This section contains the following HCB Waiver services:

1. Community options program (COPES)
2. New Freedom consumer directed services (New Freedom)
3. Program of all-inclusive care for the elderly (PACE)

• Working clients on long-term care programs (Waiver, Residing in a medical institution, or MPC
• 1619B and "Deemed SSI eligible" clients (after DAC, Pickle/COLA, Widower exclusion)
• HCS services in residential settings, room and board, ETRs, Bed-hold processes
• Dependent/family allocation used in CN Waiver or Institutional Participation Calculation
• WAC 388-106-0315 When do COPES Services start?
• WAC 388-106-0325 How do I pay for COPES Services
• Hospice index
• Roads to Community Living (RCL) Clarifying Information

Institutional standards used in determining initial and post eligibility (participation) in long term care change annually. Depending on the standard, these changes occur in January, April, July and August. See the Institutional standard chart for current standards used in long term care. This chart indicates the formula for the standard and when the standard last changed.

• LTC and LTSS Income and Resource standards chart
• LTSS Personal Needs Allowance (PNA) Chart

Personal needs allowance (PNA) for clothing, personal items and incidentals (CPI):

Personal needs allowance (PNA) for clothing, personal items and incidentals (CPI). Client's are allowed the highest personal needs allowance in a given month based on living arrangement, authorized service and marital status. If a client resided at home the first day of the month and went into a nursing home the same day, we would allow the in home PNA because they were residing in a home setting at least one moment during that given month. If a client went from a nursing home to an adult family home on HCB waiver services the first day of the month, we would allow the ALF PNA as it is the highest allowed. If that client were then discharged home from the ALF on the last day of the month, the benefit would be recalculated allowing the in home PNA

Medical Expenses used to reduce participation

To reduce participation, deduct medical expenses not already used to reduce excess resources as described in WAC 182-513-1350.

• See Allowable medical expenses.

Income and Deduction changes in HCB Waivers. Method 3 effective 8/29/2014

WAC 182-504-0120 (12) Effective 8/29/2014 a change in income or deductions is effective the first of the month following the date the change was reported rather than the month the income or deduction changed (Method 1). Method 1 is used for clients residing in medical institutions. Method 3 is used for HCB Waivers.

When a change in income, or allowable expenses, changes the amount the client pays toward participation for a home and community-based waiver or service, we calculate the new participation amount effective the first of the month following the date the change was reported. The exception is if the change occurs due to the loss of an income source that is to last 2 months or longer and is reported timely.

Any change to an HCB Waiver client's income or post eligibility deductions that affect cost of care take effect in the ongoing month in ACES.

• With the exception of loss of an income source or the lowering of income
  • The change takes effect the actual month of change.
  • We will make these historical changes in ACES.
  • To be considered a loss or reduction of income:
    • We must have a timely report of the change to income
    • We must have verification that this change is to last two months or longer;
    • Otherwise, it is a "change" in income that takes effect the following month.

What if a loss or lower of income is not reported timely?

• Financial will not make historical adjustments in ACES.
• Treat as an underpayment, or "client reimbursement".
• Send the DSHS 07-104 in barcode to let the case manager know what the client's income or deduction actually was, and what we had in ACES. Indicate what the correct participation should have been for each month and that change was not reported timely.
• The case manager/social worker will determine if the provider is to be paid more, if the client is owed any money or if there is a client overpayment.

Training information on Method 3 can be found on the financial program SharePoint under training, policy changes.

Note: Facility daily rates reported to financial by the social worker need to be made effective in the month the daily rate change occurred. Make these changes historical as it will affect the calculation in Provider One if there is a split participation month.

Overview of HCB Waivers

DDA home and community based (HCB) waivers

Additional clarification and worker responsibilities can be found in the Participation in a medical facility section.

See General eligibility for Long Term Care

Clarifying information

A medical redetermination is required for individuals who lose CN or ABP coverage during their certification period, which can be under any of the following medical groups:

• Classic Apple Health (redetermination done by agency staff)
  • SSI terminations (S01, L01 or L21)
  • SSI-Related Medicaid (S02, G03)
  • Breast and Cervical Cancer (S30)
  • Institutional Medicaid (L02, K01, I01)
  • Hospice and Home and Community Waiver programs (L22)
• MAGI-based Apple Health (redetermination for other MAGI-based programs automatically done by Washington Healthplanfinder)
  • Apple Health for Families/Caretaker Relatives (N01)
  • Apple Health for Newborns (N10)
  • Apple Health for Kids, with or without premiums (N11, N13, N31, N33)
  • Apple Health for Pregnant Women (N03, N23)
  • Apple Health for Adults (N05)

Note: Medical redetermination does not apply to individuals who lose eligibility during their certification period under the Apple Health Medical Care Services program (MCS).

