WAC 182-504-0105 Washington apple health -- Changes that must be reported.

Effective August 29, 2014.

1. You must report changes in your household and family circumstances to us (the agency or its designee) timely according to WAC 182-504-0110.
2. We tell you what you are required to report at the time you are approved for WAH coverage. We also will tell you if the reporting requirements change.
3. You must report the following:
   1. Change in residential address;
   2. Change in mailing address;
   3. Change in marital status;
   4. When family members or dependents move in or out of the residence;
   5. Pregnancy;
   6. Incarceration;
   7. Change in institutional status;
   8. Change in health insurance coverage including medicare eligibility; and
   9. Change in immigration or citizenship status.
4. If you are eligible for a WAH long-term care program described in chapter 182-513 or 182-515 WAC, you must also report changes to the following:
   1. Income;
   2. Resources;
   3. Medical expenses; and
   4. Spouse or dependent changes in income or shelter cost when expenses are allowed for either.
5. If you get WAH parent or caretaker (as described in WAC 182-505-0240) or WAH modified adjusted gross income (MAGI)-based adult coverage (as described in WAC 182-505-0250), you must also report changes to the following:
   1. When total income increases or total deductions decrease by one hundred fifty dollars or more a month and the change will continue for at least two months;
   2. Your federal income tax filing status that you expect to use when you file your taxes for the current tax filing year (such as changing from "married filing separately" to "married filing jointly"); and
   3. The tax dependents you expect to claim when you file your federal income tax return for the current tax filing year.
6. If you get WAH based on age, blindness, or disability (SSI-related medical), then you must also report changes to the following:
   1. Income; and
   2. Resources. 

WAC 182-504-0035 Washington apple health -- Renewals.

Effective December 8, 2023.

1. For all Washington apple health (WAH) programs, the following applies:
   1. You are required to complete a renewal of eligibility at least every 12 months with the following exceptions:
      1. If you are eligible for WAH medically needy with spenddown, then you must complete a new application at the end of each three- or six-month base period;
      2. If you are eligible for WAH alien emergency medical, then you are certified for a specific period of time to cover emergency inpatient hospitalization costs only (see WAC 182-507-0115(8));
      3. If you are eligible for WAH refugee coverage, you must complete a renewal of eligibility after 12 months; or
      4. If you are a child on apple health for kids without premiums, your first renewal is due the month of your sixth birthday.
   2. You may complete renewals online, by phone, or by paper application that you mail or fax to us (the agency or its designee).
   3. If your WAH is renewed, we decide the certification period according to WAC 182-504-0015.
   4. We review all eligibility factors subject to change during the renewal process.
   5. We redetermine eligibility as described in WAC 182-504-0125 and send you written notice as described in WAC 182-518-0005 before WAH is terminated.
   6. If you need help meeting the requirements of this section, we provide equal access services as described in WAC 182-503-0120.
2. For programs based on modified adjusted gross income (MAGI) as described in WAC 182-503-0510:
   1. Sixty days prior to the end of the certification period:
      1. When information from electronic sources shows income is reasonably compatible (as defined in WAC 182-500-0095), we administratively renew your coverage (as defined in WAC 182-500-0010) for a new certification period and send you a notice of renewal with the information used. You are required to inform us if any of the information we used is wrong.
      2. If we are unable to complete an administrative renewal (as defined in WAC 182-500-0010), you must give us a signed renewal in order for us to decide if you will continue to get WAH coverage beyond the current certification period.
      3. We follow the requirements described in WAC 182-518-0015 to request any additional information needed to complete the renewal process or to terminate coverage for failure to renew.
   2. If your WAH coverage is terminated because you did not renew, you have 90 days from the termination date to give us a completed renewal. If we decide you are still eligible to get WAH coverage, we will restore your WAH without a gap in coverage.
3. For non-MAGI based programs (as described in WAC 182-503-0510):
   1. Forty-five days prior to the end of the certification period, we send notice with a renewal form. You must renew before the end of the certification period by either calling the department of social and health services at the number listed on the form to renew by telephone, renew online at www.washingtonconnection.org, or mailing or delivering to the department of social and health services a signed renewal form with the information required by WAC 182-503-0005.
   2. We follow the requirements in WAC 182-518-0015 to request any additional information needed to complete the renewal process or to terminate coverage for failure to renew.
   3. To complete your renewal, you must give us all the other information requested on the application that is needed to determine your eligibility.
   4. If you are terminated for failure to renew, you have 30 days from the termination date to submit a completed renewal. If still eligible, we will restore your WAH without a gap in coverage.
4. If we determine that you are not eligible for renewal of your WAH coverage, we:
   1. Consider your eligibility for all other WAH programs before ending your WAH coverage; and
   2. Coordinate with the health benefit exchange any request for information that is necessary to determine your eligibility for:
      1. Other WAH programs; and
      2. With respect to qualified health plans, health insurance premium tax credits (as defined in WAC 182-500-0045) and cost-sharing reductions (as defined in WAC 182-500-0020).
5. We reconsider our decision that you are not eligible for WAH coverage without a new application from you when:
   1. We receive the information that we need to decide if you are eligible within 30 days of the date on the termination notice; or
   2. You request a hearing within 90 days of the date on the renewal denial letter and an administrative law judge (ALJ) or HCA review judge decides our decision was wrong (per chapter 182-526 WAC).
6. If you disagree with our decision, you can ask for a hearing. If we decided that you are not eligible for renewal because we do not have enough information, the ALJ will consider the information we already have and anymore information you give us. The ALJ does not consider the previous absence of information or failure to respond in determining if you are eligible.

