WAC 182-503-0050 Verification of eligibility factors.

Effective November 3, 2019

1. General rules.
   1. We may verify the information we use to determine, redetermine, or terminate your apple health eligibility.
   2. We verify the eligibility factors listed in WAC 182-503-0505(3).
   3. Before we ask you to provide records to verify an eligibility factor, we use information available from state databases, including data from the department of social and health services and the department of employment security, federal databases, or commercially available databases to verify the eligibility factor.
   4. We may require information from third parties, such as employers, landlords, and insurance companies, to verify an eligibility factor if the information we received:
      1. Cannot be verified through available data sources;
      2. Did not verify an eligibility factor; or
      3. Is contradictory, confusing, or outdated.
   5. We do not require you to submit a record unless it is necessary to determine or redetermine your eligibility.
   6. If you can obtain verification within three business days and we determine the verification is sufficient to confirm an eligibility factor, we base our initial eligibility decision upon that record.
   7. If we are unable to verify eligibility as described in (f) of this subsection, then we may consider third-party sources.
   8. If a fee is required to obtain a necessary record, we pay the fee directly to the holder of the record.
   9. We do not deny or delay your application if you failed to provide information to verify an eligibility factor in a particular type or form.
   10. Except for eligibility factors listed in WAC 182-503-0505 (3)(c) and (d), we accept alternative forms of verification. If you give us a reasonable explanation that confirms your eligibility, we may not require additional documentation.
   11. Once we verify an eligibility factor that will not change, we may not require additional verification. Examples include:
       1. U.S. citizenship;
       2. Family relationships by birth;
       3. Social Security numbers; and
       4. Dates of birth, death, marriage, dissolution of marriage, or legal separation.
   12. If we cannot verify your immigration status and you are otherwise eligible for Washington apple health, we approve coverage and give additional time as needed to verify your immigration status.
2. Submission timelines.
   1. We allow at least ten calendar days for you to submit requested information.
   2. If you request more time to provide information, we allow the time requested.
   3. If the tenth day falls on a weekend or a legal holiday as described in RCW 1.16.050, the due date is the next business day.
   4. We do not deny or terminate your eligibility when we give you more time to provide information.
   5. If we do not receive your information by the due date, we make a determination based on all the information available.
3. Notice requirements.
   1. When we need more information from you to determine your eligibility for apple health coverage, we send all notices according to the requirements of WAC 182-518-0015.
   2. If we cannot determine you are eligible, we send you a denial or termination notice including information on when we reconsider a denied application under WAC 182-503-0080.
4. Equal access and limited-English proficiency services. If you are eligible for equal access services under WAC 182-503-0120 or limited-English proficiency services under WAC 182-503-0110, we provide legally sufficient support services.
5. Eligibility factors for nonmodified adjusted gross income (MAGI)-based programs. If you apply for a non-MAGI program under WAC 182-503-0510(3), we verify the factors in WAC 182-503-0505(3). In addition, we verify:
   1. Household composition, if spousal or dependent deeming under chapter 182-512 WAC or spousal or dependent allowance under chapters 182-513 and 182-515 WAC applies;
   2. Income and income deductions;
   3. Resources, including:
      1. Trusts, annuities, life estates and promissory notes under chapter 182-516 WAC;
      2. Real property transactions; and
      3. Financial records, as defined in WAC 182-503-0055, held by financial institutions.
   4. Medical expenses required to meet any spenddown liability under WAC 182-519-0110;
   5. All post-eligibility deductions used to determine cost of care for clients eligible for long-term services and supports under chapters 182-513 and 182-515 WAC;
   6. Transfers of assets under chapter 182-513 WAC and WAC 182-503-0055 when the program is subject to transfer of assets limitations;
   7. Shelter costs for long-term care cases where spousal and dependent allowances apply;
   8. Blindness or disability, if you claim either; and
   9. Social Security number for a community spouse if needed when you apply for long-term care.
6. Verification for MAGI-based programs.
   1. After we approve your coverage based on your self-attestation, we may conduct a post-eligibility review to verify your self-attested information.
   2. When conducting a post-eligibility review, we attempt to verify eligibility factors using your self-attested information available to us through state, federal, and commercially available data sources, or other third parties, before requiring you to provide information.
   3. You may be required to provide additional information if:
      1. We cannot verify an eligibility factor through other data sources listed in subsection (b) of this section; or
      2. The information received from the data source is not reasonably compatible with your self-attestation.
7. Reapplication following post-eligibility review. If your eligibility for MAGI-based apple health terminates because of a post-eligibility review and you reapply, we may request verification of eligibility factors prior to determining eligibility.

