Public Law 111-3 (Children's Health Insurance Program Reauthorization Act of 2009). 11-03-001, § 388-505-0211, filed 1/5/11, effective 2/5/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.402, 74.09.470, and 2008 session law. 09-07-086, § 388-505-0211, filed 3/17/09, effective 4/17/09. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, 74.09.700, and 2007 c 5. 08-05-018, § 388-505-0211, filed 2/12/08, effective 3/14/08. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.522, 74.09.450, and 2004 c 276. 04-16-064, § 388-505-0211, filed 7/30/04, effective 8/30/04. Statutory Authority: RCW 74.08.090, 74.09.055, 2004 c 276. 04-08-125, § 388-505-0211, filed 4/7/04, effective 5/8/04.]

     (1) For ((medical assistance)) health care coverage for targeted low-income children from birth through age eighteen, as described in section 4 of the Title XXI state plan.

     (2) For ((medical assistance)) health care coverage for unborn children, as described in section 4.1.2.1 of the Title XXI state plan.

     (3) For ((medical assistance)) health care coverage for medicaid-eligible children, as described in CHIPRA, section 214.

     (4) For ((medical assistance)) health care coverage for medicaid-eligible children, as described in section 2105 (g)(4)(A) and (B) of the ((act)) SSA.

     (5) For allowable administrative expenditures under the ten percent cap, as defined in section 2105 (a)(1)(D) of the act in the following order:

     (a) First, for reasonable expenditures necessary to administer the plan, including staffing for eligibility determinations, plan administration, quality assurance, and similar costs.

     (b) Second, for a toll-free 800 telephone number providing information regarding the Washington apple health for kids program.

     (c) Third, for health services initiatives, such as the funding of the Washington poison center, to the extent that state funds are appropriated by the legislature.

     (d) Fourth, for translation or interpretation services in connection with the enrollment, retention, or use of services under this title by individuals for whom English is not their primary language, but only to the extent that state-matching funds are made available.

     (e) Fifth, for outreach services for the Washington apple health for kids program, to the extent that appropriated state-matching funds are available.

     (f) Sixth, for other CMS-approved activities to the extent that federal matching funds are available, and where such activities do not duplicate efforts conducted under this subsection.

[Statutory Authority: RCW 41.05.021, 74.04.050, 74.04.057, 74.09.500, and PPACA, § 2102 (b)(1)(A) of the Social Security Act, and Public Law 111-3 (CHIPRA). 11-23-077, § 182-505-0235, filed 11/15/11, effective 12/16/11.]

     (1) Chapter ((388-538)) 182-538 WAC, Managed care (except WAC ((388-538-061)) 182-538-061, ((388-538-063)) 182-538-063, and ((388-538-065)) 182-538-065) if the child is covered under federally matched CN coverage;

     (2) WAC ((388-505-0210 (4) and (5), apple health for kids program eligibility;

     (3) WAC 388-505-0211, Premium requirements for premium-based coverage under programs included in apple health for kids;

     (4) WAC 388-416-0015(12))) 182-504-0015(8), Certification periods for categorically needy (CN) scope of care medical assistance programs; and

     (((5))) (3) WAC ((388-418-0025)) 182-504-0125, Effect of changes on medical program eligibility.

[12-13-056, recodified as WAC 182-505-0237, filed 6/15/12, effective 7/1/12. Statutory Authority: RCW 74.04.050, 74.04.057, and 74.08.090, and Apple Health for Kids Act (ESHB 2128); 42 U.S.C. 1305; Public Law 111-3 (Children's Health Insurance Program Reauthorization Act of 2009). 11-03-001, § 388-542-0020, filed 1/5/11, effective 2/5/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.402, 74.09.470, and 2008 session law. 09-07-086, § 388-542-0020, filed 3/17/09, effective 4/17/09. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, 74.09.700, and 2007 c 5. 08-05-018, § 388-542-0020, filed 2/12/08, effective 3/14/08. Statutory Authority: RCW 74.08.090 and 74.09.522. 06-07-014, § 388-542-0020, filed 3/3/06, effective 4/3/06. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.522, 74.09.450, and 2004 c 276. 04-16-064, § 388-542-0020, filed 7/30/04, effective 8/30/04.]

