WAC 182-503-0005 Washington apple health -- How to apply.

Effective June 4, 2023

1. You may apply for Washington apple health at any time.
2. For apple health programs for children, pregnant people, parents and caretaker relatives, and adults age 64 and under without medicare, (including people who have a disability or are blind), you may apply:
   1. Online via the Washington Healthplanfinder at www.wahealthplanfinder.org;
   2. By calling the Washington Healthplanfinder customer support center and completing an application by telephone;
   3. By completing the application for health care coverage (HCA 18-001P), and mailing or faxing to Washington Healthplanfinder; or 
   4. At a department of social and health services (DSHS) community services office (CSO).
3. ​If you seek apple health coverage and are age 65 or older, have a disability, are blind, need assistance with medicare costs, or seek coverage of long-term services and supports, you may apply:
   1. Online via Washington Connection at www.WashingtonConnection.org;
   2. By completing the application for aged, blind, disabled/long-term care coverage (HCA 18-005) and mailing or faxing it to DSHS;
   3. By calling the DSHS customer service contact center and completing an application by telephone;
   4. In person at a local DSHS CSO or home and community services (HCS) office; or
   5. As specified in subsection (2) of this section, if you are a child, pregnant, a parent or caretaker relative, or an adult age 64 and under without medicare.
4. You may receive help filing an application.
   1. For households containing people described in subsection (2) of this section:
      1. Call the Washington Healthplanfinder customer support center number listed on the application for health care coverage form (HCA 18-001P); or 
      2. Contact a navigator, health care authority volunteer assistor, or broker.
   2. For people described in subsection (3) of this section who are not applying with a household containing people described in subsection (2) of this section:
      1. Call or visit a local DSHS CSO or HCS office; or 
      2. Call the DSHS community services customer service contact center number listed on the medicaid application form. 
5. To apply for tailored supports for older adults (TSOA), see WAC 182-513-1625.
6. You must apply directly with the service provider for the following programs:
   1. The breast and cervical cancer treatment program under WAC 182-505-0120;
   2. The family planning only programs under chapter 182-532 WAC; and
   3. The kidney disease program under chapter 182-540 WAC.
7. For the confidential pregnant minor program under WAC 182-505-0117 and for minors living independently, you must complete a separate application directly with us (the medicaid agency). More information on how to give us an application may be found at the agency's web site:  www.hca.wa.gov/free-or-low-cost-health-care (search for "teen").
8. As the primary applicant or head of household, you may start an application for apple health by providing your:
   1. Full name;
   2. Date of birth; 
   3. Physical address, and mailing addresses (if different); and
   4. Signature.
9. To complete an application for apple health, you must also give us all of the other information requested on the application.
10. You may have an authorized representative apply on your behalf as described in WAC 182-503-0130.
11. We help you with your application or renewal for apple health in a manner that is accessible to you. We provide equal access (EA) services as described in WAC 182-503-0120 if you:
    1. ​Ask for EA services, you apply for or receive long-term services and supports, or we determine that you would benefit from EA services; or
    2. Have limited-English proficiency as described in WAC 182-503-0110. 

WAC 182-503-0010 Washington apple health -- Who may apply.

Effective January 16, 2020.

1. You may apply for Washington apple health for yourself.
2. You may apply for apple health for another person if you are:
   1. A legal guardian;
   2. An authorized representative (as described in WAC 182-503-0130);
   3. A parent or caretaker relative of a child age eighteen or younger;
   4. A tax filer applying for a tax dependent;
   5. A spouse; or
   6. A person applying for someone who is unable to apply on their own due to a medical condition and who is in need of long-term care services.
3. If you reside in an institution of mental diseases (as defined in WAC 182-500-0050(1)) or a public institution (as defined in WAC 182-500-0050(4)), including a Washington state department of corrections facility, city, tribal, or county jail, or secure community transition facility or total confinement facility (as defined in RCW 71.09.020), you, your representative, or the facility may apply for you to get the apple health coverage for which you are determined eligible.
4. You are automatically enrolled in apple health and do not need to submit an application if you are a:
   1. Supplemental security income (SSI) recipient;
   2. Person deemed to be an SSI recipient under 1619(b) of the SSA;
   3. Newborn as described in WAC 182-505-0210; or
   4. Child in foster care placement as described in WAC 182-505-0211.
5. You are the primary applicant on an application if you complete and sign the application on behalf of your household.
6. If you are an SSI recipient, then you, your authorized representative as defined in WAC 182-500-0010, or another person applying on your behalf as described in subsection (2) of this section, must turn in a signed application to apply for long-term care services as described in WAC 182-513-1315.

WAC 182-503-0040 Washington apple health -- Interview requirements.

Effective July 25, 2013

1. An individual applying for Washington apple health (WAH) (as defined in WAC 182-500-0120) is not required to have an in-person interview to determine eligibility.
2. The agency or its designee may contact an individual by phone or in writing to gather any additional information that is needed to make an eligibility determination.
3. A phone or in-person interview is required to determine initial financial eligibility for WAH long-term care services.
4. The interview requirement described in subsection (3) of this section may be waived if the applicant is unable to comply:
   1. Due to his or her medical condition; or
   2. Because the applicant does not have a family member or another individual that is able to conduct the interview on his or her behalf.

WAC 182-503-0060 Washington apple health -- Application processing times.

Effective August 8, 2021

1. We process applications for Washington apple health medicaid within forty-five calendar days, with the following exceptions:
   1. If you are pregnant, we process your application within fifteen calendar days;
   2. If you are applying for a program that requires a disability decision, we process your application within sixty calendar days; or
   3. The modified adjusted gross income (MAGI)-based apple health application process using Washington Healthplanfinder may provide faster or real-time determination of eligibility for medicaid.
2. For calculating time limits, "day one" is the day we get an application from you that includes at least the information described in WAC 182-503-0005(8). If you give us your paper application during business hours, "day one" is the day you give us your application. If you give us your paper application outside of business hours, "day one" is the next business day. If you experience technical difficulties while attempting to give us your application in Washington Healthplanfinder, "day one" is the day we are able to determine, based on the evidence available, that you first tried to submit an application that included at least the information described in WAC 182-503-0005(8).
3. We determine eligibility as quickly as possible and respond promptly to applications and information received. We do not delay a decision by using the time limits in this section as a waiting period.
4. If we need more information to decide if you can get apple health coverage, we will send you a letter within twenty calendar days of your initial application that:
   1. Follows the rules in chapter 182-518 WAC;
   2. States the additional information we need; and
   3. Allows at least ten calendar days to provide it. We will allow you more time if you ask for more time or need an accommodation due to disability or limited-English proficiency.
5. Good cause for a delay in processing the application exists when we acted as promptly as possible but:
   1. The delay was the result of an emergency beyond our control;
   2. The delay was the result of needing more information or documents that could not be readily obtained;
   3. You did not give us the information within the time frame specified in subsection (1) of this section.
6. Good cause for a delay in processing the application does NOT exist when:
   1. We caused the delay in processing by:
      1. Failing to ask you for information timely; or
      2. Failing to act promptly on requested information when you provided it timely; or
   2. We did not document the good cause reason before missing a time frame specified in subsection (1) of this section. 

WAC 182-503-0070 Washington apple health (WAH)-- When coverage begins.

Effective August 29, 2014.

1. Your Washington apple health (WAH) coverage starts on the first day of the month you applied for and we decided you are eligible to receive coverage, unless one of the exceptions in subsection (4) of this section applies to you.
2. Sometimes we can start your coverage up to three months before the month you applied (see WAC 182-504-0005).
3. If you are confined or incarcerated as described in WAC 182-503-0010, your coverage cannot start before the day you are discharged, except when:
   1. You are hospitalized during your confinement; and
   2. The hospital requires you to stay overnight.
4. Your WAH coverage may not begin on the first day of the month if:
   1. Subsection (3) of this section applies to you. In that case, your coverage would start on the first day of your hospital stay;
   2. You must meet a medically needy spenddown liability (see WAC 182-519-0110). In that case, your coverage would start on the day your spenddown is met; or
   3. You are eligible under the WAH alien emergency medical program (see WAC 182-507-0115). In that case, your coverage would start on the day your emergent hospital stay begins.
5. For long-term care, the date your services start is described in WAC 388-106-0045.

