WAC 182-513-1205 Determining eligibility for noninstitutional coverage in an alternate living facility (ALF).

Effective February 8, 2020

1. This section describes the eligibility determination for noninstitutional coverage for a client who lives in a agency-contracted alternate living facility (ALF) defined under WAC 182-513-1100.
2. The eligibility criteria for noninstitutional Washington apple health (medicaid) coverage in an ALF follows SSI-related rules under WAC 182-512-0050 through 182-512-0960, with the exception of the higher income standard under subsection (3) of this section.
3. A client is eligible for noninstitutional coverage under the categorically needy (CN) program if the client's monthly income after allowable exclusions under chapter 182-512 WAC:
   1. Does not exceed the special income level (SIL) defined under WAC 182-513-1100; and
   2. Is less than or equal to the client's assessed state rate at a agency-contracted facility. To determine the CN standard: ((y × 31) + $38.84), where "y" is the state daily rate. $38.84 is based on the cash payment standard for a client living in an ALF setting under WAC 388-478-0006.
4. A client is eligible for noninstitutional coverage under the medically needy (MN) program if the client's monthly income after allowable exclusions under chapter 182-512 WAC is less than or equal to the client's private rate at a agency-contracted facility. To determine the MN standard: ((z × 31) + $38.84), where "z" is the facility's private daily rate. To determine MN spenddown liability, see chapter 182-519 WAC.
5. For both CN and MN coverage, a client's countable resources cannot exceed the standard under WAC 182-512-0010.
6. The agency or the agency's designee approves CN noninstitutional coverage for twelve months.
7. The agency or the agency's designee approves MN noninstitutional coverage for a period of months described in WAC 182-504-0020 for an SSI-related client, provided the client satisfies any spenddown liability under chapter 182-519 WAC.
8. Clients who receive medicaid personal care (MPC) or community first choice (CFC) pay all of their income to the ALF except a personal needs allowance under WAC 182-513-1105.
9. A client may have to pay third-party resources as defined under WAC 182-513-1100 in addition to the payment under this subsection.

WAC 182-513-1200 Long-term services and supports authorized under Washington Apple Health programs

Effective February 20, 2017

1. Long-term services and supports (LTSS) programs available to people eligible for noninstitutional Washington apple health coverage who meet the functional requirements.
   1. Noninstitutional apple health coverage in an alternate living facility (ALF) under WAC 182-513-1205.
   2. Community first choice (CFC) under WAC 182-513-1210.
   3. Medicaid personal care (MPC) under WAC 182-513-1225.
   4. For people who do not meet institutional status under WAC 182-513-1320, skilled nursing or rehabilitation is available under the CN, medically needy (MN) or alternative benefits plan (ABP) scope of care if enrolled into a managed care plan.
2. Non-HCB waiver LTSS programs that use institutional rules under WAC 182-513-1315 and 182-513-1380 or HCB waiver rules under chapter 182-515 WAC, depending on the person's living arrangement:
   1. Program of all-inclusive care for the elderly (PACE) under WAC 182-513-1230.
   2. Roads to community living (RCL) under WAC 182-513-1235.
   3. Hospice under WAC 182-513-1240.

WAC 182-513-1100 Definitions related to long-term services and supports (LTSS)

Revised March 1, 2025

This section defines the meaning of certain terms used in chapters 182-513 and 182-515 WAC. Within these chapters, institutional, home and community-based services (HCB) waiver, program of all-inclusive care for the elderly (PACE), and hospice in a medical institution are referred to collectively as long-term care (LTC). Long-term services and supports (LTSS) is a broader definition which includes institutional, HCB waiver, and other services such as medicaid personal care (MPC), community first choice (CFC), PACE, and hospice in the community.

• See chapter 182-516 WAC for definitions related to trusts, annuities, life estates, and promissory notes.
• See chapter 388-106 WAC for long-term care services definitions.
• See WAC 182-513-1405 for long-term care partnership definitions.
• See chapter 182-500 WAC for additional definitions.

"Adequate consideration" means that the fair market value (FMV) of the property or services received, in exchange for transferred property, approximates the FMV of the property transferred.

"Administrative costs" or "costs" means necessary costs paid by the guardian or conservator including attorney fees.

"Aging and long-term support administration (ALTSA)" means the administration within the Washington state department of social and health services (DSHS).

"Alternate living facility (ALF)" is not an institution under WAC 182-500-0050; it is one of the following community residential facilities:

(a) Adult family home (AFH) licensed under chapter 70.128 RCW.

(b) Adult residential care facility (ARC) licensed under chapter 18.20 RCW.

(c) Assisted living facility (AL) licensed under chapter 18.20 RCW.

(d) Behavioral health adult residential treatment facility (RTF) licensed under chapter 246-337 WAC.

(e) Intensive behavioral health treatment facility (IBHTF) is an RTF licensed under chapter 246-337 WAC.

(f) Developmental disabilities administration (DDA) group home (GH) licensed as an adult family home under chapter 70.128 RCW or an assisted living facility under chapter 18.20 RCW.

(g) Enhanced adult residential care facility (EARC) licensed as an assisted living facility under chapter 18.20 RCW.

(h) Enhanced service facility (ESF) licensed under chapter 70.97 RCW.

