Overview
To explain the general eligibility requirements for SSI-related individuals seeking Categorically Needy (CN) or Medically Needy (MN) health care coverage.
The SSI-Related eligibility requirements may be found in the following WACs:
- General requirements (WAC 182-512-0050 through WAC 182-512-0150)
- Resources (WAC 182-512-0200 through WAC 182-512-0550)
- Income, earned and unearned (WAC 182-512-0600 through WAC 182-512-0750)
- Income exclusions and disregards (WAC 182-512-0770 through WAC 182-512-0860)
- Special income disregards (WAC 182-512-0880)
- Income allocation and deeming (WAC 182-512-0900 through WAC 182-512-0960)
For related eligibility rules and other information:
- Definitions of terms used in discussing health care coverage, see WAC 182-500-0005.
- Medically Needy (MN) health care coverage, see WAC 182-519-0100.
- Supplemental Security Income (SSI), see chapter 388-474 WAC.
- Aged, Blind, or Disabled cash assistance, see WAC 388-449-0001.
- Long-Term Care, see chapters 182-513 WAC, 182-514 WAC and 182-515 WAC.
- Hospice Services, see chapter 182-551 WAC.
- Equal Access requirements, see WAC 182-503-0120.
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WAC 182-512-0050 SSI-related medical -- General information.
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WAC 182-512-0050 SSI-related medical -- General information.
Effective April 14, 2014.
- The agency (which includes its designee for purposes of this chapter) provides health care coverage under the Washington apple health (WAH) categorically needy (CN) and medically needy (MN) SSI-related programs for SSI-related people, meaning those who meet at least one of the federal SSI program criteria as being:
- Age sixty-five or older;
- Blind with:
- Central visual acuity of 20/200 or less in the better eye with the use of a correcting lens; or
- A field of vision limitation so the widest diameter of the visual field subtends an angle no greater than twenty degrees.
- Disabled:
- "Disabled" means unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment, which:
- Can be expected to result in death; or
- Has lasted or can be expected to last for a continuous period of not less than twelve months; or
- In the case of a child seventeen years of age or younger, if the child suffers from any medically determinable physical or mental impairment of comparable severity.
- Decisions on SSI-related disability are subject to the authority of:
- Federal statutes and regulations codified at 42 U.S.C. Section 1382c and 20 C.F.R., parts 404 and 416, as amended; and
- Controlling federal court decisions, which define the OASDI and SSI disability standard and determination process.
- "Disabled" means unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment, which:
- A denial of Title II or Title XVI federal benefits by SSA solely due to failure to meet the blindness or disability criteria is binding on the agency unless the applicant's:
- Denial is under appeal in the reconsideration stage in SSA's administrative hearing process, or SSA's appeals council; or
- Medical condition has changed since the SSA denial was issued.
- The agency considers a person who meets the special requirements for SSI status under Sections 1619(a) or 1619(b) of the Social Security Act as an SSI recipient. Such a person is eligible for WAH CN health care coverage under WAC 182-510-0001.
- Persons referred to in subsection (1) must also meet appropriate eligibility criteria found in the following WAC and EA-Z Manual sections:
- For all programs:
- WAC 182-506-0015, Medical assistance units;
- WAC 182-504-0015, Categorically needy and WAC 182-504-0020, Medically needy certification periods;
- Program specific requirements in chapter 182-512 WAC;
- WAC 182-503-0050, Verification;
- WAC 182-503-0505, General eligibility requirements for medical programs;
- WAC 182-503-0540, Assignment of rights and cooperation;
- Chapter 182-516 WAC, Trusts, annuities and life estates.
- For LTC programs:
- For WAH MN, chapter 182-519 WAC, Spenddown;
- For WAH HWD, program specific requirements in chapter 182-511 WAC.
- For all programs:
- Aliens who qualify for medicaid coverage, but are determined ineligible because of alien status may be eligible for programs as specified in WAC 182-507-0110.
- The agency pays for a person's medical care outside of Washington according to WAC 182-501-0180.
- The agency follows income and resource methodologies of the supplemental security income (SSI) program defined in federal law when determining eligibility for SSI-related medical or medicare savings programs unless the agency adopts rules that are less restrictive than those of the SSI program.
- Refer to WAC 182-504-0125 for effects of changes on medical assistance for redetermination of eligibility.
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.
- The agency (which includes its designee for purposes of this chapter) provides health care coverage under the Washington apple health (WAH) categorically needy (CN) and medically needy (MN) SSI-related programs for SSI-related people, meaning those who meet at least one of the federal SSI program criteria as being:
Worker responsibility
- When SSA terminates an individual’s SSI cash payment, but is determining 1619(a) or 1619(b) eligibility for that individual, continue the individual on S01 medical until you receive additional information on the SDX referring the individual back to the State for a Medicaid determination (R on the medical eligibility field on SDX1).
- While the individual is in 1619(b) status, SSA sends notification to the State on the SDX interface using the 'C' code in the medical eligibility field on the SDX1.
- After the SSA sends the final decision on the SDX record, determine eligibility for any appropriate programs based on the SSA decision.
- When SSA terminates the individual’s SSI cash eligibility for reasons other than disability ending or improvement, a new referral to DDDS is needed to get the disability end date – the date a new disability determination will be needed. Set an alert at least 90 days prior to the disability end date to begin the process of getting the new disability determination from DDDS.
- To be an SSI-related individual, the individual must be age 65 or older or determined blind or disabled by either the federal SSI/SSA program or by DDDS. An individual who is only receiving disability benefits such as VA, L&I, Railroad Retirement Benefits (RRB), etc., is not necessarily an SSI-related individual. For a disability determination, initiate a Non-Grant Medical Assistance (NGMA) referral.