WAC 182-503-0080 Washington apple health -- Application denials and withdrawals.

Effective November 3, 2019. 

1. We follow the rules about notices and letters in chapter 182-518 WAC. We follow the rules about timelines in WAC 182-503-0060.
2. We deny your application for apple health coverage when:
   1. You tell us either orally or in writing to withdraw your request for coverage; or
   2. Based on all information we have received from you and other sources within the time frames stated in WAC 182-503-0060, including any extra time given at your request or to accommodate a disability or limited-English proficiency:
      1. We are unable to determine that you are eligible; or
      2. We determine that you are not eligible.
   3. You are subject to asset verification and do not provide authorization as described in WAC 182-503-0055.
3. We send you a written notice explaining why we denied your application (per chapter 182-518 WAC).
4. We reconsider our decision to deny your apple health coverage without a new application from you when:
   1. We receive the information that we need to decide if you are eligible within thirty days of the date on the denial notice;
   2. You give us authorization to verify your assets as described in WAC 182-503-0055 within thirty days of the date on the denial notice;
   3. You request a hearing within ninety days of the date on the denial letter and an administrative law judge (ALJ) or HCA review judge decides our denial was wrong (per chapter 182-526 WAC).
5. If you disagree with our decision, you can ask for a hearing. If we denied your application because we do not have enough information, the ALJ will consider the information we already have and any more information you give us. The ALJ does not consider the previous absence of information or failure to respond in determining if you are eligible. 

WAC 182-527-2730 Definitions

Effective March 16, 2016

The following definitions apply to this chapter:

"Contract health service delivery area (CHSDA)" means the geographic area within which contract health services will be made available by the Indian health service to members of an identified Indian community who reside in the area as identified in 42 C.F.R. Sec. 136.21(d) and 136.22.

"Estate" means all property and any other assets that pass upon the client's death under the client's will or by intestate succession under chapter 11.04 or 11.62 RCW. The value of the estate will be reduced by any valid liability against the client's property when the client died. An estate also includes:

1. For a client who died after June 30, 1995, and before July 27, 1997, nonprobate assets as defined by RCW 11.02.005, except property passing through a community property agreement; or
2. For a client who died after July 26, 1997, and before September 14, 2006, nonprobate assets as defined by RCW 11.02.005.
3. For a client who died on or after September 14, 2006, nonprobate assets as defined by RCW 11.02.005 and any life estate interest held by the client immediately before death.

"Heir" means a person entitled to inherit a deceased client's property under a valid will accepted by the court, or a person entitled to inherit under the Washington state intestacy statute, RCW 11.04.015. 

Life estate" means an ownership interest in a property only during the lifetime of the person owning the life estate. 

"Lis pendens" means a notice filed in public records warning that title to certain real property is in litigation and the outcome of the litigation may affect the title.

"Long-term care services (LTC)" means, for the purposes of this chapter only, the services administered directly or through contract by the department of social and health services (DSHS) for clients of the home and community services division of DSHS and the developmental disabilities administration of DSHS including, but not limited to, nursing facility care and home and community services.

"Property" means everything a person owns, whether in whole or in part.

1. "Personal property" means any movable or intangible thing a person owns, whether in whole or in part; 
2. "Real property" means land and anything growing on, attached to, or built on it, excluding anything that may be removed without injury to the land;
3. "Trust property" means any type of property held in trust for the benefit of another.

"Qualified long-term care insurance partnership" means an agreement between the Centers for Medicare and Medicaid services (CMS) and the Washington state insurance commission which allows for the disregard of any assets or resources in an amount equal to the insurance benefit payments that are made to or on behalf of a person who is a beneficiary under a long-term care insurance policy that has been determined by the Washington state insurance commission to meet the requirements of section 1917 (b)(1)(C)(iii) of the act.

"Recover" or "recovery" means the agency or the agency's designee's receipt of funds to satisfy the client's debt.

WAC 182-527-2734 Liens during a client's lifetime.

Effective July 1, 2017

For the pur­poses of this section, the term "agency" includes the agency's desig­nee.

1. When the agency may file.
   1. The agency may file a lien against the property of a Washing­ton apple health client during the client's lifetime if:
      1. The client resides in a skilled nursing facility, intermedi­ate care facility for individuals with an intellectual disability, or other medical institution under WAC 182-500-0050;
      2. The agency determines that a client cannot reasonably be expected to return home because:
         1. The agency receives a physician's verification that the client will not be able to return home; or
         2. The client has resided for six months or longer in an institution as defined in WAC 182-500-0050; and
      3. None of the following people lawfully reside in the client's home:
         1. The client's spouse or state-registered domestic partner;
         2. The client's child who is age twenty or younger, or is blind or permanently disabled as defined in WAC 182-512-0050; or
         3. A client's sibling who has an equity interest in the home and who has been residing in the home for at least one year immediately before the client's admission to the medical institution.
   2. If the client returns home from the medical institution, the agency releases the lien.
2. Amount of the lien.
   1. The agency may file a lien to recoup the cost of all non-MAGI-based and deemed eligible services under WAC 182-503-0510 it correctly purchased on the client's behalf, regardless of the client's age on the date of service.
   2. Services provided under the medicaid transformation project, defined in WAC 182-500-0070, are excluded when determining the amount of the lien.
3. Notice requirement.
   1. Before the agency may file a lien under this section, it sends notice via first class mail to:
      1. The client's last known address;
      2. The client's authorized representative, if any;
      3. The address of the property subject to the lien; and
      4. Any other person known to hold title to the property.
   2. The notice states:
      1. The client's name;
      2. The agency's intent to file a lien against the client's property;
      3. The county in which the property is located; and
      4. How to request an administrative hearing.
4. Interest assessed on past-due debt.
   1. Interest on a past-due debt accrues at a rate of one percent per month under RCW 43.17.240.
   2. A lien under this section becomes a past-due debt when the agency has recorded the lien in the county where the property is loca­ted and:
      1. Thirty days have passed since the property was transferred or
      2. Nine months have passed since the lien was filed.
   3. The agency may waive interest if reasonable efforts to sell the property have failed.
5. Administrative hearing. An administrative hearing under this section is governed by WAC 182-527-2753.

WAC 182-527-2738 Estate recovery—General right to recover.

Effective March 14, 2016

For the purposes of this section, the term "agency" includes the agency's designee.

1. When the agency may file. After a Washington apple health client has died, the medicaid agency may file liens to recover the cost of services subject to recovery that were correctly paid on the client's behalf.
2. Notice requirement.
   1. Before the agency may file a lien under this section, it sends notice via first class mail as follows:
      1. If the estate has a personal representative, the agency sends notification to:
         1. The personal representative; and
         2. Any known title holder.
      2. If the estate has known heirs but no personal representative, the agency sends notification to:
         1. Any known heir; and
         2. Any known title holder.
      3. If the estate has no personal representative and no known heirs, the agency sends notification to:
         1. The address listed on the title; and
         2. Any known title holder.
   2. The notice states:
      1. The agency's intent to file a lien against the deceased client's property;
      2. The amount the agency seeks to recover;
      3. The deceased client's name, identification number, date of birth, and date of death;
      4. The county in which the property is located; and
      5. How to request an administrative hearing.
3. The agency may not recover from the client's estate so long as there remains:
   1. A surviving spouse; or
   2. A surviving child who:
      1. Is age twenty or younger; or
      2. Is blind or disabled as defined in WAC 182-512-0050.
4. Interest assessed on past-due debt.
   1. Interest on a past-due debt accrues at a rate of one percent per month under RCW 43.17.240.
   2. A lien under this section becomes a past-due debt when the agency has recorded the lien in the county where the property is located and nine months have passed since the lien was recorded or a creditor's claim was filed, whichever is sooner.
   3. The agency may waive interest if reasonable efforts to sell the property have failed.
5. Administrative hearing. An administrative hearing under this section is governed by WAC 182-527-2753.

