WAC 182-543-5000 Prosthetics/orthotics.

Effective January 1, 2019

1. The medicaid agency pays for, without prior authorization (PA), the following prosthetics and orthotics. Items that meet the definition of medical equipment may be covered under the requirements for medical equipment. Prosthetics and orthotics that do not meet those definitions are covered, with stated limitations:
   1. Thoracic-hip-knee-ankle orthosis (THKAO) standing frame - One every five years.
   2. Preparatory, above knee "PTB" type socket, nonalignable system, pylon, no cover, SACH foot plaster socket, molded to model - One per lifetime, per limb.
   3. Preparatory, below knee "PTB" type socket, nonalignable system, pylon, no cover, SACH foot thermoplastic or equal, direct formed - One per lifetime, per limb.
   4. Socket replacement, below the knee, molded to patient model - One per twelve-month period, per limb.
   5. Socket replacement, above the knee/knee disarticulation, including attachment plate, molded to patient model - One per twelve-month period, per limb.
   6. All other prosthetics and orthotics are limited to one per twelve-month period per limb.
   7. Prosthetics and orthotics beyond these limits may be prior authorized when medically necessary, as defined in WAC 182-500-0070.
2. The agency pays only licensed prosthetic and orthotic providers to supply prosthetics and orthotics. This licensure requirement does not apply to the following:
   1. Providers who are not required to have specialized skills to provide select orthotics, but meet medical equipment and pharmacy provider licensure requirements;
   2. Occupational therapists providing orthotics who are licensed by the Washington state department of health in occupational therapy; and
   3. Out-of-state providers, who must meet the licensure requirements of that state.
3. The agency pays only for prosthetics or orthotics that are listed as such by the Centers for Medicare and Medicaid Services (CMS), that meet the definition of prosthetic or orthotic in WAC 182-543-1000 and are prescribed under WAC 182-543-1100.
4. The agency pays for repair or modification of a client's current prosthesis. To receive payment, all of the following must be met:
   1. All warranties are expired;
   2. The cost of the repair or modification is less than fifty percent of the cost of a new
      prosthesis and the provider has submitted supporting documentation; and
   3. The repair must have a warranty for a minimum of ninety days.
5. Clients are responsible for routine maintenance of their prosthetic or orthotic. If a client
   does not have the physical or mental ability to perform this task, the client's caregiver is
   responsible for routine maintenance of the prosthetic or orthotic. The agency requires PA for extensive maintenance to a prosthetic or orthotic.

WAC 182-543-2000 Eligible providers and provider requirements.

Effective December 9, 2021

1. The medicaid agency pays qualified providers for medical equipment on a fee-for-service basis as follows:
   1. Providers who are enrolled with medicare for medical equipment and related repair services;
   2. Qualified complex rehabilitation technology (CRT) suppliers who are enrolled with medicare;
   3. Medical equipment dealers and pharmacies who are enrolled with medicare, and have a national provider identifier (NPI) for medical supplies;
   4. Prosthetics and orthotics providers who are licensed by the Washington state department of health in prosthetics and orthotics. Medical equipment dealers and pharmacies that do not require state licensure to provide selected prosthetics and orthotics may be paid for those selected prosthetics and orthotics only as long as the medical equipment dealers and pharmacies meet the medicare enrollment requirement;
   5. Occupational therapists providing orthotics who are licensed by the Washington state department of health in occupational therapy;
   6. Physicians who provide medical equipment in the office; and
   7. Out-of-state prosthetics and orthotics providers who meet their state regulations.
2. Providers and suppliers of medical equipment must:
   1. Meet the general provider requirements in chapter 182-502 WAC;
   2. Have the proper business license and be certified, licensed and bonded if required, to perform the services billed to the agency;
   3. Have a valid prescription for the medical equipment.
      1. To be valid, a prescription must:
         1. Be written on the agency's Prescription Form (HCA 13-794). The agency's electronic forms are available online at: https://www.hca.wa.gov/billers-providers/forms-and-publications;
         2. Be written by an authorized practitioner as defined in WAC 182-551-2010 and meet the face-to-face encounter requirements described in WAC 182-551-2040;
         3. Be written, signed (including the prescriber's credentials), and dated by the prescriber on the same day and before delivery of the medical equipment. Prescriptions must not be back-dated;
         4. Be no older than one year from the date the prescriber signs the prescription; and
         5. State the specific item or service requested, diagnosis, estimated length of need (weeks, months, or years), and quantity.
      2. For dual-eligible clients when medicare is the primary payer and the agency is being billed for only the copay, only the deductible, or both, subsection (2)(a) of this section does not apply.
   4. Provide instructions for use of equipment;
   5. Provide only new equipment to clients, which include full manufacturer and dealer warranties. See WAC 182-543-2250(3);
   6. Provide documentation of proof of delivery, upon agency request (see WAC 182-543-2200); and
   7. Bill the agency using only the allowed procedure codes listed in the agency's published medical equipment billing guide.