WAC 182-504-0025 Medicare savings program certification periods.

Effective December 1, 2011

Certification periods for the different kinds of Medicare Savings Programs are not all the same. The chart below explains the differences.

WAC 182-504-0020 Certification periods for the noninstitutional medically needy program.

Effective July 11, 2015

1. The certification period for the noninstitutional medically needy (MN) program for clients with countable income equal to or below the medically needy income level (MNIL):
   1. Begins on the first day of the month in which eligibility is established; and
   2. Is approved for twelve calendar months.
2. The certification period for the noninstitutional MN program for clients with countable income above the MNIL:
   1. Begins on the day that spenddown is met; and
   2. Continues through the last day of the final month of the base period as described in WAC 182-519-0110.
3. A retroactive MN certification period may be established for up to three months preceding the month of application.
4. Expenses used to meet the spenddown liability for the current or the retroactive certification periods are the responsibility of the client. The agency is not responsible for paying any expense or portion of an expense which has been used to meet the spenddown liability. See WAC 182-519-0110.
5. A new application must be submitted for each subsequent certification period for which medically needy coverage is requested.

WAC 182-504-0015 Washington apple health -- Certification periods for categorically needy programs.

Effective October 25, 2024

1. A certification period is the period of time we determine that you are eligible for a categorically needy (CN) Washington apple health program. Unless otherwise stated in this section, the certification period begins on the first day of the month of application and continues through the end of the last month of the certification period.
2. Newborn coverage begins on the child's date of birth and continues through the end of the month of the child's first birthday.
3. If you are eligible for apple health based on pregnancy, the certification period continues through the last day of the month the pregnancy ends. After-pregnancy coverage begins the first day of the month, following the ends of the pregnancy, and ends the last day of the 12th month from the time after-pregnancy coverage began.
4. If you are newly eligible for apple health coverage and had a pregnancy end within the last 12 months, your certification period for after-pregnancy coverage:
   1. Begins the first day of the month you are eligible; and
   2. Ends the last day of the 12th month following the end of your pregnancy.
5. If you are eligible for the refugee program, the certification period ends at the end of the 12th month following your date of entry to the United States.
6. If you are a child under age six receiving apple health for kids without a premium, your certification period ends the month of your sixth birthday.
7. If you are eligible for newborn coverage, your coverage continues through the last day of the month of your first birthday. Apple health for kids coverage begins the first day of the month after your newborn coverage ends and the certification period ends the last day of the month of your sixth birthday.
8. For all other CN coverage, the certification period is 12 months.
9. If you are a child, eligibility is continuous throughout the certification period regardless of a change in circumstances, unless you:
   1. Turn age 19;
   2. Move out-of-state; or
   3. Die.
10. When you turn 19, the certification period ends after the redetermination process described in WAC 182-504-0125 is completed, even if the 12-month period is not over, unless:
    1. You are receiving inpatient  services (described in WAC 182-514-0230) on the last day of the month you turn 19;
    2. The inpatient stay continues into the following month or months; and
    3. You remain eligible except for turning age 19.
11. A retroactive certification period is described in WAC 182-504-0005.
12. Coverage under premium-based programs included in apple health for kids as described in chapter 182-505 WAC begins no sooner than the month after creditable coverage ends.

WAC 182-504-0005 Washington apple health -- Retroactive certification period.

Effective November 14, 2022.

