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

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

Effective October 25, 2024.

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

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

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

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

Effective January 23, 2021.

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

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

WAC 182-505-0211 Washington apple health -- Foster Care.

WAC 182-505-0211 Washington apple health -- Foster Care.

Effective January 1, 2023.

  1. A client under the age of 18 is eligible for Washington apple health foster care coverage when they:
    1. Are in foster care as determined by the department of children, youth, and families (DCYF) under the legal responsibility of the state, or a federally recognized tribe located within the state; and
    2. Meet Washington residency requirements as described in WAC 182-503-0520 or 182-503-0525.
  2. A client age 20 or younger is eligible for coverage when the client meets:
    1. Washington residency requirements as described in WAC 182-503-0520 or 182-503-0525;
    2. Citizenship or immigration status requirements as described in WAC 182-503-0535;
    3. Social Security number requirements as described in WAC 182-503-0515; and
    4. One of the following requirements:
      1. Is in foster care, or is eligible for continued foster care services as determined by the children's administration, under the legal responsibility of the state, or a federally recognized tribe located within the state; or
      2. Receives subsidized adoption services through the children's administration; or
      3. Is enrolled in the unaccompanied refugee minor (URM) program as authorized by the office of refugee and immigrant assistance (ORIA); or
      4. Is living in a community facility (as defined in WAC 110-700-005) operated or contracted by DCYF's juvenile rehabilitation.
  3. A client age 18 or older but under age 26 is eligible for Washington Apple Health coverage when a client:
    1. Was in foster care under the legal responsibility of any state or a federally recognized tribe located within any state.
      1. On the client's 18th birthday; or
      2. At such higher age as to when the state or tribe extends foster care coverage; and
    2. Meets residency, Social Security number, and citizenship requirements as described in subsection (2) of this section.
  4. A client described in subsections (1) through (3) of this section is not eligible for full-scope coverage if the client is confined to a public institution as defined in WAC 182-500-0050, except:
    1. If the client is under age 21;
    2. Resides in an institution for mental disease (IMD); and
    3. Meets the institutional status requirements in WAC 182-513-1320, 182-514-0250, or 182-514-0260.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

WAC 182-505-0210 Eligibility for children.

WAC 182-505-0210 Eligibility for children.

Effective December 8, 2023.

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

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

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

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

Effective September 14, 2015

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

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

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

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

Effective June 24, 2022.

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

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

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

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

Effective June 24, 2022.

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

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

WAC 182-504-0130 Washington apple health -- Continued coverage pending an appeal.

WAC 182-504-0130 Washington apple health -- Continued coverage pending an appeal.

Effective December 1, 2016

  1. Continued coverage is when you continue to receive Washington apple health benefits while appealing a medicaid agency adverse action to terminate, suspend, or reduce your:
    1. Medicaid eligibility; or
    2. Authorization for a covered service.
  2. To qualify for continued coverage, you must request a hearing on the adverse action no later than:
    1. The tenth day after we (the medicaid agency or its designee) sent a notice of the action to you; or
    2. The last day of the month before the action takes effect.
  3. If your last day to request a hearing and still qualify for continued coverage falls on a Saturday, Sunday, or a designated holiday under WAC 357-31-005, you have until 5:00 p.m. on the next business day to request the hearing.
  4. Continued coverage ends when:
    1. You state in writing you no longer wish to receive continued coverage;
    2. You withdraw the appeal;
    3. You default and an order of dismissal is entered;
    4. An administrative law judge or a review judge issues an adverse ruling or written decision:
      1. Terminating your continued coverage; or
      2. Ruling you do not qualify for benefits.
  5. You cannot receive continued coverage if the adverse action was solely to a change in statute, federal regulation, or administrative rule, unless there is a question about whether you are in the class of people affected by the change.
  6. If you are receiving medically needy coverage, you cannot receive continued coverage past the end of the certification period described in WAC 182-504-0020.
  7. If you are receiving coverage under an alien medical program, you cannot receive continued coverage past the end of the certification period described in chapter 182-507 WAC.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

WAC 182-504-0125 Washington apple health -- Effect of reported changes.

WAC 182-504-0125 Washington apple health -- Effect of reported changes.

