Eligibility review

Revised date
Purpose statement

To explain how often the agency reviews individuals' eligibility based on the health care coverage they receive and their circumstances.

WAC 182-504-0035 Washington apple health -- Renewals.

WAC 182-504-0035 Washington apple health -- Renewals.

Effective December 8, 2023.

  1. For all Washington apple health (WAH) programs, the following applies:
    1. You are required to complete a renewal of eligibility at least every 12 months with the following exceptions:
      1. If you are eligible for WAH medically needy with spenddown, then you must complete a new application at the end of each three- or six-month base period;
      2. If you are eligible for WAH alien emergency medical, then you are certified for a specific period of time to cover emergency inpatient hospitalization costs only (see WAC 182-507-0115(8));
      3. If you are eligible for WAH refugee coverage, you must complete a renewal of eligibility after 12 months; or
      4. If you are a child on apple health for kids without premiums, your first renewal is due the month of your sixth birthday.
    2. You may complete renewals online, by phone, or by paper application that you mail or fax to us (the agency or its designee).
    3. If your WAH is renewed, we decide the certification period according to WAC 182-504-0015.
    4. We review all eligibility factors subject to change during the renewal process.
    5. We redetermine eligibility as described in WAC 182-504-0125 and send you written notice as described in WAC 182-518-0005 before WAH is terminated.
    6. If you need help meeting the requirements of this section, we provide equal access services as described in WAC 182-503-0120.
  2. For programs based on modified adjusted gross income (MAGI) as described in WAC 182-503-0510:
    1. Sixty days prior to the end of the certification period:
      1. When information from electronic sources shows income is reasonably compatible (as defined in WAC 182-500-0095), we administratively renew your coverage (as defined in WAC 182-500-0010) for a new certification period and send you a notice of renewal with the information used. You are required to inform us if any of the information we used is wrong.
      2. If we are unable to complete an administrative renewal (as defined in WAC 182-500-0010), you must give us a signed renewal in order for us to decide if you will continue to get WAH coverage beyond the current certification period.
      3. We follow the requirements described in WAC 182-518-0015 to request any additional information needed to complete the renewal process or to terminate coverage for failure to renew.
    2. If your WAH coverage is terminated because you did not renew, you have 90 days from the termination date to give us a completed renewal. If we decide you are still eligible to get WAH coverage, we will restore your WAH without a gap in coverage.
  3. For non-MAGI based programs (as described in WAC 182-503-0510):
    1. Forty-five days prior to the end of the certification period, we send notice with a renewal form. You must renew before the end of the certification period by either calling the department of social and health services at the number listed on the form to renew by telephone, renew online at www.washingtonconnection.org, or mailing or delivering to the department of social and health services a signed renewal form with the information required by WAC 182-503-0005.
    2. We follow the requirements in WAC 182-518-0015 to request any additional information needed to complete the renewal process or to terminate coverage for failure to renew.
    3. To complete your renewal, you must give us all the other information requested on the application that is needed to determine your eligibility.
    4. If you are terminated for failure to renew, you have 30 days from the termination date to submit a completed renewal. If still eligible, we will restore your WAH without a gap in coverage.
  4. If we determine that you are not eligible for renewal of your WAH coverage, we:
    1. Consider your eligibility for all other WAH programs before ending your WAH coverage; and
    2. Coordinate with the health benefit exchange any request for information that is necessary to determine your eligibility for:
      1. Other WAH programs; and
      2. With respect to qualified health plans, health insurance premium tax credits (as defined in WAC 182-500-0045) and cost-sharing reductions (as defined in WAC 182-500-0020).
  5. We reconsider our decision that you are not eligible for WAH coverage without a new application from you when:
    1. We receive the information that we need to decide if you are eligible within 30 days of the date on the termination notice; or
    2. You request a hearing within 90 days of the date on the renewal denial letter and an administrative law judge (ALJ) or HCA review judge decides our decision was wrong (per chapter 182-526 WAC).
  6. If you disagree with our decision, you can ask for a hearing. If we decided that you are not eligible for renewal because we do not have enough information, the ALJ will consider the information we already have and anymore information you give us. The ALJ does not consider the previous absence of information or failure to respond in determining if you are eligible.

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 Review Periods

The table below shows when an individual's eligibility is up for review (typically the end of the certification period) for each Apple Health program.

Program Default review period
Apple Health Pregnancy Coverage (N03/N23) 12 months After Pregnancy Coverage (APC)
L99 and MN with Spenddown 3 or 6 months (chosen by applicant)
All other Apple Health programs (other than AEM) 12 months

Worker Responsibilities

Review of Current Circumstances

  1. As part of the eligibility review process for a paper review form, ensure that the person answered all questions clearly and completely. If doing a review in-person or over the telephone, ensure that all eligibility factors are reviewed.
  2. If applicable, review the record for the Equal Access (EA) plan (see EA).
  3. Review the record to see if earlier actions or changes may have an impact on eligibility.
  4. Review for eligibility factors, especially:
    1. Income for all Apple Health programs; and
    2. Resources for Classic Apple Health programs
      1. Review resources the household claims to see if there are any changes to resources we earlier excluded or decided were not available.
      2. Review funds in joint checking accounts that we excluded earlier.
      3. Review the plan to exclude business property of a self-employed person to decide if the property leads to full or partial self support.
      4. Review the value of liquid and nonliquid resources. Look for an increase in the value of real estate, cash value of life insurance, and securities that can be sold such as stocks, bonds, and certificates of deposit.
  5. Review and get proof of eligibility factors that have changed.
  6. Review and document previous proof to ensure that:
    1. Previously verified factors are clear and complete in the case file; and
    2. We are not asking the individual to give us duplicate or unneeded proof.
  7. Document proof you received.
  8. If any changes were made, send the appropriate letter.

Incomplete and Late Reviews

If an administrative review for a renewal cannot be completed and no review has been completed over the phone or in-person, then the household is ineligible for coverage. No review form is needed if the review is completed on or before the eligibility review end date or within the first 30 days after termination for Classic cases or 90 days for MAGI.

Note: If a household does not return a review form or returns it late, check the household record for an Equal Access Plan.

If you initiate a review for CN coverage, ACES keeps Apple Health open even if the individual does not return the required proof. When pending a review, set an alert to check the case and determine if the individual returned the required proof.

  1. If someone does not provide the proof you asked for, close the medical AU with advance and adequate notice (see WAC 182-518-0025).
  2. If you receive information to establish eligibility:
    1. For Classic Apple Health, within 30 days after the month the review was due, reopen coverage.
    2. For MAGI Apple Health, within 90 days after the month the review was due, Washington Healthplanfinder reopens coverage back to the first of the month following termination of coverage.

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