     (a) ((Receiving temporary assistance for needy families (TANF) cash benefits;

     (b) Receiving Tribal TANF;

     (c) Receiving cash diversion assistance, except SFA relatable families, described in WAC 388-400-0010(2);

     (d) Eligible for TANF cash benefits but choose not to receive;

     (e) Over the TANF cash payment standard but under the family medical payment standard as described in WAC 388-478-0065; or

     (f) Not eligible for or receiving TANF cash assistance, but meet the eligibility criteria for aid to families with dependent children (AFDC) in effect on July 16, 1996 except that:

     (i) Earned income is treated as described in WAC 388-450-0210; and

     (ii) Resources are treated as described in WAC 388-470-0005 for applicants and 388-470-0026 for recipients.

     (2) An adult cannot receive a family medicaid program unless the household includes a child who is eligible for:

     (a) Family medicaid;

     (b) SSI; or

     (c) Children's medicaid.

     (3) A person is eligible for CN family medical coverage when the person is not eligible for or receiving cash benefits solely because the person:

     (a) Received sixty months of TANF cash benefits or is a member of an assistance unit which has received sixty months of TANF cash benefits;

     (b) Failed to meet the school attendance requirement in chapter 388-400 WAC;

     (c) Is an unmarried minor parent who is not in a department-approved living situation;

     (d) 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 one hundred eighty days;

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

     (f) Was convicted of a drug related felony;

     (g) Was convicted of receiving benefits unlawfully;

     (h) Was convicted of misrepresenting residence to obtain assistance in two or more states;

     (i) Has gross earnings exceeding the TANF gross income level; or

     (j) Is not cooperating with WorkFirst requirements.

     (4) An adult must cooperate with the division of child support in the identification, use, and collection of medical support from responsible third parties, unless the person meets the medical exemption criteria described in WAC 388-505-0540 or the medical good cause criteria described in chapter 388-422 WAC.

     (5) Except for a client described in WAC 388-505-0210(6), a person who is an inmate of a public institution, as defined in WAC 388-500-0005, is not eligible for CN or MN medical coverage.)) Is a parent or caretaker relative of an eligible dependent child described in WAC 182-503-0565;

     (b) Meets citizenship and immigration status requirements described in WAC 182-503-0535;

     (c) Meets general eligibility requirements described in WAC 182-503-0535; and

     (d) Has countable income below thirty-five percent of the federal poverty level (FPL).

     (2) To be eligible for WAH coverage as a caretaker relative, a person must be related to an eligible dependent child in one of the ways defined in WAC 182-500-0020.

     (3) A person must cooperate with the state of Washington in the identification, use and collection of medical support from responsible third parties.

     (4) A person who does not cooperate with the requirements in subsection (3) of this section is not eligible for WAH coverage.

[12-13-056, recodified as WAC 182-505-0240, filed 6/15/12, effective 7/1/12. Statutory Authority: RCW 74.04.050, 74.04.057, and 74.08.090. 11-13-031, § 388-505-0220, filed 6/7/11, effective 7/8/11. Statutory Authority: RCW 74.04.050 and 74.08.090. 08-19-099 and 08-20-014, § 388-505-0220, filed 9/17/08 and 9/18/08, effective 10/18/08 and 10/19/08. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.04.510, and 74.08.090. 08-14-105, § 388-505-0220, filed 6/30/08, effective 8/1/08. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and 74.09.530. 05-16-127, § 388-505-0220, filed 8/3/05, effective 9/3/05. Statutory Authority: RCW 74.08.090, 74.08A.100, 74.09.080, and 74.09.415. 02-17-030, § 388-505-0220, filed 8/12/02, effective 9/12/02. Statutory Authority: RCW 74.08.090, 74.04.050, [74.04.]055, and [74.04.]057. 01-11-110, § 388-505-0220, filed 5/21/01, effective 6/21/01; 98-16-044, § 388-505-0220, filed 7/31/98, effective 9/1/98. Formerly WAC 388-507-0740 and 388-522-2210.]