(i) Facility for children and youth 20 years of age and younger where a state-operated living alternative program, as defined under chapter 71A.10 RCW, is operated.

(j) Group care facility for medically complex children licensed under chapter 74.15 RCW.

(k) Staffed residential facility licensed under chapter 74.15 RCW.

"Assets" means all income and resources of a person and of the person's spouse, including any income or resources which that person or that person's spouse would otherwise currently be entitled to but does not receive because of action:

(a) By that person or that person's spouse;

(b) By another person, including a court or administrative body, with legal authority to act in place of or on behalf of the person or the person's spouse; or

(c) By any other person, including any court or administrative body, acting at the direction or upon the request of the person or the person's spouse.

"Authorization date" means the date payment begins for long-term services and supports (LTSS) under WAC 388-106-0045.

"Clothing and personal incidentals (CPI)" means the cash payment (under WAC 388-478-0090, 388-478-0006, and 388-478-0033) issued by the department for clothing and personal items for people living in an ALF or medical institution.

"Community first choice (CFC)" means a medicaid state plan home and community based service developed under the authority of section 1915(k) of the Social Security Act under chapter 388-106 WAC.

"Community options program entry system (COPES)" means a medicaid home and community-based services (HCBS) waiver program developed under the authority of section 1915(c) of the Social Security Act under chapter 388-106 WAC.

"Community spouse (CS)" means the spouse of an institutionalized spouse.

"Community spouse resource allocation (CSRA)" means the resource amount that may be transferred without penalty from:

(a) The institutionalized spouse (IS) to the community spouse (CS); or

(b) The spousal impoverishment protections institutionalized (SIPI) spouse to the spousal impoverishment protections community (SIPC) spouse.

"Community spouse resource evaluation" means the calculation of the total value of the resources owned by a married couple on the first day of the first month of the institutionalized spouse's most recent continuous period of institutionalization.

"Comprehensive assessment reporting evaluation (CARE) assessment" means the evaluation process defined under chapter 388-106 WAC used by a department designated social services worker or a case manager to determine a person's need for long-term services and supports (LTSS).

"Conservator" has the same meaning given in RCW 11.130.010.

"Conservatorship" means the process outlined in chapter 11.130 RCW for appointing a conservator and a conservator's carrying out of any duties pursuant to an order entered under RCW 11.130.360 through 11.130.575.

"Conservatorship fees" or "fees" means necessary fees charged by a conservator for services rendered on behalf of a client.

"Continuing care contract" means a contract to provide a person, for the duration of that person's life or for a term in excess of one year, shelter along with nursing, medical, health-related, or personal care services, which is conditioned upon the transfer of property, the payment of an entrance fee to the provider of such services, or the payment of periodic charges for the care and services involved.

"Continuing care retirement community" means an entity which provides shelter and services under continuing care contracts with its members and which sponsors or includes a health care facility or a health service.

"Dependent" means a minor child, or one of the following who meets the definition of a tax dependent under WAC 182-500-0105: Adult child, parent, or sibling.

"Developmental disabilities administration (DDA)" means an administration within the Washington state department of social and health services (DSHS).

"Developmental disabilities administration (DDA) home and community-based services (HCBS) waiver" means a medicaid HCB waiver program developed under the authority of section 1915(c) of the Social Security Act under chapter 388-845 WAC authorized by DDA. There are five DDA HCB waivers:

(a) Basic Plus;

(b) Core;

(c) Community protection;

(d) Children's intensive in-home behavioral support (CIIBS); and

(e) Individual and family services (IFS).

"Equity" means the fair market value of real or personal property less any encumbrances (mortgages, liens, or judgments) on the property.

"Fair market value (FMV)" means the price an asset may reasonably be expected to sell for on the open market in an agreement, made by two parties freely and independently of each other, in pursuit of their own self-interest, without pressure or duress, and without some special relationship (arm's length transaction), at the time of transfer or assignment.

"Guardian" has the same meaning given in RCW 11.130.010.

"Guardianship" means the process outlined in chapter 11.130 RCW for appointing a guardian and a guardian's carrying out of any duties pursuant to an order entered under RCW 11.130.265 through 11.130.355.

"Guardianship fees" or "fees" means necessary fees charged by a guardian for services rendered on behalf of a client.

"Home and community-based services (HCBS) waiver programs authorized by home and community services (HCS)" means medicaid HCBS waiver programs developed under the authority of Section 1915(c) of the Social Security Act under chapter 388-106 WAC authorized by HCS. There are three HCS HCBS waivers: Community options program entry system (COPES), new freedom consumer directed services (New Freedom), and residential support waiver (RSW).

"Home and community based services (HCBS)" means LTSS provided in the home or a residential setting to persons assessed by the department.

"Institutional services" means services paid for by Washington apple health, and provided:

(a) In a medical institution;

(b) Through an HCBS waiver; or

(c) Through programs based on HCBS waiver rules for post-eligibility treatment of income under chapter 182-515 WAC.

"Institutionalized individual" means a person who has attained institutional status under WAC 182-513-1320.

"Institutionalized spouse" means a person who, regardless of legal or physical separation:

(a) Has attained institutional status under WAC 182-513-1320; and

(b) Is legally married to a person who is not in a medical institution.

"Life care community" see continuing care community.

"Likely to reside" means the agency or its designee reasonably expects a person will remain in a medical institution for 30 consecutive days. Once made, the determination stands, even if the person does not actually remain in the facility for that length of time.