1. The medicaid agency approves a retroactive Washington apple health (WAH) certification period for the three months immediately before the month of application when an individual:
   1. Requests retroactive WAH on the application, within the certification period following the retroactive period, or before the determination of benefits and any appeal process is final;
   2. Would have been eligible for WAH for any or all of the three months if the individual had applied during the retroactive period; and
   3. The individual received covered medical services as described in WAC 182-501-0060 and 182-501-0065.
2. When an individual is eligible only during the three-month retroactive certification period, that period is the only period of certification, except when:
   1. A pregnant individual is eligible in one of the three months immediately before the month of application, but no earlier than the month of conception. Eligibility continues as described in WAC 182-504-0015 (3) and (4).
   2. An individual who is applying within 12 months of their last pregnancy end date is eligible for after pregnancy coverage in any of the three months immediately before the month of application. Continuous eligibility begins from the earliest month the individual is found eligible as described in WAC 182-504-0015 (3) and (4).
   3. A child is eligible for categorically needy (CN) WAH as described in WAC 182-505-0210 (1) through (5) and (7) in at least one of the three months immediately before the month of application. Eligibility after the retroactive period continues as described in WAC 182-504-0015 (9).
3. An individual applying for the medically needy (MN) spenddown program may be eligible for a retroactive certification period as described in WAC 182-504-0020.
4. An individual applying for a medicare savings program may be eligible for a retroactive certification period as described in WAC 182-504-0025.

WAC 182-503-0565 Washington apple health -- Age requirements for medical programs based on modified adjusted gross income (MAGI).

​Effective August 29, 2014

The following age requirements apply to persons whose eligibility for Washington apple health (WAH) is based on modified adjusted gross income (MAGI) methodology per WAC 182-509-0305.

1. You must be age sixty-four or younger to be eligible for WAH MAGI-based adult coverage as described in WAC 182-505-0250.
2. Your household must include an eligible dependent child age seventeen or younger to be eligible for WAH parent or caretaker relative coverage as described in WAC 182-505-0240. For purposes of this subsection, an "eligible dependent child" is a child related to you in one of the ways described in WAC 182-500-0020.
3. A child must be age eighteen or younger to be eligible for WAH for kids as described in WAC 182-505-0210 with the following exceptions:
   1. An institutionalized child may still qualify under a children's health care program through the age of twenty-one (see WAC 182-514-0230);
   2. A foster care child may qualify for WAH foster care coverage through the age of twenty-six (see WAC 182-505-0211).

WAC 182-503-0540 Assignment of rights and cooperation.

Effective January 27, 2019.

1. When you become eligible for any of the agency's health care programs, you assign certain rights to the state of Washington. You assign all rights to any type of coverage or payment for health care that comes from:
   1. A court order;
   2. An administrative agency order; or
   3. Any third-party benefits or payment obligations for medical care which are the result of subrogation or contract (see WAC 182-501-0100).
2. When you sign the application you assign the rights described in subsection (1) of this section to the state for:
   1. Yourself; and
   2. Any eligible person for whom you can legally make such assignment.
3. You must cooperate with us in identifying, using or collecting third-party benefits. If you do not cooperate, your health care coverage may end unless you can show good reason not to cooperate with us. Examples of good reason include, but are not limited to:
   1. Your reasonable belief that cooperating with us would result in serious physical or emotional harm to you, a child in your care, or a child related to you; and
   2. Your being incapacitated without the ability to cooperate with us.
4. Your WAH coverage will not end due solely to the noncooperation of any third party.
5. You will have to pay for your health care services if you:
   1. Received and kept the third-party payment for those services; or
   2. Refused to give to the provider of care your legal signature on insurance forms.
6. The state is limited to the recovery of its own costs for health care costs paid on behalf of a recipient of health care coverage. The legal term which describes the method by which the state acquires the rights of a person for whom the state has paid costs is called subrogation.

WAC 182-503-0535 Washington apple health -- Citizenship and immigration status.