A medical redetermination is not required in the following situations. The individual:

• Dies;
• Moves out of state;
• Cannot be found (whereabouts unknown);
• Is not federally qualified to receive Medicaid due to citizenship or immigration status; or
• Asks the department to close medical coverage.

To complete the redetermination, the agency is required to review the individual's record for any indication that the individual may be eligible for another CN program, such as pregnancy or disability. The agency refers to this as "ex parte review", which is a required part of the redetermination process.

Clarifying Information

An application for TSOA may be submitted in several ways, either in person, by mail, by fax or online. In addition, a person may contact a Home and Community Services office by calling their local intake line, or by contacting an Area Agency on Aging (AAA) office at 1-855-567-0252.

Many people need help applying for services or Medicaid. Often there are family members or friends, or staff members of a hospital or nursing home or other agency, who are able to help. Help is also available from your local AAA and from DSHS staff, especially for people who have physical or mental impairments that make it hard to get through the application process on their own.

In order to determine if a person meets the financial eligibility criteria for the TSOA program, a person is required to have an interview. The interview may be conducted with the applicant, their spouse, authorized representative, guardian, or caregiver. If a person isn’t able to complete the interview due to the person’s medical condition, and no-one else is available to do the interview on their behalf, this requirement may be waived.

TSOA applications follow the same standard of promptness as regular medicaid applications and must be processed within 45 days, unless good cause applies.

How to request a long-term care (LTC) assessment

Call and schedule an assessment through the DSHS Central intake lines. Social Service central intake lines are divided by Regions in the State of Washington. This is used to request a social service assessment for home and community services (in-home care, care in a residential facility, nursing facility coverage).

Region 1 North

HCS-Adams, Chelan, Douglas, Ferry, Grant, Lincoln, Okanagan, Pend Oreille, Spokane, Stevens, and Whitman counties:
Phone: 1-866-323-9409

Region 1 South

HCS-Asotin, Benton, Columbia, Franklin, Garfield, Kittitas, Klickitat, Walla Walla, and Yakima counties. Contact the local Home and Community Service (HCS) office based on county.

Region 2 North

HCS – Island, San Juan, Skagit, Snohomish, and Whatcom, counties:
Phone: 1-800-780-7094
Fax: 425-339-4859

Region 2 South

HCS - King County:
Phone: 206-341-7750
Fax: 206-373-6855

Region 3

HCS- Clallam, Clark, Cowlitz, Grays Harbor, Jefferson, Kitsap, Lewis, Mason, Pacific, Pierce, Thurston, and Wahkiakum Counties:
Phone: 1-800-786-3799 or 360-664-9138
Fax: 360-586-0499

Clarifying Information

TSOA doesn’t provide health care coverage, therefore, many of the requirements under Apple Health don’t apply to TSOA applicants and recipients. However, the same client rights do apply, including hearing rights full TSOA determinations.

What is Medicaid Personal Care (MPC)

A Medicaid program that is allowed under Washington State’s Medicaid State Plan, that provides assistance with activities of daily living to individuals who are eligible for noninstitutional categorically needy (CN) or Alternative Benefit Plan (ABP) medical programs.

Functional eligibility for this program is based on Chapter 388-106 WAC.

MPC services are available in the individual’s own home, adult family homes (AFH), assisted living or DDA group home for clients that do not meet NFLOC, but meet functional eligibility for MPC.

MPC is authorized by Home and Community Services (HCS) and Developmental Disabilities (DDA) administrations.

A CARE assessment is done by a case manager, nurse or social service specialist from DDA, HCS or Area Agency on Aging (AAA).

Individuals must meet the functional criteria based on the social service assessment and financial eligibility based on eligibility for a noninstitutional CN or ABP Medicaid program.

The only exception is the Alien Emergent Medical (AEM) Modified Adjusted Gross Income (MAGI) medical program under N21 and N25. AEM programs do not cover Medicaid Personal Care (MPC) services.

MPC individuals pay room and board if living in a adult family home, adult residential center (ARC) or DDA group home.

What is room and board

Throughout the manual both terms, room and board and board and room are used to describe a living arrangement in which an individual purchases food, shelter, and household maintenance requirements from one vendor. In other words, room and board is considered "rent".

There is also a term used by ALTSA and DDA called the room and board rate. This rate is based on the FBR minus the HCS/COPES Waiver PNA in an ALF.

Most MPC individuals pay the ALTSA standard room and board rate for their rent.

The exception is individuals receiving medical under the G03 program. This is because the standard that is used to make them eligible for a CN program has been raised based on having to pay all of their countable income minus the PNA to the provider. This rate for the purpose of the G03 program is called the individual's total responsibility.

