Apple Health for Kids, with and without premiums

Revised date

WAC 182-505-0210 Eligibility for children.

WAC 182-505-0210 Eligibility for children.

Effective December 8, 2023.

  1. General eligibility. For purposes of this section, a child must:
    1. Be a Washington state resident under WAC 182-503-0520 and 182-503-0525;
    2. Provide a Social Security number under WAC 182-503-0515, unless exempt; and
    3. Meet program-specific requirements.
  2. Deemed eligibility groups. A child is automatically eligible for coverage without an application if the child meets the program-specific requirements in (a) through (c) of this subsection.
    1. Newborn coverage. A child under age one is eligible for categorically needy (CN) coverage if the birth parent was eligible for Washington apple health on the date of delivery:
      1. Including a retroactive eligibility determination; or
      2. By meeting a medically needy (MN) spenddown liability with expenses incurred by the date of the newborn's birth:
    2. Washington apple health for supplemental security income (SSI) recipients. A child who is eligible for SSI is automatically eligible for CN coverage under WAC 182-510-0001.
    3. Foster care coverage. A child age 20 and younger is eligible for CN coverage under WAC 182-505-0211 when the child is in foster care or receives subsidized adoption services. For children who age out of the foster care program, see WAC 182-505-0211(3).
  3. Continuous eligibility for children under age six. Children are eligible for Washington apple health continuous eligibility for children under age six when they:
    1. Have household income at or below 215 percent of the federal poverty level at the time of application; or
    2. Received coverage under subsection (5) of this section and are no longer eligible for deemed coverage under subsection (5) (b) or (c) of this section.
  4. MAGI-based eligibility groups. A child age 18 and younger is eligible for CN coverage based on modified adjusted gross income (MAGI):
    1. At no cost when the child's countable income does not exceed the standard in WAC 182-505-0100 (6)(a);
    2. With payment of a premium when the child's countable income does not exceed the standard in WAC 182-505-0100 (6)(b), and the child meets additional eligibility criteria in WAC 182-505-0215;
    3. Under chapter 182-514 WAC, if the child needs long-term care services because the child resides or is expected to reside in an institution, as defined in WAC 182-500-0050, for 30 days or longer. An institutionalized child is eligible for coverage under the medically needy program if income exceeds the CN income standard for a person in an institution (special income level);
    4. Under WAC 182-505-0117, if a child is pregnant;
    5. When the child has household income at or below 215 percent of the federal poverty level at the time of application and is eligible for Washington apple health continuous eligibility for children under age six.
  5. Non-MAGI-based children's programs. The agency determines eligibility for the:
    1. Medically needy (MN) program according to WAC 182-510-0001(6) and 182-519-0100. A child age 18 and younger is eligible if the child:
      1. Is not eligible for MAGI-based coverage under subsection (3) of this section;
      2. Meets citizenship or immigration requirements under WAC 182-503-0535 (2)(a), (b), (c), or (d); and
      3. Meets any spenddown liability required under WAC 182-519-0110.
    2. SSI-related program. A child age 18 and younger is eligible for CN or MN SSI-related coverage if the child meets:
      1. SSI-related eligibility under chapter 182-512 WAC;
      2. Citizenship or immigration requirements under WAC 182-503-0535 (2)(a), (b), (c), or (d); and
      3. Any MN spenddown liability under WAC 182-519-0110.
    3. SSI-related long-term care program.
      1. A child age 18 and younger is eligible for home and community based (HCB) waiver programs under chapter 182-515 WAC if the child meets:
        1. SSI-related eligibility under chapter 182-512 WAC;
        2. Citizenship or immigration requirements under WAC 182-503-0535 (2)(a), (b), (c), or (d); and
        3. Program-specific age and functional requirements under chapters 388-106 and 388-845 WAC.
      2. A child age 18 and younger who resides or is expected to reside in a medical institution as defined in WAC 182-500-0050 is eligible for institutional medical under chapter 182-513 WAC if the child meets:
        1. Citizenship or immigration requirements under WAC 182-503-0535 (2)(a), (b), (c), or (d);
        2. Blindness or disability criteria under WAC 182-512-0050; and
        3. Nursing facility level of care under chapter 388-106 WAC.
  6. Alien emergency medical program. A child age 20 and younger who does not meet the eligibility requirements for a program described under subsections (2) through (5) of this section is eligible for the alien emergency medical (AEM) program if the child meets:
    1. The eligibility requirements of WAC 182-507-0110; and
    2. MN spenddown liability, if any, under WAC 182-519-0110.
  7. Other provisions.
    1. A child residing in an institution for mental disease (IMD) as defined in WAC 182-500-0050(1) is not eligible for inpatient hospital services, unless the child is unconditionally discharged from the IMD before receiving the services.
    2. A child incarcerated in a public institution as defined in WAC 182-500-0050(4) is only eligible for inpatient hospital services.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

WAC 182-505-0215 Children's Washington apple health with premiums.