WAC 182-527-2740 Estate recovery - Age-related limitations.

Effective March 14, 2016

For the purposes of this section, the term "agency" includes the agency's designee.

1. Liability for medicaid services.
   1. Beginning July 26, 1987, a client's estate is liable for medicaid services subject to recovery that were provided on or after the client's sixty-fifth birthday.
   2. Beginning July 1, 1994, a client's estate is liable for medicaid services subject to recovery that were provided on or after the client's fifty-fifth birthday.
2. Liability for state-only-funded long-term care services.
   1. A client's estate is liable for all state-only-funded long-term care services provided by the home and community services division of the department of social and health services (DSHS) on or after July 1, 1995.
   2. A client's estate is liable for all state-only-funded long-term care services provided by the developmental disabilities administration of DSHS on or after June 1, 2004.

WAC 182-527-2742 Estate recovery-Service-related limitations.

Effective June 23, 2024

For the purposes of this section, the term "agency" includes the agency's designee.

The agency's payment for the following services is subject to recovery:

1. State-only funded services, except:
   1. Adult protective services;
   2. Offender reentry community safety program services;
   3. Supplemental security payments (SSP) authorized by the developmental disabilities administration (DDA);
   4. Volunteer chore services; and
   5. Guardianship and conservatorship assistance program services.
2. For dates of service on or after January 1, 2014:
   1. Basic Plus waiver services;
   2. Community first choice (CFC) services;
   3. Community option program entry system (COPES) services;
   4. Community protection waiver services;
   5. Core waiver services;
   6. Hospice services;
   7. Intermediate care facility for individuals with intellectual disabilities services provided in either a private community setting or in a rural health clinic;
   8. Individual and family services;
   9. Medicaid personal care services;
   10. New Freedom consumer directed services;
   11. Nursing facility services;
   12. Personal care services funded under Title XIX or XXI;
   13. Private duty nursing administered by aging and long-term support administration (ALTSA) or the DDA;
   14. Residential habilitation center services;
   15. Residential support waiver services;
   16. Roads to community living demonstration project services;
   17. The portion of the managed care premium used to pay for ALTSA-authorized long-term care services under the program of all-inclusive care for the elderly (PACE); and
   18. The hospital and prescription drug services provided to a client while the client was receiving services listed in this subsection.
3. For dates of service beginning January 1, 2010, through December 31, 2013:
   1. Medicaid services;
   2. Premium payments to managed care organizations (MCOs); and
   3. The client's proportional share of the state's monthly contribution to the Centers for Medicare and Medicaid Services to defray the costs for outpatient prescription drug coverage provided to a person who is eligible for medicare Part D and medicaid.
4. For dates of service beginning June 1, 2004, through December 31, 2009:
   1. Medicaid services;
   2. Medicare premiums for individuals also receiving medicaid;
   3. Medicare savings programs (MSPs) services for people also receiving medicaid; and
   4. Premium payments to MCOs.
5. For dates of service beginning July 1, 1995, through May 31, 2004:
   1. Adult day health services;
   2. Home and community-based services;
   3. Medicaid personal care services;
   4. Nursing facility services;
   5. Private duty nursing services; and
   6. The hospital and prescription drug services provided to a client while the client was receiving services listed in this subsection.
6. For dates of service beginning July 1, 1994, through June 30, 1995:
   1. Home and community-based services;
   2. Nursing facility services; and
   3. Hospital and prescription drug services provided to a client while the client was receiving services listed in this subsection.
7. For dates of service beginning July 26, 1987, through June 30, 1994: Medicaid services.
8. For dates of service through December 31, 2009. If a client was eligible for the MSP, but not otherwise medicaid eligible, the client's estate is liable only for any sum paid to cover medicare premiums and cost-sharing benefits.
9. For dates of service beginning January 1, 2010. If a client was eligible for medicaid and the MSP, the client's estate is not liable for any sum paid to cover medical assistance cost-sharing benefits.
10. For dates of service beginning July 1, 2017, long-term services and supports authorized under the medicaid transformation project are exempt from estate recovery. Exempted services include those provided under:
    1. Medicaid alternative care under WAC 182-513-1600;
    2. Tailored supports for older adults under WAC 182-513-1610;
    3. Supportive housing under WAC 388-106-1700 through 388-106-1765; or
    4. Supported employment under WAC 388-106-1800 through 388-106-1865.

WAC 182-527-2746 Estate recovery—Asset-related limitations.

Effective March 14, 2016

For the purposes of this section, the term "agency" includes the agency's designee.

1. Before July 25, 1993. For services received before July 25, 1993, that are subject to recovery, the agency may exempt:
   1. The first fifty thousand dollars of the estate's value at the time of the client's death; and
   2. Sixty-five percent of the remaining value of the estate.
2. July 24, 1993, through June 30, 1994. For services that are subject to recovery that were received on or after July 25, 1993, through June 30, 1994, the agency exempts two thousand dollars' worth of personal property.
3. Life estate.
   1. The agency may file a lien against a client's life estate interest in real property.
   2. The agency's lien against the property may not exceed the value of the client's life estate. Under this subsection, value means the fair market value of the property multiplied by the life estate factor that corresponds to the client's age on the client's last birthday. For a list of life estate factors, see the life estate and remainder interest tables maintained by the Social Security Administration.
   3. The agency may not enforce a lien under this subsection against any property right that vested before July 1, 2005.
4. Joint tenancy.
   1. The agency may file a lien against property in which a client was a joint tenant when the client died.
   2. The agency's lien against the property may not exceed the value of the client's interest in the property. Under this subsection, value means the fair market value of the property divided by the number of joint tenants on the day the client died.
   3. The agency may not enforce a lien under this subsection against any property right that vested before July 1, 2005.
5. Qualified long-term care partnership.
   1. Assets designated as protected by a qualified long-term care partnership (QLTCP) policy issued after November 30, 2011, may be disregarded for estate recovery purposes if:
      1. The insured person's estate is the recipient of the estate recovery exemption; or
      2. The insured person holds title to property which is potentially subject to a predeath lien and that person asserts the property is protected under the QLTCP policy.
   2. A person must provide clear and convincing evidence to the office of financial recovery that the asset in question was designated as protected, including:
      1. Proof of a valid QLTCP policy;
      2. Verification from the LTC insurance company of the dollar amount paid out by the policy; and
      3. A current department of social and health services QLTCP asset designation form when the QLTCP policy paid out more than was previously designated.
   3. The insured person's estate must provide clear and convincing evidence proving an asset is protected before the final recovery settlement.
6. Rules specific to American Indians and Alaska natives.
   1. Certain properties belonging to American Indians/Alaska natives (AI/AN) are exempt from estate recovery if at the time of death:
      1. The deceased client was enrolled in a federally recognized tribe; and
      2. The estate or heir documents the deceased client's ownership interest in trust or nontrust real property and improvements located on a reservation, near a reservation as designated and approved by the Bureau of Indian Affairs of the U.S. Department of the Interior, or located:
         1. Within the most recent boundaries of a prior federal reservation; or
         2. Within the contract health service delivery area boundary for social services provided by the deceased client's tribe to its enrolled members.
   2. Protection of trust and nontrust property under subsection (4) of this section is limited to circumstances when the real property and improvements pass from an Indian (as defined in 25 U.S.C. Chapter 17, Sec. 1452(b)) to one or more relatives (by blood, adoption, or marriage), including Indians not enrolled as members of a tribe and non-Indians, such as spouses and stepchildren, that their tribe would nonetheless recognize as family members, to a tribe or tribal organization and/or to one or more Indians.
   3. Certain AI/AN income and resources (such as interests in and income derived from tribal land and other resources currently held in trust status and judgment funds from the Indian Claims Commission and the U.S. Claims Court) are exempt from estate recovery by other laws and regulations.
   4. Ownership interests in or usage rights to items that have unique religious, spiritual, traditional, and/or cultural significance or rights that support subsistence or a traditional life style according to applicable tribal law or custom.
   5. Government reparation payments specifically excluded by federal law in determining eligibility are exempt from estate recovery as long as such funds have been kept segregated and not commingled with other countable resources and remain identifiable.