What is Classic Medicaid

Classic Medicaid are programs for individuals that are aged, blind or disabled (ABD).

The ABD classic medical programs are also called SSI-related programs. In order to receive one of these medical programs, you must be age 65 or over, or considered disabled or blind by Social Security criteria. All individuals age 65 or over or on Medicare must be considered for a Classic program unless they do not meet citizenship requirements for federal Medicaid.

Classic Medicaid included the institutional group (ABD individuals living in a medical institution 30 days or more) and Home and Community Based (HCB) Waiver programs. (L track).

What is the basic difference between "institutional" and "noninstitutional"

Institutional Medicaid has different income standards and rules for initial eligibility and higher resource standards for a couple when only one needs institutional services.

Institutional also has a 2nd eligibility component called "post-eligibility treatment of income". This 2nd eligibility computation determines the amount the individual must pay toward their cost of care to the medical institution or to the HCB Waiver provider. This is called "participation".

Noninstitutional Medicaid does not have a "post eligibility" component, therefore individuals living in the community on noninstitutional Medicaid do not "participate" toward the cost of their personal care.

MPC individuals do not pay "participation" but they are responsible to pay room and board (their rent) when living in an alternate living facility.

Classic Programs that do not fall into the aged/blind/disabled group:

• Foster care medical authorized and maintained by the Health Care Authority. Some foster care children may be disabled, but disability is not a requirement for this program that can be authorized up to age 26. (D01, D02, D26)
• Institutional children (K01, K95, K99) This program uses Modified Adjusted Gross Income (MAGI) income methodology to determine initial eligibility but the eligibility is not done by the Health Benefit Exchange. The eligibility is determined by the Health Care Authority and is primarily used for children's mental health facilities (CLIP) and children needing hospitalization that are not eligible for medical under a N track MAGI program.

Consult the medical program chart desk tool under the MPC column to determine what classic medical programs can authorize MPC.

What is Modified Adjusted Gross Income (MAGI) Medicaid

MAGI Medicaid eligibility is determined by the Health Benefit Exchange.

These programs show up as "N" track in ACES and are for children, pregnant woman, and adults under age 65. In order to be considered for medical under MAGI methodology, you can't be on Medicare.

It is possible for a disabled individual not on Medicare to qualify under MAGI by the Health Benefit Exchange.

Once an individual is eligible to receive Medicare, the case is redetermined from the MAGI program to a ABD Classic Medicaid program.

Individuals receiving MAGI programs under "N" track in ACES with the exception of AEM N21 and N25 are eligible to receive MPC if functionally eligible.

What is Medical Care Services (MCS)

MCS is a state funded medical program used for legally admitted non citizens that do not qualify for a Classic or MAGI Medicaid program because they are in their 5 year bar for federal Medicaid.

MCS covers nursing home and HCS has a state funded residential program for individuals eligible to receive MCS.

MCS does not cover MPC or HCB Waiver.

Agency responsibilities

CSD, HCS, and DDA LTC specialty unit Financial staff determines eligibility for classic medical assistance programs.

The Health Benefit Exchange (HBE) determines eligibility for MAGI-based medical.

The Medical Care Services ​(MCS) program includes a chart to indicate which specific agency is responsible to determine financial eligibility for each medical program.

DDA, HCS, or AAA case manager responsible for placement and case management services, determines functional eligibility, initiates the payment to the provider via ProviderOne and determines the amount the individual must pay to the facility for their cost of care and notifies the individual.

The assigned case manager/social service specialist indicates what services are authorized with the start date, the state daily rate, the current address and any other pertinent information needed to process the case such as if a payee or power of attorney is involved in the case.

The financial worker is responsible to determine the financial eligibility for Classic Medicaid. Changes need to be reported back and forth between the financial worker and assigned case manager/social service specialist.

HCS social service specialists use the DSHS 14-443 Financial/Social Service communication form in barcode.

DDA case managers use the DSHS 15-345 DDA Communication in barcode.

Clarifying Information

Medicaid Alternative Care (MAC) change of circumstance

MAC recipients must report changes following the requirements under Chapter 182-504 WAC since all MAC recipients are eligible for Washington Apple Health coverage. 

MAC recipients may freely transition between the MAC program and long-term services and supports through the Community First Choice (CFC) program without filing a new financial application.  This could be because the care receiver’s needs can no longer be met under the MAC program or because the client chooses to access services that are only available under CFC. A person who needs services under a Home and Community based waiver would need to complete an Apple Health application (HCA 18-005 Application for Aged, Blind, Disabled/LTC form).

