WAC 182-513-1440 Determining how many of my assets can be protected.

Effective February 20, 2017

You can protect assets based on the amount paid by your LTC partnership policy. Assets are protected in both LTC eligibility and estate recovery. If the partnership for long-term care program is discontinued, an individual who purchased an approved plan before the date the program is discontinued remains eligible to receive dollar-for-dollar asset disregard and asset protection under the long-term care (LTC) medicaid program.

WAC 182-513-1415 Assets that can't be protected under the LTC partnership provisions.

Effective February 20, 2017

The following assets cannot be protected under a LTC partnership policy.

1. Resources in a trust under WAC 182-516-0100 (6) and (7).
2. Annuity interests in which Washington must be named as a preferred remainder beneficiary as under WAC 182-516-0201.
3. Home equity in excess of the standard under WAC 182-513-1350. Individuals who have excess home equity interest are not eligible for long-term care medicaid services.
4. Any portion of the value of an asset that exceeds the dollar amount paid out by the LTC partnership policy.
5. The unprotected value of any partially protected asset is subject to estate recovery described in chapter 182-527 WAC.

WAC 182-513-1319 State-funded programs for noncitizens who are not eligible for a federally funded program.

Effective February 20, 2017

1. This section describes the state-funded programs available to a person who does not meet the citizenship and immigration status criteria under WAC 182-513-1316 for federally funded coverage.
2. If a person meets the eligibility and incapacity criteria of the medical care services (MCS) program under WAC 182-508-0005, the person may receive nursing facility care or state-funded residential services in an alternate living facility (ALF).
3. Noncitizens age nineteen or older may be eligible for the state-funded long-term care services program under WAC 182-507-0125. A person must be preapproved by the aging and long-term support administration (ALTSA) for this program due to enrollment limits.
4. Noncitizens under age nineteen who meet citizenship and immigration status under WAC 182-503-0535 (2)(e) are eligible for:
   1. Nursing facility services if the person meets nursing facility level of care; or
   2. State-funded personal care services if functionally eligible based on a department assessment under chapter 388-106 or 388-845 WAC.

WAC 182-512-0900 SSI-related medical -- Deeming and allocation of income.

Effective April 14, 2014.

The agency considers income of financially responsible persons to determine if a portion of that income must be regarded as available to other household members.