WAC 182-527-2750 Estate recovery - Delay of recovery for undue hardship.

Effective March 14, 2016

For the purposes of this section, the term "agency" includes the agency's designee.

1. If an undue hardship exists at the time of the client's death, an heir may ask the agency to delay recovery.
   1. Undue hardship exists only when:
      1. The property subject to recovery is the sole income-producing asset of an heir;
      2. Recovery would deprive an heir of shelter and the heir cannot afford alternative shelter; or
      3. The client is survived by a state-registered domestic partner.
   2. Undue hardship does not exist if the client or the heir created circumstances to avoid estate recovery.
2. If the agency determines recovery would cause an undue hardship for an heir, the agency may delay recovery until the hardship no longer exists.
3. If the agency denies an heir's request to delay recovery, the agency notifies the heir in writing.  The notice includes instructions on how to request a hearing.
4. If the agency grants a delay of recovery under this section, the heir must:
   1. Timely comply with any agency request for information or records;
   2. Not sell, transfer, or encumber the property;
   3. Reside on the property;on the property;
   4. Timely pay property taxes and utilities;
   5. Ensure the property for its fair market  value;
   6. Name the state of Washington as the primary payee on the property insurance policy;
   7. Provide the agency with a copy of the property insurance policy upon request;
   8. Continue to satisfy the requirements in subsection (1) of this section.
5. If the heir dies, or violates any provision of subsection (4) of this section, the agency may begin recovery.
6. If the agency denies the request, the heir may request an administrative hearing under WAC 182-527-2753. 

WAC 182-527-2753 Hearings.

Effective March 14, 2016

For the purposes of this section, the term "agency" includes the agency's designee.

1. An administrative hearing to contest action under this chapter determines only:
   1. In the case of a lien filed during the client's lifetime under WAC 182-527-2734:
      1. Whether the client can reasonably be expected to return home from the medical institution;
      2. Whether the client, or the client's estate, holds legal title to the identified property; and
      3. Whether the client received services subject to recovery.
   2. In the case of a lien filed after the client's death:
      1. The cost the agency correctly paid for services subject to recovery;
      2. Whether the client, or the client's estate, holds legal title to the identified property; and
      3. Whether the agency's denial of an heir's request for a delay of recovery for undue hardship under WAC 182-527-2750 was correct.
2. A request for an administrative hearing must:
   1. Be in writing;
   2. State the basis for contesting the agency's proposed action;
   3. Be signed by the requestor and include the client's name, the requestor's address and telephone number; and
   4. Within twenty-eight days of the date on the agency's notice, be filed with the office of financial recovery either:
      1. In person at the Office of Financial Recovery, 712 Pear St. S.E., Olympia, WA 98504-0001; or
      2. By certified mail, return receipt requested, to Office of Financial Recovery, P.O. Box 9501, Olympia, WA 98507-9501.
3. Upon receiving a request for an administrative hearing, the office of administrative hearings notifies any known titleholder of the time and place of the administrative hearing.
4. An administrative hearing under this subsection is governed by chapters 34.05 RCW and 182-526 WAC and this section. If a provision in this section conflicts with a provision in chapter 182-526 WAC, the provision in this section governs.
5. Disputed assets must not be distributed while in litigation.
6. Absent an administrative or court order to the contrary, the agency may file a lien twenty-eight calendar days after the date the agency mailed notice of its intent to file a lien.

WAC 182-503-0520 Washington apple health -- Residency requirements -- Persons who are not residing in an institution.

Effective August 29, 2014.

1. A resident is a person (including an emancipated person under age eighteen and a married person under age eighteen who is capable of indicating intent) who currently lives in Washington and:
   1. Intends to reside here, including persons without a fixed address; or
   2. Entered the state looking for a job; or
   3. Entered the state with a job commitment.
2. A person does not need to live in the state for a specific period of time prior to meeting the requirements in subsection (1) of this section before being considered a resident.
3. A child under age eighteen who is not covered by subsection (1) of this section, is a resident if:
   1. The child lives in the state, with or without a fixed address, including with a custodial parent or caretaker; or
   2. The child's parent or caretaker is a resident as defined in subsection (1) of this section.
4. A resident applying for or receiving health care coverage can temporarily be out of the state for more than one month without their health care coverage being denied or terminated, if the person:
   1. Intends to return to the state once the purpose of his or her absence has been accomplished and provides adequate information of this intent after a request by the agency or its designee; and
   2. Has not been determined eligible for medicaid or state-funded health care coverage in another state (other than coverage in another state for incidental or emergency health care).
5. A person who enters Washington state only for health care is not a resident and is not eligible for any medical program. The only exception is for a person who moves from another state directly into an institution in Washington state. Residency rules for institutionalized persons are described in WAC 182-503-0525.
6. A person of any age who receives a state supplemental payment (SSP) is considered a resident of the state that is making the payment.
7. A person who receives federal payments for foster or adoption assistance is considered a resident of the state where the person physically resides even if:
   1. The person does not live in the state that is making the foster or adoption assistance payment; or
   2. The person does not live in the state where the adoption agreement was entered.
8. In a dispute between states, the state of residence is the state in which the person is physically located.

WAC 182-503-0525 Washington apple health -- Residency requirements for an institutionalized person.

Effective August 29, 2014.

1. An institutionalized person is a person who resides in an institution as defined in WAC 182-500-0050. The term "person" used in this section means an "institutionalized person" unless otherwise indicated. It does not include persons who receive services under a home and community-based waiver program. When a state is making a placement for a person in another state, the term institution also includes foster care homes, licensed as described in 45 C.F.R. 1355.20.
2. The agency must determine whether a person is capable of indicating their intent to reside in Washington state when deciding whether that person is a resident of the state. The agency determines that persons who meet the following criteria are deemed incapable of indicating intent to reside in the state:
   1. The person is judged legally incompetent by a court of law;
   2. A physician, psychologist or licensed medical professional in the field of intellectual disabilities has determined that the person is incapable of indicating intent; or
   3. The person is incapable of declaring intent due to a documented medical condition.
3. When a person is placed in an out-of-state institution by the agency, its designee or by a department of social and health services-contracted agency, the state arranging the placement is considered the person's state of residence, unless the person is capable of expressing intent and:
   1. Indicates a desire to change his or her state of residence; or
   2. Asks the current state of residence for help in relocating. This may include assistance in locating an institutional placement in the new state of residence.
4. If another state has not authorized the placement in the institution, as described in subsection (3) of this section, the agency or its designee uses one of the following criteria to determine the state of residence for a person who is age twenty or younger:
   1. The state of residence is the state where the parent or legal guardian is a resident at the time of the placement in the institution. To determine a parent's or legal guardian's place of residence, follow rules described in WAC 182-503-0520 for a noninstitutionalized person.
   2. The state of residence is the state where the parent or legal guardian currently is a resident if the person resides in an institution in that state.
   3. If the parents of the person are separated and live in different states, the state of residence is that of the parent filing the application.
   4. If the parental rights are terminated and the person has a legal guardian, the state of residence is where the legal guardian is a resident.
   5. If the person has both a guardian of the estate and a guardian of the person, the state of residence is where the guardian of the person is a resident, unless the state has laws which delegate guardianship to a state official or agency for persons who are admitted to state institutions. In that case, the state of residence for the person is the state where the institution is located (unless another state has authorized the placement).
   6. If the person has been abandoned by the parents or legal guardian, and an application is filed on their behalf by another party, the state of residence is the state where the person is institutionalized. The term abandoned also includes situations where the parents or legal guardian are deceased.
5. A person age twenty-one or older that is capable of indicating intent is considered a resident of the state where he or she is living and intends to reside.
6. A person age twenty-one or older who became incapable of indicating intent at age twenty-one or older is considered a resident of the state where the person is physically residing, unless the person has been placed in the institution by another state.
7. A person age twenty-one or older who became incapable of indicating intent before the age of twenty-one is considered a resident of the state where the parents or legal guardian were residents at the time of the placement in the institution.
8. If a noninstitutionalized person moves directly from another state to an institution in Washington state, it is not necessary for the person to establish residency in Washington state prior to entering the facility. The person is considered a resident if he or she intends to reside in the state unless the placement was made by the other state.
9. A person of any age who receives a state supplemental payment (SSP) is considered a resident of the state that is making the payment.
10. In a dispute between states, the state of residence is the state in which the person is physically located. 