WAC 182-560-100 Achieving a Better Life Experience (ABLE) Act.

Effective September 8, 2018

This rule describes a qualified achieving a better life experience (ABLE) account and its effect on the determination of eligibility for Washington apple health coverage.

1. A qualified ABLE account:
   1. Is established and maintained by a state, or its designated agency or entity;
   2. Meets federal requirements under 26 U.S.C. Sec. 529A; and
   3. Is used to save funds for the disability related expenses of the account's designated beneficiary.
2. This section applies to ABLE account beneficiaries who:
   1. Are entitled to benefits based on blindness or disability under Title II or XVI of the Social Security Act; or
   2. Meet the blindness or disability requirements under WAC 182-512-0050 (1)(b) and (c).
3. The disability or blindness described in subsection (2)(a) or (b) of this section must have occurred before age twenty-six.
4. This section does not apply if the total combined annual contributions to an ABLE account exceed the limit under 26 U.S.C Sec. 529A.
5. When determining countable income for apple health programs for the account's designated beneficiary, the medicaid agency or the agency's designee does not:
   1. Count contributions made by a person other then the designated beneficiary to the ABLE account;
   2. Count funds distributed from the account;
   3. Count earnings generated by the account, such as accrued interest or dividends; or
   4. Reduce income used to determine eligibility by the amount of contributions made to the account, including any funds the designated beneficiary may contribute to it.
6. When determining eligibility for apple health programs, the agency or the agency's designee excludes as resources:
   1. The value of an ABLE account, including any earnings generated by the account; and
   2. Subject to subsection (8) of this section, distributions from the account for qualified disability expenses as long as the beneficiary:
      1. Maintains an ABLE account;
      2. Contributes to an ABLE account; or
      3. Receives distributions from such ABLE account.
7. "Qualified disability expense (QDE)" means any expense related to the beneficiary's blindness or disability that is made for the benefit of the beneficiary, including the following expenses:
   1. Education;
   2. Housing;
   3. Transportation;
   4. Employment training and support;
   5. Assistive technology and personal support services;
   6. Health;
   7. Prevention and wellness;
   8. Financial management;
   9. Legal fees;
   10. Expenses for oversight and monitoring; and
   11. Funeral and burial expenses.
8. Distributions under subsection (6)(b) of this section, which are retained into a subsequent calendar month:
   1. Remain excluded as resources as long as the distributions are identifiable and the beneficiary still intends to use the distribution for a QDE;
   2. Are available resources on the first day of a subsequent calendar month if the intent of the beneficiary changes such that the beneficiary will not use the distribution for a QDE; and
   3. Are available resources on the first day of any subsequent month when the distribution is actually used for a non-QDE.
9. The agency or the agency's designee counts as a resource on the first day of the following month any funds distributed for purposes other than paying a QDE expense described in subsection (7) of this section.
10. If the beneficiary has multiple ABLE accounts, the agency or the agency's designee applies this section to the first ABLE account established.
11. Funds remaining in the ABLE account when the beneficiary dies are subject to estate recovery under chapter 182-527 WAC, less any:
    1. Outstanding QDE debts; and
    2. Premium payments made from the ABLE account on behalf of the beneficiary to obtain coverage under the apple health care for workers with disabilities described in WAC 182-511-1000.

WAC 182-505-0100 Monthly income standards for MAGI -based programs.

Effective November 1, 2024.

