WAC 182-509-0320 MAGI income -- Noncountable income.

Effective September 18, 2020.

For purposes of determining eligibility for modified adjusted gross income (MAGI)–based Washington apple health (see WAC 182-509-0300):

1. Some types of income are not counted when determining eligibility for MAGI-based apple health. Under the MAGI income methodology described in WAC 182-509-0300, income is not counted if the Internal Revenue Service (IRS) permits it to be excluded or deducted for purposes of determining the tax liability of a person. (See 26 U.S.C. Sections 62(a) and 101-140.)
2. Examples of income that are not counted include, but are not limited to:
   1. Bona fide loans, except certain student loans as specified under WAC 182-509-0335;
   2. Federal income tax refunds and earned income tax credit payments for up to 12 months from the date received;
   3. Child support payments received by any person included in household size under WAC 182-506-0010;
   4. Nontaxable time loss benefits or other compensation received for sickness or injury, such as benefits from the department of labor and industries (L&I) or a private insurance company;
   5. Title IV-E and state foster care and adoption support maintenance payments;
   6. Veteran's benefits including, but not limited to, disability compensation and pension payments for disabilities paid to the veteran or family members; education, training and subsistence; benefits under a dependent-care assistance program for veterans, housebound allowance and aid and attendance benefits;
   7. Money withheld from a benefit to repay an overpayment from the same income source;
   8. One-time payments issued under the Department of State or Department of Justice reception and replacement programs, such as Voluntary Agency (VOLAG) payments;
   9. Nontaxable income from employment and training programs;
   10. Any portion of income used to repay the cost of obtaining that income source;
   11. Insurance proceeds or other income received as a result of being a Holocaust survivor;
   12. Federal economic stimulus payments that are excluded for federal and federally assisted state programs;
   13. Income from a sponsor given to a sponsored immigrant;
   14. Fringe benefits provided on a pretax basis by an employer, such as transportation benefits or moving expenses;
   15. Employer contributions to certain pretax benefits funded by an employee's elective salary reduction, such as amounts for a flexible spending account;
   16. Distribution of pension payments paid by the employee (such as premiums or contributions) that were previously subject to tax;
   17. Gifts as described in IRS Publication 559; Survivors, Executors, and Administrators;
   18. Cash or noncash inheritances, except that the agency counts income produced by an inheritance;
   19. Death benefits from life insurance and certain benefits paid for deaths that occur in the line of duty;
   20. Working families' tax credit payments under RCW 82.08.0206; and
   21. Other payments that are excluded from income under state or federal law.
3. Income received from other agencies or organizations as needs-based assistance is not countable income under this section.
   1. "Needs-based" means eligibility for the program is based on having limited income, or resources, or both. Examples of needs-based assistance are:
      1. Clothing;
      2. Food;
      3. Household supplies;
      4. Medical supplies (nonprescriptions);
      5. Personal care items;
      6. Shelter;
      7. Transportation; and
      8. Utilities (e.g. lights, cooking fuel, the cost of heating or heating fuel).
   2. Needs-based cash programs include, but are not limited to, the following apple health programs:
      1. Diversion cash assistance (DCA);
      2. Temporary assistance for needy families (TANF);
      3. State family assistance (SFA);
      4. Pregnant women's assistance (PWA);
      5. Refugee cash assistance (RCA);
      6. Aged, blind, disabled cash assistance (ABD); and
      7. Supplemental security income (SSI).

WAC 182-509-0315 MAGI income -- Ownership of income.

Effective January 9, 2014.

1. For purposes of determining eligibility for modified adjusted gross income (MAGI)–based Washington apple health (WAH) (see WAC 182-509-0300) income is considered available to a person if:
   1. An individual in the person's medical assistance unit receives or can reasonably predict that he or she will receive the income.
   2. The income must be counted based on rules under chapter 182-509 WAC.
   3. The person has control over the income, which means the income is available to them. If the person has a representative payee, protective payee, or other individual who manages the income on the person's behalf, it is considered as if the person has control over this income.
   4. The person can use the income to meet current needs.
2. Income that is included in the person's taxable gross income which is required to be reported to the Internal Revenue Service (IRS) is considered as available even if it is paid to someone else or withheld to pay a garnishment, lien or other obligation. (For example, a person manages a block of apartments and lives in one of the apartments. The employer withholds a portion of the person's monthly wages as rent due for the apartment in which he resides. The income that is counted is the gross amount prior to the deduction for rent.)
3. The agency may conduct post-eligibility reviews of health care applications as described in WAC 182-503-0050. Upon request by the agency, a person must provide proof about a type of income, including submitting clarification on:
   1. Who owns the income;
   2. Who has legal control of the income;
   3. The amount of the income; or
   4. If the income is available.