WAC 182-505-0250 Washington apple health -- MAGI-based adult medical.

Effective August 29, 2014.

1. Effective on or after January 1, 2014, a person is eligible for Washington apple health (WAH) modified adjusted gross income (MAGI)-based adult coverage when he or she meets the following requirements:
   1. Is age nineteen or older and under the age of sixty-five;
   2. Is not entitled to, or enrolled in, medicare benefits under Part A or B of Title XVIII of the Social Security Act;
   3. Is not otherwise eligible for and enrolled in mandatory coverage under one of the following programs:
      1. WAH SSI-related categorically needy (CN);
      2. WAH foster care program; or
      3. WAH adoption support program;
   4. Meets citizenship and immigration status requirements described in WAC 182-503-0535;
   5. Meets general eligibility requirements described in WAC 182-503-0505; and
   6. Has net countable income that is at or below one hundred thirty-three percent of the federal poverty level for a household of the applicable size.
2. Parents or caretaker relatives of an eligible dependent child as described in WAC 182-503-0565 are first considered for WAH for families as described in WAC 182-505-0240. A person whose countable income exceeds the standard to qualify for family coverage is considered for coverage under this section.
3. Persons who are eligible under this section are eligible for WAH alternative benefit plan as defined in WAC 182-500-0010 coverage. A person described in this section is not eligible for medically needy WAH.
4. Other coverage options for adults not eligible under this section are described in WAC 182-508-0001.

WAC 182-505-0115 Washington apple health -- Eligibility for pregnancy and after-pregnancy coverage.

Effective June 24, 2022.

1. A pregnant person is eligible for Washington apple health pregnancy coverage if the person:
   1. Meets citizenship or immigration status under WAC 182-503-0535;
   2. Meets Social Security number requirements under WAC 182-503-0115;
   3. Meets Washington state residency requirements under WAC 182-503-0520 and 182-503-0525; and
   4. Has countable income at or below the limit described in:
      1. WAC 182-505-0100 to be eligible for categorically needy (CN) coverage; or
      2. WAC 182-505-0100 to be eligible for medically needy (MN) coverage. MN coverage begins when the pregnant person meets any required spenddown liability as described in WAC 182-519-0110.
2. A noncitizen pregnant person who does not meet the requirements in subsection (1)(a) or (b) of this section is eligible for apple health pregnancy coverage if they meet countable income standards for CN or MN coverage as described in subsection (1)(d) of this section.
3. The assignment of medical support rights as described in WAC 182-503-0540 does not apply to pregnant people.
4. A person who was eligible for and covered under any CN or MN scope of coverage apple health program on the last day of pregnancy remains continuously eligible for after-pregnancy coverage for 12 months, beginning the month after their pregnancy ends. This includes people who meet an MN spenddown liability with expenses incurred no later than the date the pregnancy ends.
5. Pregnancy coverage has CN scope of care for all people except those enrolled through the MN program who have MN scope of care. A person's after-pregnancy coverage has the same scope of coverage as their pregnancy coverage.
6. A person who does not meet the requirements in subsection (4) of this section may qualify for after-pregnancy coverage if they:
   1. Apply for and meet all requirements of the apple health pregnancy coverage program other than pregnancy; and
   2. Apply any time during their 12-month postpartum period to receive ongoing medical coverage until the end of the 12th month after their pregnancy ends.

WAC 182-505-0117 Washington apple health -- Eligibility for pregnant minors.

Effective June 24, 2022.

1. For the purposes of this rule, "minor" means a person under the age of 19.
2. A pregnant minor who meets Washington state residency requirements under WAC 182-503-0520 and 182-503-0525 is eligible for the Washington apple health for kids program.
3. The medical assistance unit (MAU) of a pregnant minor is the pregnant minor.
4. There are no income standards and no resource tests for a pregnant minor to be eligible for apple health for kids.
5. To ensure reimbursement from the U.S. Department of Health and Human Services, every pregnant minor applicant for apple health for kids must provide their Social Security number, unless they are exempt under WAC 182-503-0515, and must provide their citizenship or immigration status. The immigration status of a pregnant minor who is an undocumented alien (see WAC 182-503-0530) will not be disclosed to any third party.
6. The assignment of rights as described in WAC 182-503-0540 does not apply to pregnant minors.
7. A pregnant minor covered by the apple health for kids program has a one-year certification period. If a minor has their 19th birthday during their pregnancy, they are automatically enrolled in apple health for pregnancy coverage through the end of the month their pregnancy ends. They are eligible for after-pregnancy coverage for 12 months, beginning the first day of the month after their pregnancy ends.

WAC 182-505-0120 Washington apple health breast and cervical cancer treatment program for women--Client eligibility.

Effective September 14, 2015

1. Effective April 1, 2014, a woman is eligible for categorically needy (CN) coverage under the Washington apple health (WAH) breast and cervical cancer treatment program (BCCTP) only when she:
   1. Has been screened for breast or cervical cancer under the department of health's breast, cervical, and colon health program (BCCHP);
   2. Requires treatment for breast cancer, cervical cancer, or a related precancerous condition;
   3. Is under sixty-five years of age;
   4. Is not eligible for other WAH-CN coverage, including coverage under the MAGI-based adult group;
   5. Is uninsured or does not otherwise have creditable coverage;
   6. Meets residency requirements under WAC 182-503-0520;
   7. Meets Social Security number requirements under WAC 182-503-0515;
   8. Is a U.S. citizen, U.S. national, qualifying American Indian born abroad, or qualified alien under WAC 182-503-0535; and
   9. Meets the income standard set by the BCCHP in DOH form 342-031.
2. The certification period for breast and cervical cancer treatment covered under this section is twelve months, as provided in WAC 182-504-0015. To remain continuously enrolled, the client must renew her eligibility before the certification period ends. Eligibility for BCCTP coverage under subsection (1)(b) of this section continues throughout the course of treatment as certified by the BCCHP. Retroactive coverage may be available under WAC 182-504-0005.

WAC 182-505-0210 Eligibility for children.

Effective December 8, 2023.