1. Deeming is the process of determining how much of another person's income is counted when determining Washington apple health (WAH) eligibility of an SSI-related applicant. When income is deemed to the SSI-related applicant from other household members, that income is considered the applicant's income. Income is deemed only:
   1. From a nonapplying spouse who lives with the SSI-related applicant; or
   2. From a parent(s) residing with an SSI-related applicant child.
2. An allocation is an amount deducted from income counted in the eligibility determination and considered to be set aside for the support of a person other than the SSI-related applicant. When income is allocated to other household members from the SSI-related applicant(s) or from the applicant's spouse, that income is not counted as income of the SSI-related applicant.
3. An SSI-related person applying for WAH categorically needy (CN) health care coverage must have countable income at or below the SSI categorically needy income level (CNIL) described in WAC 182-512-0010 unless the person is working and meets all requirements for the health care for workers with disabilities (HWD) program described in WAC 182-511-1000 through 182-511-1250.
4. For WAH institutional or home and community based waiver programs, use rules described in WAC 182-513-1315.
5. The agency follows rules described in WAC 182-512-0600 through 182-512-0880 to determine the countable income of an SSI-related applicant or SSI-related couple.
6. If countable income of the applicant exceeds the one-person SSI CNIL prior to considering the income of a nonapplying spouse or children, the applicant is not eligible for WAH CN health care coverage and the agency determines eligibility for the WAH medically needy (MN) program. If the countable income does not exceed the SSI CNIL, see WAC 182-512-0920 to determine if income is to be deemed to the applicant from the nonapplying spouse.
7. If countable income (after allowable deductions) of an SSI-related couple both applying for medical coverage exceeds the two-person SSI CNIL, the couple is not eligible for WAH CN health care coverage and the agency determines eligibility for the WAH medically needy (MN) program.
8. For WAH CN health care coverage, allocations to children are deducted from the nonapplying spouse's unearned income, then from their earned income before income is deemed to the SSI-related applicant. See WAC 182-512-0820.
9. For MN medical coverage, allocations to children are deducted from the income of the SSI-related applicant or SSI-related applicant couple. See subsection (10) of this section to determine the amount of the allocation.
10. An SSI-related person or couple applying for WAH MN health care coverage is allowed an allocation to a nonapplying spouse, their SSI recipient spouse or their dependent child(ren) to reduce countable income before comparing income to the effective medically needy income level (MNIL) described in WAC 182-519-0050. The agency allocates income:
    1. Up to the effective one-person MNIL to a nonapplying spouse or SSI recipient spouse minus the spouse's countable income; and
    2. Up to one-half of the federal benefit rate (FBR) to each dependent minus each dependent's countable income. See WAC 182-512-0820 for child exclusions.
11. A portion of a nonapplying spouse's income may be deemed to the SSI-related applicant:
    1. See WAC 182-512-0920(5) to determine how much income is deemed from a nonapplying spouse to the SSI-related applicant when determining WAH CN eligibility; and
    2. See WAC 182-512-0920(10) to determine how much income is deemed from a nonapplying spouse to the SSI-related applicant when determining WAH MN eligibility.
12. A portion of the income of an ineligible parent or parents is allocated to the needs of an SSI-related applicant child. See WAC 182-512-0940 (4) through (7) to determine how much income is allocated from ineligible parent(s).
13. When income must be deemed from the sponsor or sponsors of a noncitizen applicant or recipient, see WAC 182-512-0795 to determine the amount that must be counted as income of the noncitizen applicant or recipient.

WAC 182-510-0005 Supplemental security income, essential person, and ineligible spouse.

Effective July 11, 2015

1. If you are a supplemental security income (SSI) recipient, you automatically get categorically needy (CN) coverage (WAC 182-512-0100) unless you:
   1. Refuse to provide private medical insurance information; or
   2. Refuse to assign the right to recover insurance funds to the agency (WAC 182-503-0540).
2. If you are an essential person as described in WAC 182-510-0001 you get CN coverage as long as you continue to live with the SSI recipient.
3. If you are an ineligible spouse you are not considered an SSI recipient. You must have your Washington apple health eligibility determined separately.

WAC 182-512-0300 SSI-related medical -- Resources eligibility.

Effective January 27, 2019

1. At 12:00 a.m. on the first day of the month a client's countable resources must be at or below the resource standard to be eligible for noninstitutional medical benefits for that month. If the total of the client's countable resources is above the resource standard at 12:00 a.m. on the first day of the month, the client is ineligible for noninstitutional medical benefits for that entire month regardless of resource status at the time of application during that month. For resource eligibility relating to long term care eligibility see chapter 182-513 WAC.
2. An excluded resource converted to another excluded resource remains excluded.
3. Cash received from the sale of an excluded resource becomes a countable resource the first of the month following conversion unless the cash is:
   1. Used to replace the excluded resource;
   2. Invested in another excluded resource in the same month or within the longer time allowed for home sales under WAC 182-512-0350; or
   3. Spent.
4. The unspent portion of a nonrecurring lump sum payment is counted as a resource on the first of the month following its receipt with the following exception: the unspent portion of any Title II (SSA) or Title XVI (SSI) retroactive payment is excluded as a resource for nine months following the month of receipt. These exclusions apply to lump sums received by the client, client's spouse or any other person who is financially responsible for the client.
5. Clients applying for SSI related medical coverage for long term care (LTC) services must meet different resource rules. See chapter 182-513 WAC for LTC rules.
6. The transfer of a resource without adequate consideration does not affect medical program eligibility except for LTC services described in chapters 182-513 and 182-515 WAC. In those programs, the transfer may make a client ineligible for medical benefits for a period of time. See WAC 182-513-1363 for LTC rules.