     (a) Is age nineteen or older and under the age of sixty-five;

     (b) Is not entitled to, or enrolled in, medicare benefits under Part A or B of Title XVIII of the Social Security Act;

     (c) Is not otherwise eligible for and enrolled in mandatory coverage under one of the following programs:

     (i) WAH SSI-related categorically needy (CN);

     (ii) WAH foster care program; or

     (iii) WAH adoption support program;

     (d) Meets citizenship and immigration status requirements described in WAC 182-503-0535;

     (e) Meets general eligibility requirements described in WAC 182-503-0505; and

     (f) Has net countable income that is at or below one hundred thirty-three percent of the federal poverty level for a household of the applicable size.

     (2) Parents or caretaker relatives of an eligible dependent child as described in WAC 182-503-0565 are first considered for WAH for families as described in WAC 182-505-0240. An individual whose countable income exceeds the standard to qualify for family coverage is considered for coverage under this section.

     (3) Persons who are eligible under this section are eligible for WAH alternative benefit plan as defined in WAC 182-500-0010 coverage. A person described in this section is not eligible for medically needy WAH.

     (4) Other coverage options for adults not eligible under this section are described in WAC 182-508-0001

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     The following sections of the Washington Administrative Code are repealed:

WAC 182-505-0220	Definitions for premium-based health care coverage under programs included in apple health for kids.
WAC 182-505-0230	Waiting period for premium-based health care coverage under programs included in apple health for kids following employer coverage.
WAC 182-505-0245	Income and resource standards for family medical programs.
WAC 182-505-0515	Medical coverage resulting from a cash grant.

OTS-5463.2

     (2) We send you written notices (letters) when we:

     (a) Approve you for health care coverage for any program;

     (b) Reconsider your application for other types of health care coverage based on new information;

     (c) Deny you health care coverage, including if you withdrew your application, for any program (according to rules in WAC 182-503-0080);

     (d) Ask you for more information to decide if you can start or renew getting health care coverage;

     (e) Renew your health care coverage; or

     (f) Change or terminate your health care coverage, even if we approve you for another kind of coverage.

     (3) We send notices to you in your primary language if you don't read or understand English, according to the rules in WAC 182-503-0110 and follow equal access rules described in WAC 182-503-0120.

     (4) All WAH notices we send you include the following information:

     (a) Specific contact information for you if you have questions or need help with the notice;

     (b) Your appeal rights, if an appeal is available, and the availability of free legal assistance; and

     (c) Other information required by state or federal law.

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     (2) Approval notices include:

     (a) The eligibility status for each person approved, reopened or reinstated;

     (b) The certification period for the WAH program that is approved; and

     (c) The eligibility effective date.

     (3) Denial and withdrawal notices include:

     (a) The date of denial;

     (b) Specific reason(s) supporting the decision; and

     (c) Specific rules or statutes that support or require the decision.

     (4) If your request for health care coverage is denied or withdrawn for failure to provide requested information to us, the notice includes:

     (a) A list of the information you did not provide;

     (b) The date we asked you for the information and the day it was due;

     (c) Notice that your eligibility will be reconsidered if we receive all information needed to determine your eligibility, including any changes to information we have, within thirty days of the date of the denial letter; and

     (d) Information described in subsection (2) of this section.

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     (a) The information that we need;

     (b) When we must have the information (see WAC 182-503-0060 for applications and WAC 182-504-0035 for renewals);

     (c) What action we will take and on what date, if we do not receive the information; and

     (d) Information described in WAC 182-518-0005(4).