"Long-term care services" see "Institutional services."

"Long-term services and supports (LTSS)" includes institutional and noninstitutional services authorized by the department.

"Medicaid alternative care (MAC)" is a Washington apple health benefit authorized under Section 1115 of the Social Security Act. It enables the medicaid agency and the agency's designees to deliver an array of person-centered long-term services and supports (LTSS) to unpaid caregivers caring for a medicaid-eligible person who meets nursing facility level of care under WAC 388-106-0355 and 182-513-1605.

"Medicaid personal care (MPC)" means a medicaid state plan home and community based service under chapter 388-106 WAC.

"Most recent continuous period of institutionalization (MRCPI)" means the current period an institutionalized spouse has maintained uninterrupted institutional status when the request for a community spouse resource evaluation is made. Institutional status is determined under WAC 182-513-1320.

"Noninstitutional medicaid" means any apple health program not based on HCB waiver rules under chapter 182-515 WAC, or rules based on a person residing in an institution for 30 days or more under chapter 182-513 WAC.

"Nursing facility level of care (NFLOC)" is described in WAC 388-106-0355.

"Participation" means the amount a person must pay each month toward the cost of long-term care services received each month; it is the amount remaining after the post-eligibility process under WAC 182-513-1380, 182-515-1509, or 182-515-1514. Participation is not room and board.

"Penalty period" or "period of ineligibility" means the period of time during which a person is not eligible to receive services that are subject to transfer of asset penalties.

"Personal needs allowance (PNA)" means an amount set aside from a person's income that is intended for personal needs. The amount a person is allowed to keep as a PNA depends on whether the person lives in a medical institution, ALF, or at home.

"Presumptive eligibility (PE)" for long-term services and supports is described in WAC 182-513-1110.

"Program of all-inclusive care for the elderly (PACE)" provides long-term services and supports (LTSS), medical, mental health, and substance use disorder (SUD) treatment through a department-contracted managed care plan using a personalized plan of care for each enrollee.

"Roads to community living (RCL)" is a demonstration project authorized under Section 6071 of the Deficit Reduction Act of 2005 (P.L. 109-171) and extended through the Patient Protection and Affordable Care Act (P.L. 111-148).

"Room and board" means the amount a person must pay each month for food, shelter, and household maintenance requirements when that person resides in an ALF. Room and board is not participation.

"Short stay" means residing in a medical institution for a period of 29 days or fewer.

"Significant financial duress" means, but is not limited to, threatened loss of, or financial burden from, basic shelter, food, or medically necessary health care. It means that a member of a couple has established to the satisfaction of a hearing officer that the community spouse needs income above the level permitted by the community spouse maintenance standard to provide for medical, remedial, or other support needs of the community spouse to permit the community spouse to remain in the community.

"Special income level (SIL)" means the monthly income standard that is 300 percent of the supplemental security income (SSI) federal benefit rate.

"Spousal impoverishment protections" means the financial provisions within Section 1924 of the Social Security Act that protect income and assets of the community spouse through income and resource allocation. The allocation process is used to discourage the impoverishment of a spouse due to the other spouse's need for LTSS. This includes services provided in a medical institution, HCB waivers authorized under 1915(c) of the Social Security Act, and through September 30, 2027, services authorized under 1115 and 1915(k) of the Social Security Act.

"Spousal impoverishment protections community (SIPC) spouse" means the spouse of a SIPI spouse.

"Spousal impoverishment protections institutionalized (SIPI) spouse" means a legally married person who qualifies for the noninstitutional categorically needy (CN) Washington apple health SSI-related program only because of the spousal impoverishment protections under WAC 182-513-1220.

"State spousal resource standard" means the minimum CSRA standard for a CS or SIPC spouse.

"Tailored supports for older adults (TSOA)" is a federally funded program approved under Section 1115 of the Social Security Act. It enables the medicaid agency and the agency's designees to deliver person-centered long-term services and supports (LTSS).

"Third-party resource (TPR)" means funds paid to or on behalf of a person by a third party, where the purpose of the funds is for payment of activities of daily living, medical services, or personal care. The agency does not pay for these services if there is a third-party resource available.

"Transfer" means, in the context of long-term care eligibility, the changing of ownership or title of an asset, such as income, real property, or personal property, by one of the following: (a) An intentional act that changes ownership or title; or(b) A failure to act that results in a change of ownership or title.

"Uncompensated value" means the fair market value (FMV) of an asset on the date of transfer, minus the FMV of the consideration the person receives in exchange for the asset.

"Undue hardship" means a person is not able to meet shelter, food, clothing, or health needs. A person may apply for an undue hardship waiver based on criteria under WAC 182-513-1367.

WAC 182-512-0960 SSI-related medical -- Allocating income -- Determining eligibility for a spouse when the other spouse receives long-term services and supports.

Effective February 20, 2017.