1. General eligibility. For purposes of this section, a child must:
   1. Be a Washington state resident under WAC 182-503-0520 and 182-503-0525;
   2. Provide a Social Security number under WAC 182-503-0515, unless exempt; and
   3. Meet program-specific requirements.
2. Deemed eligibility groups. A child is automatically eligible for coverage without an application if the child meets the program-specific requirements in (a) through (c) of this subsection.
   1. Newborn coverage. A child under age one is eligible for categorically needy (CN) coverage if the birth parent was eligible for Washington apple health on the date of delivery:
      1. Including a retroactive eligibility determination; or
      2. By meeting a medically needy (MN) spenddown liability with expenses incurred by the date of the newborn's birth:
   2. Washington apple health for supplemental security income (SSI) recipients. A child who is eligible for SSI is automatically eligible for CN coverage under WAC 182-510-0001.
   3. Foster care coverage. A child age 20 and younger is eligible for CN coverage under WAC 182-505-0211 when the child is in foster care or receives subsidized adoption services. For children who age out of the foster care program, see WAC 182-505-0211(3).
3. Continuous eligibility for children under age six. Children are eligible for Washington apple health continuous eligibility for children under age six when they:
   1. Have household income at or below 215 percent of the federal poverty level at the time of application; or
   2. Received coverage under subsection (5) of this section and are no longer eligible for deemed coverage under subsection (5) (b) or (c) of this section.
4. MAGI-based eligibility groups. A child age 18 and younger is eligible for CN coverage based on modified adjusted gross income (MAGI):
   1. At no cost when the child's countable income does not exceed the standard in WAC 182-505-0100 (6)(a);
   2. With payment of a premium when the child's countable income does not exceed the standard in WAC 182-505-0100 (6)(b), and the child meets additional eligibility criteria in WAC 182-505-0215;
   3. Under chapter 182-514 WAC, if the child needs long-term care services because the child resides or is expected to reside in an institution, as defined in WAC 182-500-0050, for 30 days or longer. An institutionalized child is eligible for coverage under the medically needy program if income exceeds the CN income standard for a person in an institution (special income level);
   4. Under WAC 182-505-0117, if a child is pregnant;
   5. When the child has household income at or below 215 percent of the federal poverty level at the time of application and is eligible for Washington apple health continuous eligibility for children under age six.
5. Non-MAGI-based children's programs. The agency determines eligibility for the:
   1. Medically needy (MN) program according to WAC 182-510-0001(6) and 182-519-0100. A child age 18 and younger is eligible if the child:
      1. Is not eligible for MAGI-based coverage under subsection (3) of this section;
      2. Meets citizenship or immigration requirements under WAC 182-503-0535 (2)(a), (b), (c), or (d); and
      3. Meets any spenddown liability required under WAC 182-519-0110.
   2. SSI-related program. A child age 18 and younger is eligible for CN or MN SSI-related coverage if the child meets:
      1. SSI-related eligibility under chapter 182-512 WAC;
      2. Citizenship or immigration requirements under WAC 182-503-0535 (2)(a), (b), (c), or (d); and
      3. Any MN spenddown liability under WAC 182-519-0110.
   3. SSI-related long-term care program.
      1. A child age 18 and younger is eligible for home and community based (HCB) waiver programs under chapter 182-515 WAC if the child meets:
         1. SSI-related eligibility under chapter 182-512 WAC;
         2. Citizenship or immigration requirements under WAC 182-503-0535 (2)(a), (b), (c), or (d); and
         3. Program-specific age and functional requirements under chapters 388-106 and 388-845 WAC.
      2. A child age 18 and younger who resides or is expected to reside in a medical institution as defined in WAC 182-500-0050 is eligible for institutional medical under chapter 182-513 WAC if the child meets:
         1. Citizenship or immigration requirements under WAC 182-503-0535 (2)(a), (b), (c), or (d);
         2. Blindness or disability criteria under WAC 182-512-0050; and
         3. Nursing facility level of care under chapter 388-106 WAC.
6. Alien emergency medical program. A child age 20 and younger who does not meet the eligibility requirements for a program described under subsections (2) through (5) of this section is eligible for the alien emergency medical (AEM) program if the child meets:
   1. The eligibility requirements of WAC 182-507-0110; and
   2. MN spenddown liability, if any, under WAC 182-519-0110.
7. Other provisions.
   1. A child residing in an institution for mental disease (IMD) as defined in WAC 182-500-0050(1) is not eligible for inpatient hospital services, unless the child is unconditionally discharged from the IMD before receiving the services.
   2. A child incarcerated in a public institution as defined in WAC 182-500-0050(4) is only eligible for inpatient hospital services.

WAC 182-505-0215 Children's Washington apple health with premiums.

Effective January 23, 2021.

1. A child is eligible for Washington apple health with premiums if the child:
   1. Meets the requirements in WAC 182-505-0210(1);
   2. Has countable income below the standard in WAC 182-505-0100 (6)(b); and
   3. Pays the required premium under WAC 182-505-0225, unless the child is exempt under WAC 182-505-0225 (2)(c).
2. A child is not eligible for Washington apple health with premiums if the child:
   1. Is eligible for no-cost Washington apple health;
   2. Has creditable health insurance coverage as defined in WAC 182-500-0020.
3. A child with creditable health insurance coverage may be eligible for Washington apple health with premiums if the child is eligible for either:
   1. Public employees benefits board (PEBB) health insurance coverage based on a family member's employment with a Washington state agency, or a Washington state university, community college, or technical college; or
   2. School employees benefits board (SEBB) health insurance coverage based on a family member's employment with a Washington school district, charter school, or educational service district; and
   3. Meets the requirements in WAC 182-505-0210 (1).

WAC 182-505-0225 Children's Washington apple health with premiums - Calculation and determination of premium amount.

Effective October 25, 2024.

1. For the purposes of this chapter, "premium" means an amount paid for health care coverage under WAC 182-505-0215.
2. Premium requirement. The Washington apple health premium-based program under WAC 182-505-0215 requires payment of a monthly premium.
   1. The first monthly premium is due in the month following the determination of eligibility.
   2. There is no premium requirement for health care coverage received in the month eligibility is determined or in any prior month.
   3. A child who is American Indian or Alaska native is exempt from the monthly premium requirement.
3. Monthly premium amount.
   1. The premium amount for the medical assistance unit (MAU) is based on countable income under chapter 182-509 WAC and the number of people in the MAU under chapter 182-506 WAC.
   2. The premium amount is as follows:
      1. If the MAU's countable income exceeds 210 percent of the federal poverty level (FPL) but does not exceed 260 percent of the FPL, the monthly premium for each child is $20.
      2. If the MAU's countable income exceeds 260 percent of the FPL but does not exceed 312 percent of the FPL, the monthly premium for each child is $30.
      3. The medicaid agency charges a monthly premium for no more than two children per household.
      4. Payment of the full premium is required. Partial payments cannot be designated for a specific child or month.
      5. Any third party may pay the premium on behalf of the household. Failure of a third party to pay the premium does not eliminate the obligation of the household to pay past due premiums.
   3. A change that affects the premium amount takes effect the month after the change is reported.
4. Nonpayment of premiums.
   1. The agency writes off past-due premiums after 12 months.

WAC 182-519-0050 Monthly income and countable resource standards for medically needy (MN).

Effective February 10, 2023

1. Changes to the Medically Needy Income Level (MNIL) occur on January 1st of each calendar year when the Social Security Administration (SSA) issues a cost-of-living adjustment.
2. Medically Needy (MN) standards for people who meet institutional status requirements are in WAC 182-513-1395. The standard for a client who lives in an alternate living facility is in WAC 182-513-1205.
3. The resource standards for institutional programs are in WAC 182-513-1350. The institutional standard chart is found at Long Term Care Standards.
4. Countable resource standards for the noninstitutional MN program are:
   1. One person $2,000.
   2. A legally married couple $3,000.
   3. For each additional family member add $50.
5. People who do not meet institutional status requirements use the "effective" MNIL income standard to determine eligibility for the MN program. The "effective" MNIL is the one-person federal benefit rate (FBR) established by SSA each year, or the MNIL listed in the chart below, whichever amount is higher. The FBR is the supplemental security income (SSI) payment standard. For example, in 2023 the FBR is $914.

