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

Effective January 23, 2021.

A child is eligible for Washington apple health with premiums if the child: Meets the requirements in WAC 182-505-0210 (1); Has countable income below the standard in WAC 182-505-0100 (6)(b); and Pays the required premium under WAC 182-505-0225 , unless the child is exempt under WAC 182-505-0225 (2)(c).

A child is not eligible for Washington apple health with premiums if the child: Is eligible for no-cost Washington apple health; Has creditable health insurance coverage as defined in WAC 182-500-0020 .

A child with creditable health insurance coverage may be eligible for Washington apple health with premiums if the child is eligible for either: 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 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 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 .

Clarifying information

Eligibility for medical assistance is now "delinked" from receipt of cash assistance. Assistance unit rules for MAGI-based eligibility for children is described in WAC 182-506-0010 . Assistance unit rules for Non-MAGI eligibility programs are found in chapter WAC 182-506-0015 .

For children who are not eligible for MAGI-based coverage under this section, refer to the following categories: SSI-related Medical for children who may meet SSI disability criteria services and are ineligible for any other medical program; Pregnancy for medical programs for pregnant individuals; Emergency Assistance: Alien Emergency Medical Program for an alien child who is related to a Medicaid program, including the aged, blind, and disabled; Long Term Care for children requiring nursing facility or home and community-based services; Medical Extensions for a family who has an increase in earned income, spousal support, or child support; Spenddown for a child, pregnant individuals, or an SSI-related child whose income exceeds program standards. They may be eligible to receive Medically Needy (MN) coverage.

Children found eligible for a categorically needy scope of care medical program are continuously eligible for Categorically Needy (CN) medical for 12 months regardless of changes; except for aging out of the program, moving out of state, incarceration, or death (See WAC 182-504-0125 ). The scope of coverage is identical for these programs regardless of the source of funding.

Apple Health for Kids

Newborn Medical (N10): See WAC 182-505-0210 (2). Newborns are automatically entitled to receive this CN Medicaid program through the end of month of their first birthday as long as: Their birthparent was eligible for medical (Apple Health or CHIP) on the day of delivery, including any retroactive eligibility determination. For MN spenddown pending on the day of delivery, spenddown was met with the labor and delivery expenses, and The newborn is a Washington State resident. It is important that a ProviderOne ID be obtained as soon as possible after the day of delivery to ensure there are no interruptions in coverage. Until the baby has their own ProviderOne ID: Birthparent is on fee-for-service: The newborn is covered under the birthparent's ProviderOne ID through the month that includes the baby's 60th day of life or until they are assigned their own ProviderOne ID. Birthparent is on managed care: The newborn is covered under the birthparent's ProviderOne ID through the month in which the 21st day of life occurs. If the newborn's eligibility begins in a month other than the month of birth, the eligibility worker may need to use the retro medical process to approve missing months of eligibility.

Apple Health for Kids CN coverage (N11/N31): See WAC 182-505-0210 (3). These children receive federal or state-funded CN Medicaid. Federally-funded children are enrolled in a managed care plan while state funded children remain fee-for-service.

Apple Health for Kids with Premiums CN Coverage (N13/N33): See WAC 182-505-0210 (4). These children receive federal or state funded CN medical, but are required to pay a premium see WAC 182-505-0225 . Federally-funded children are enrolled in managed care, while state-funded children remain fee-for-service.

Apple Health for Kids (MN) Medically Needy coverage (F99, S99, K99): See WAC 182-505-0210 (4). These children receive slightly less coverage than CN Medicaid and do not enroll in managed care. They must meet a spenddown before any services are paid. See Spenddown for more information.

Children's Institutional coverage (K01, K95, K99): See WAC 182-505-0210 (3) WAC 182-514-0230 through WAC 182-514-0265: These children are approved for medical assistance based on institutional rules once they reside or are expected to reside in an institution for 30 days or longer.

Children's Alien Medical Program (AMP) coverage (F99): See WAC 182-505-0210 (5): These alien children are eligible for MN coverage for emergency medical services only. Their coverage under F99 does not require an acute and emergent medical need to set up the spenddown.

Nonqualified children eligibility

Nonqualified children under age 19 with family income under 312% FPL are related to and approved for the appropriate Apple Health for Kids program not AMP.

Apple Health for Kids with Premiums

Apple Health for Kids with Premiums CN Coverage (N13/N33): See WAC 182-505-0210 (4). These children receive federal or state funded CN medical, but are required to pay a premium see WAC 182-505-0225 . Federally-funded children are enrolled in managed care, while state-funded children remain fee-for-service.

American Indian/Alaska Native children are exempt from the premium requirement.

Children who have access to coverage through PEBB/SEBB plan are eligible for Apple Health for Kids with Premiums. Children are NOT eligible for Apple Health for Kids with Premiums coverage (N13/N33) if they have other credible health insurance coverage through a private plan such as employer sponsored insurance.

Age

Children age 0-6 who are eligible for an Apple Health for Kids program will receive continuous eligibility through their sixth birthday month regardless of changes in household income. This also applies to children enrolled in a MAGI-based Long-Term Care medical program (K01).

Children age 6-18 who are eligible for an Apple Health for Kids program will receive twelve months of continuous eligibility from the date of application or renewal.

When an individual is an Apple Health recipient in the month of their twenty-first birthday and they receive active inpatient psychiatric treatment which extends beyond their twenty-first birthday, they remain eligible for CN or MN coverage under the family institutional medical program (K01, K95) until the date they discharge from the facility or until their twenty-second birthday, whichever happens first.

When an individual applies in the same month they reach the age limit for the specific program, they can still be approved for the month of application even though they may have already had their birthday.