WAC 182-509-0310 MAGI income -- Timing of income.

Effective January 9, 2014.

For purposes of determining eligibility for modified adjusted gross income (MAGI)–based Washington apple health (WAH) (see WAC 182-509-0300):

1. The agency uses a point-in-time estimate to determine a person's countable income.
2. Point-in-time means that the income is received, or is likely to be received, in the month in which the person submits an application or renewal for WAH, or the month in which the agency completes a redetermination of coverage, with the following provisions:
   1. When a person is paid less frequently than on a monthly basis, (for example, they are self-employed), the agency uses an average to calculate the monthly amount. The average is calculated by:
      1. Adding the total income for representative period of time;
      2. Dividing by the number of months in the time frame; and
      3. Using the result as a monthly average.
   2. When a person is paid more frequently than on a monthly basis, the agency uses the following budgeting method to calculate a monthly amount:
      1. If the person is paid weekly, the agency multiplies weekly expected income by 4.3;
      2. If the person is paid every other week, the agency multiplies expected income by 2.15.
   3. If the person's current income does not represent his or her projected income as evidenced by clear indications of future changes in income, the agency permits the person to estimate a monthly amount by averaging income over a representative period of time.
3. If the person normally gets the income:
   1. On a specific day, the agency counts it as available on that date.
   2. Monthly or twice monthly and pay dates change due to a reason beyond the person's control, such as a weekend or holiday, it is counted in the month it would normally be received.
   3. Weekly or every other week and pay dates change due to a reason beyond the person's control, it is counted in the month it would normally be received.
4. For information about how income is verified, see WAC 182-503-0050.
5. If the person reports a change in income as required under WAC 182-504-0105 and the change is expected to last for two months or longer, the agency updates the estimate of income based on this change, unless the person receives categorically needy WAH coverage as a pregnant woman or child.

WAC 182-509-0305 MAGI income -- Persons subject to the modified adjusted gross income (MAGI) methodology.

Effective November 1, 2024.

1. Eligibility for Washington apple health for the following people is determined using the modified adjusted gross income (MAGI) methodology described in WAC 182-509-0300:
   1. Parents or caretaker relatives with an eligible dependent child (described in WAC 182-503-0565) whose net countable income is below 54 percent of the federal poverty level (FPL) as described in WAC 182-505-0240.
   2. Parents or caretaker relatives with an eligible dependent child whose net countable income exceeds the standard described in (a) of this subsection but is at or below 133 percent FPL as described in WAC 182-505-0250 and 182-507-0110.
   3. Adults with no eligible dependent child with net countable income at or below 133 percent FPL as described in WAC 182-505-0250 and 182-507-0110.
   4. Pregnant people whose net countable income, based on a household size that includes any unborn children, is equal to or below 210 percent FPL at the time of application, as described in WAC 182-505-0115.
   5. People within the 12-month postpartum period beginning the month after the pregnancy ends whose net countable income is equal to or below 210 percent FPL at the time of application, as described in WAC 182-505-0115.
   6. Children age 18 or younger in households with net countable income which is equal to or below 210 percent FPL as described in WAC 182-505-0210.
   7. Children age 18 or younger in households with net countable income that is greater than 210 percent but equal to or below 312 percent FPL, as described in WAC 182-505-0215. Children who are eligible under this section are subject to premiums as described in WAC 182-505-0225.
2. Household size for a person who is subject to MAGI income methodologies is determined according to WAC 182-506-0010.

WAC 182-509-0300 Modified adjusted gross income (MAGI).

Effective September 18, 2020.