1. General Information.
   1. This section describes how the agency determines household income and resources when the household contains both institutional and noninstitutional household members.
   2. A separate medical assistance unit is always established for persons who meet institutional status under WAC 182-513-1320. See WAC 182-506-0015 for rules on how to determine medical assistance units for households that include people related to the supplemental security income (SSI) program.
   3. Throughout this section, "home" means "own home" as defined in WAC 388-106-0010.
   4. The income and resources of each spouse are available to the other through the end of the month in which the spouses stopped living together, unless subsection (3) of this section applies.
   5. The agency determines income and resources separately starting the first day of the month following the month of separation if spouses stop living together in the same home.
   6. When one, or both members of a couple live in an alternative living facility (ALF), the agency considers the couple to be living:
      1. Apart when:
         1. Only one spouse enters the ALF;
         2. Both spouses enter the same ALF but have separate rooms; or
         3. Both spouses enter separate ALFs.
      2. Together when both spouses share a room in an ALF.
2. The agency counts income and resources under this chapter when both members of a couple live in the same house and the community spouse or spousal impoverishment protections community (SIPC) spouse applies for coverage and his or her spouse receives:
   1. Home and community-based (HCB) waiver;
   2. Program for all inclusive care to the elderly (PACE);
   3. Roads to community living (RCL);
   4. Hospice; or
   5. Community first choice (CFC).
3. When one member of a couple lives apart from their spouse and the community spouse or SIPC spouse applies for coverage, and the spouse who receives long-term services and supports lives:
   1. In an institution:
      1. The agency counts income under this chapter, plus any allocation the institutionalized spouse has made available to the community spouse; and
      2. The agency counts resources under this chapter, plus any resources allocated to the community spouse when eligibility for the institutionalized spouse was determined, that remain in the name of the institutionalized spouse and are available to the community spouse under WAC 182-512-0250.
   2. In an ALF and receives HCB waiver, PACE, RCL, or hospice:
      1. The agency counts income under this chapter, plus any allocation the institutionalized spouse has made available to the community spouse; and
      2. The agency counts resources under this chapter, plus any resources allocated to the community spouse when eligibility for the institutionalized spouse was determined, that remain in the name of the institutionalized spouse, and are available to the community spouse under WAC 182-512-0250; and
   3. In an ALF and receives CFC:
      1. The agency counts income under this chapter; and
      2. The agency counts resources under this chapter, plus any resources allocated to the SIPC spouse when eligibility for the spousal impoverishment protections institutionalized (SIPI) spouse was determined, that remain in the name of the SIPI spouse and are available to the community spouse under WAC 182-512-0250.
4. Determining household income when the spouse of an HCB waiver recipient is not eligible for categorically needy (CN) coverage.
   1. When the community spouse is not eligible for categorically needy (CN) coverage under subsection (2) of this section, the agency determines eligibility under the medically needy program;
   2. The agency counts income and resources as described under subsection (2) of this section;
   3. The agency allocates income to the institutionalized spouse before comparing the community spouse's income to the medically needy income level (MNIL) if:
      1. The community spouse lives in the same household as the institutionalized spouse;
      2. The institutionalized spouse is receiving home and community-based waiver services under WAC 182-515-1505 or institutional hospice services under WAC 182-513-1240; and
      3. The institutionalized spouse has gross income under the MNIL.
   4. The allocation in (c) of this subsection cannot exceed the one-person effective MNIL minus the institutionalized spouse's income.

WAC 182-512-0940 SSI-related medical -- Deeming income from an ineligible parent(s) to a child applying for SSI-related medical.

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. A portion of the income of a parent(s) is considered available to the SSI-related applicant child when the child is age seventeen or younger and the parent(s) is:
   1. Financially responsible for the SSI-related child as described in WAC 182-506-0015;
   2. The natural, adoptive, or step-parent of the child;
   3. Living in the same household with the child;
   4. Not receiving a needs-based payment such as TANF, SFA or SSI; and
   5. Not related to SSI or not applying for medical assistance.
2. If an SSI-related applicant between the ages of eighteen to twenty-one lives with their parents, only consider the parent's income available to the applicant if it is actually contributed to the applicant. If income is not contributed, count only the applicant's own separate income.
3. Income that is deemed to the child is considered as that child's income.
4. When determining whether a parent's income is countable, the agency:
   1. Follows the income rules described in WAC 182-512-0600 through 182-512-0780; and
   2. Excludes income described in WAC 182-512-0800 and 182-512-0840, and all income excluded under a federal statute or state law as described in WAC 182-512-0860.
5. When determining the amount of income to be deemed from a parent(s) to an SSI-related minor child for Washington apple health (WAH) categorically needy (CN) and medically needy (MN) coverage, the agency reduces the parent(s) countable income in the following order:
   1. Court ordered child support paid out for a child not in the home;
   2. An amount equal to one half of the federal benefit rate (FBR) for each SSI-eligible sibling living in the household, minus any countable income of that child. See WAC 182-512-0010 for FBR amount;
   3. A twenty dollar general income exclusion;
   4. A deduction equal to sixty-five dollars plus one-half of the remainder from any remaining earned income of the parent(s);
   5. An amount equal to the one-person SSI CNIL for a single parent or the two-person SSI CNIL for a two parent household;
   6. Any income remaining after these deductions is considered countable income to the SSI-related child and is added to the child's own income. If there is more than one child applying for SSI-related health care coverage, the deemed parental income is divided equally between the applicant children; and
   7. The deductions described in this section are deducted first from unearned income then from earned income unless they are specific to earned income.
6. The SSI-related applicant child is also allowed all applicable income exclusions and disregards described in chapter 182-512 WAC from their own income. After determining the child's nonexcluded income, the agency:
   1. Allows the twenty dollar general income exclusion from any unearned income;
   2. Deducts sixty-five dollars plus one half of the remainder from any earned income which has not already been excluded under the student earned income exclusion (see WAC 182-512-0820); and
   3. Adds the child's countable income to the amount deemed from their parent(s). If the combination of the child's countable income plus deemed parental income is equal to or less than the SSI CNIL, the child is eligible for SSI-related WAH CN health care coverage.
7. If the combination of the child's countable income plus deemed parental income is greater than the SSI CNIL, the agency considers the child for SSI-related WAH medically needy (MN) coverage. Any amount exceeding the effective medically needy income level (MNIL) is used to calculate the amount of the child's spenddown liability as described in WAC 182-519-0110. See WAC 182-519-0050 for the current MNIL standards.