WAC 182-500-0010 Medical assistance definitions -- A.

Effective November 25, 2023

"Administrative renewal" means the agency uses electronically available income and resources data sources to verify and recertify a person's Washington apple health benefits for a subsequent certification period. A case is administratively renewed when the person's self-attested income and resources are reasonably compatible (as defined in WAC 182-500-0095) with the information available to the agency from the electronic data sources and the person meets citizenship, immigration, Social Security number, and age requirements.

"After-pregnancy coverage (APC)" means full-scope Washington apple health (medicaid) health care coverage for people up to 12 months after the month their pregnancy ends under WAC 182-505-0115.

"Agency" or "medicaid agency" means the Washington state health care authority (HCA).

"Agency's designee" means any entity expressly designated by the agency to act on its behalf.

"Allowable costs" are the documented costs as reported after any cost adjustment, cost disallowances, reclassifications, or reclassifications to nonallowable costs which are necessary, ordinary and related to the outpatient care of medical care clients or not expressly declared nonallowable by applicable statutes or regulations. Costs are ordinary if they are of the nature and magnitude which prudent and cost-conscious management would pay.

"Alternative benefits plan" means the range of health care services included within the scope of service categories described in WAC 182-501-0060 available to persons eligible to receive health care coverage under the Washington apple health modified adjusted gross income (MAGI)-based adult coverage described in WAC 182-505-0250.

"Ancillary services" means additional services ordered by the provider to support the core treatment provided to the patient. These services may include, but are not limited to, laboratory services, radiology services, drugs, physical therapy, occupational therapy, and speech therapy.

"Apple health for kids" is the umbrella term for health care coverage for certain groups of children that is funded by the state and federal governments under Title XIX medicaid programs, Title XXI Children's Health Insurance Program, or solely through state funds (including the program formerly known as the children's health program). Funding for any given child depends on the program for which the child is determined to be eligible. Apple health for kids programs are included in the array of health care programs available through Washington apple health (WAH).

"Attested income" or "attested resources" means a self-declared statement of a person's income or resources made under penalty of perjury to be true. (See also "self-attestation.")

"Authorization" means the agency's or the agency's designee's determination that criteria are met, as one of the preconditions to the agency's or the agency's designee's decision to provide payment for a specific service or device. (See also "expedited prior authorization" and "prior authorization.")

"Authorized representative" is defined under WAC 182-503-0130.

WAC 182-500-0010 Medical assistance definitions -- A.

Effective November 25, 2023

"Administrative renewal" means the agency uses electronically available income and resources data sources to verify and recertify a person's Washington apple health benefits for a subsequent certification period. A case is administratively renewed when the person's self-attested income and resources are reasonably compatible (as defined in WAC 182-500-0095) with the information available to the agency from the electronic data sources and the person meets citizenship, immigration, Social Security number, and age requirements.

"After-pregnancy coverage (APC)" means full-scope Washington apple health (medicaid) health care coverage for people up to 12 months after the month their pregnancy ends under WAC 182-505-0115.

"Agency" or "medicaid agency" means the Washington state health care authority (HCA).

"Agency's designee" means any entity expressly designated by the agency to act on its behalf.

"Allowable costs" are the documented costs as reported after any cost adjustment, cost disallowances, reclassifications, or reclassifications to nonallowable costs which are necessary, ordinary and related to the outpatient care of medical care clients or not expressly declared nonallowable by applicable statutes or regulations. Costs are ordinary if they are of the nature and magnitude which prudent and cost-conscious management would pay.

"Alternative benefits plan" means the range of health care services included within the scope of service categories described in WAC 182-501-0060 available to persons eligible to receive health care coverage under the Washington apple health modified adjusted gross income (MAGI)-based adult coverage described in WAC 182-505-0250.