TSOA changes of circumstances  

TSOA recipients must report changes within 30 days of the date of the change; however, once a person is determined eligible for TSOA, they remain continuously eligible throughout the 12 month certification unless one of the following changes happens:

• The person no longer meets NFLOC
• The person is no longer a WA state resident
• The person moves into an institution (nursing facility)
• The person becomes eligible for CN or ABP Medicaid
• The person passes away. 

There is no requirement to report changes in income or resources for a TSOA recipient.

Like MAC, TSOA recipients may transition to other LTSS services that they may be eligible for.  However most TSOA recipients don’t qualify for Apple Health coverage because they are spending down their resources to qualify, or their income is too high.  Also, although some TSOA recipients may qualify for Apple Health coverage, either under a medically needy program or a program with limited scope such as a Medicare Savings Program, these programs don’t provide CFC or HCB waiver services.  In both scenarios, a care receiver receiving TSOA services who needs to access Community First Choice or HCB waiver services must complete an Apple Health application to determine if they meet eligibility criteria for traditional long-term services and supports.  

Equally, existing clients who receive traditional LTSS may also choose to stop receiving those services and receive MAC or TSOA services instead.  Since there are many factors that may influence a person’s  decision, staff must take time to explain the options available and any consequences of making that decision, such as, the loss of Apple Health coverage if someone were to choose TSOA services.

Clarifying Information

TSOA Renewals must be completed once every 12 months and may be completed by phone, online, or on paper.  At the time of renewal, the person must still be receiving services under the TSOA program.

MAC renewals are based upon the certification period of the program the person is eligible under.

Follow HCS equal access policies to contact the person to complete the renewal.

Clarifying Information

SSI-Related Special Income Disregards

When SSI cash assistance closes because the individual begins to receive Title II Social Security Income, ACES does several automated checks to determine if the individual would continue to qualify for CN Apple Health due to one or more of the special income disregards below:

• Use the Application/Benefit field on the bottom of the UNER screen is used to identify the reason and date an individual was terminated from SSI.
  Note: ACES automatically populates the "Ever Received SSI?" field with a "Y" (Yes) and adds the SSI closure date when an SDX record is received showing the individual is no longer in pay status for SSI. Do not change this designation.
• SSI closure codes are available to help identify individuals who are eligible for an SSI-related special income disregard. These codes are:
  • H - Receipt of DAC Benefits, or a COLA to DAC benefits
  • I - Receipt of Widows Benefits (Group 1)
  • J - Receipt of or COLA to Widow/Widowers/Surviving Spouse Benefits (Group 2)
  • K - SSI terminated for any other reason and the individual received Title II benefits at the time of termination or by the time ACES rechecks for Title II benefits 60 days after termination. (Pickle disregard)
  • T - SSI terminated for any other reason and the individual did NOT receive Title II benefits at the time of termination or within 60 days of the termination.
  • U - Unable to determine the reason for the SSI termination. This is a system generated code and must be updated to the correct value at the next review or application.
  • C - Old code prior to October 2009.
• When ACES identifies that SSI closed because of a cost of living increase (COLA), Disabled Adult Child (DAC) benefit, or widow(er) income, it updates the reason code to the bottom of the UNER screen.
• If ACES is unable to determine the reason for the SSI closure, you need to manually update the closure codes with the correct information while completing the eligibility review required for the redetermination process. See Worker Responsibilities.

Cost of Living Adjustment (COLA) and the Pickle Disregard

The Pickle disregard applies to individuals who lose SSI eligibility due to their beginning to receive Title II Social Security benefits or a Cost of Living Adjustment (COLA) to the Title II benefits. An individual must have been entitled to both SSI and the Title II benefits within the same month for the Pickle disregard to apply. This does not mean that the individual must have received an SSI check and a Title II check in the same month. An individual who loses SSI in one month and receives Title II income in the following month meets the criteria for the Pickle disregard. Individuals who become ineligible for SSI/SSP because of a COLA may be eligible for CN Apple Health through the disregard of COLA. The COLA disregard is allowed only for CN Apple Health. The disregard does not apply to other Apple Health programs.

Disabled Adult Child (DAC) Disregard

The DAC disregard applies to individuals who lose eligibility for SSI because they begin to receive DAC benefits or a COLA to DAC benefits. The DAC disregard is only allowed for CN Apple Health. To receive DAC income, an individual must have been found disabled prior to their twenty-second birthday. Requirements to receive the DAC disregard include:

• Individual is 18 years of age or older.
• Individual meets the aged, blind or disabled criteria.
• Individual has an SSI closure date that is 7/1/88 or later.
• Net countable income after applying the disregard is below the categorically needy income level (CNIL).
• Individual meets all other SSI-related CN eligibility requirements.

