WSR 13-17-104

PROPOSED RULES

HEALTH CARE AUTHORITY

(Medicaid Program)

[Filed August 21, 2013, 9:49 a.m.]

Original Notice.

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

Title of Rule and Other Identifying Information: WAC 182-500-0105 Medical assistance definitions—T, 182-503-0100 Washington apple health—Rights and responsibilities, 182-503-0110 Washington apple health—Limited English proficient (LEP), 182-503-0120 Washington apple health—Equal access services, 182-503-0510 Washington apple health—Program summary, 182-504-0130 Washington apple health—Continues coverage pending an appeal, 182-507-0110 Washington apple health—Alien medical programs, 182-514-0230 Washington apple health—MAGI-based long-term care program, 182-514-0235 Definitions, 182-514-0240 Washington apple health—General eligibility requirements for MAGI-based long-term care program, 182-514-0245 Washington apple health—Resource eligibility for MAGI-based long-term care program, 182-514-0250 Washington apple health—MAGI-based long-term care program for adults age twenty-one or older, 182-514-0255 Washington apple health—MAGI-based long-term care program for young adults nineteen and twenty years of age, 182-514-0260 Washington apple health—MAGI-based long-term care coverage for children eighteen years of age or younger, 182-514-0265 Washington apple health—How the agency or its designee determines how much of an institutionalized person's income must be paid towards the cost of care for the MAGI-based long-term care program, and 182-514-0270 When an involuntary commitment to eastern or western state hospital is covered by medicaid.

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 September 24, 2013, at 10:00 a.m.

Date of Intended Adoption: Not sooner than September 25, 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 September 24, 2013.

Assistance for Persons with Disabilities: Contact Kelly Richters by September 16, 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 administrations and supervision of Washington's medicaid program (Washington apple health (WAH)).

Reasons Supporting Proposal: See Purpose statement.

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) 725-1344; Implementation and Enforcement: Jessie Minier, P.O. Box 45534, Olympia, WA 98504-5534, (360) 725-1501.

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.

August 21, 2013

Kevin M. Sullivan

Rules Coordinator

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

WAC 182-500-0105 Medical assistance definitions—T.

"Tax filing terms":

(1) "Tax filer" means a person who is required to file a tax return.

(2) "Tax dependent" means a person for whom another person claims a deduction for a personal exemption under Section 151 of the Internal Revenue Code of 1986 for a taxable year. A tax dependent may be either a qualified child or a qualified relative as defined below:

(a) "Qualified child" means a child who meets the criteria to be claimed as a tax dependent based on one of the following relationships to the tax filer: Natural, adoptive, step, or foster child; natural, adoptive, step or half-sibling; or a descendant of any of the above; and meets the following criteria:

(i) The child is:

(A) Under the age of nineteen;

(B) Under the age of twenty-four and a full-time student; or

(ii) The child lived in the tax filer's household for more than one-half of the year;

(iii) The child provided for less than one-half of his/her own support for the year; and

(iv) The child is not filing a joint tax return for the year unless the return is filed only as a claim for a refund of taxes.

(b) "Qualified relative" means a person who:

(i) Cannot be claimed as a qualifying child or the qualifying child of another tax filer;

(ii) Has lived in the tax filer's household for the full year or is related to the tax filer in one of the ways listed below and the relationship has not been ended by death or divorce:

(A) The tax filer's child, stepchild, foster child, or a descendant of any of them;

(B) A sibling, half-sibling or step-sibling;

(D) A niece, nephew, aunt, or uncle;

(E) In-law relationships (son, daughter, father, mother, brother or sister-in-law).

(iii) Has gross income below an annual threshold set by the Internal Revenue Service (IRS) (three thousand nine hundred dollars for tax year 2013 with some exceptions). See IRS publication 501 for more information; and

(iv) Relies on the tax filer to pay over one-half of their total support for the year.

(3) "Nonfiler" means a person who is not required to file a tax return and also includes those who are not required to file but choose to file for another purpose, such as to claim a reimbursement of taxes paid.

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

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

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

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

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

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

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

NEW SECTION

WAC 182-503-0100 Washington apple health—Rights and responsibilities.