1. The agency uses the modified adjusted gross income (MAGI) methodology to determine eligibility for MAGI-based Washington apple health programs described in WAC 182-509-0305.
2. MAGI methodology is described in WAC 182-509-0300 through 182-509-0375. Generally, MAGI includes adjusted gross income (as determined by the Internal Revenue Code (IRC)) increased by:
   1. Any amount excluded from gross income under Section 911 of the IRC;
   2. Any amount of interest received or accrued by the taxpayer during the taxable year which is exempt from tax; and
   3. Any amount of Title II Social Security income or Tier 1 Railroad Retirement income which is excluded from gross income under Section 86 of the IRC.
3. When calculating a person's eligibility for the programs listed in WAC 182-509-0305, the agency uses the person's MAGI income with the following exceptions:
   1. Scholarships or fellowship grants described in WAC 182-509-0335 used for education purposes are excluded from income;
   2. Income received by American Indian/Alaskan Native individuals described in WAC 182-509-0340 is excluded from income; and
   3. Any income received as a lump sum as described in WAC 182-509-0375 is counted as income only in the month in which it is received; and
   4. Income received by a child are eighteen or younger or a tax dependent as described in WAC 182-509-0360 is excluded from income.
4. Countable MAGI income is reduced by an amount equal to five percentage points of the federal poverty level (FPL) based on household size to determine net income except that there is no such reduction of countable MAGI income for parents or caretaker relatives with an eligible dependent child whose net countable income is below fifty-four percent of the FPL (as described in WAC 182-509-0305(1)). Net income is compared to the applicable standard described in WAC 182-505-0100.
5. When calculating a person's eligibility for MAGI-based programs listed in WAC 182-509-0305, the agency determines the medical assistance unit for each person according to WAC 182-506-0010.

WAC 182-509-0220 Washington apple health -- How resources are considered.

Effective February 7, 2025.

1. A resource is any cash, other personal property, or real property that a person:
   1. Owns;
   2. Has the right, authority, or power to convert to cash (if not already cash); and
   3. Has the legal right to use for their support and maintenance.
2. There is no resource limit for an applicant or recipient of the following Washington apple health (medicaid) programs:
   1. Apple Health for workers with disabilities (HWD) program, as described in chapter 182-511 WAC;
   2. Apple Health foster care program (see WAC 182-505-0211);
   3. Medicare savings programs (see WAC 182-517-0100);
   4. All programs that are based on modified adjusted gross income (MAGI) methodologies, as described in WAC 182-503-0510. This includes the following:
      1. Apple Health for parents and caretaker relatives (see WAC 182-505-0240);
      2. Apple health pregnancy coverage (see WAC 182-505-0115);
      3. Apple health for kids (see WAC 182-505-0210);
      4. Premium-based apple health for kids (see WAC 182-505-0215);
      5. Apple health long-term care for children and adults (see WAC 182-514-0230);
      6. Apple health for MAGI-based adult coverage (see WAC 182-505-0250);
      7. Apple health MAGI-based adult alien emergency medical (see WAC 182-507-0110); and 
      8. Apple health expansion coverage.
3. For all other apple health programs, the resource limits and exclusions can be found in the following chapters:
   1. Apple health SSI-related medical (see chapter 182-512 WAC);
   2. Apple health long-term care (see chapters 182-513 and 182-515 WAC);
   3. SSI-related apple health alien medical program (see chapter 182-507 WAC);
   4. Apple health for refugees (see WAC 182-507-0130); and
   5. Medical care services (see WAC 182-508-0005).
4. The agency or its designee determines how trusts, annuities and life estates affect eligibility for apple health coverage for the programs listed in subsection (3)(a) through (e) of this section by following the rules described in chapter 182-516 WAC.
5. Receipt of money by a member of a federally recognized tribe from exercising federally protected rights or extraction of protected resources, such as fishing, shell-fishing, or selling timber, is considered conversion of an exempt resource during the month of receipt. Any amounts remaining from the conversion of this exempt resource on the first of the month after the month of receipt will remain exempt if the funds were used to purchase another exempt resource. Any amounts remaining in the form of countable resources (such as in checking or savings accounts) on the first of the month after receipt, will be added to other countable resources for eligibility determinations when a resource determination is required by the specific apple health program. If no resource determination is required by the specific apple health program, eligibility is not affected.