Widow(er) Group 1 Disregard - Additional Reduction Factor

The widow(er) Group 1 disregard applies to a small group of individuals who meet specific age criteria. When Social Security changed how it calculates Title II benefits for widow(er)s in 1983, SSI ended for some in this group because of an increase in their Title II benefit. These individuals were grandfathered into continued CN eligibility.

Widow(er) Group 2 Disregard - Early Medicare

The widow(er) Group 2 disregard applies to individuals who lose SSI eligibility because of their having to apply for Title II widow(er) benefits or a COLA to those benefits. The disregard protects CN eligibility for these individuals until they are entitled to receive Medicare. Individuals who meet these criteria automatically meet the criteria for the Pickle disregard if they have income from another Title II source.

Clarifying information

A person's citizenship or immigration status must be determined as part of the eligibility determination for health care coverage under Apple Health (which includes both Classic Medicaid program and MAGI-based Medicaid programs). Everyone falls into one of the following four citizenship/immigration status groups for purposes of determining Apple Health eligibility:

• Lawfully Present Qualified Immigrant;
• Lawfully Present Nonqualified Immigrant;
• Not Lawfully Present (Undocumented) Immigrant; or
• Citizen or U.S. National.

Lawfully present

A lawfully present immigrant refers to any noncitizen or immigrant presently permitted to remain in the United States. Lawfully present means that USCIS has actively granted these immigrants permission to remain in the U.S. and has issued documentation of their lawfully present status that is currently valid. A lawfully present immigrant must still meet state residency requirements in WAC 182-503-0520 in order to qualify for health care coverage.

For a list of typical citizenship/immigration documents see the:

• National immigration Law Center (NILC) Guide in Appendix II; or
• Documents Typically Used by Lawfully Present Immigrants.

Qualified immigrant/nonqualified immigrant terms

Qualified immigrant and nonqualified immigrant are terms used in federal immigration law and do not by themselves indicate whether an immigrant is eligible for Apple Health coverage benefits. Both qualified immigrants and nonqualified immigrants may be eligible for health care coverage.

• For an overview of citizenship and immigration status eligibility rules, see the Citizenship and Immigration Status Guide.

Note: If there is uncertainty about whether a particular individual has met the conditions for citizenship or immigration status, legal assistance is available at the Northwest Immigrant Rights Project in Western Washington at 206-587-4009 or in Eastern Washington at 509-854-2100.

Qualified immigrants

A qualified immigrant who is exempt from, or who has met, the 5-year bar is potentially eligible for federally-funded Apple Health (Medicaid) programs.
A qualified immigrant who is not exempt or has not yet met the 5-year bar is potentially eligible for state-funded Apple Health programs if they are a child, pregnant, or they have a qualifying medical emergency under the Alien Emergency Medical (AEM) program as described under WAC 182-507-0110.

Immigrants included in the qualified immigrant category can be found at Citizenship and Immigration Status Guide.

5-year bar

Federal law requires many qualified immigrants to wait five years before becoming eligible for Apple Health (Medicaid). This 5-year waiting period is commonly referred to as the 5-year bar. Unless exempt, the 5-year waiting period usually begins when the person receives their qualifying immigration status, not when they entered the U.S.

Note: The five-year bar does not apply to individuals that have obtained a qualified immigration status within the last 5 years, if they entered the U.S. prior to August 8, 1996, and have continuously lived in the U.S. since August 22, 1996.

Note: The category code on the I-551 Permanent Resident Card (green card) indicates how an LPR entered the U.S. If an individual entered the U.S. under a status that is exempt from the 5-year bar.

For more information on the 5-year bar see the Citizenship and Immigration Status Guide.

The following immigrant categories are exempt from the 5-year bar:

Refugee

An immigrant outside their own country of origin who is unable or unwilling to return to their country of origin because of persecution or on account of race, religion, nationality, membership in a particular social group, or political opinion as defined in sec. 101 (a)(42) of the INA, who are admitted under section 207 of the INA.

Asylee

A non-citizen in the U.S. or at a port of entry found to be unable or unwilling to return to their country or nationality, or to seek protection of that country because of persecution or well-founded fear of persecution.

Withholding of removal

Non-citizens in removal proceedings are granted withholding of removal when they can establish that it is more likely than not that their life or freedom would be threatened on account of race, religion, nationality, membership in a particular social group, or political opinion if returned to their native country. Only a judge can grant withholding of removal.

Amerasian

Amerasians who were born to U.S. citizen armed services member in Korea, Vietnam, Laos, Kambuchea, or Thailand, after December 31, 1950, but before October 22, 1982, who were admitted to the U.S. as immigrants pursuant to Section 584 of the Foreign Operation, Export Financing, and Related Programs Appropriations Act.