For the purposes of this chapter, "we" refers to the agency or its designee and "you."

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

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

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

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

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

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

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

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

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

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

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

(k) Request voter registration assistance;

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

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

(2) You are responsible to:

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

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

(d) Complete renewals when asked;

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

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

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

NEW SECTION

WAC 182-503-0110 Washington apple health—Limited-English proficient (LEP) services.

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

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

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

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

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

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

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

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

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

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

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

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

NEW SECTION

WAC 182-503-0120 Washington apple health—Equal access services.

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

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

(a) Arranging for or providing help to:

(i) Apply for or renew coverage;

(ii) Complete and submit forms;

(iii) Obtain information to determine or continue eligibility;

(iv) Request continued coverage; and

(v) Request a hearing.

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

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

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

(a) On written notices;

(b) In the Rights and Responsibilities form; and

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

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

(b) Has a developmental disability;

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

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

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

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

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

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

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

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

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

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

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

WAC 182-503-0510 ((How a client is determined "related to" a categorical program.)) Washington apple health—Program summary.

(((1) A person is related to the supplemental security income (SSI) program if they are:

(a) Aged, blind, or disabled as defined in chapter 388-475 WAC; or

(b) Considered as eligible for SSI under chapter 388-475 WAC; or

(2) A person or family is considered to be related to the temporary assistance for needy families (TANF) program if they:

(a) Meet the program requirements for the TANF cash assistance programs or the requirements of WAC 388-505-0220; or

(b) Would meet such requirements except that the assistance unit's countable income exceeds the TANF program standards in WAC 388-478-0065.

(3) Persons related to SSI or to TANF are eligible for categorically needy (CN) or medically needy (MN) medical coverage if they meet the other eligibility criteria for these medical programs. See chapters 388-475, 388-505 and 388-519 WAC for these eligibility criteria.

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

(a) Those that use a modified adjusted gross income (MAGI)-based methodology described in WAC 182-509-0300, called MAGI-based WAH programs;

(b) Those that use an income methodology other than MAGI, called non-MAGI-based WAH programs, which include:

(i) Supplemental security income (SSI)-related WAH programs;

(ii) Temporary assistance for needy families (TANF)-related WAH programs; and

(iii) Other WAH programs not based on MAGI, SSI, or TANF methodologies.

(c) Those that provide coverage based on a specific status or entitlement in federal rule and not on countable income, called deemed eligible WAH programs.

(2) MAGI-based WAH programs include the following:

(a) WAH parent and caretaker relative program described in WAC 182-505-0240;

(b) MAGI-based WAH adult medical program described in WAC 182-505-0250, for which the scope of coverage is called the alternative benefits plan (ABP) described in WAC 182-500-0010;

(d) WAH for kids program described in WAC 182-505-0210 (3)(a);

(e) Premium-based WAH for kids described in WAC 182-505-0215;

(f) WAH long-term care for children and adults described in chapter 182-514 WAC; and

(g) WAH alien emergency medical program described in WAC 182-507-0110 through 182-507-0125 when the person is eligible based on criteria for a MAGI-based WAH program.

(3) Non-MAGI-based WAH programs include the following:

(a) SSI-related programs which use the income methodologies of the SSI program (except where the agency has adopted more liberal rules than SSI) described in chapter 182-512 WAC to determine eligibility:

(i) WAH for workers with disabilities (HWD) described in chapter 182-511 WAC;

(ii) WAH SSI-related programs described in chapters 182-512 and 182-519 WAC;

(iii) WAH long-term care and hospice programs described in chapters 182-513 and 182-515 WAC;

(iv) WAH medicare savings programs described in chapter 182-517 WAC; and

(v) WAH alien emergency medical (AEM) programs described in WAC 182-507-0110 and 182-507-0125 when the person meets the age, blindness or disability criteria specified in WAC 182-512-0050.