WAC 182-519-0100 Eligibility for the medically needy program

Effective January 27, 2019

1. A person who meets the following conditions may be eligible for medically needy (MN) coverage under the special rules in chapters 182-513 and 182-515 WAC:
   1. Meets the institutional status requirements of WAC 182-513-1320;
   2. Resides in a medical institution as described in WAC 182-513-1395.
2. A supplemental security income (SSI)-related person who lives in a medicaid agency-contracted alternate living facility may be eligible for MN coverage under WAC 182-513-1205.
3. A person may be eligible for MN coverage under this chapter when he or she is:
   1. Not covered under subsection (1) and (2) of this section; and
   2. Eligible for categorically needy (CN) medical coverage in all other respects, except that his or her CN countable income is above the CN income standard.
4. MN coverage may be available if the person is:
   1. A child;
   2. A pregnant woman;
   3. A refugee;
   4. An SSI-related person, including an aged, blind, or disabled person, with countable income under the CN income standard, who is an ineligible spouse of an SSI recipient; or
   5. A hospice client with countable income above the special income level (SIL).
5. A person who is not eligible for CN medical who applies for MN coverage has the right to income deductions in addition to, or instead of, those used to calculate CN countable income. These deductions to income are applied to each month of the base period to calculate MN countable income:
   1. The agency disregards the difference between the medically needy income level (MNIL) described in WAC 182-519-0050 and the federal benefit rate (FBR) established by the Social Security Administration each year. The FBR is the one-person SSI payment standard;
   2. All health insurance premiums, except for medicare Part A through Part D premiums, expected to be paid by the person or family member during the base period or periods;
   3. Any allocations to a spouse or to dependents for an SSI-related person who is married or who has dependent children. Rules for allocating income are described in WAC 182-512-0900 through 182-512-0960;
   4. For an SSI-related person who is married and lives in the same home as his or her spouse who receives home and community-based waiver services under chapter 182-515 WAC, an income deduction equal to the MNIL, minus the nonapplying spouse's income; and
   5. A child or pregnant woman applying for MN coverage is eligible for income deductions allowed under temporary assistance for needy families (TANF) and state family assistance (SFA) rules and not under the rules for CN programs based on the federal poverty level. See WAC 182-509-0001(4) for exceptions to the TANF and SFA rules that apply to medical programs and not to the cash assistance program.
6. The MNIL for a person who qualifies for MN coverage under subsection (1) of this section is based on rules in chapters 182-513 and 182-515 WAC.
7. The MNIL for all other people is described in WAC 182-519-0050. If a person has countable income at or below the MNIL, the person is certified as eligible for up to 12 months of MN medical coverage.
8. If a person has countable income over the MNIL, the countable income that exceeds the agency's MNIL standards is called "excess income."
9. A person with "excess income" is not eligible for MN coverage until the person gives the agency or its designee evidence of medical expenses incurred by that person, their spouse, or family members living in the home for whom they are financially responsible. See WAC 182-519-0110(8). An expense is incurred when:
   1. The person receives medical treatment or medical supplies, is financially liable for the medical expense, and has not paid the bill; or
   2. The person pays for the expense within the current or retroactive base period under WAC 182-519-0110.
10. Incurred medical expenses or obligations may be used to offset any portion of countable income that is over the MNIL. This is the process of meeting "spenddown."
11. The agency or its designee calculates the amount of a person's spenddown by multiplying the monthly excess income amount by the number of months in the certification period under WAC 182-519-0110. The qualifying medical expenses must be greater than or equal to the total calculated spenddown amount.
12. A person who is considered for MN coverage under this chapter may not spenddown excess resources to become eligible for the MN program. Under this chapter, a person is ineligible for MN coverage if the person's resources exceed the program standard in WAC 182-519-0050. A person who is considered for MN coverage under WAC 182-513-1395, 182-514-0250 or 182-514-0263 is allowed to spenddown excess resources.
13. There is no automatic redetermination process for MN coverage. A person must apply for each eligibility period under the MN program.
14. A person who requests a timely administrative hearing under WAC 182-518-0025 is not eligible for continued benefits beyond the end of the original certification date under the MN program.

WAC 182-519-0110 Spenddown of excess income for the medically needy program

Effective January 27, 2019

1. A person who applies for Washington apple health (WAH) and is eligible for medically needy (MN) coverage with a spenddown may choose a three-month or a six-month base period. A base period is a time period used to compute the spenddown liability amount. The months must be consecutive calendar months, unless a condition in subsection (4) of this section applies.
2. A base period begins on the first day of the month a person applies for WAH, unless a condition in subsection (4) of this section applies.
3. A person may request a separate base period to cover up to three calendar months immediately before the month of application. This is called a retroactive base period.
4. A base period may vary from the terms in subsections (1), (2), or (3) of this section if:
   1. A three-month base period would overlap a previous eligibility period;
   2. The person has countable resources over the applicable standard for any part of the required base period;
   3. The person is not or will not be able to meet the temporary assistance to needy families (TANF)-related or supplemental security income (SSI)-related requirement for the required base period;
   4. The person is eligible for categorically needy (CN) coverage for part of the required base period; or
   5. The person was not otherwise eligible for MN coverage for each month of the retroactive base period.
5. The medicaid agency or its designee calculates a person's spenddown liability. The MN countable income from each month of the base period is compared to the effective medically needy income level (MNIL) under WAC 182-519-0050. Income over the effective MNIL standard (based on the person's household size) in each month in the base period is added together to determine the total spenddown amount.
6. If household income varies and a person's MN countable income falls below the effective MNIL for one or more months, the difference offsets the excess income in other months of the base period. See WAC 182-519-0100(7) if a spenddown amount results in zero dollars and cents.
7. If a person's income decreases, the agency or its designee approves CN coverage for each month in the base period when the person's countable income and resources are equal to or below the applicable CN standards. Children age eighteen and younger and pregnant women who become CN eligible in any month of the base period are continuously eligible for CN coverage for the remainder of the certification, even if there is a subsequent increase in income.
8. Once a person's spenddown amount is determined, qualifying medical expenses are deducted. A qualifying medical expense must:
   1. Be an expense for which the person is financially liable;
   2. Not have been used to meet another spenddown;
   3. Not be the confirmed responsibility of a third party. The agency or its designee allows the entire expense if a third party has not confirmed its coverage of the expense within:
      1. Forty-five days of the date of service; or
      2. Thirty days after the base period ends.
   4. Be an incurred expense for the person:
      1. The person's spouse;
      2. A family member residing in the person's home for whom the person is financially responsible; or
      3. A relative residing in the person's home who is financially responsible for the person.
   5. Meet one of the following conditions:
      1. Be an unpaid liability at the beginning of the base period;
      2. Be for paid or unpaid medical services incurred during the base period;
      3. Be for medical services incurred and paid during the three-month retroactive base period if eligibility for WAH was not established in that base period. Paid expenses that meet this requirement may be applied towards the current base period; or
      4. Be for medical services incurred during a previous base period, either unpaid or paid, if it was necessary for the person to make a payment due to delays in the certification for that base period.
9. An exception to subsection (8) of this section exists for qualifying medical expenses paid on the person's behalf by a publicly administered program during the current or the retroactive base period. The agency or its designee uses the qualifying medical expenses to meet the spenddown liability. To qualify for this exception, the program must:
   1. Not be federally funded or make payments from federally matched funds;
   2. Not pay the expenses before the first day of the retroactive base period; and
   3. Provide proof of the expenses paid on the person's behalf.
10. Once the agency or its designee determines the expenses are a qualified medical expense under subsection (8) or (9) of this section, the expenses are subtracted from the spenddown liability to determine the date the person's eligibility for medical coverage begins. Qualifying medical expenses are deducted in the following order:
    1. First, medicare and other health insurance deductibles, coinsurance charges, enrollment fees, copayments, and premiums that are the person's responsibility under medicare Part A through Part D. (Health insurance premiums are income deductions under WAC 182-519-0100(5));
    2. Second, medical expenses incurred and paid by the person during the three-month retroactive base period if eligibility for WAH was not established in that base period;
    3. Third, current payments on, or unpaid balance of, medical expenses incurred before the current base period that were not used to establish eligibility for medical coverage in another base period. The agency or its designee sets no limit on the age of an unpaid expense; however, the expense must be a current liability and be unpaid at the beginning of the base period;
    4. Fourth, other medical expenses that are not covered by the agency's or its designee's medical programs, minus any third-party payments that apply to the charges. A licensed health care provider must provide or prescribe the items or services allowed as a medical expense;
    5. Fifth, other medical expenses incurred by the person during the base period that are potentially payable by the MN program (minus any confirmed third-party payments that apply to the charges). This deduction is allowed even if payment is denied for these services because they exceed the agency's or its designee's limits on amount, duration, or scope of care. Scope of care is described in WAC 182-501-0060 and 182-501-0065; and
    6. Sixth, other medical expenses incurred by the person during the base period that are potentially payable by the MN program (minus any confirmed third-party payments that apply to the charges) and that are within the agency's or its designee's limits on amount, duration, or scope of care.
11. If a person submits verification of qualifying medical expenses with his or her application that meet or exceed the spenddown liability, the person is eligible for MN medical coverage for the remainder of the base period unless their circumstances change. See WAC 182-504-0105 to determine which changes must be reported to the agency or its designee. The beginning of eligibility is determined under WAC 182-504-0020.
12. If a person cannot meet the spenddown amount when the application is submitted, the person is not eligible until he or she provides proof of additional qualifying expenses that meet the spenddown liability.
13. Each dollar of a qualifying medical expense may count once against a spenddown period that leads to eligibility for MN coverage. However, medical expenses may be used more than once if:
    1. The person did not meet his or her total spenddown liability and become eligible in a previous base period and the bill remains unpaid; or
    2. The medical expense was incurred and paid within three months of the current application, and the agency or its designee could not establish WAH eligibility for the person in the retroactive base period.
14. The person must provide the proof of qualifying medical expense information to the agency or its designee within thirty days after the base period ends, unless there is a good reason for delay.
15. Once a person meets the spenddown requirement and the certification begin date is established, newly identified expenses are not considered toward that spenddown unless:
    1. There is a good reason for the delay in submitting the expense; or
    2. The agency or its designee made an error when determining the correct begin date.
16. Good reasons for delay in providing medical expense information to the agency or its designee include, but are not limited to:
    1. The person did not receive a timely bill from his or her medical provider or insurance company;
    2. The person has medical issues that prevent him or her from submitting proof on time; or
    3. The person meets the criteria for needing equal access under chapter WAC 182-503-0120.
17. The agency or its designee does not pay for any expense or portion of an expense used to meet a person's spenddown liability.
18. If an expense is potentially payable under the MN program, and only a portion of the medical expense is assigned to meet spenddown, the medical provider must not:
    1. Bill the person for more than the amount assigned to the remaining spenddown liability; or
    2. Accept or retain any additional amount for the covered service from the person. Any additional amount may be billed to the agency or its designee. See WAC 182-502-0160, Billing a client.
19. The agency or its designee determines whether any payment is due to the medical provider on medical expenses partially assigned to meet a spenddown liability under WAC 182-502-0100.
20. If the medical expense assigned to spenddown was incurred outside of a period of MN eligibility, or if the expense is not covered by WAH, the agency or its designee does not pay any portion of the bill.