Hmong or Highland Laotian tribe members

Hmong (or Highland Laotian) tribe members born before May 8, 1975, whose tribe assisted the U.S. military during Vietnam era (August 5, 1964 to May 7, 1975) are “qualified immigrants” and potentially eligible for Apple Health (Medicaid) without having to meet the 5-year bar. The tribe member's spouse and unmarried dependent children under age 19 automatically qualify.

If the applicant does not have USCIS documentation of this status, he or she may submit the following statement under penalty of perjury: I was a Hmong (or Highland Laotian) tribe member when the tribe assisted the U.S. military during Vietnam era (August 5,1964 to May 7, 1975).

Cuban/Haitian entrants

Individuals approved for the Haitian Family Reunification Parole (HFRP) program will enter the U.S. as Cuban/Haitian entrants under 501(e) of the Refugee Education Assistance Act of 1980 and are "qualified immigrants" who are exempt from the 5-year bar.

Cuban/Haitian entrants include:

• Cuban and Haitian nationals who have current or expired parole;
• Cuban and Haitian nationals who are in pending removal proceedings;
• Cuban and Haitian nationals who have a pending application for asylum; or
• Have an I-94 stamped Cuban/Haitian Entrant pending.

Cuban/Haitian entrants who apply for asylum are exempt from the 5-year bar while their application is pending. Asylum applicants of other nationalities are non-qualified immigrants.

Cuban/Haitian entrants who are in removal proceedings remain exempt from the 5-year bar until a final, non-appealable, and legally enforceable order of removal, deportation, or exclusion has been issued. If a Cuban/Haitian Entrant is in removal proceedings, or is suspected of being in removal proceedings, or indicates a previous order is under appeal, call the Executive Office of Immigration Review (EOIR) at 1-800-898-7180 to confirm their current status.

Victims of human trafficking

Per the Victims of Trafficking and Violence Protection Act of 2000, the U.S. Department of Health and Human Services (HHS) is the sole federal agency authorized to certify foreign adult victims of human trafficking. Victims of trafficking will be issued a certification letter from the Office on Trafficking in Persons (OTIP). If you have questions about the validity of an OTIP certification letter, call 1-866-401-5510. Derivative T-statuses (family members of the primary victim) do not receive a certification letter.

Iraqi or Afghan special immigrants

Immigrants from Iraq or Afghanistan who were granted Special Immigrant Status under section 101(a)(27) of the INA; or Special Immigrant Conditional Permanent Residence; or Paroled under section 602(b)(1) of the Afghan Allies Protection Act or section 1059(a) of the National Defense Authorization Act of 2006 are qualified immigrants and are eligible for federally-funded Washington Apple Health. Their eligibility period starts from their date of entry into the United States or, if occurred after the U.S. entry, the date Special Immigrant Status was granted. .

Afghans granted humanitarian parole

Under the Consolidated Appropriations Act of 2023, Afghans granted humanitarian parole between July 31, 2021, and September 30, 2023 and their spouses and children, and the parents and guardians of unaccompanied minors who are granted parole after September 30, 2022, are evaluated as qualified immigrants until March 31, 2023, or the end or their parole term, whichever is later.

Ukrainians granted humanitarian parole

Ukrainians (and non-Ukrainians who last habitually resided in Ukraine) granted humanitarian parole between February 24, 2022, and September 30, 2023 and their spouses and children, and the parents and guardians of unaccompanied minors who are granted parole after September 30, 2022, under Section 401 of the Additional Ukrainian Supplemental Appropriations Act of 2022 are evaluated as qualified immigrants.

Citizens of the Republic of the Marshall Islands, the Republic of Palau and the Federated States of Micronesia

Citizens of Marshall Islands, Micronesia or Palau may have a birth certificate, current or expired I94 arrival or departure record, current or expired passport or other document verifying they are citizens of one of these countries. These individuals have special rights under Compacts of Free Association and are lawfully allowed to enter, reside and work in the U.S., but are not U.S. nationals. They are considered lawfully present qualified immigrants exempt from the 5-year bar unless they have some other immigration status.

Armed Service Members or Veterans

Lawful Permanent Residents, parolees, or battered immigrants who are also an armed services member or veteran, or a family member of a veteran as described below:

• On active duty in the US military, other than active duty for training;
• An honorably discharged US veteran;
• A Veteran of the military of the Philippines who served prior to July 1, 1946;
• The spouse, an un-remarried widow or widower; or Unmarried dependent child of a veteran or active-duty service member.

Nonqualified immigrants

Nonqualified immigrants have temporary permission to stay in the U.S. and potentially qualify for Apple Health for children, pregnancy, or Alien Emergency Medical (AEM) as described under WAC 182-507-0110.

Some lawfully present nonqualified aliens have temporary status or pending applications and consequently their status may expire when their document is expired or when a final denial of their application is issued.