(b) TANF-related programs which use the income methodologies based on the TANF cash program described in WAC 388-450-0170 to determine eligibility, with variations as specified in WAC 182-509-0001(5) and program specific rules:

(i) WAH refugee medical assistance (RMA) program described in WAC 182-507-0130; and

(ii) WAH medically needy (MN) coverage for pregnant women and children who do not meet SSI-related criteria.

(i) WAH breast and cervical cancer program described in WAC 182-505-0120;

(ii) WAH TAKE CHARGE program described in WAC 182-532-0720; and

(iii) WAH medical care services described in WAC 182-508-0005.

(4) Deemed eligible WAH programs include:

(a) WAH SSI medical program described in chapter 182-510 WAC, or a person who meets the medicaid eligibility criteria in 1619b of the Social Security Act;

(b) WAH newborn medical program described in WAC 182-505-0210(2);

(d) WAH medical extension program described in WAC 182-523-0100; and

(e) WAH family planning extension described in WAC 182-505-0115(5).

(5) A person is eligible for categorically needy (CN) health care coverage when the household's countable income is at or below the categorically needy income level (CNIL) for the specific program.

(6) If income is above the CNIL, a person is eligible for the MN program if the person is:

(a) A child;

(b) A pregnant woman; or

(7) MN health care coverage is not available to parents, caretaker relatives, or adults unless they are eligible under subsection (6) of this section.

(8) A person who is eligible for the WAH MAGI-based adult program listed in subsection (2)(b) of this section is eligible for ABP health care coverage as defined in WAC 182-500-0010. Such a person may apply for more comprehensive coverage through another WAH program at any time.

(9) For the other specific program requirements a person must meet to qualify for WAH, see chapters 182-503 through 182-527 WAC.

NEW SECTION

WAC 182-504-0130 Washington apple health—Continued coverage pending an appeal.

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

(2) If a person appeals a WAH decision within the time limits described in WAC 182-518-0005, WAH coverage will continue or be reinstated until the appeals process ends, unless otherwise specified in this section. This is called continued coverage.

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

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

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

(b) The person:

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

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

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

(5) A person is not eligible for continued coverage when a change in WAH is the result of a mass change. A mass change is when rules change that impact coverage for a class of applicants and recipients or due to a legislative or statutory change.

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

AMENDATORY SECTION (Amending WSR 12-24-038, filed 11/29/12, effective 12/30/12)

WAC 182-507-0110 Washington apple health—Alien medical programs.

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

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

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

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

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

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

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

(iv) WAC 182-505-0115, for a pregnant woman;

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

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

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

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

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

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

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

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

AMENDATORY SECTION (Amending WSR 12-02-034, filed 12/29/11, effective 1/1/12)

WAC 182-514-0230 Washington apple health—MAGI-based long-term care ((for families and children)) program.

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

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

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

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

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

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

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

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

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

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

AMENDATORY SECTION (Amending WSR 12-02-034, filed 12/29/11, effective 1/1/12)

WAC 182-514-0235 Definitions.

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

(("Categorically needy income level (CNIL)" - The standard used by the department to determine eligibility under a categorically needy medicaid program.))

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

(("Categorically needy (CN) medicaid" - Federally funded full scope of care medical benefits under Title XIX of the Social Security Act.))

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

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

"Institution for mental diseases (IMD)" - A hospital, nursing facility, or other institution of more than sixteen beds, that is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases, including medical attention, nursing care, and related services. Inpatient chemical dependency facilities of more than sixteen beds which provide residential treatment for alcohol and substance abuse are also considered an IMD.

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

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

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

(1) Hospitals;

(2) Nursing homes or the nursing home section of a state veteran's facility;

(3) Hospice care centers;

(4) An intermediate care facility for the mentally retarded (ICF/MR); or

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

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

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

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

(("Psychiatric facility" - Designated long-term inpatient psychiatric residential treatment facilities, state psychiatric hospitals, designated distinct psychiatric units, and medicare-certified distinct units in acute care hospitals.))

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

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

AMENDATORY SECTION (Amending WSR 12-02-034, filed 12/29/11, effective 1/1/12)

WAC 182-514-0240 Washington apple health—General eligibility requirements for ((family institutional medical coverage)) MAGI-based long-term care program.