1. Each year, the federal government publishes new federal poverty level (FPL) income standards in the Federal Register found at https://aspe.hhs.gov/poverty-guidelines.
   1. The income standards for the following Washington apple health programs change on the first day of April every year based on the new FPL, except for subsections (2) and (3) of this section.
   2. The agency determines income eligibility by comparing countable income as determined of the person's medical assistance unit (MAU), under WAC 182-506-0010 and 182-506-0012, to the applicable income standard. Rules for determining countable income are in chapter 182-509 WAC.
2. Parents and caretaker relatives under WAC 182-505-0240 must have countable income equal to or below the following standards:
   

   Medical Assistance Unit Size	1	2	3	4	5	6	7	8	9	10	11+
   Medical Assistance Unit Size	$511	$658	$820	$972	$1,127	$1,284	$1,471	$1,631	$1,792	$1,951	$1,951

3. Parents and caretaker relatives with earned income above the limits in subsection (2) of this section are the only people who may be eligible for the transitional medical program described in WAC 182-523-0100.
4. Adults described in WAC 182-505-0250 who are not eligible under subsection (2) or (3) of this section must have countable income equal to or below 133 percent of the FPL.
5. Pregnant people described in WAC 182-505-0115 must have countable income equal to or below 210 percent of the FPL.
6. Children with countable income:
   1. Equal to or below 210 percent of the FPL as described in WAC 182-505-0210 (3)(a)(i) receive coverage at no cost.
   2. Greater than 210 percent but equal to or less than 312 percent as described in WAC 182-505-0210 receive premium-based coverage. Premium amounts are described in WAC 182-505-0225.

WAC 182-513-1660 Medicaid alternative care (MAC) and tailored supports for older adults (TSOA)—Spousal impoverishment.

Effective February 25, 2023

1. The medicaid agency or the agency's designee determines financial eligibility for medicaid alternative care (MAC) or tailored supports for older adults (TSOA) using spousal impoverishment protections under this section, when an applicant or recipient:
   1. Is married to, or marries a person not in a medical institution; and
   2. Is ineligible for a noninstitutional categorically needy (CN) SSI-related program or the TSOA program due to:
      1. Spousal deeming rules under WAC 182-512-0920 for MAC;
      2. Exceeding the resource limit in WAC 182-512-0010 for MAC, or the limit under WAC 182-513-1640 for TSOA; or
      3. Both (b)(i) and (ii) of this subsection.
2. When a resource test applies, the agency or the agency's designee determines countable resources using the SSI-related resource rules under chapter 182-512 WAC, except pension funds owned by the spousal impoverishment protections community (SIPC) spouse are not excluded as described under WAC 182-512-0550:
   1. Resource standards:
      1. For MAC, the resource standard is $2,000; or
      2. For TSOA, the resource standard is $53,100.
   2. Before determining countable resources used to establish eligibility for the applicant, the agency or the agency's designee allocates the state spousal resource standard to the SIPC spouse.
   3. The resources of the SIPC spouse are unavailable to the spousal impoverishment protections institutionalized (SIPI) spouse the month after eligibility for MAC or TSOA services is established.
3. The SIPI spouse has until the end of the month of the first regularly scheduled eligibility review to transfer countable resources in excess of $2,000 (for MAC) or $53,100 (for TSOA) to the SIPC spouse.
4. Income eligibility:
   1. For MAC:
      1. The agency or the agency's designee determines countable income using the SSI-related income rules under chapter 182-512 WAC, but uses only the applicant or recipient's income;
      2. If the applicant's or recipient's countable income is at or below the SSI categorically needy income level (CNIL), the applicant or recipient is considered a SIPI spouse and is income eligible for noninstitutional CN coverage and MAC services;
   2. For TSOA, see WAC 182-513-1635.
5. Once a person no longer receives MAC services, eligibility is redetermined without using spousal impoverishment protections under WAC 182-504-0125.
6. If the applicant's separate countable income is above the standards described in subsection (4) of this section, the applicant is not income eligible for MAC or TSOA services.
7. The spousal impoverishment protections described in this section are time-limited for MAC clients and expire on September 30, 2027.
8. Standards described in this chapter are located at www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/program-standard-income-and-resources.

WAC 182-513-1655 Tailored supports for older adults (TSOA) — Renewals.