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WAC 182-512-0010 Supplemental security income (SSI) standards, SSI-related categorically needy income level (CNIL), and countable resource standards.
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WAC 182-512-0010 Supplemental security income (SSI) standards, SSI-related categorically needy income level (CNIL), and countable resource standards.
Effective January 27, 2019
- The SSI payment standards, also known as the federal benefit rate (FBR), change each January 1st.
- See WAC 388-478-0055 for the amount of the state supplemental payments (SSP) for SSI recipients.
- See WAC 182-513-1205 for standards of clients living in an alternate living facility.
- The SSI-related CNIL standards are the same as the SSI payment standards for single persons and couples. Those paying out shelter costs have a higher standard than people who have supplied shelter.
- The countable resource standards for SSI and SSI-related CN medical programs are:
- One person $2,000
- A legally married couple $3,000
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.
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WAC 182-512-0150 SSI-related medical -- Medically needy (MN) medical eligibility.
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WAC 182-512-0150 SSI-related medical -- Medically needy (MN) medical eligibility.
Effective June 26, 2022.
- Washington apple health (WAH) medically needy (MN) health care coverage is available for any of the following:
- A person who is SSI-related and not eligible for WAH categorically needy (CN) medical coverage because the person has countable income that is above the WAH CN income level (CNIL) (or for long-term care (LTC) recipients, above the special income limit (SIL)):
- The person's countable income is at or below WAH MN standards, leaving no spenddown requirement; or
- The person's countable income is above WAH MN standards requiring the person to spenddown their excess income (see subsection (4) of this section). See WAC 182-512-0500 through 182-512-0800 for rules on determining countable income, and WAC 182-519-0050 for program standards or chapter 182-513 WAC for institutional standards.
- An SSI-related ineligible spouse of an SSI recipient;
- A person who meets SSI program criteria but is not eligible for the SSI cash grant due to immigration status or sponsor deeming. See WAC 182-503-0535 for limits on eligibility for aliens;
- A person who meets the WAH MN LTC services requirements of chapter 182-513 WAC;
- A person who lives in an alternate living facility and meets the requirements of WAC 182-513-1205; or
- A person who meets resource requirements as described in chapter 182-512 WAC, elects and is certified for hospice services per chapter 182-551 WAC.
- A person who is SSI-related and not eligible for WAH categorically needy (CN) medical coverage because the person has countable income that is above the WAH CN income level (CNIL) (or for long-term care (LTC) recipients, above the special income limit (SIL)):
- A person whose countable resources are above the SSI resource standards is not eligible for WAH MN noninstitutional health care coverage. See WAC 182-512-0200 through 182-512-0550 to determine countable resources.
- A person who qualifies for services under WAH long-term care programs has different criteria and may spend down excess resources to become eligible for WAH LTC institutional or waiver health care coverage. Refer to WAC 182-513-1315 and 182-513-1395.
- A person with income over the effective WAH MN income limit (MNIL) described in WAC 182-519-0050 may become eligible for WAH MN coverage when the person has incurred medical expenses that are equal to the excess income. This is the process of meeting spenddown. Refer to chapter 182-519 WAC for spenddown information.
- A person may be eligible for health care coverage for any or all of the three months immediately prior to the month of application, if the person has:
- Met all eligibility requirements for the months being considered; and
- Received medical services covered by medicaid during that time.
- A person who is eligible for WAH MN without a spenddown is certified for up to 12 months. For a person who must meet a spenddown, refer to WAC 182-519-0110. For a person who is eligible for a WAH long-term care MN program, refer to WAC 182-513-1395 and 182-513-1315.
- A person must reapply for each certification period. There is no continuous eligibility for WAH MN.
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.
- Washington apple health (WAH) medically needy (MN) health care coverage is available for any of the following:
Worker responsibilities
- Make sure a new application is mailed to the individual before the end of the base period, especially if the review has fallen out of the ACES review cycle or if the individual moved.
- The 3-month retroactive period of eligibility does not require a separate application.
- For reported changes that will alter the spenddown amount:
- If the individual has met spenddown, no change can be made for previous months. Recalculate spenddown for the remaining base period using the new information. If the change increases the spenddown, changes are effective the month after the month of change, following the rules of advance and adequate notice. If the change makes the individual eligible for CN coverage, make those changes for the appropriate months. Be sure to send an award letter explaining the changes.
- If the individual has not met spenddown, recalculate the spenddown using current information and notify the individual of the changes. See the Change of Circumstances of the Spenddown chapter of the manual.
- Allow an individual 30 days after the base period has expired to send in bills to meet spenddown. It may take this long for the individual to gather medical bills. If the individual requests more time to send bills in, allow it. If a fair hearing is filed, allow the individual to continue submitting bills incurred during the established base period until the fair hearing is resolved.
Referral process to Division of Disability Determination Services (DDDS):
In Washington State, DDDS makes the blindness and disability determinations for both:
- Social Security Administration (Social Security disability benefits and SSI cash grant); and
- SSI-related individuals who:
- Do not receive SSI or SSA disability;
- Need a reexamination for continuing eligibility;
- Were terminated from SSI due to no longer meeting disability criteria;
- Meet SSI-related income and resource standards; or
- Have gross monthly earnings at or above the current substantial gainful activity (SGA) level (See SSA "Substantial Gainful Activity - Amounts"). For more information about SGA, see the SSA Red Book.
- If an individual is currently receiving SSI or SSA disability, DDDS has already determined that the individual is blind or disabled.
- When a blindness or disability determination is needed, follow instructions described in the NGMA overview.