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

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

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

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

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

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

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

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

(A) A family medical program described in WAC 388-505-0220;

(B) A transitional family medical program described in WAC 388-523-0100; or

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

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

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

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

(A) Have a qualifying emergency condition; and

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

(((v) Be an individual nineteen through twenty years of age but not eligible under subsections (i) through (iv) of this section.

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

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

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

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

(a) Income received by the individual in his or her own name;

(b) Funds given to him or her by another individual towards meeting his or her needs; and

(4) Individuals eligible for a cash grant under the temporary assistance for needy families (TANF) program can remain eligible for a cash payment and the categorically needy (CN) medicaid program while in the institution. The expected length of stay in the institution may impact the amount of the TANF payment.

(a) When the institutionalized individual is expected to return to the home within one hundred and eighty days, the department considers this to be a temporary absence from the home and the individual remains eligible for their full TANF grant. Rules defining a temporary absence are described in WAC 388-454-0015.

(b) When the department determines that the institutionalized individual's stay in the facility is likely to exceed one hundred and eighty days, the department reduces his or her share of the TANF grant to the personal needs allowance (PNA) described in WAC 388-478-0040. This is also referred to as the clothing, personal maintenance and necessary incidentals (CPI) amount.

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

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

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

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

(7) Parents and caretaker relatives who meet the criteria under WAC 182-505-0240 are not eligible for the WAH MAGI-based long-term care program and must have eligibility determined under SSI-related institutional rules described in chapter 182-513 WAC.

AMENDATORY SECTION (Amending WSR 12-02-034, filed 12/29/11, effective 1/1/12)

WAC 182-514-0245 Washington apple health—Resource eligibility for ((family institutional medical coverage)) MAGI-based long-term care program.

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

(2) For individuals nineteen years of age or older, there is a one thousand dollar countable resource limit for new applicants for family medical coverage not meeting the additional resource exclusion of WAC 388-470-0026, and all of the following apply:

(a) In order to determine which resources it must count, the department follows rules in WAC 388-470-0026, 388-470-0045 (with the exception of subsection (3) relating to primary residence), 388-470-0060, and 388-470-0070.

(b) Applicants and current categorically needy (CN) or medically needy (MN) medical assistance clients receiving long-term care services under the family institutional medical program are subject to transfer of asset regulations as described in WAC 388-513-1363 through 388-513-1366.

(c) Individuals who apply for long-term care services on or after May 1, 2006, who have an equity interest greater than five hundred thousand dollars in their primary residence are not eligible for long-term care services. This does not apply if the individual's spouse or blind, disabled or dependent child under twenty-one years of age is lawfully residing in the primary residence. Individuals who are denied or terminated from long-term care services due to excess home equity may apply for an undue hardship waiver as described in WAC 388-513-1367.

(d) Once an individual has been determined eligible for any family medical program, the department does not consider any subsequent increase in that individual's resources after the month of application, as described in WAC 388-470-0026. Subsequent increases in a family's resources are not applied towards the cost of care in any month in which the resources have exceeded the eligibility standard.

(e) When both spouses of a legally married couple are institutionalized, the department determines resource eligibility for each spouse separately, as if each were a single individual.

(f) When only one spouse in a legally married couple applies for family institutional coverage, the rules in WAC 388-513-1350 (8) through (13) apply.

(g) For countable resources over one thousand dollars that are not otherwise excluded by WAC 388-470-0026:

(i) The department reduces the excess resources in an amount equal to medical expenses incurred by the institutionalized individual, such as:

(A) Premiums, deductibles, coinsurance or copayments for health insurance and medicare;

(B) Necessary medical care recognized under state law, but not covered under the state's medical plan; and

(ii) Medical expenses that the department uses to reduce excess resources must not:

(A) Be the responsibility of a third party payer;

(B) Have been used to satisfy a previous spenddown liability;

(D) Have been used to reduce client responsibility toward cost of care;

(E) Have been incurred during a transfer of asset penalty; or

(F) Have been written off by the medical provider (the individual must be financially liable for the expense).