Immigrants included in the non-qualified category can be found at the Citizenship and Immigration Status Guide.

Deferred Action Childhood Arrival (DACA or "Dream Act"), is technically considered a non-qualified status; however, they are not eligible for federally-funded Washington Apple Health. DACA persons may be eligible for state-funded health care coverage, including Apple Health for children, pregnancy, or Alien Emergency Medical (AEM).

Undocumented individuals

Undocumented individuals are individuals who are not lawfully present. This includes both individuals who entered the U.S. without document inspection and individuals whose lawful presence status has expired.

An individual whose lawful presence has expired may be in the process of pursuing an extension or change of status. Without evidence of actively pursuing an extension or change of status, an individual whose lawful presence status has expired will be considered an undocumented individual.

Citizens/U.S. nationals/qualifying American Indians born abroad

U.S. citizens

U.S. citizens include the following:

• Individuals born in the U.S; or its territories - Guam, Puerto Rico, the U.S. Virgin Islands; and residents of the Northern Mariana Islands who chose to become U.S. citizens.
• Individuals who have become naturalized U.S. citizens.
• *Certain individuals born abroad to at least one U.S. citizen.

U.S. nationals

Individuals born in America Samoa or Swain Island and residents of the Mariana Islands who did not choose to become U.S. citizens.

American Indians/Alaska Natives

The term American Indian refers to members of federally recognized (and in some cases, state-recognized) tribes in the U.S. The term Alaska Native refers to members of Alaska Native Villages and of Alaska Native Corporations under the Alaska Native Corporation Settlement Act.

American Indians and Alaska Natives born outside the United States are eligible for federal benefits to the same extent as American Indians and Alaska Natives born in the U.S. if they are:

• A member of a federally-recognized American Indian tribe (see Governor's Office of Indian Affairs website); or
• Alaska Native Village or Corporations (see Federal Register Notice).

Note: Noncitizen American Indians have the same eligibility for health care coverage as U.S. Citizens, but citizen documentation requirements do not apply. Instead they will need to provide tribal verification.

Example: A member of a federally recognized tribe (e.g., Pueblo) who is a Mexican citizen gives birth to a child outside of the U.S. The child qualifies as a member of the tribe but is not a citizen. That child is potentially eligible for Washington Apple Health as long as the child can establish that he or she is a member of the federal tribe.

Qualifying American Indians born abroad

• Individuals born in Canada who have at least fifty percent American blood, regardless of tribal membership; or
• Individuals born outside of the United States who are:
  • Members of a federally recognized tribe; or
  • Alaska Natives enrolled by the Secretary of the Interior under the Alaska Native Claims Settlement Act.

Qualifying American Indians born abroad have the same eligibility requirements as U.S. citizens; however, citizenship and identity requirements do not apply. They will need to provide the following verification as appropriate:

• Canadian birth certificate;
• Tribal affiliation; and/or
• Blood quantum

The Child Citizenship Act of 2000

For children born outside the U.S. to acquire citizenship under the Child Citizenship Act of 2000, they must meet all the conditions in WAC 182-503-0530 on or after February 27, 2001. The Act applies to children related to the citizen parent by birth or adoption only - stepchildren are not included unless also adopted. Citizenship for these children can depend on:

• Which parent is a U.S. citizen;
• How long the citizen parent resided in the U.S.; and
• Whether the parents were married at the time.

Once a child becomes a citizen under the Act, subsequent changes in the parents' marital status, such as separation or divorce, have no bearing on the child's citizenship. Nor does it matter whether the parent in question became a U.S. citizen after entering the U.S.

If a child is 18 years or older when the parent becomes a citizen, child citizenship laws do not apply, and he/she must independently apply for naturalization.

For individuals who automatically become citizens under terms of the Child Citizenship Act of 2000 or previous legislation, USCIS issues no documentation unless requested. Individuals themselves may not be aware that they or their children are already citizens.

If unable to verify, refer individual to an immigration attorney at:

• Northwest Justice Project at 206-464-1519 or 888-201-1012
• Northwest Immigrant Rights Project - Seattle - 206-587-4009 or 800-445-5771
• Northwest Immigrant Rights Project - Tacoma - 253-383-0519 or 877-814-6444
• Northwest Immigrant Rights Project - Granger - 509-854-2100 or 888-756-3641; or
• Northwest Immigrant Rights Project - Wenatchee - 509-570-0054 or 866-271-2084

Reasonable opportunity period

Individuals otherwise eligible for Apple Health are conditionally approved and granted a reasonable opportunity period (ROP) of up to 90 days to obtain and provide verification of their citizenship or immigration status. The ROP may extend beyond 90 days if the individual requests additional time, and they are making a good faith effort to obtain the necessary documentation.