WAC 182-507-0115 Alien emergency medical program (AEM).

Effective February 17, 2023

1. A person nineteen years of age or older who is not pregnant and meets the eligibility criteria under WAC 182-507-0110 is eligible for the alien emergency medical program's scope of covered services described in this section if the person meets the requirements of (a) of this subsection, as well as the requirements of either (b), (c), or (d) of this subsection:
   (a) The medicaid agency determines that the primary condition requiring treatment is an emergency medical condition as defined in WAC 182-500-0030, and the condition is confirmed through review of clinical records; and
   (b) The person's qualifying emergency medical condition is treated in one of the following hospital settings:
   (i) Inpatient;
   (ii) Outpatient surgery;
   (iii) Emergency room services, which must include an evaluation and management (E&M) visit by a physician; or
   (c) Involuntary Treatment Act (ITA) and voluntary inpatient admissions to a hospital psychiatric setting that are authorized by the agency's inpatient mental health designee (see subsection (5) of this section); or
   (d) For the assessment and treatment of the COVID-19 virus, the agency covers one physician visit provided in any outpatient setting, including the office or clinic setting, or via telemedicine, online digital or telephonic services to assess/evaluate and test, if clinically indicated, as follows:
   (i) If the test is positive, in addition to the services described in (b) of this subsection and subsection (2)(b) of this section, any medically necessary services to treat, including:
   (A) Follow-up office visits;
   (B) Medications, prior authorization requirements may apply;
   (C) Respiratory services and supplies; and
   (D) Medical supplies, prior authorization requirements may apply.
   (ii) If a test is negative, any treatment described in (d)(i)(A) through (B) of this subsection, as a precautionary measure for an anticipated positive test result.
   (e) The coverage described in (d) of this subsection is in effect only during the time period, as determined by the agency in its sole discretion, that a public health emergency related to COVID-19 exists.
   (2) If a person meets the criteria in subsection (1) of this section, the agency will cover and pay for all related medically necessary health care services and professional services provided:
   (a) By physicians in their office or in a clinic setting immediately prior to the transfer to the hospital, resulting in a direct admission to the hospital; and
   (b) During the specific emergency room visit, outpatient surgery or inpatient admission. These services include, but are not limited to:
   (i) Medications;
   (ii) Laboratory, x-ray, and other diagnostics and the professional interpretations;
   (iii) Medical equipment and supplies;
   (iv) Anesthesia, surgical, and recovery services;
   (v) Physician consultation, treatment, surgery, or evaluation services;
   (vi) Therapy services;
   (vii) Emergency medical transportation; and
   (viii) Nonemergency ambulance transportation to transfer the person from a hospital to a long term acute care (LTAC) or an inpatient physical medicine and rehabilitation (PM&R) unit, if that admission is prior authorized by the agency or its designee as described in subsection (3) of this section.
   (3) The agency will cover admissions to an LTAC facility or an inpatient PM&R unit if:
   (a) The original admission to the hospital meets the criteria as described in subsection (1) of this section;
   (b) The person is transferred directly to this facility from the community hospital; and
   (c) The admission is prior authorized according to LTAC and PM&R program rules (see WAC 182-550-2590 for LTAC and WAC 182-550-2561 for PM&R).
   (4) The agency does not cover any services, regardless of setting, once the person is discharged from the hospital after being treated for a qualifying emergency medical condition authorized by the agency and its designee under this program. Exceptions:
   (a) For admissions to treat COVID-19 or complications thereof, the agency will cover up to two postdischarge physician follow-up visits, regardless of how the visits are conducted or where they are conducted.
   (b) Pharmacy services, drugs, devices, and drug-related supplies listed in WAC 182-530-2000, prescribed on the same day and associated with the qualifying visit or service (as described in subsection (1) of this section) will be covered for a one-time fill and retrospectively reimbursed according to pharmacy program rules.
   (5) Medical necessity of inpatient psychiatric care in the hospital setting must be determined, and any admission must be authorized by the agency's inpatient mental health designee according to the requirements in WAC 182-550-2600.
   (6) There is no precertification or prior authorization for eligibility under this program. Eligibility for the AEM program does not have to be established before an individual begins receiving emergency treatment.
   (7)Under this program, certification is only valid for the period of time the person is receiving services under the criteria described in subsection (1) of this section. The exception for pharmacy services is also applicable as described in subsection (4) of this section.
   (a) For inpatient care, the period of eligibility is only for the period of time the person is in the hospital, LTAC, or PM&R facility the admission date through the discharge date. Upon discharge the person is no longer eligible for coverage.
   (b) For an outpatient surgery or emergency room services the period of eligibility is only for the date of service. If the person is in the hospital overnight, the eligibility period will be the admission date through the discharge date. Upon release form the hospital, the person is no longer eligible for coverage.
   (8) Under this program, any visit or service not meeting the criteria described in subsection (1) of this section is considered not within the scope of covered services as described in WAC 182-501-0060. This includes, but is not limited to:
   (a) Hospital services, care, surgeries, or inpatient admissions to treat any condition which is not considered by the agency to be a qualifying emergency medical condition, including but not limited to:
   (i) Laboratory, x-ray, or other diagnostic procedures;
   (ii) Physical, occupational, speech therapy, or audiology services;
   (iii) Hospital clinic services; or
   (iv) Emergency room visits, surgery, or hospital admissions.
   (b) Any services provided during a hospital admission or visit (meeting the criteria described in subsection (1) of this section), which are not related to the treatment of the qualifying emergency medical condition;
   (c) Organ transplants, including preevaluations, postoperative care, and antirejection medication;
   (d) Services provided outside the hospital settings described in subsection (1) of this section including, but not limited to:
   (i) Office or clinic-based services rendered by a physician, an ARNP, or any other licensed practitioner;
   (ii) Prenatal care, except labor and delivery;
   (iii) Laboratory, radiology, and any other diagnostic testing;
   (iv) School-based services;
   (v) Personal care services;
   (vi) Physical, respiratory, occupational, and speech therapy services;
   (vii) Waiver services;
   (viii) Nursing facility services;
   (ix) Home health services;
   (x) Hospice services;
   (xi) Vision services;
   (xii) Hearing services;
   (xiii) Dental services;
   (xiv) Durable and non durable medical supplies;
   (xv) Nonemergency medical transportation;
   (xvi) Interpreter services; and
   (xvii) Pharmacy services, except as described in subsection (4) of this section.
   (9) The services listed in subsection (8) of this section are not within the scope of service categories for this program and therefore the exception to rule process is not available.
   (10) Providers must not bill the agency for visits or services that do not meet the qualifying criteria described in this section. The agency will identify and recover payment for claims paid in error.