WAC 182-512-0920 SSI-related medical -- Deeming/allocation of income from nonapplying spouse.

Effective April 1, 2024.

The agency considers the income of financially responsible persons to determine if a portion of that income is available to other household members.

1. A portion of the income of a nonapplying spouse is considered available to meet the needs of a Washington apple health SSI-related applicant. A nonapplying spouse is defined as someone who is:
   1. Financially responsible for the SSI-related applicant as described in WAC 182-506-0015 and 182-512-0960. For apple health institutional and home and community based waiver programs, see WAC 182-513-1315;
   2. Living in the same household with the SSI-related applicant;
   3. Not receiving a needs based payment such as temporary assistance to needy families (TANF) or state-funded cash assistance (SFA); or
   4. Not related to SSI, or is not applying for apple health coverage including spouses receiving SSI.
2. An ineligible spouse is the spouse of an SSI cash recipient and is either not eligible for SSI for themselves or who has elected to not receive SSI cash so that their spouse may be eligible. An SSI-related applicant who is the ineligible spouse of an SSI cash recipient is not eligible for apple health categorically needy (CN) health care coverage and must be considered for health care coverage under the apple health medically needy (MN) program or for a modified adjusted gross income-based program if the person does not receive medicare.
3. When determining whether a nonapplying spouse's income is countable, the agency:
   1. Follows the income rules described in WAC 182-512-0600 through 182-512-0780;
   2. Excludes income described in WAC 182-512-0800 (2) through (10), and all income excluded under federal statute or state law as described in WAC 182-512-0860;
   3. Excludes work-related expenses described in WAC 182-512-0840, with the exception that the $65 plus one half earned income deduction described in WAC 182-512-0840(2) does not apply;
   4. Deducts any court ordered child support which the nonapplying spouse pays for a child outside of the home (current support or arrears); and
   5. Deducts any applicable child-related income exclusions described in WAC 182-512-0820.
4. The agency allocates income of the nonapplying spouse to nonapplying children who reside in the home as described in WAC 182-512-0820. Allocations to children are deducted first from the nonapplying spouse's unearned income, then from their earned income.
   1. For apple health CN medical determinations, allocations to children are not allowed out of the income of the SSI-related applicant, only from the income of the nonapplying spouse.
   2. For apple health MN medical determinations, allocations to children are allowed from the income of the SSI-related applicant if the applicant is unmarried.
5. For apple health SSI-related CN medical determinations, a portion of the countable income of a nonapplying spouse remaining after the deductions and allocations described in subsections (3) and (4) of this section may be deemed to the SSI-related applicant. If the nonapplying spouse's countable income is:
   1. Less than or equal to one-half of the federal benefit rate (FBR), no income is deemed to the applicant. Compare the applicant's countable income to the one-person SSI categorically needy income level (CNIL) described in WAC 182-512-0010.
   2. Greater than one-half of the FBR, then the entire nonapplying spouse's countable income is deemed to the applicant. Compare the applicant's income to the two-person SSI CNIL.
6. When income is not deemed to the SSI-related applicant from the nonapplying spouse per subsection (5)(a) of this section, allow all allowable income deductions and exclusions as described in chapter 182-512 WAC to the SSI-related applicant's income, and compare the net remaining income to the one-person SSI CNIL.
7. When income is deemed to the SSI-related applicant from the nonapplying spouse per subsection (5)(b) of this section:
   1. Combine the applicant's unearned income with any unearned income deemed from the nonapplying spouse and allow one $20 general income exclusion to the combined amount. If there is less than $20 of unearned income, the remainder of the twenty dollar general income exclusion is deducted from earned income.
   2. Combine the applicant's earned income with any earned income deemed from the nonapplying spouse and allow the $65 plus one half of the remainder earned income deduction (described in WAC 182-512-0840(2)) to the combined amount.
   3. Add together the net unearned and net earned income amounts and compare the total to the two-person SSI CNIL described in WAC 182-512-0010. If the income is equal to or below the applicable two-person standard, the applicant is eligible for apple health CN health care coverage.
8. An SSI-related applicant who is working, whose level of work activity and earnings is determined not to be "substantial gainful activity" in accordance with all applicable Social Security disability determination rules and standards, but who is not eligible for apple health CN coverage under the regular apple health SSI-related program, may be considered for eligibility under the HWD program. For HWD program rules, see chapter 182-511 WAC.
9. If the SSI-related applicant's countable income is above the applicable SSI CNIL standard, the agency or its authorized representative considers eligibility under the apple health MN program or under the HWD program if the person is under the age of sixty-five and working. An SSI-related applicant who meets the following criteria is not eligible for apple health MN coverage and eligibility must be determined under HWD or under a MAGI-based apple health program:
   1. The applicant is blind or disabled and, for a MAGI-based apple health program, under the age of 65;
   2. The applicant's level of work activity and earnings is determined to be "substantial gainful activity" in accordance with all applicable Social Security disability determination rules and standards; and
   3. The applicant is not receiving a title II Social Security cash benefit based on blindness or disability.
10. For SSI-related apple health MN medical determinations, a portion of the countable income of a nonapplying spouse remaining after the deductions and allocations described in subsections (3) and (4) of this section may be deemed to the SSI-related applicant. If the nonapplying spouse's countable income is:
    1. Less than or equal to the effective one-person MNIL described in WAC 182-519-0050, no income is deemed to the applicant and a portion of the applicant's countable income is allocated to the nonapplying spouse's income to raise it to the effective MNIL standard.
    2. Greater than the effective MNIL, then the amount in excess of the effective one-person MNIL is deemed to the applicant. Compare the applicant's income to the effective one-person MNIL.
11. When income is not deemed to the SSI-related applicant from the nonapplying spouse per subsection (10)(a) of this section:
    1. Allocate income from the applicant to bring the income of the nonapplying spouse up to the effective one-person MNIL standard;
    2. Allow all allowable income deductions and exclusions as described in chapter 182-512 WAC to the SSI-related applicant's remaining income;
    3. Allow a deduction for medical insurance premium expenses (if applicable); and
    4. Compare the net countable income to the effective one-person MNIL.
12. When income is deemed to the SSI-related applicant from the nonapplying spouse per subsection (10)(b) of this section:
    1. Combine the applicant's unearned income with any unearned income deemed from the nonapplying spouse and allow one $20 general income exclusion to the combined amount (if there is less than $20 of unearned income, the remainder of the twenty dollar general income exclusion is deducted from earned income);
    2. Combine the applicant's earned income with any earned income deemed from the nonapplying spouse and allow the $65 plus one half of the remainder earned income deduction (described in WAC 182-512-0840(2)) to the combined amount;
    3. Add together the net unearned and net earned income amounts;
    4. Allow a deduction for medical insurance premium expenses (if applicable) per WAC 182-519-0100(5); and
    5. Compare the net countable income to the effective one-person MNIL described in WAC 182-519-0050. If the income is:
       1. Equal to or below the effective one-person MNIL, the applicant is eligible for apple health MN health care coverage with no spenddown.
       2. Greater than the effective MNIL, the applicant is only eligible for apple health MN health care coverage after meeting a spenddown liability as described in WAC 182-519-0110.
13. The ineligible spouse of an SSI-cash recipient applying for apple health MN coverage is eligible to receive the deductions and allocations described in subsection (10)(a) of this section.