Effective February 7, 2025

1. Definitions.
   1. Nonqualified alien means someone who is lawfully present in the United States (U.S.) but who is not a qualified alien, a U.S. citizen, a U.S. national, or a qualifying American Indian born abroad.
   2. Qualified alien means someone who is lawfully present in the United States and who is one or more of the following:
      1. A person lawfully admitted for permanent residence (LPR).
      2. An abused spouse or child, a parent of an abused child, or a child of an abused spouse who no longer resides with the person who committed the abuse, and who has one of the following:
         1. A pending or approved I-130 petition or application to immigrate as an immediate relative of a U.S. citizen or as the spouse of an unmarried LPR younger than 21 years of age.
         2. Proof of a pending application for suspension of deportation or cancellation of removal under the Violence Against Women Act (VAWA).
         3. A notice of prima facie approval of a pending self-petition under VAWA. An abused spouse's petition covers his or her child if the child is younger than 21 years of age. In that case, the child retains qualified alien status even after he or she turns 21 years of age.
      3. A person who has been granted parole into the U.S. for one year or more, under the Immigration and Nationality Act (INA) Section 212 (d)(5), including public interest parolees.
      4. A member of a Hmong or Highland Laotian tribe that rendered military assistance to the U.S. between August 5, 1964, and May 7, 1975, including the spouse, unremarried widow or widower, and unmarried dependent child of the tribal member.
      5. A person who was admitted into the U.S. as a conditional entrant under INA Section 203 (a)(7) before April 1, 1980.
      6. A person admitted to the U.S. as a refugee under INA Section 207.
      7. A person who has been granted asylum under INA Section 208.
      8. A person granted withholding of deportation or removal under INA Section 243(h) or 241 (b)(3).
      9. A Cuban or Haitian national who was paroled into the U.S. or given other special status.
      10. An Amerasian child of a U.S. citizen under 8 C.F.R. Section 204.4(a).
      11. A person from Iraq or Afghanistan who has been granted one of the following:
          1. Special immigrant status under INA Section 101 (a) (27);
          2. Special immigrant conditional permanent resident; or
          3. Parole under Section 602 (b) (1) of the Afghan Allies Protection Act of 2009 or Section 1059(a) of the National Defense Authorization Act of 2006.
      12. An Afghan granted humanitarian parole between July 31, 2021, and September 30, 2023, their spouse or child, or a parent or guardian of an unaccompanied minor who is granted parole after September 30, 2022, under Section 2502 of the Extending Government Funding and Delivering Emergency Assistance Act of 2021.
      13. A citizen or national of Ukraine (or a person who last habitually resided in Ukraine) who, under section 401 of the Additional Ukrainian Supplemental Appropriations Act, 2022 (AUSAA) and the Ukraine Security Supplemental Appropriations Act, 2024 (USSAA), is evaluated as a qualified alien until the end of their parole term when:
          1. Granted parole into the United States between February 24, 2022, and September 30, 2024; or
          2. Granted parole into the United States after September 30, 2024, and is:
             1. The spouse or child of a person described in (b)(xiii)(A) of this subsection; or
             2. The parent or guardian of a person described in (b)(xiii)(A) of this subsection who is an unaccompanied minor.
      14. A person who has been certified or approved as a victim of trafficking by the federal office of refugee resettlement, or who is:
          1. The spouse or child of a trafficking victim of any age; or
          2. The parent or minor sibling of a trafficking victim who is younger than 21 years of age. 
      15. A person from the Federated States of Micronesia, the Republic of Palau, or the Republic of the Marshall Islands living in the United States in accordance with the Compacts of Free Association. 
   3. U.S. citizen means someone who is a United States citizen under federal law.
   4. U.S. national means someone who is a United States national under federal law.
   5. Undocumented person means someone who is not lawfully present in the U.S.
   6. Qualifying American Indian born abroad means someone who:
      1. Was born in Canada and has at least 50 percent American Indian blood, regardless of tribal membership; or
      2. Was born outside of the United States and is a member of a federally recognized tribe or an Alaska Native enrolled by the Secretary of the Interior under the Alaska Native Claims Settlement Act.
2. Eligibility.
   1. A U.S. citizen, U.S. national or qualifying American Indian born abroad may be eligible for:
      1. Apple health for adults;
      2. Apple health for kids;
      3. Apple health for pregnant women; or
      4. Classic medicaid.
   2. A qualified alien who meets or is exempt from the five-year bar may be eligible for:
      1. Apple health for adults;
      2. Apple health for kids;
      3. Apple health for pregnant women; or
      4. Classic medicaid.
   3. A qualified alien who neither meets nor is exempt from the five-year bar may be eligible for:
      1. Alien medical programs;
      2. Apple health for kids;
      3. Apple health for pregnant women; or
      4. Medical care services.
   4. A nonqualified alien may be eligible for:
      1. Alien medical programs;
      2. Apple health for kids;
      3. Apple health for pregnant women; or
      4. Medical care services.
   5. An undocumented person may be eligible for:
      1. Alien medical programs;
      2. State-only funded apple health for kids; 
      3. State-only funded apple health for pregnant women; or
      4. State-only funded apple health expansion.
3. The five-year bar.
   1. A qualified alien meets the five-year bar if he or she:
      1. Continuously resided in the U.S. for five years or more from the date he or she became a qualified alien; or
      2. Entered the U.S. before August 22, 1996, and:
         1. Became a qualified alien before August 22, 1996; or
         2. Became a qualified alien on or after August 22, 1996, and has continuously resided in the U.S. between the date of entry into the U.S. and the date he or she became a qualified alien.
   2. A qualified alien is exempt from the five-year bar if he or she is:
      1. A qualified alien as defined in subsections (1)(b)(vi) through (xv) of this section;
      2. An LPR, parolee, or abused person, who is also an armed services member or veteran, or a family member of an armed services member or veteran, as described below:
         1. An active-duty member of the U.S. military, other than active-duty for training;
         2. An honorably discharged U.S. veteran;
         3. A veteran of the military forces of the Philippines who served before July 1, 1946, as described in Title 38 U.S.C. Section 107; or
         4. The spouse, unremarried widow or widower, or unmarried dependent child of an honorably discharged U.S. veteran or active-duty member of the U.S. military.