WAC 182-509-0001 Countable income for Washington apple health programs.

Effective December 27, 2024.

1. For purposes of Washington apple health program eligibility, a person's countable income is income which remains when:
   1. The income cannot be specifically excluded; and
   2. All appropriate deductions and disregards allowed by a specific program have been applied.
2. A person's countable income may not exceed the income standard for the specific Washington apple health program, unless the program allows for those limits to be exceeded. Specific program standards are described below:
   1. For modified adjusted gross income (MAGI)-based programs described in WAC 182-503-0510, see WAC 182-505-0100 for the applicable program standard based on a percentage of the federal poverty level (FPL);
   2. For Washington apple health SSI-related CN coverage, see WAC 182-512-0010;
   3. For Washington apple health MN coverage, see WAC 182-519-0050;
   4. For Washington apple health medicare savings programs, see WAC 182-517-0100;
   5. For Washington apple health noninstitutional medical in an alternative living facility, see WAC 182-513-1205; and
   6. For Washington apple health long-term care programs, see WAC 182-513-1315 and 182-513-1395.
3. For the MAGI-based programs listed below, the agency or its designee determines eligibility based on the countable MAGI income of the members of the person's medical assistance unit as determined per WAC 182-506-0010:
   1. Washington apple health for parents and caretaker relatives program as described in WAC 182-505-0240;
   2. Washington apple health pregnancy program as described in WAC 182-505-0115;
   3. Washington apple health for kids programs as described in WAC 182-505-0210 with the following exceptions:
      1. Newborn children born to a person who is eligible for WAH on the date of the newborn's birth, including a retroactive eligibility determination;
      2. Children who are receiving SSI;
      3. Children who are in foster care or receiving subsidized adoption services.
   4. Washington apple health MAGI-based adult medical as described in WAC 182-505-0250; and
   5. Washington apple health MAGI-based alien emergency medical as described in WAC 182-507-0110.
4. For the following SSI-related Washington apple health programs, unless the state has adopted more liberal rules, income rules for the SSI program are used to determine a person's countable income:
   1. Washington apple health noninstitutional SSI-related CN or medically needy (MN) coverage described in chapters 182-511 and 182-512 WAC;
   2. Washington apple health institutional SSI-related CN or MN long-term care or hospice coverage described in chapters 182-513 and 182-515 WAC;
   3. Washington apple health alien emergency medical programs based on age 65 or older or disability described in chapter 182-507 WAC; and
   4. Washington apple health medicare savings programs described in chapter 182-517 WAC.
5. Anticipated nonrecurring lump sum payments received by an applicant or recipient of a Washington apple health SSI-related medical program are counted as income in the month of receipt, subject to reporting requirements, with the exception of retroactive supplemental security income (SSI)/Social Security disability lump sum payments. See WAC 182-512-0300(4) and 182-512-0700 for more information.
6. Countable income for the Washington apple health refugee medical (RMA) program and Washington apple health MN program for pregnant people and children is determined as follows:
   1. The agency or its designee allows the following deductions from a household's gross earnings:
      1. The first $500 of earnings and 50 percent of the remaining earnings;
      2. Actual work-related child and dependent care expenses, which are the person's responsibility; and
      3. Court or administratively ordered current or back support paid to meet the needs of legal dependents.
   2. Only income actually contributed to a person from the person's sponsor is countable unless the sponsor signs the affidavit of support I-864 or I-864A.
   3. Nonrecurring lump sum payments are counted as income in the month of receipt and as a resource if the person retains the payment after the month of receipt (resource limits do not apply to MN coverage for pregnant people and children). For RMA, nonrecurring lump sum payments are counted as income if received in the month of application and not considered if received thereafter per WAC 182-507-0130.
7. Countable income rules for other Washington apple health programs that are not MAGI-based or SSI-related are described in the specific program rules listed in WAC 182-503-0510 (3)(c).
8. Some Washington apple health programs are not based on a person's or household's countable income but are based on a specific status or entitlement in federal rule. The rules for these deemed eligible Washington apple health programs are described in WAC 182-503-0510(4).