Effective July 1, 2017

1. A person who receives tailored supports for older adults (TSOA) services must complete a renewal of all eligibility factors for the program at least every twelve months.
2. Forty-five days prior to the end of the certification period, notice is sent with the HCA 18-008 application for TSOA form. Complete the TSOA renewal in any of the following ways:
   1. Complete the TSOA application form, sign it, and mail it to P.O. Box 45826, Olympia, WA 98605 by the due date on the letter;
   2. Complete the TSOA application form, sign it, and fax it to 1-855-635-8305 by the due date on the letter;
   3. Renew online at Washington connection at https://www.washingtonconnection.org by the due date on the letter; or
   4. Call your local home and community services office at the telephone number on the letter by the due date on the letter.
3. During the renewal process, the medicaid agency or the agency's designee reviews all eligibility factors to determine ongoing eligibility for TSOA, and may request additional verification of eligibility factors under WAC 182-503-0050 if unable to verify information through existing data sources. If additional information is needed, the agency or the agency's designee sends written notice under WAC 182-518-0015.
4. If the agency or the agency's designee is unable to complete the renewal or determine eligibility for TSOA beyond the certification period, prior to ending eligibility for TSOA, the agency or the agency's designee sends a written termination notice as described in WAC 182-518-0025.
5. A person who is terminated from TSOA for failure to renew has thirty days from the termination date to submit a completed renewal. If still eligible, TSOA is reopened without a break in eligibility.
6. Equal access services as described in WAC 182-503-0120 are provided for anyone who needs help meeting the requirements of this section.
7. Anyone who disagrees with an action regarding TSOA eligibility may ask for a hearing under chapter 182-526 WAC.

WAC 182-513-1650 Tailored Supports for Older Adults (TSOA) — Changes of Circumstances Requirements.

Effective July 1, 2017

1. Changes in tailored supports for older adults (TSOA) household and family circumstances described in subsection (2) of this section must be reported to the medicaid agency or the agency's designee within thirty days of the date of the change.
2. The following changes must be reported:
   1. A change in residential or mailing address, including if the TSOA recipient moves out-of-state;
   2. When a person admits to an institution, as defined in WAC 182-500-0050, and is likely to reside there for thirty days or longer; or
   3. The person dies.
3. Effective date is the date of the changes.
   1. When TSOA terminates because the recipient dies, the effective date is the date of death.
   2. When TSOA terminates because of one of the following reasons, the effective date is the first day of the month following the advance notice period described in subsection (4) of this section. The TSOA recipient:
      1. Is admitted to an institution as defined in WAC 182-503-0050, and is expected to reside there for thirty days or longer;
      2. Is approved for coverage under a home and community-based waiver program;
      3. No longer meets nursing facility level of care under WAC 388-106-0355; or
      4. Becomes eligible for categorically need (CN) or alternative benefits plan (ABP) apple health coverage. The recipient may continue to receive authorized services through the medical alternative care (MAC) program under WAC 182-513-1600. The person may also apply for other long-term services and supports available under chapters 182-513 and 182-515 WAC.
4. The advance notice period:
   1. Begins on the day the letter about the change is mailed; and
   2. Is determined according to the rules in WAC 182-518-0025.
5. When the law or regulation is the effective date of the change.

WAC 182-513-1645 Tailored supports for older adults (TSOA) — Certification periods.

Effective July 1, 2017

1. A certification period is the period of time a person is determined eligible for the tailored supports for older adults (TSOA) program. It begins on the first day of the month that the medicaid agency or the agency's designee determines the person is eligible for TSOA services, and continues through the last day of the month of the certification period.
2. TSOA is certified for twelve months of continuous coverage regardless of a change in circumstances, unless the person:
   1. Moves out-of-state;
   2. Meets institutional status under WAC 182-513-1320;
   3. Becomes eligible for a categorically needy or alternate benefit plan Washington apple health program; or
   4. Dies.
3. Financial eligibility for the TSOA program may not be approved prior to the date of a presumptive or full eligibility determination.

WAC 182-513-1640 Tailored supports for older adults (TSOA) — Resource eligibility.

Effective October 9, 2023

1. The resource standard for a single applicant for tailored supports for older adults (TSOA) is six times the Washington state average monthly private nursing facility rate, as determined by the department of social and health services under chapter 74.46 RCW.
2. The resource standard for a married couple is six times the Washington state average monthly private nursing facility rate, as determined by the department of social and health services under chapter 74.46 RCW, for the TSOA applicant plus the state spousal resource standard for the spousal impoverishment protections community (SIPC) spouse. The state spousal resource standard may change annually on July 1st.
3. The medicaid agency or the agency's designee uses rules in WAC 182-513-1350 (1), (3) and (4) to determine general eligibility relating to resources, availability of resources, and which resources count.
4. The TSOA recipient has one year from the date of initial eligibility of TSOA to transfer resources in excess of the TSOA standard to the SIPC spouse.
5. The resource standard for TSOA changes annually on January 1st based on the current average private nursing facility rate, as determined by the department of social and health services under chapter 74.46 RCW.
6. The current TSOA standards and the current average private nursing facility rate are found on the Washington apple health income and resource standards chart, institutional standards section; see www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/program-standard-income-and-resources.