Examples of good faith effort includes:

• Up-to-date documents showing immigration status is pending with DHS/United States Citizenship and Immigration Services (USCIS).
• Other verification that reasonably verifies that a good faith effort is being made.

When the individual's citizenship or immigration status has not been verified by the end of the ROP, coverage may end.

Immigration documentation

Expired documents versus expired immigration status.

Many immigration documents have expiration dates; however, an expired immigration document does not necessarily mean the immigration status has expired. For instance, qualified immigration status does not expire even if the immigration documents expire, with the following exceptions:

• Lawful Permanent Residents with Conditions (2-year Conditional Residents): Conditional residents receive a 2-year LPR card, often based on a recent marriage to a U.S. citizen. At the end of the 2 years, they must either file a joint petition to remove the condition or a request for a waiver of the joint filing requirement (for instance, on grounds of divorce and /or domestic violence). Clients with this expired status must provide proof of a pending petition to remove the condition or of an application to waive the joint filing requirement.
• Parolees: Their status expires after the expiration date. Parolees usually have an I-94 arrival/departure record stamped with an entry and expiration date. Some may have their expiration date stamped "waived" or "indefinite".

On the other hand, nonqualified immigration status (including those in the U.S. on nonimmigrant visas) typically expires when their immigration documents expire.

Additional information regarding specific document types and status

Form I-797

Notice of Action may or may not have an expiration date. It is used to notify the individual that a fee was paid, an application was accepted, the case is pending, a step in the process is completed, or status is approved. Individuals with I-797s are undocumented unless it verifies that status has been approved.

Example: An example that a step in the process has been completed but status has not been approved is the Notice of Approval for Immigrant Petition for Relative. This is the initial step in the family-related immigrant application process. It solely establishes relationship. It does not establish status. If this is the only document provided, the individual is considered undocumented for purposes of benefits eligibility.

Example: An example that status is approved is the Approval Notice of an I-360 Self-Petition under the Violence Against Women Act (VAWA). In most cases a VAWA self-petitioner will first receive a Prima Facie notice, indicating that the petitioner has submitted evidence sufficient to establish a case. Both notices verify that the individual is a qualified immigrant and their status does not expire.

Order from Immigration Judge

An order is issued because the immigrant is or has been in removal proceedings. The Judge provides a decision notifying the individual whether the individual can remain in the country. The order does not have an expiration date.

Example: An example of a status granted by an Order from Immigration Judge are Granted Withholding of Deportation which is a qualified immigrant category and Order of Supervision which is a nonqualified immigrant category.

Form I-589

Application for Asylum (nonqualified immigrant) does not have an expiration date; however, USCIS is required to provide a decision within 180 days. Despite this requirement, some asylum applicants may not receive a decision within the 180 day deadline. If the document is more than 180 days old, staff will need to check USCIS website (see below) to determine if it is still pending a decision. If still pending a decision, the asylum applicant retains their nonqualified status.

Note: If an applicant for Asylum is a national of Cuba or Haiti, they are Cuban/Haitian Entrants eligible for benefits to the same extent as refugees while their application is pending.

Form I-912

In cases with expired immigration documents, individuals should apply with USCIS for renewal and submit the Form I-912 (Request for Fee Waiver) at the same time. Individuals seeking or receiving public assistance, including Apple Health, are eligible for Fee Waivers with their application. Fee Waiver Guidance can be found at USCIS - Fee Waiver Guidance.

• If USCIS denies the fee waiver request, they will notify the individual with a notice of rejection and an explanation why the fee waiver request was denied. In these cases, copy the notice of rejection into the individual’s file and offer help paying for the documents. If USCIS approves the fee waiver request, the individual will also be notified.
• Staff can check the current case status of pending USCIS documents by entering the receipt number on the document at the USCIS website.

Note: If you are uncertain about someone’s eligibility for benefits after reviewing this clarifying page, please contact your area representative.

For a list of typical citizenship/immigration documents see the:

• National Immigration Law Center (NILC) Guide in Appendix II; or
• Documents Typically Used by Lawfully Present Immigrants.

Clarifying information

When another party (a third party) has been identified as responsible for payment of a health care expense, Apple Health does not pay the health care claim until after the third party has paid. When Apple Health has paid a claim for a health care expense prior to third party payment, the Health Care Authority or Managed Care Organization is entitled to collect third party benefits.

The limit of the recoupment from the settlement, judgment or awards of monies is the amount of the health care expense paid by the Health Care Authority or Managed Care Organization. The method of determining what portion of a settlement represents past medical expenses is left to the state, the parties, and/or the court. Refer all such questions or challenges to Health Care Authority at 1-800-562-3022.

Assignment of rights is effective for all periods of eligibility certification, including any retroactive period of eligibility.