     (2) We allow you at least ten days to return the information. If you ask, we may allow you more time to get us the information. If the tenth day falls on a weekend or holiday, the due date is the next business day.

     (3) If the information we ask for costs money, we will pay for it or help you get the information in another way.

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     (2) When we can admistratively renew your coverage (as defined in WAC 182-500-0010) we send you written notice that includes:

     (a) Your new certification period;

     (b) The information we used to recertify your coverage; and

     (c) A request for you to give us updated information, if any of the information we used is inaccurate.

     (3) When we cannot administratively renew your coverage, we send you written notice that includes:

     (a) Information we currently have on record;

     (b) How to complete the renewal using any of the methods described in WAC 182-504-0035 (1)(b); and

     (c) If we need more information to renew your WAH coverage, we follow the rules in WAC 182-518-0015.

     (4) We send your renewal notice following the timeline in:

     (a) WAC 182-504-0035(2) for programs based on modified adjusted gross income (MAGI); or

     (b) WAC 182-504-0035(3) for non-MAGI based programs.

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     Reviser's note: The spelling 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.
NEW SECTION
WAC 182-518-0025   Washington apple health -- Notice requirements -- Changes in and terminations of coverage.   (1) We (the agency or its designee) send you written notice if your Washington apple health (WAH) coverage changes or terminates. The notice includes:

     (a) The change in coverage;

     (b) The date your coverage is changing or terminating;

     (c) Specific reason(s) for the decision;

     (d) Specific rules the decision is based on; and

     (e) Information found in WAC 182-518-0005(4).

     (2) When we terminate your WAH coverage because your income is more than the modified adjusted gross income (MAGI) standard, we redetermine your eligibility for other health care coverage as described in WAC 182-504-0125, before sending you the notice telling you your WAH coverage is terminating.

     (3) We notify you at least ten days before we change or terminate your health care coverage unless:

     (a) You asked us to change or terminate your coverage;

     (b) We are changing or terminating your coverage due to a change in law that affects many people;

     (c) We are terminating your coverage because everyone in your household is dead or they have been accepted to get medicaid coverage somewhere else (another local jurisdiction, state, territory, or commonwealth);

     (d) We are terminating your coverage because mail we have sent to you has been returned to us with no forwarding address; or

     (e) You are incarcerated and it is expected to last more than thirty days.

     (4) The ten-day advance notice period starts on the day we send the notice to you and ends on the tenth day. If we do not have to give ten days' advance notice, we send the notice right away after getting the information that caused the change, but no later than the date we took the action the notice is about.

     (5) You may request an appeal if you disagree with our decision to change or terminate your health care coverage and you may request continued coverage as described in WAC 182-504-0130.

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     (2) For programs based on modified adjusted gross income (MAGI), you have the right to choose to get WAH eligibility notices by regular mail or in an electronic format.

     (3) The primary applicant on an application may receive WAH notices electronically. To receive electronic notices you must:

     (a) Have an account with Washington Healthplanfinder. (There is no charge to create an account); and

     (b) Provide us with sufficient information to set up the electronic notices, such as a valid e-mail address, name and application identification number.

     (4) You may ask to receive WAH notices electronically by:

     (a) Mailing or giving us a written letter;

     (b) Logging on to your Healthplanfinder account online and selecting the "I would prefer to receive written communications by e-mail" check box on the contact information page;

     (c) Calling the Healthplanfinder customer support center.

     (5) When you have asked for electronic notification, we:

     (a) Send the notice to your Healthplanfinder account no later than one business day after creating the notice.

     (b) Send you an e-mail message to notify you when a new WAH notice has been sent electronically to your Healthplanfinder account.

     (i) The e-mail notice will not include the notice, information about the content of the notice, or other confidential information; and

     (ii) You must log on to your Healthplanfinder account to get the notice.

     (6) We will stop sending WAH notices electronically to you if you ask us. You must notify us if your e-mail address changes.

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