WAC 182-512-0880 SSI-related medical -- Special income disregards.

Effective April 14, 2014.

Portions of a person's income the agency otherwise counts are disregarded when determining eligibility for Washington apple health (WAH) SSI-related medical programs.

1. The agency disregards cost of living adjustments (COLAs) to Social Security benefits and provides categorically needy (CN) SSI-related medicaid benefits under the Pickle Amendment criteria of 42 C.F.R. 435.135(1)(a) to a person who:
   1. Is currently receiving Title II Social Security benefits;
   2. Was eligible for and received SSI or State Supplement payments (SSP) but became ineligible for those payments after April, 1977; and
   3. Would still be eligible for SSI or SSP payments if the amount of Social Security COLA increases paid under section 215(i) of the Social Security Act were deducted from his or her current Title II Social Security benefits.
   4. To satisfy this provision, a person must have been eligible for and received SSI or SSP payments and in the same month was entitled to, but did not necessarily receive, a Title II Social Security benefit for at least one month since April 1977. This includes a person who receives a Title II Social Security benefit payment the month after the last SSI or SSP payment is made due to the fact that Social Security is paid the month after entitlement begins.
   5. For purposes of this section, the agency also disregards COLAs received by a person, his or her financially responsible spouse, and other financially responsible family members, such as a parent.
2. In determining SSI-related CN-WAH coverage, the agency disregards:
   1. Widow(er)'s benefits for a person who:
      1. Was entitled to SSA title II (widow/widower's) benefits in December 1983;
      2. Was at least fifty years old, but not yet sixty at that time;
      3. Received title II benefits and SSI in January 1984;
      4. Would continue to be eligible for SSI/SSP payments if the title II benefits were disregarded; and
      5. Filed an application for medicaid with the state by July 1, 1988.
   2. Widow, Widower or Surviving Divorced Spouse (title II) benefits for a person who:
      1. Received SSI/SSP benefits the month prior to receipt of title II benefits;
      2. Would continue to be eligible for SSI/SSP benefits if the title II benefits or the COLA(s) to those benefits were disregarded; and
      3. Is not eligible for medicare Part A. This person is considered an SSI recipient until becoming entitled to medicare Part A.
3. A disabled adult child (DAC) who is ineligible for SSI/SSP solely due to receipt of either Social Security benefits as a disabled adult child of a person with a Social Security account or due to receipt of a COLA to the DAC benefits, may be income eligible for WAH categorically needy (CN) health care coverage if disregarding the SSA DAC benefits and COLA brings countable income below the CN standards, and the person:
   1. Is eighteen years of age or older;
   2. Remains related to the SSI program through disability or blindness;
   3. Lost SSI eligibility on or after July 1, 1988, due solely to the receipt of DAC benefits from SSA or a COLA to those benefits; and
   4. Meets the other WAH SSI-related CN medical requirements.
4. A person is eligible for WAH CN coverage if:
   1. In August 1972, the person received:
      1. Old age assistance (OAA);
      2. Aid to blind (AB);
      3. Aid to families with dependent children (AFDC); or
      4. Aid to the permanently and totally disabled (APTD).
   2. The person was entitled to or received retirement, survivors, and disability insurance (RSDI) benefits; or
   3. The person was ineligible for OAA, AB, AFDC, SSI, or APTD solely because of the twenty percent increase in Social Security benefits under P.L. 92-336.
5. Persons who stop receiving an SSI cash payment due to earnings, but still meet all of the other SSI eligibility rules and have income below the higher limit established by the Social Security Act's Section 1619(b) are eligible for continued WAH CN medicaid.
6. TANF income methodology is used to determine countable income for children and pregnant women applying for WAH medically needy (MN) coverage unless the SSI methodology would be more beneficial to the person. When using the TANF income methodologies, deduct:
   1. A fifty percent earned income disregard described in WAC 388-450-0170;
   2. Actual child care and dependent care expenses related to employment; and
   3. Child support actually paid.