WAC 182-508-0150 Enrollment cap for medical care services (MCS).

Effective February 1, 2022 

1. Enrollment in medical care services (MCS) coverage is subject to available funds.
2. The medicaid agency may limit enrollment into MCS coverage by implementing an enrollment cap and wait list.
3. If a person is denied MCS coverage due to an enrollment cap:
   1. The person is added to the MCS wait list based on the date the person applied.
   2. Applicants with the oldest application date will be the first to receive an opportunity for enrollment when MCS coverage is available as long as the person remains on the MCS wait list.
4. A person is exempted from the enrollment cap and wait list rules when:
   1. MCS was terminated due to agency error;
   2. The person is in the 30-day reconsideration period for incapacity reviews under WAC 388-447-0110(4);
   3. The person is being terminated from a categorically needy (CN) medical program and was receiving and eligible for CN coverage prior to the date a wait list was implemented and at the time their CN coverage ended, the person met eligibility criteria to receive benefits under either the aged, blind, or disabled program as described in WAC 388-400-0060 or the housing and essential needs referral program as described in WAC 388-400-0070; or
   4. The person applied for a determination by the department of social and health services (DSHS) to be eligible for benefits under one of the following programs, but the determination was not completed before the enrollment cap effective date:
      1.  The aged, blind, or disabled program as described in WAC 388-400-0060 ; 
      2. The housing and essential needs referral program as described in WAC 388-400-0070; or
      3. The survivors of certain crimes (SCC) program, as described in WAC 388-424-0035, which includes victims of human trafficking as described in RCW 74.04.005.
5. The person is removed from the MCS wait list if the person:
   1. Is not a Washington resident;
   2. Is deceased;
   3. Requests removal from the wait list;
   4. Is found eligible for categorically or medically needy coverage; or
   5. Is no longer determined by DSHS to be eligible for benefits under:
      1. The aged, blind, or disabled program as described in WAC 388-400-0060;
      2. The housing and essential needs referral program as described in WAC 388-400-0070; or
      3. The SCC program as described in WAC 388-424-0035.

WAC 182-508-0005 Washington apple health medical care services - eligibility and scope of coverage.

Effective February 12, 2023

1. A person is eligible for state-funded Washington apple health medical care services (MCS) coverage to the extent of available funds if the person is:
   1. Determined by the department of social and health services to be eligible for benefits under:
      1. The aged, blind, or disabled program as described in WAC 388-400-0060;
      2. The housing and essential needs referral program as described in WAC 388-400-0070; or
      3. The survivors of certain crimes (SCC) program, as described in WAC 388-424-0035, which includes victims of human trafficking as described in RCW 74.04.005;
   2. Not eligible for another federally funded categorically needy (CN) (as defined in WAC 182-500-0020) or alternative benefits plan (ABP) (as defined in WAC 182-500-0010) Washington apple health program and
   3. Not residing in a public institution as defined in WAC 182-500-0050.
2. If an enrollment cap exists under WAC 182-508-0150, a waiting list of people may be established.
3. A person's period of eligibility for MCS is the same as the person's period of eligibility for:
   1. The aged, blind, or disabled program as described in WAC 388-449-0150;
   2. The person's incapacity authorization period for the housing and essential needs referral program as described in WAC 388-447-0110;
   3. The person's period of eligibility for the SCC program as described in WAC 388-424-0035.
4. The MCS program covers only the medically necessary services defined in WAC 182-501-0060.
5. The MCS program does not cover medical services received outside the state of Washington unless the medical services are provided in a border city listed in WAC 182-501-0175.

WAC 182-508-0001 Washington apple health – Coverage options for adults not eligible under MAGI methodologies.