WAC 182-504-0120 Washington apple health -- Effective dates of changes.

Effective August 29, 2014.

1. We (the agency or its designee) determine the date a change affects your Washington apple health (WAH) coverage based on:
   1. The date you report the change to us;
   2. The date you give us the requested verification; and
   3. The type of WAH you or your family is receiving.
2. When you report a change after you submit your application, but before your application is processed, the change is considered when processing your application.
3. If another person, agency, or data source reports a change in circumstances, the information may be used in determining your eligibility. We will not rely on information received from a person, agency, or data source to terminate your WAH coverage without requesting additional information from you.
4. A change in income affects your ongoing eligibility only if it is expected to continue beyond the month when the change is reported, and only if it is expected to last more than two months.
5. A change that results in termination of your WAH coverage takes effect the first of the month following the advance notice period.
6. The advance notice period:
   1. Begins on the day we send the letter about the change to you; and
   2. Is determined according to the rules in WAC 182-518-0025.
7. A change that results in a decreased scope of care takes effect on the first of the month following the advance notice period. Examples of a decreased scope of care are:
   1. Termination of WAH categorically needy (CN) medical and approval for other WAH coverage with a lesser scope of care such as WAH medically needy (MN) medical;
   2. WAH-MN recipient with a change that increases the spenddown liability amount;
   3. WAH-MN recipient with no spenddown liability with a change that results in WAH-MN with a spenddown liability.
8. A change that results in an increased scope of care takes effect on the first of the month following the date the change was reported, when you provide the required verification:
   1. Within ten days of the date we requested the verification; or
   2. By the end of the month of your change report, whichever is later.

      If you are a WAH-MN applicant with a spenddown liability that has not yet been met and you report a change that results in your becoming eligible for WAH-CN medical or WAH for adults, your change report will be treated as a new application for purposes of retroactive WAH coverage as described in WAC 182-504-0005.

9. If you do not provide the required verification timely under subsection (8) of this section, we make the change effective the first of the month following the month in which you provide the verification. We may terminate your WAH coverage if you do not provide the required verification.
10. When a law or regulation requires a change in WAH, the date specified by the law or regulation is the effective date of the change.
11. When a change in income or allowable expenses is reported timely (within thirty days) and changes the amount you pay towards the cost of your care for institutional programs (residing in a medical institution), we calculate your new participation amount based on:
    1. Either actual income received in a month or allowable deductions incurred in a month, or both; or
    2. An estimate of your monthly or allowable expenses in a prospective period of six months or less, based on both actual income received in a preceding period of six months or less and income expected to be received during the prospective period. At the end of the prospective period or when any significant change occurs, we reconcile this estimate for the period with income received during the same period.
12. When a change in income, or allowable expenses, changes the amount you pay towards the cost of your care for a home and community-based waiver or service, we calculate your new participation amount effective the first of the month following the date the change was reported, except that the new participation amount will be effective the month the change occurs if the change is the loss of an income source that you report within thirty days of the change.
13. We use the following rules to determine the effective date of change for the health care for workers with disabilities (HWD) program:
    1. HWD coverage begins the month after coverage in another medical program ends and the premium amount has been approved by the eligible person; and
    2. If a change in income increases or decreases the monthly premium, the change is effective the first of the month after the change is reported. For more information on premium requirements for this program, see WAC 182-511-1250.

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 182-526-0495 Equitable estoppel.

Effective March 16, 2017

1. Equitable estoppel is a legal doctrine that may be used only as
   1. an affirmative defense to prevent the health care authority (HCA) from collecting an overpayment. Equitable estoppel may not be used to require HCA to continue to provide something or to require HCA to take action contrary to a statute.
2. There are five elements of equitable estoppel. A party asserting the doctrine of equitable estoppel must prove all of the following five elements by clear and convincing evidence:
   1. HCA made a statement or took an action or failed to take an action, which is inconsistent with a later claim or position by HCA.
   2. The party reasonably relied on HCA's original statement, action or failure to act.
   3. The party will be injured to its detriment if HCA is allowed to contradict the original statement, action or failure to act.
   4. Equitable estoppel is needed to prevent a manifest injustice. Factors to be considered in determining whether a manifest injustice would occur include, but are not limited to, whether:
      1. The party cannot afford to repay the money to HCA;
      2. The party gave HCA timely and accurate information when required;
      3. The party did not know that HCA made a mistake;
      4. The party is free from fault; and
      5. The overpayment was caused solely by an HCA mistake.
   5. The exercise of government functions is not impaired.
3. If the administrative law judge (ALJ) concludes that the party has proven all of the elements of equitable estoppel by clear and convincing evidence, HCA is estopped or prevented from taking action or enforcing a claim of overpayment against that party.