"Ancillary services" means additional services ordered by the provider to support the core treatment provided to the patient. These services may include, but are not limited to, laboratory services, radiology services, drugs, physical therapy, occupational therapy, and speech therapy.

"Apple health for kids" is the umbrella term for health care coverage for certain groups of children that is funded by the state and federal governments under Title XIX medicaid programs, Title XXI Children's Health Insurance Program, or solely through state funds (including the program formerly known as the children's health program). Funding for any given child depends on the program for which the child is determined to be eligible. Apple health for kids programs are included in the array of health care programs available through Washington apple health (WAH).

"Attested income" or "attested resources" means a self-declared statement of a person's income or resources made under penalty of perjury to be true. (See also "self-attestation.")

"Authorization" means the agency's or the agency's designee's determination that criteria are met, as one of the preconditions to the agency's or the agency's designee's decision to provide payment for a specific service or device. (See also "expedited prior authorization" and "prior authorization.")

"Authorized representative" is defined under WAC 182-503-0130.

WAC 182-513-1325 Determining available income for an SSI-related single client for long-term care (LTC) services.

Effective February 20, 2017

This section describes income the agency or its designee determines available when evaluating an SSI-related single client's eligibility for long-term care (LTC) services.

1. See WAC 182-513-1330 for rules related to available income for legally married couples.
2. The agency or its designee applies the following rules when determining income eligibility for SSI-related LTC services:
   1. WAC 182-512-0600 SSI-related medical—Definition of income;
   2. WAC 182-512-0650 SSI-related medical—Available income;
   3. WAC 182-512-0700 SSI-related medical—Income eligibility;
   4. WAC 182-512-0750 SSI-related medical—Countable unearned income;
   5. WAC 182-512-0840 (3) self-employment income-allowable expenses
   6. WAC 182-512-0785, 182-512-0790, and 182-512-0795 for sponsored immigrants and how to determine if sponsors' income counts in determining benefits.
3. In initial categorically needy income eligibility for LTC, the agency does not allow any deductions listed in 1612(b) of the Social Security Act, for example:
   1. Twenty dollars per month income exclusion under WAC 182-512-0800;
   2. The first $65 and the remaining one-half earned income work incentive under WAC 182-512-0840; and
   3. Impairment related work expense or blind work expense under WAC 182-512-0840.

WAC 182-513-1330 Determining available income for legally married couples for long-term care (LTC) services.

Effective August 26, 2018

This section describes income the agency or its designee determines available when evaluating a legally married person's eligibility for long-term care (LTC) services.

1. The agency or the agency's designee applies the following rules when determining income eligibility for LTC services:
   1. WAC 182-512-0600 SSI-related medical—Definition of income;
   2. WAC 182-512-0650 SSI-related medical—Available income;
   3. WAC 182-512-0700 SSI-related medical—Income eligibility;
   4. WAC 182-512-0750 SSI-related medical—Countable unearned income;
   5. WAC 182-512-0840(3), self-employment income-allowance expenses;
   6. WAC 182-512-0960 SSI-related medical —Allocating income—Determining eligibility for a spouse when the other spouse receives long-term services and supports (LTSS);
   7. WAC 182-512-0785, 182-512-0790, and 182-512-0795 for sponsored immigrants and how to determine if the sponsors' income counts in determining benefits.
2. In initial categorically needy income eligibility for LTC, the agency does not allow any deductions listed in 1612(b) of the Social Security Act, for example:
   1. Twenty dollars per month income exclusion under WAC 182-512-0800;
   2. The first $65 and the remaining one-half earned income work incentive under WAC 182-512-0840; and
   3. Impairment related work expense or blind work expense under WAC 182-512-0840.
3. The following income is available to an institutionalized spouse, unless subsections (5) and (6) apply:
   1. Income received in the institutionalized spouse's name;
   2. Income paid to a representative on the institutionalized spouse's behalf; and
   3. One-half of the income received in the names of both spouses.
4. The following income is unavailable to an institutionalized spouse:
   1. Separate income received in the name of the community spouse; and
   2. Income established as unavailable through a court order.
5. For the determination of eligibility only, if available income under subsection (3)(a) through (c) of this section, minus income exclusions under WAC 182-513-1340, exceeds the special income level (SIL), defined under WAC 182-513-1100, the agency or its designee:
   1. Follows Washington state community property law when determining ownership of income;
   2. Presumes all income received after the marriage by either spouse to be community income;
   3. Considers one-half of all community income available to the institutionalized spouse.
6. If the total of subsection (5)(c) of this section plus the institutionalized spouse's separate income is over the SIL, determine available income using subsection (3) of this section.
7. A stream of income, not generated by a transferred resource, is available to the institutionalized spouse, even if the institutionalized spouse transfers or assigns the rights to the stream of income to one of the following:
   1. The community spouse; or
   2. A trust for the benefit of the community spouse.