WAC 182-512-0860 SSI-related medical -- Income exclusions under federal statute or other state laws.

Effective April 14, 2014.

The Social Security Act and other federal statutes or state laws list income that the agency excludes when determining eligibility for Washington apple health (WAH) SSI-related medical programs. These exclusions include, but are not limited to:

1. Income tax refunds;
2. Federal earned income tax credit (EITC) payments for 12 months after the month of receipt;
3. Compensation provided to volunteers in the Corporation for National and Community Service (CNCS), formerly known as ACTION programs established by the Domestic Volunteer Service Act of 1973. P.L. 93-113;
4. Assistance to a person (other than wages or salaries) under the Older Americans Act of 1965, as amended by section 102 (h)(1) of Pub. L. 95-478 (92 Stat. 1515, 42 U.S.C. 3020a);
5. Federal, state and local government payments including assistance provided in cash or in-kind under any government program that provides medical or social services;
6. Certain cash or in-kind payments a person receives from a governmental or nongovernmental medical or social service agency to pay for medical or social services;
7. Value of food provided through a federal or nonprofit food program such as WIC, donated food program, school lunch program;
8. Assistance based on need, including:
   1. Any federal SSI income or state supplement payment (SSP) based on financial need;
   2. Basic Food;
   3. State-funded cash assistance;
   4. CEAP;
   5. TANF; and
   6. Bureau of Indian Affairs (BIA) general assistance.
9. Housing assistance from a federal program such as HUD if paid under:
   1. United States Housing Act of 1937 (section 1437 et seq. of 42 U.S.C.);
   2. National Housing Act (section 1701 et seq. of 12 U.S.C.);
   3. Section 101 of the Housing and Urban Development Act of 1965 (section 1701s of 12 U.S.C., section 1451 of 42 U.S.C.);
   4. Title V of the Housing Act of 1949 (section 1471 et seq. of 42 U.S.C.);
   5. Section 202(h) of the Housing Act of 1959; or
   6. Weatherization provided to low-income homeowners by programs that consider income in the eligibility determinations.
10. Energy assistance payments including:
    1. Those to prevent fuel cutoffs; and
    2. Those to promote energy efficiency.
11. Income from employment and training programs as specified in WAC 182-512-0780.
12. Foster grandparents program;
13. Title IV-E and state foster care maintenance payments if the foster child is not included in the assistance unit;
14. The value of any childcare provided or arranged (or any payment for such care or reimbursement for costs incurred for such care) under the Child Care and Development Block Grant Act, as amended by section 8(b) of P.L. 102-586 (106 Stat. 5035);
15. Educational assistance as specified in WAC 182-512-0760;
16. The excluded income described in WAC 182-512-0770 and other income received by American Indians/Alaska Natives that is excluded by federal law;
17. Payments from Susan Walker v. Bayer Corporation, et al., 96-c-5024 (N.D. Ill) (May 8, 1997) settlement funds;
18. Payments from Ricky Ray Hemophilia Relief Fund Act of 1998, P.L. 105-369;
19. Disaster assistance paid under Federal Disaster Relief P.L. 100-387 and Emergency Assistance Act, P.L. 93-288 amended by P.L. 100-707 and for farmers P.L. 100-387;
20. Payments to certain survivors of the Holocaust as victims of Nazi persecution; payments excluded pursuant to section 1(a) of the Victims of Nazi Persecution Act of 1994, P.L. 103-286 (108 Stat. 1450);
21. Payments made under section 500 through 506 of the Austrian General Social Insurance Act;
22. Payments made under the Netherlands' Act on Benefits for Victims of Persecution (WUV);
23. Restitution payments and interest earned to Japanese Americans or their survivors, and Aleuts interned during World War II, established by P.L. 100-383;
24. Payments made from the Agent Orange Settlement Funds or any other funds to settle Agent Orange liability claims established by P.L. 101-201;
25. Payments made under section six of the Radiation Exposure Compensation Act established by P.L. 101-426;
26. Any interest or dividend is excluded as income, except for the community spouse of an institutionalized person; and
27. Working families' tax credit payments under RCW 82.08.0206.