April 1, 2024

1. This chapter provides information on eligibility determinations for adults who:
   1. Need a determination of eligibility on the basis of being aged, blind, or disabled;
   2. Need a determination of eligibility based on the need for long-term institutional care or home and community-based services;
   3. Are excluded from coverage under a modified adjusted gross income (MAGI)-based program as referenced in WAC 182-503-0510 on the basis of medicare entitlement;
   4. Are not eligible for health care coverage under chapter 182-505 WAC due to citizenship or immigration requirements; or
   5. Are not eligible for health care coverage under chapter 182-505 WAC due to income which exceeds the applicable standard for coverage.
2. The agency determines eligibility for Washington apple health (WAH) noninstitutional categorically needy (CN) coverage under chapter 182-512 WAC for an adult who is age 65 or older, or who meets the federal blind or disabled criteria of the federal SSI program, and:
   1. Meets citizenship/immigration, residency, and Social Security number requirements as described in chapter 182-503 WAC; and
   2. Has CN countable income and resources that do not exceed the income and resource standards in WAC 182-512-0010.
3. The agency determines eligibility for WAH health care for workers with disabilities (HWD) CN coverage for adults who meet the requirements described in WAC 182-511-1050, as follows:
   1. Are age 16 or older;
   2. Meet citizenship/immigration, residency, and Social Security number requirements as described in chapter 182-503 WAC;
   3. Meet the federal disability requirements described in WAC 182-511-1150;
   4. Are employed full or part-time (including self-employment) as described in WAC 182-511-1200.
4. The agency determines eligibility for WAH long-term care CN coverage for adults who meet the institutional status requirements defined in WAC 182-513-1320 under the following rules:
   1. When the person receives coverage under a MAGI-based program and needs long-term care services in an institution, the agency follows rules described in chapter 182-514 WAC;
   2. When the person meets aged, blind, or disabled criteria as defined in WAC 182-512-0050 and needs long-term care services, the agency follows rules described in:
      1. Chapter 182-513 WAC, for an adult who resides in an institution; and
      2. Chapter 182-515 WAC, for an adult who is determined eligible for WAH home and community-based waiver services.
5. The agency determines eligibility for WAH noninstitutional CN or medically needy (MN) health care coverage for an adult who resides in an alternate living facility under rules described in WAC 182-513-1205.
6. The agency determines eligibility for WAH-CN coverage under institutional rules described in chapters 182-513 and 182-515 WAC for an adult who:
   1. Has made a voluntary election of hospice services;
   2. Is not otherwise eligible for noninstitutional CN or MN health care coverage or for whom hospice is not included in the benefit service package available to the person; and
   3. Meets the aged, blind, or disabled criteria described in WAC 182-512-0050.
7. The agency uses the following rules to determine eligibility for an adult under the WAH-MN program:
   1. Noninstitutional WAH-MN is determined under chapter 182-519 WAC for an adult with countable income that exceeds the applicable CN standard; and
   2. Non-SSI-related institutional WAH-MN long-term care coverage is determined under WAC 182-514-0263 for pregnant people and people age 20 and younger:
      1. Meets institutional status requirements described in WAC 182-513-1320;
      2. Do not meet blind or disabled criteria described in WAC 182-512-0050; and
      3. Have countable income that exceeds the applicable CN standard.
   3. WAH-MN long-term care coverage is determined under WAC 182-513-1395 for an aged, blind, or disabled adult who resides in an institution and has countable income that exceeds the special income level (SIL).
8. An adult is eligible for WAH-MN coverage when he or she:
   1. Meets citizenship/immigration, residency, and Social Security number requirements as described in WAC 182-503-0505;
   2. Has MN countable income that does not exceed the effective MN income standards in WAC 182-519-0050, or meets the excess income spenddown requirements in WAC 182-519-0110;
   3. Meets the countable resource standards in WAC 182-519-0050; and
   4. Is 65 years of age or older or meets the blind or disabled criteria of the federal SSI program.
9. WAH-MN coverage is available for an aged, blind, or disabled ineligible spouse of an SSI recipient. See WAC 182-519-0100 for additional information.
10. An adult who does not meet citizenship or alien status requirements described in WAC 182-503-0535 may be eligible for the WAH alien emergency medical program as described in WAC 182-507-0110.
11. An adult is eligible for the state-funded medical care services (MCS) program when he or she meets the requirements under WAC 182-508-0005.
12. A person who is entitled to medicare is eligible for coverage under a medicare savings program or the state-funded buy-in program when he or she meets the requirements described in chapter 182-517 WAC.