WAC 182-503-0130 Authorized representative.

Effective August 17, 2015

1. ​Designating an authorized representative (AREP).
   1. A person may designate an AREP to act on his or her behalf in eligibility-related interactions with the medicaid agency by completing the agency's Authorized Representative Designation Form (DSHS 14-532), or through any of the methods described in 42 C.F.R. 435.907(a) and 42 C.F.R. 435.923. The Authorized Representative Designation Form is available online at https://www.dshs.wa.gov/fsa/forms.
   2. A court-appointed legal guardian with authority to make financial decisions on a person's behalf is that person's AREP.
   3. An agreement creating power of attorney (POA) that grants decision-making authority regarding the person's financial interactions with the agency establishes the POA as the AREP.
   4. If a person is unable to designate an AREP due to a medical condition, an individual may designate himself or herself as the AREP by signing the agency's Authorized Representative Designation Form (DSHS 14-532).
2. Serving as an AREP. To serve as an AREP, an individual or organization must:
   1. Have a good-faith belief that the information he or she provides to the agency is correct.
   2. Report any change in circumstance required under WAC 182-504-0105 unless doing so would exceed the scope of authorized representation or violate state or federal law.
   3. A provider, staff member, or volunteer of an organization must also comply with 42 C.F.R. 435.923(d-e).
3. Terminating authorized representation.
   1. The person or the AREP may terminate the authorized representation at any time for any reason by notifying the agency verbally or in writing.
   2. Authorized representation terminates automatically when the person dies.

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

Effective March 31, 2014.