WAC 182-512-0840 SSI-related medical -- Work and agency-related income exclusions.

Effective April 14, 2014.

The agency excludes the following when determining eligibility for Washington apple health (WAH) SSI-related medical programs:

1. Work related expenses:
   1. That enable an SSI-related person to work; or
   2. That allows a blind or disabled person to work and that are directly related to the person's impairment.
2. First sixty-five dollars plus one-half of the remainder of earned income. This is considered a work allowance/incentive. This deduction does not apply to income already excluded.
3. Any portion of self-employment income normally allowed as an income deduction by the Internal Revenue Service (IRS).
4. Earned income of a person age twenty-one or younger if that person meets the definition of a student as defined in WAC 182-512-0820.
5. Veteran's aid and attendance, housebound allowance, unusual/unreimbursed medical expenses (UME) paid by the VA to some disabled veterans, their spouses, widows or parents. For people receiving WAH long-term care services, see chapter 182-513 WAC.
6. Department of veterans affairs benefits designated for the veteran's dependent as long as the SSI-related applicant is not the dependent receiving the income. If an SSI-related applicant receives a dependent allowance based on the veteran's or veteran's survivor claim, the income is countable as long as it is not paid due to unusual medical expenses (UME).
7. Payments provided in cash or in-kind, to an ineligible or nonapplying spouse, under any government program that provides social services provided to the person, such as chore services or attendant care.
8. SSA refunds for medicare buy-in premiums paid by the person when the state also paid the premiums.
9. Income that causes a person to lose SSI eligibility, due solely to reduction in the SSP.
10. Tax rebates or special payments excluded under other statutes.
11. Any public agency refund of taxes paid on real property or on food.

WAC 182-512-0820 SSI-related medical -- Child-related income exclusions and allocations.

Effective June 10, 2019.

1. For the purposes of Washington apple health SSI-related medical eligibility determinations under chapter 182-512 WAC, a child is defined as a person who is:
   1. Unmarried;
   2. Living in the household of the SSI-related applicant;
   3. The natural, adopted or stepchild of the SSI-related applicant or the applicant's spouse;
   4. Not receiving a needs-based cash payment such as TANF or SSI; and
   5. Either:
      1. Age seventeen or younger; or
      2. Age twenty-one or younger and meets the SSI-related definition of a student described in subsection (6) of this section.
2. The agency allows an allocation for the support of a child when determining the countable income of an SSI-related applicant. The allocation is calculated as follows:
   1. For apple health categorically needy (CN) health care coverage, the allocation is deducted from the countable income of a nonapplying spouse before determining the amount of the nonapplying spouse's income to be deemed to the SSI-related applicant. Allocations to children are not deducted from the income of an unmarried SSI-related applicant.
   2. For apple health medically needy (MN) medical coverage, the allocation is first deducted from the income of the nonapplying spouse as described in subsection (2)(a) of this section when the SSI-related applicant is married, and from the income of the applicant when the applicant is not married.
3. The child's countable income, if any, is subtracted from the maximum child's allowance before determining the amount of allocation.
4. Foster care payments received for a child who is not SSI-eligible and who is living in the household, placed there by a licensed, nonprofit or public child placement or childcare agency are excluded from income regardless of whether the client requesting or receiving SSI-related medical is the adult foster parent or the child who was placed.
5. Adoption support payments, received by an adult for a child in the household that are designated for the child's needs, are excluded as income. Adoption support payments that are not specifically designated for the child's needs are not excluded and are considered unearned income to the adult.
6. The agency excludes the earned income of a client age twenty-one or younger if that client is a student. In order to allow the student earned income exclusion, a student must:
   1. Attend a school, college, or university a minimum of eight hours a week; or
   2. Pursue a vocational or technical training program designed to prepare the student for gainful employment a minimum of twelve hours per week; or
   3. Attend school or be home schooled in grades seven through twelve at least twelve hours per week.
7. Any portion of a grant, scholarship, fellowship, or gift used for tuition, fees and/or other necessary educational expenses at any educational institution is excluded from income and not counted as a resource for nine months after the month of receipt.
8. One-third of child support payments received for a child who is an applicant for SSI-related medical is excluded from the child's income. Child support payments that are subject to the one-third deduction may be voluntary or court-ordered payments for current support or arrears.
9. The following gifts to, or for the benefit of, a client under eighteen years old who has a life-threatening condition, from an organization described in section 501 (c)(3) of the Internal Revenue Code of 1986 which is exempt from taxation under section 501(a) of that code, are excluded:
   1. In-kind gifts that are not converted to cash; and
   2. Cash gifts up to a total of two thousand dollars in a calendar year.
10. Veteran's payments made to, or on behalf of, natural children of Vietnam veterans regardless of their age or marital status, for any disability resulting from spina bifida suffered by these children are excluded from income. Any portion of a veteran's payment that is designed as the dependent's income is countable income to the dependent and not the applicant (assuming the applicant is not the dependent).