WAC 182-503-0525 Washington apple health -- Residency requirements for an institutionalized person.

Effective August 29, 2014.

1. An institutionalized person is a person who resides in an institution as defined in WAC 182-500-0050. The term "person" used in this section means an "institutionalized person" unless otherwise indicated. It does not include persons who receive services under a home and community-based waiver program. When a state is making a placement for a person in another state, the term institution also includes foster care homes, licensed as described in 45 C.F.R. 1355.20.
2. The agency must determine whether a person is capable of indicating their intent to reside in Washington state when deciding whether that person is a resident of the state. The agency determines that persons who meet the following criteria are deemed incapable of indicating intent to reside in the state:
   1. The person is judged legally incompetent by a court of law;
   2. A physician, psychologist or licensed medical professional in the field of intellectual disabilities has determined that the person is incapable of indicating intent; or
   3. The person is incapable of declaring intent due to a documented medical condition.
3. When a person is placed in an out-of-state institution by the agency, its designee or by a department of social and health services-contracted agency, the state arranging the placement is considered the person's state of residence, unless the person is capable of expressing intent and:
   1. Indicates a desire to change his or her state of residence; or
   2. Asks the current state of residence for help in relocating. This may include assistance in locating an institutional placement in the new state of residence.
4. If another state has not authorized the placement in the institution, as described in subsection (3) of this section, the agency or its designee uses one of the following criteria to determine the state of residence for a person who is age twenty or younger:
   1. The state of residence is the state where the parent or legal guardian is a resident at the time of the placement in the institution. To determine a parent's or legal guardian's place of residence, follow rules described in WAC 182-503-0520 for a noninstitutionalized person.
   2. The state of residence is the state where the parent or legal guardian currently is a resident if the person resides in an institution in that state.
   3. If the parents of the person are separated and live in different states, the state of residence is that of the parent filing the application.
   4. If the parental rights are terminated and the person has a legal guardian, the state of residence is where the legal guardian is a resident.
   5. If the person has both a guardian of the estate and a guardian of the person, the state of residence is where the guardian of the person is a resident, unless the state has laws which delegate guardianship to a state official or agency for persons who are admitted to state institutions. In that case, the state of residence for the person is the state where the institution is located (unless another state has authorized the placement).
   6. If the person has been abandoned by the parents or legal guardian, and an application is filed on their behalf by another party, the state of residence is the state where the person is institutionalized. The term abandoned also includes situations where the parents or legal guardian are deceased.
5. A person age twenty-one or older that is capable of indicating intent is considered a resident of the state where he or she is living and intends to reside.
6. A person age twenty-one or older who became incapable of indicating intent at age twenty-one or older is considered a resident of the state where the person is physically residing, unless the person has been placed in the institution by another state.
7. A person age twenty-one or older who became incapable of indicating intent before the age of twenty-one is considered a resident of the state where the parents or legal guardian were residents at the time of the placement in the institution.
8. If a noninstitutionalized person moves directly from another state to an institution in Washington state, it is not necessary for the person to establish residency in Washington state prior to entering the facility. The person is considered a resident if he or she intends to reside in the state unless the placement was made by the other state.
9. A person of any age who receives a state supplemental payment (SSP) is considered a resident of the state that is making the payment.
10. In a dispute between states, the state of residence is the state in which the person is physically located.