1. When you have a mental, neurological, cognitive, physical or sensory impairment, or limitation that prevents you from receiving health care coverage, we provide services to help you apply for, maintain, and understand the health care coverage options available and eligibility decisions we make. These services are called equal access (EA) services.
2. We provide EA services on an ongoing basis to ensure that you are able to maintain health care coverage and access to services we provide. EA services include, but are not limited to:
   1. Helping you to:
      1. Apply for or renew coverage;
      2. Complete and submit forms;
      3. Give us information to determine or continue your eligibility;
      4. Ask for continued coverage;
      5. Ask for reinstated (restarted) coverage after your coverage ends; and
      6. Ask for and participate in a hearing.
   2. Giving you additional time, when needed, for you to give us information before we reduce or end your health care coverage;
   3. Explaining our decision to change, reduce, end, or deny your health care coverage;
   4. Working with your authorized representative, if you have one, and giving that person copies of notices and letters we send you; and
   5. Providing you the services of a sign language interpreter/transliterator who is certified by the Registry of Interpreters for the Deaf at the appropriate level of certification.
      1. These services may include in-person sign language interpreter services, relay interpreter services, and video interpreter services, as well as other services; we decide which services to offer you based on your communication needs and preferences.
      2. We offer these services as a reasonable accommodation, free of charge, if you are deaf, hard-of-hearing, or a deaf-blind person who uses sign language to communicate.
   6. Not taking adverse action in your case, or automatically reinstating your coverage for up to three months after the adverse action was taken, if we determine that your impairment or limitation was the cause of your failure to follow through on something you need to do to get or keep your Washington apple health coverage, such as:
      1. Applying for or renewing coverage;
      2. Completing and submitting forms;
      3. Giving us information to determine or continue your eligibility;
      4. Asking for continued or reinstated coverage; or
      5. Asking for and participating in a hearing.
3. We inform you of your right to EA services listed in subsection (2) of this section:
   1. On printed applications and notices, including the printed rights and responsibilities form;
   2. In the Washington healthplanfinder web site, including the electronic rights and responsibilities form; and
   3. During contact with us.
4. We provide you the EA services listed in subsection (2) of this section if you ask for EA services, you are receiving services through the aging and long-term support administration, or we determine that you would benefit from EA services. We determine you would benefit from EA services if you:
   1. Appear to have or claim to have any impairment or limitation described in subsection (1) of this section;
   2. Have a developmental disability;
   3. Are disabled by alcohol or drug addiction;
   4. Are unable to read or write in any language;
   5. Appear to have limitations in your ability to communicate, understand, remember, process information, exercise judgment and make decisions, perform routine tasks, or relate appropriately with others (whether or not you have a disability) that may prevent you from understanding the nature of EA services or affect your ability to access our programs; or
   6. Are a minor not residing with your parents.
5. If we determine that you are eligible for EA services, we develop and document an EA plan appropriate to your needs. The plan may be updated or changed at any time based on your request or a change in your needs.
6. You may at any time refuse the EA services offered to you.
7. We reinstate your coverage when:
   1. We end coverage because we were unable to determine if you continue to qualify; and
   2. You provide proof that you are still qualified for coverage within twenty calendar days from when we ended your coverage. We restore your coverage retroactive to the first of the month so there is no break in your coverage.
8. If you believe that we have discriminated against you on the basis of a disability or another protected status, the person may file a complaint with the U.S. Department of Health and Human Services at https://www.hhs.gov/civil-rights/filing-a-complaint/complaint-process/ or Region Manager, Office for Civil Rights, U.S. Department of Health and Human Services, 2201 Sixth Ave. – M/S: RX-11, Seattle, WA 98121-1831 (voice phone 800-368-1019, fax 206-615-2297, TDD 800-537-7697).

WAC 182-503-0535 Washington apple health -- Citizenship and immigration status.