WAC 182-505-0215 Children's Washington apple health with premiums.

Effective January 23, 2021.

  1. A child is eligible for Washington apple health with premiums if the child:
    1. Meets the requirements in WAC 182-505-0210(1);
    2. Has countable income below the standard in WAC 182-505-0100 (6)(b); and
    3. Pays the required premium under WAC 182-505-0225, unless the child is exempt under WAC 182-505-0225 (2)(c).
  2. A child is not eligible for Washington apple health with premiums if the child:
    1. Is eligible for no-cost Washington apple health;
    2. Has creditable health insurance coverage as defined in WAC 182-500-0020.
  3. A child with creditable health insurance coverage may be eligible for Washington apple health with premiums if the child is eligible for either:
    1. Public employees benefits board (PEBB) health insurance coverage based on a family member's employment with a Washington state agency, or a Washington state university, community college, or technical college; or
    2. School employees benefits board (SEBB) health insurance coverage based on a family member's employment with a Washington school district, charter school, or educational service district; and
    3. Meets the requirements in WAC 182-505-0210 (1).

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

Clarifying Information

Eligibility for medical assistance is now "delinked" from receipt of cash assistance. Assistance unit rules for MAGI-based eligibility for children is described in WAC 182-506-0010. Assistance unit rules for Non-MAGI eligibility programs are found in chapter WAC 182-506-0015.

  1. For children who are not eligible for MAGI-based coverage under this section, refer to the following categories:
    1. SSI-related Medical for children who may meet SSI disability criteria services and are ineligible for any other medical program;
    2. Pregnancy for medical programs for pregnant women;
    3. Emergency Assistance: Alien Emergency Medical Program for an alien child who is related to a Medicaid program, including the aged, blind, and disabled;
    4. Long Term Care for children requiring nursing facility or home and community-based services;
    5. Medical Extensions for a family who has an increase in earned income, spousal support, or child support;
    6. Spenddown for a child, pregnant woman, or an SSI-related child whose income exceeds program standards. They may be eligible to receive Medically Needy (MN) coverage.

Children found eligible for a categorically needy scope of care medical program are continuously eligible for Categorically Needy (CN) medical for 12 months regardless of changes; except for aging out of the program, moving out of state, failing to pay a required premium, incarceration, or death. (See WAC 182-504-0125.) The scope of coverage is identical for these programs regardless of the source of funding.

Apple Health for Kids

  1. Newborn Medical (N10): See WAC 182-505-0210 (2). Newborns are automatically entitled to receive CN Medicaid through their first birthday as long as:
    1. Their mother was eligible for medical (Apple Health or CHIP) on the day of delivery, including any retroactive eligibility determination.
    2. For MN spenddown pending on the day of delivery, spenddown was met with the labor and delivery expenses, and
    3. The newborn is a Washington State resident.

      It is important that a ProviderOne ID be obtained as soon as possible after the day of delivery to ensure there are no interruptions in coverage.

      Until the baby has their own ProviderOne ID:

      • Mom is on fee-for-service: The newborn is covered under the mother's ProviderOne ID through the month that includes the baby's 60th day of life or until they are assigned their own ProviderOne ID.
      • Mom is on managed care: The newborn is covered under the mother's ProviderOne ID through the month in which the 21st day of life occurs.
      • If the newborn's eligibility begins in a month other than the month of birth, the eligibility worker may need to use the retro medical process to approve missing months of eligibility.
  2. Apple Health for Kids CN coverage (N11/N31): See WAC 182-505-0210 (3). These children receive federal or state-funded CN Medicaid. Federally-funded children are enrolled in a managed care plan while state funded children remain fee-for-service.
  3. Apple Health for Kids with Premiums CN Coverage (N13/N33): See WAC 182-505-0210 (4). These children receive federal or state funded CN medical, but are required to pay a premium see WAC 182-505-0225. Federally-funded children are enrolled in managed care, while state-funded children remain fee-for-service.
  4. Apple Health for Kids (MN) Medically Needy coverage (F99, S99, K99): See WAC 182-505-0210 (4). These children receive slightly less coverage than CN Medicaid and do not enroll in managed care. They must meet a spenddown before any services are paid. See Spenddown for more information.
  5. Children's Institutional coverage (K01, K95, K99): See WAC 182-505-0210(3) WAC 182-514-0230 through WAC 182-514-0265: These children are approved for medical assistance based on institutional rules once they reside or are expected to reside in an institution for 30 days or longer.
  6. Children's Alien Medical Program (AMP) coverage (F99): See WAC 182-505-0210 (5): These alien children are eligible for MN coverage for emergency medical services only. Their coverage under F99 does not require an acute and emergent medical need to set up the spenddown.