WAC 182-517-0100 Federal medicare savings programs.

Effective April 1, 2024

1. Available programs. The medicaid agency offers eligible clients the following medicare savings programs (MSPs):
   1. The qualified medicare beneficiary (QMB) program;
   2. The specified low-income medicare beneficiary (SLMB) program;
   3. The qualified individual (QI-1) program; and
   4. The qualified disabled and working individuals (QDWI) program.
2. Eligibility requirements.
   1. To be eligible for an MSP, a client must:
      1. Be entitled to medicare Part A; and
      2. Meet the general eligibility requirements under WAC 182-503-0505.
   2. To be eligible for QDWI, a client must be under age 65.
   3. Income limits.
      1. Income limits for all MSPs are found at www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/program-standard-income-and-resources.
      2. If a client's countable income is less than or equal to 110 percent of the federal poverty level (FPL), the client is income eligible for the QMB program.
      3. If a client's countable income is over 100 percent of the FPL, but does not exceed 120 percent of the FPL, the client is income eligible for the SLMB program.
      4. If a client's countable income is over 120 percent of the FPL, but does not exceed 138 percent of the FPL, the client is income eligible for the QI-1 program.
      5. If a client's countable income is over 138 percent of the FPL, but does not exceed 200 percent of the FPL, the client is income eligible for the QDWI program if the client is employed and meets disability requirements described in WAC 182-512-0050.
   4. The federal MSPs do not require a resource test.
3. MSP income eligibility determinations.
   1. The agency has two methods for determining if a client is eligible for an MSP:
      1. The agency first determines if the client is eligible based on SSI-rated methodologies under chapter 182-512 WAC. Under this method, the agency calculates the household's net countable income and compares the result to the one-person standard. However, if the spouse's income is deemed to the client, or if both spouses are applying, the household's net countable income is compared to the two-person standard.
      2. If the client is not eligible under the methodology described in (a)(i) of this subsection, the agency compares the same countable income, as determined under (a)(i) of this subsection, to the appropriate FPL standard based on family size. The number of individuals that count for family size include:
         1. The client;
         2. The client's spouse who lives with the client;
         3. The client's dependents who live with the client;
         4. The spouse's dependents who live with the spouse, if the spouse lives with the client; and
         5. Any unborn children of the client, or of the spouse if the spouse lives with the client.
   2. Under both eligibility determinations, the agency follows the rules for SSI-related people under chapter 182-512 WAC for determining
      1. Countable income;
      2. Availability of income;
      3. Allowable income deductions and exclusions; and
      4. Deemed income from and allocated income to a nonapplying spouse and dependents.
      5. The agency uses the eligibility determination that provides the client with the highest level of coverage.
         1. If the MSP applicant is eligible for QMB coverage under (a)(i) of this subsection, the agency approves the coverage.
         2. If the MSP applicant is not eligible for QMB coverage, the agency determines if the applicant is eligible under (a)(ii) of this subsection.
         3. If neither eligibility determination results in QMB coverage, the agency uses the same process to determine if the client is eligible under any other MSP.
      6. When calculating income under this section:
         1. The agency subtracts client participation from a long-term care client's countable income under WAC 182-513-1380, 182-515-1509, or 182-515-1514.
         2. The agency counts the annual Social Security cost-of-living increase beginning April 1st each year.
4. Covered costs.
   1. The QMB program pays:
      1. Medicare Part A and Part B premiums using the start date in WAC 182-504-0025; and
      2. Medicare coinsurance, copayments, and deductibles for Part A, Part B, and Part C, subject to the limitations in WAC 182-502-0110.
   2. If the client is eligible for both SLMB and another medicaid program:
      1. The SLMB program pays the Part B premiums using the start date in WAC 182-504-0025; and
      2. The medicaid program pays medicare coinsurance, copayments, and deductibles for Part A, Part B, and Part C subject to the limitations in WAC 182-502-0110.
   3. If the client is only eligible for SLMB, the SLMB program covers medicare Part B premiums using the start date in WAC 182-504-0025.
   4. The QI-1 program pays medicare Part B premiums using the start date in WAC 182-504-0025 until the agency's federal funding allotment is spent. The agency resumes QI-1 benefit payments the beginning of the next calendar year.
   5. The QDWI program covers medicare Part A premiums using the start date in WAC 182-504-0025.
5. MSP eligibility. Medicaid eligibility may affect MSP eligibility:
   1. QMB and SLMB clients may receive medicaid and still be eligible to receive QMB or SLMB benefits.
   2. QI-1 and QDWI clients who begin receiving medicaid are no longer eligible for QI-1 or QDWI benefits, but may be eligible for the state-funded medicare buy-in program under WAC 182-517-0300.
6. Right to request administrative hearing. A person who disagrees with agency action under this section may request an administrative hearing under chapter 182-526 WAC.

WAC 182-517-0300 State-funded medicare buy-in programs.

Effective July 23, 2016

1. A person is eligible for the state-funded medicare buy-in program if the person:
   1. Is entitled to or receiving medicare;
   2. Is not eligible for a federal medicare savings program under WAC 182-517-0100; and
   3. Is eligible for coverage under:
      1. The categorically needy (CN) program; or
      2. The medically needy (MN) program;
2. The SBIP begins the second month after the month a person meets eligibility requirements.
3. The SBIP pays only medicare Part B premiums.
4. The agency pays medicare deductibles and coinsurance under WAC 182-502-0110.
5. A person who disagrees with agency action under this section may request an administrative hearing under chapter 182-526 WAC.

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 182-512-0010 Supplemental security income (SSI) standards, SSI-related categorically needy income level (CNIL), and countable resource standards.

Effective January 27, 2019

1. The SSI payment standards, also known as the federal benefit rate (FBR), change each January 1st.
2. See WAC 388-478-0055 for the amount of the state supplemental payments (SSP) for SSI recipients.
3. See WAC 182-513-1205 for standards of clients living in an alternate living facility.
4. The SSI-related CNIL standards are the same as the SSI payment standards for single persons and couples. Those paying out shelter costs have a higher standard than people who have supplied shelter.
5. The countable resource standards for SSI and SSI-related CN medical programs are:
   1. One person                          $2,000
   2. A legally married couple        $3,000

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.