WAC 182-512-0050 SSI-related medical -- General information.

Effective April 14, 2014.

1. 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:
   1. Age sixty-five or older;
   2. Blind with:
      1. Central visual acuity of 20/200 or less in the better eye with the use of a correcting lens; or
      2. A field of vision limitation so the widest diameter of the visual field subtends an angle no greater than twenty degrees.
   3. Disabled:
      1. "Disabled" means unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment, which:
         1. Can be expected to result in death; or
         2. Has lasted or can be expected to last for a continuous period of not less than twelve months; or
         3. 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.
      2. Decisions on SSI-related disability are subject to the authority of:
         1. Federal statutes and regulations codified at 42 U.S.C. Section 1382c and 20 C.F.R., parts 404 and 416, as amended; and
         2. Controlling federal court decisions, which define the OASDI and SSI disability standard and determination process.
2. 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:
   1. Denial is under appeal in the reconsideration stage in SSA's administrative hearing process, or SSA's appeals council; or
   2. Medical condition has changed since the SSA denial was issued.
3. 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.
4. Persons referred to in subsection (1) must also meet appropriate eligibility criteria found in the following WAC and EA-Z Manual sections:
   1. For all programs:
      1. WAC 182-506-0015, Medical assistance units;
      2. WAC 182-504-0015, Categorically needy and WAC 182-504-0020, Medically needy certification periods;
      3. Program specific requirements in chapter 182-512 WAC;
      4. WAC 182-503-0050, Verification;
      5. WAC 182-503-0505, General eligibility requirements for medical programs;
      6. WAC 182-503-0540, Assignment of rights and cooperation;
      7. Chapter 182-516 WAC, Trusts, annuities and life estates.
   2. For LTC programs:
      1. Chapter 182-513 WAC, Long-term care services;
      2. Chapter 182-515 WAC, Waiver services.
   3. For WAH MN, chapter 182-519 WAC, Spenddown;
   4. For WAH HWD, program specific requirements in chapter 182-511 WAC.
5. 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.
6. The agency pays for a person's medical care outside of Washington according to WAC 182-501-0180.
7. 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.
8. Refer to WAC 182-504-0125 for effects of changes on medical assistance for redetermination of eligibility.

WAC 182-512-0100 SSI-related medical -- Categorically needy (CN) medical eligibility.

Effective April 14, 2014.

1. Washington apple health (WAH) categorically needy (CN) coverage is available for an SSI-related person who meets the criteria in WAC 182-512-0050, SSI-related medical—General information.
2. To be eligible for SSI-related WAH CN medical programs, a person must also have:
   1. Countable income and resources at or below the SSI-related WAH CN medical monthly standard (refer to WAC 182-512-0010) or be eligible for an SSI cash grant but choose not to receive it; or
   2. Countable resources at or below the SSI resource standard and income above the SSI-related WAH CN medical monthly standard, but the countable income falls below that standard after applying special income disregards as described in WAC 182-512-0880; or
   3. Met requirements for long-term care (LTC) WAH CN income and resource requirements that are found in chapters 182-513 and 182-515 WAC if wanting LTC or waiver services.
3. An ineligible spouse of an SSI recipient is not eligible for noninstitutional SSI-related WAH CN health care coverage. If an ineligible spouse of an SSI recipient has dependent children in the home, eligibility may be determined for health care coverage under the WAH medically needy program or for a modified adjusted gross income-based program.

WAC 182-512-0150 SSI-related medical -- Medically needy (MN) medical eligibility.

Effective June 26, 2022.

1. Washington apple health (WAH) medically needy (MN) health care coverage is available for any of the following:
   1. 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)):
      1. The person's countable income is at or below WAH MN standards, leaving no spenddown requirement; or
      2. 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.
   2. An SSI-related ineligible spouse of an SSI recipient;
   3. 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;
   4. A person who meets the WAH MN LTC services requirements of chapter 182-513 WAC;
   5. A person who lives in an alternate living facility and meets the requirements of WAC 182-513-1205; or
   6. 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.
2. 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.
3. 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.
4. 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.
5. 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:
   1. Met all eligibility requirements for the months being considered; and
   2. Received medical services covered by medicaid during that time.
6. 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.
7. A person must reapply for each certification period. There is no continuous eligibility for WAH MN.

WAC 182-511-1000 Health care for workers with disabilities (HWD) -- Program description.

Effective January 1, 2020

This section describes the apple health for workers with disabilities (HWD) program.

1. The HWD program provides categorically needy (CN) scope of care as described in WAC 182-501-0060.
2. The HWD program also provides long-term services and supports described in chapters 182-513 and 182-515 WAC for a client who meets the functional requirements for those programs, are approved for those services, and choose to enroll in HWD.
3. The medicaid agency approves HWD coverage for twelve months effective the first of the month in which a person applies and meets program requirements. See WAC 182-511-1100 for retroactive coverage for months before the month of application.
4. A person who is eligible for another medicaid program may choose not to participate in the HWD program.
5. A person is not eligible for HWD coverage for a month in which the person received benefits under the medically needy (MN) program.