(h) If an individual has excess resources remaining, after using incurred medical expenses to reduce those resources, the department uses the following calculations to determine if an individual is eligible for family institutional medical coverage under the CN or MN program:

(i) If countable income is below the CN income standard, and the combination of countable income plus excess resources is below the monthly cost of care at the state medicaid rate, the individual is eligible for family institutional medical coverage under the CN program.

(ii) If countable income is below the CN income standard, but the combination of countable income plus excess resources is above the monthly cost of care at the state medicaid rate, the individual is not eligible for family institutional medical coverage.

(iii) If countable income is over the CN income standard, and the combination of countable income plus excess resources is below the monthly cost of care at the institution's private rate plus the amount of any recurring medical expenses for institutional services, the individual is eligible for family institutional coverage under the MN program. (MN coverage applies only to individuals twenty years of age or younger.)

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

(2) The transfer of asset evaluation described in WAC 182-513-1363 does not apply to applicants or recipients who are eligible under the WAH MAGI-based long-term care program.

AMENDATORY SECTION (Amending WSR 12-02-034, filed 12/29/11, effective 1/1/12)

WAC 182-514-0250 ((Eligibility for family institutional medical for individuals)) Washington apple health—MAGI-based long-term care program for adults age twenty-one ((years of age)) or older.

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

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

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

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

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

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

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

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

AMENDATORY SECTION (Amending WSR 12-02-034, filed 12/29/11, effective 1/1/12)

WAC 182-514-0255 ((Eligibility for family institutional medical for individuals)) Washington apple health—MAGI-based long-term care program for young adults nineteen and twenty years of age.

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

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

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

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

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

(4) The agency or its designee approves CN health care coverage under this section for twelve calendar months.

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

(((a) Individuals with countable income below the state monthly cost of care in the facility are eligible for MN without spenddown.

(b) If the individual's countable income exceeds the state monthly cost of care but is under the private cost of care plus the amount of any recurring medical expenses for institutional services, he or she may be required to spend down their income as described in WAC 388-519-0110.

(c) If the individual's countable income exceeds the private monthly cost of care plus the amount of any recurring medical expenses for institutional services, he or she is not eligible for family institutional medical coverage.

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

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

AMENDATORY SECTION (Amending WSR 12-02-034, filed 12/29/11, effective 1/1/12)

WAC 182-514-0260 ((Eligibility for family institutional medical)) Washington apple health—MAGI-based long-term care coverage for children eighteen years of age or younger.

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

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

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

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

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

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

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

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

(((b) Individuals with countable income below the state monthly cost of care in the facility are eligible for MN without spenddown.

(c) If the individual's countable income exceeds the state monthly cost of care, but is under the private monthly cost of care plus the amount of any recurring medical expenses for institutional services, the department may require the individual to spend down his or her income as described in WAC 388-519-0110.

(d) If the individual's countable income exceeds the private monthly cost of care plus the amount of any recurring medical expenses for institutional services, he or she is not eligible for family institutional medical coverage.

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

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

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

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

AMENDATORY SECTION (Amending WSR 12-02-034, filed 12/29/11, effective 1/1/12)

WAC 182-514-0265 Washington apple health—How the ((department)) agency or its designee determines how much of an institutionalized ((individual's)) person's income must be paid towards the cost of care for the MAGI-based long-term care program.

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

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

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

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

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

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

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

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

(d) Family maintenance allocation if married with dependents.

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

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

(g) Housing maintenance exemption:

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

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

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

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

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

AMENDATORY SECTION (Amending WSR 12-19-051, filed 9/13/12, effective 10/14/12)

WAC 182-514-0270 When an involuntary commitment to Eastern or Western State Hospital is covered by medicaid.

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

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

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

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

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

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

(f) Have countable resources below one thousand dollars. Individuals eligible under the provisions of this section may not apply excess resources towards the cost of care to become eligible. An individual with resources over the standard is not eligible for assistance under this section)):

(i) Two hundred percent of the federal poverty level if age twenty years or younger; or

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

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

(4) A person between the age of twenty-one and sixty-five, with the exception of subsection (3) of this section, is not eligible for federally funded health care coverage through Washington apple health.