Effective October 1, 2017.

  1. If you report a change required under WAC 182-504-0105 during a certification period, you continue to be eligible for Washington apple health coverage until we decide if you can keep getting apple health coverage under your current apple health program or a different apple health program.
  2. If your apple health categorically needy (CN) coverage ends due to a reported change and you meet all the eligibility requirements for a different apple health CN program, we will approve your coverage under the new apple health CN program. If you are not eligible for coverage under any apple health CN program but you meet the eligibility requirements for either apple health alternative benefits plan (ABP) coverage or apple health medically needy (MN) coverage, we will approve your coverage under the program you are eligible for. If you are not eligible for coverage under any apple health CN program but you meet the eligibility requirements for both apple health ABP coverage and apple health MN coverage, we will approve the apple health ABP coverage unless you notify us that you prefer  apple health MN coverage.
  3. If your apple health coverage ends and you are not eligible for a different apple health program, we stop your apple health coverage after giving you advance and adequate notice unless the exception in subsection (4) of this section applies to you.
  4. If you claim to have a disability and that is the only basis for you to be potentially eligible for apple health coverage, then we refer you to the division of disability determination services (within the department of social and health services) for a disability determination. Pending the outcome of the disability determination, we also determine if you are eligible for apple health coverage under the SSI-related medical program described in chapter 182-512 WAC. If you have countable income in excess of the SSI-related categorically needy income level (CNIL), then we look to see if you can get coverage under apple health MN with spenddown as described in chapter 182-519 WAC pending the final outcome of the disability determination.
  5. If you are eligible for and receive coverage under the apple health parent and caretaker relative program described in WAC 182-505-0240, you may be eligible for the apple health medical extension program described in WAC 182-523-0100, if your coverage ends as a result of an increase in your earned income.
  6. Changes in income during a certification period do not affect eligibility for the following programs:
    1. Apple health for pregnant women;
    2. Apple health for children, except as specified in subsection (7) of this section;
    3. Apple health for SSI recipients;
    4. Apple health refugee program; and
    5. Apple health medical extension program.
  7. We redetermine eligibility for children receiving apple health for kids premium-based coverage described in WAC 182-505-0210 when the:
    1. Household's countable income decreases to a percentage of the federal poverty level (FPL) that would result in either a change in premium for apple health for kids with premiums or the children becoming eligible for apple health for kids (without premiums);
    2. Child becomes pregnant;
    3. Family size changes; or
    4. Child receives SSI.
  8. If you get SSI-related apple health CN coverage and report a change in work or earned income which results in a determination by the division of disability determination services that you no longer meet the definition of a disabled person as described in WAC 182-512-0050 due to work or earnings at the level of substantial gainful activity (SGA), we redetermine your eligibility for coverage under the health care for workers with disabilities (HWD) program. The HWD program is a premium-based program that waives the SGA work or earnings test, and you must approve the premium amount before we can authorize coverage under this program. For HWD program rules, see chapter 182-511 WAC.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

WAC 182-504-0110 Washington apple health -- When to report changes.

WAC 182-504-0110 Washington apple health -- When to report changes.

Effective August 29, 2014.

  1. All changes you report to us (the agency or its designee), as required by WAC 182-504-0105, are used to decide if you can receive or keep receiving Washington apple health (WAH) coverage.
  2. You must report changes during your certification period within thirty days of when the change happened.
  3. You must report all changes during application, renewal, or redetermination of your WAH eligibility, regardless of when the change happened.
  4. For a change in income, the date a change happened is the first date you received income based on the change. For example, the date you receive your first paycheck for a new job or the date you got a paycheck with a wage increase is the date the change happened.
  5. If you do not report a change or you report a change late, we will decide if you can receive or keep receiving WAH coverage based on the date the change was required to be reported.
  6. If you do not report a change or you report a change late, and if it affects the amount you must pay toward your cost of care as described in WAC 182-513-1380 or chapter 182-515 WAC, you may become liable for overpayments we make on your behalf and you may need to pay more to your care provider.
  7. If you do not report a change or you report a change late, it may result in us overpaying you and you having to pay us back for the health care costs we overpaid. See chapter 182-520 WAC.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

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