Effective February 7, 2025

1. Definitions.
   1. Nonqualified alien means someone who is lawfully present in the United States (U.S.) but who is not a qualified alien, a U.S. citizen, a U.S. national, or a qualifying American Indian born abroad.
   2. Qualified alien means someone who is lawfully present in the United States and who is one or more of the following:
      1. A person lawfully admitted for permanent residence (LPR).
      2. An abused spouse or child, a parent of an abused child, or a child of an abused spouse who no longer resides with the person who committed the abuse, and who has one of the following:
         1. A pending or approved I-130 petition or application to immigrate as an immediate relative of a U.S. citizen or as the spouse of an unmarried LPR younger than 21 years of age.
         2. Proof of a pending application for suspension of deportation or cancellation of removal under the Violence Against Women Act (VAWA).
         3. A notice of prima facie approval of a pending self-petition under VAWA. An abused spouse's petition covers his or her child if the child is younger than 21 years of age. In that case, the child retains qualified alien status even after he or she turns 21 years of age.
      3. A person who has been granted parole into the U.S. for one year or more, under the Immigration and Nationality Act (INA) Section 212 (d)(5), including public interest parolees.
      4. A member of a Hmong or Highland Laotian tribe that rendered military assistance to the U.S. between August 5, 1964, and May 7, 1975, including the spouse, unremarried widow or widower, and unmarried dependent child of the tribal member.
      5. A person who was admitted into the U.S. as a conditional entrant under INA Section 203 (a)(7) before April 1, 1980.
      6. A person admitted to the U.S. as a refugee under INA Section 207.
      7. A person who has been granted asylum under INA Section 208.
      8. A person granted withholding of deportation or removal under INA Section 243(h) or 241 (b)(3).
      9. A Cuban or Haitian national who was paroled into the U.S. or given other special status.
      10. An Amerasian child of a U.S. citizen under 8 C.F.R. Section 204.4(a).
      11. A person from Iraq or Afghanistan who has been granted one of the following:
          1. Special immigrant status under INA Section 101 (a) (27);
          2. Special immigrant conditional permanent resident; or
          3. Parole under Section 602 (b) (1) of the Afghan Allies Protection Act of 2009 or Section 1059(a) of the National Defense Authorization Act of 2006.
      12. An Afghan granted humanitarian parole between July 31, 2021, and September 30, 2023, their spouse or child, or a parent or guardian of an unaccompanied minor who is granted parole after September 30, 2022, under Section 2502 of the Extending Government Funding and Delivering Emergency Assistance Act of 2021.
      13. A citizen or national of Ukraine (or a person who last habitually resided in Ukraine) who, under section 401 of the Additional Ukrainian Supplemental Appropriations Act, 2022 (AUSAA) and the Ukraine Security Supplemental Appropriations Act, 2024 (USSAA), is evaluated as a qualified alien until the end of their parole term when:
          1. Granted parole into the United States between February 24, 2022, and September 30, 2024; or
          2. Granted parole into the United States after September 30, 2024, and is:
             1. The spouse or child of a person described in (b)(xiii)(A) of this subsection; or
             2. The parent or guardian of a person described in (b)(xiii)(A) of this subsection who is an unaccompanied minor.
      14. A person who has been certified or approved as a victim of trafficking by the federal office of refugee resettlement, or who is:
          1. The spouse or child of a trafficking victim of any age; or
          2. The parent or minor sibling of a trafficking victim who is younger than 21 years of age. 
      15. A person from the Federated States of Micronesia, the Republic of Palau, or the Republic of the Marshall Islands living in the United States in accordance with the Compacts of Free Association. 
   3. U.S. citizen means someone who is a United States citizen under federal law.
   4. U.S. national means someone who is a United States national under federal law.
   5. Undocumented person means someone who is not lawfully present in the U.S.
   6. Qualifying American Indian born abroad means someone who:
      1. Was born in Canada and has at least 50 percent American Indian blood, regardless of tribal membership; or
      2. Was born outside of the United States and is a member of a federally recognized tribe or an Alaska Native enrolled by the Secretary of the Interior under the Alaska Native Claims Settlement Act.
2. Eligibility.
   1. A U.S. citizen, U.S. national or qualifying American Indian born abroad may be eligible for:
      1. Apple health for adults;
      2. Apple health for kids;
      3. Apple health for pregnant women; or
      4. Classic medicaid.
   2. A qualified alien who meets or is exempt from the five-year bar may be eligible for:
      1. Apple health for adults;
      2. Apple health for kids;
      3. Apple health for pregnant women; or
      4. Classic medicaid.
   3. A qualified alien who neither meets nor is exempt from the five-year bar may be eligible for:
      1. Alien medical programs;
      2. Apple health for kids;
      3. Apple health for pregnant women; or
      4. Medical care services.
   4. A nonqualified alien may be eligible for:
      1. Alien medical programs;
      2. Apple health for kids;
      3. Apple health for pregnant women; or
      4. Medical care services.
   5. An undocumented person may be eligible for:
      1. Alien medical programs;
      2. State-only funded apple health for kids; 
      3. State-only funded apple health for pregnant women; or
      4. State-only funded apple health expansion.
3. The five-year bar.
   1. A qualified alien meets the five-year bar if he or she:
      1. Continuously resided in the U.S. for five years or more from the date he or she became a qualified alien; or
      2. Entered the U.S. before August 22, 1996, and:
         1. Became a qualified alien before August 22, 1996; or
         2. Became a qualified alien on or after August 22, 1996, and has continuously resided in the U.S. between the date of entry into the U.S. and the date he or she became a qualified alien.
   2. A qualified alien is exempt from the five-year bar if he or she is:
      1. A qualified alien as defined in subsections (1)(b)(vi) through (xv) of this section;
      2. An LPR, parolee, or abused person, who is also an armed services member or veteran, or a family member of an armed services member or veteran, as described below:
         1. An active-duty member of the U.S. military, other than active-duty for training;
         2. An honorably discharged U.S. veteran;
         3. A veteran of the military forces of the Philippines who served before July 1, 1946, as described in Title 38 U.S.C. Section 107; or
         4. The spouse, unremarried widow or widower, or unmarried dependent child of an honorably discharged U.S. veteran or active-duty member of the U.S. military.