Note: Nonqualified children under age 19 with family income under 312% FPL are related to and approved for the appropriate Apple Health for Kids program not AMP.

Apple Health for Kids with Premiums

  1. Apple Health for Kids with Premiums CN Coverage (N13/N33): See WAC 182-505-0210 (4). These children receive federal or state funded CN medical, but are required to pay a premium see WAC 182-505-0225. Federally-funded children are enrolled in managed care, while state-funded children remain fee-for-service.
  2. American Indian/Alaska Native children are exempt from the premium requirement.
  3. Children who have access to coverage through PEBB/SEBB plan are eligible for Apple Health for Kids with Premiums.
  4. Children are NOT eligible for Apple Health for Kids with Premiums coverage (N13/N33) if they:
    1. Have other credible health insurance coverage through a private plan such as employer sponsored insurance; or
    2. Were closed in the prior 90 days for failing to pay the required premium (see WAC 182-505-0225 (4).

Age

  • Eligibility runs through the end of the month in which the individual reaches the age limit of the program.
  • When an individual is an Apple Health recipient in the month of their twenty-first birthday and they receive active inpatient psychiatric treatment which extends beyond their twenty-first birthday, they remain eligible for CN or MN coverage under the family institutional medical program (K01, K95) until the date they discharge from the facility or until their twenty-second birthday, whichever happens first.
  • When an individual applies in the same month they reach the age limit for the specific program, they can still be approved for the month of application even though they may have already had their birthday.

WAC 182-505-0225 Children's Washington apple health with premiums - Calculation and determination of premium amount.

WAC 182-505-0225 Children's Washington apple health with premiums - Calculation and determination of premium amount.

Effective October 25, 2024.

  1. For the purposes of this chapter, "premium" means an amount paid for health care coverage under WAC 182-505-0215.
  2. Premium requirement. The Washington apple health premium-based program under WAC 182-505-0215 requires payment of a monthly premium.
    1. The first monthly premium is due in the month following the determination of eligibility.
    2. There is no premium requirement for health care coverage received in the month eligibility is determined or in any prior month.
    3. A child who is American Indian or Alaska native is exempt from the monthly premium requirement.
  3. Monthly premium amount.
    1. The premium amount for the medical assistance unit (MAU) is based on countable income under chapter 182-509 WAC and the number of people in the MAU under chapter 182-506 WAC.
    2. The premium amount is as follows:
      1. If the MAU's countable income exceeds 210 percent of the federal poverty level (FPL) but does not exceed 260 percent of the FPL, the monthly premium for each child is $20.
      2. If the MAU's countable income exceeds 260 percent of the FPL but does not exceed 312 percent of the FPL, the monthly premium for each child is $30.
      3. The medicaid agency charges a monthly premium for no more than two children per household.
      4. Payment of the full premium is required. Partial payments cannot be designated for a specific child or month.
      5. Any third party may pay the premium on behalf of the household. Failure of a third party to pay the premium does not eliminate the obligation of the household to pay past due premiums.
    3. A change that affects the premium amount takes effect the month after the change is reported.
  4. Nonpayment of premiums.
    1. The agency writes off past-due premiums after 12 months.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

Clarifying Information

  1. Medical coverage for parenting adults of minor dependent children has been "delinked" from cash assistance. Parenting adults need to complete a separate application for medical coverage.
  2. Adults who are over income for Apple Health for Families (N01) may be eligible for Apple Health for Adults (N05) as described in WAC 182-505-0250.
  3. Adults who are ineligible for Apple Health for Families (N01) based on citizenship may be eligible for Alien Emergency Medical (N21) as described in WAC 182-507-0110.
  4. Parenting adults are eligible for Apple Health for Families (N01) even if they are eligible for Medicare and/or age 65 or older.

Individuals may apply for MAGI Medicaid using the following options:

If an individual wants help applying for MAGI Medicaid, he or she can work with a Navigator or call Healthplanfinder Customer Support at 1-855-923-4633.

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