200 Series Reason Code Protocols

Go to the reason code chart to link directly to a specific reason code or scroll through the list below.

On this page: 200-212 | 220-250 | 266-299

Reason code Reason code description WAC references - Classic Apple Health Free form text - Classic Apple Health WAC references - MAGI-based Apple Health Free form text - MAGI-based Apple Health 200 Noncitizen Medicaid Ineligibility (F-Track Only) You do not meet the citizenship requirements to receive federal Medicaid. You can get federal Medicaid only after living in the U.S. with legal status for five years or by becoming a naturalized citizen. For information on becoming a naturalized citizen visit the web at USCIS website about Naturalization . Healthplanfinder (HPF) - Noncitizen Medicaid - lawfully present but not met 5-year bar You don't meet the citizenship requirements to receive Washington Apple Health. You are ineligible for Medicaid for 5 years from your date of entry to the U.S. 182-503-0505 Need to specify which persons in AU do not meet citizenship requirements. 182-503-0535 201 Living Arrangement - Medical Assistance Due to your living arrangement, we do not consider you a member of the household. N/A Your living arrangement does not meet our requirements because (specify relevant requirement and how the individual's living situation does not meet that requirement). ( Note to users: This reason code is based on the valid value entered in the living arrangement field. 182-505-0210 182-505-0240 182-506-0015 182-507-0110 202 Citizenship / Alien Status Immigrant requirements have not been met to receive these benefits. HPF You do not meet the citizenship or immigration status requirements for Washington Apple Health. N/A If client submitted verification of immigration status: You do not meet the requirements because (specify relevant requirement and how client's immigration status does not meet that requirement). If client didn't submit verification of status: We can't determine if you meet our requirements because we do not have verification of your citizenship status. 182-503-0505 182-503-0535 182-505-0115 182-505-0210 182-505-0240 182-505-0250 182-508-0001 208 We don't have one of the following: A valid Social Security number (SSN) Proof of a recent application for an SSN N/A None required 182-505-0115 182-508-0001 182-503-0505 182-503-0515 None required 209 Failed Refugee Requirement Refugees and asylees must meet certain requirements to get benefits from this program. You do not meet the requirements. See WAC rule (Washington Administrative Code): N/A For refugees: You entered the United States on 00/00/00. (Specify why this doesn't meet the requirements.) or For asylees: You were granted asylee status on 00/00/00. (Specify why this doesn't meet the requirement.) 182-507-0130 182-507-0135 210 N/A You do not meet the residency requirements because (specify client individual facts showing why an individual is not considered a WA resident). 182-503-0505 185-503-0520 182-503-0525 None required 212 HPF No Relationship You do not meet the relationship criteria to apply for Washington Apple Health coverage for this individual 388-454-0005 388-454-0010 None Required

Reason code Reason code description WAC references - Classic Apple Health Free form text - Classic Apple Health WAC references - MAGI-based Apple Health Free form text - MAGI-based Apple Health 220 Failed Age Requirement - Medical You do not meet the age requirement for this program. See WAC rule (Washington Administrative Code): You must be __ to get benefits from this program. 182-508-0001 182-505-0210 182-505-0211 None required 225 Now Receiving SSI When you get SSI (Supplemental Security Income) you also get medical benefits from DSHS. You will get a letter telling you about SSI Medical. If you have questions, please call 800-562-3022. See WAC rule (Washington Administrative Code): HPF When you get SSI (Supplemental Security Income) you are eligible for health care coverage under the SSI program. You will get a separate letter telling you about SSI Medical. None Required 182-510-0005 None required 230 Verification You did not give us the information we asked for. We can't figure out if you are eligible without it. 388-472-0005 388-490-0005 On 00/00/00, I asked you to provide the following items by 00/00/00: List of items 235 Review Not Complete We did not get your review form. If we get it before the end of the month, we will reconsider our decision. If you have already sent it, let me know. See WAC rule (Washington Administrative Code): HPF You have not completed your renewal for Washington Apple Health. 388-434-0005 388-434-0010 388-492-0110 388-492-0100 388-492-0090 388-447-0070 None Required 182-504-0035 None required 244 Death We were notified that someone passed away. Please accept our condolences for your loss. HPF We were notified that someone passed away. Please accept our condolences for your loss. Washington Apple Health coverage has been closed for this person. N/A Specify the person who died. 182-503-0505 None required 245 No Eligible Household Members No one in your household meets the requirements to get assistance. See WAC rule (Washington Administrative Code): 388-400-0070 388-408-0005 388-408-0015 388-408-0020 388-408-0025 388-408-0035 388-408-0060 388-408-0070 388-492-0030 If no other reason code or letter: No one is eligible because (specify the requirement if not met. If more than one specifies the one that applies to all members or the one that primarily prevented eligibility). 182-503-0505 248 HPF Head of Household Not Eligible The person listed as the primary applicant on your Washington Apple Health coverage is no longer eligible. 182-503-0010 249 Healthplanfinder You already received health care coverage from another state this month. You can't get health care coverage from Washington and another state in the same month. 182-503-0505 182-505-0210 182-505-0115 182-505-0240 182-503-0520 182-503-0525 None required 250 Not Aged, Blind or Disabled - Medical You cannot get medical benefits under this program because you do not meet the rules set by the Social Security Administration (SSA). The rules say you must be age 65 or older, blind, or disabled. See WAC rule (Washington Administrative Code): None required 182-508-0001 None required

Reason code Reason code description WAC references - Classic Apple Health Free form text - Classic Apple Health WAC references - MAGI-based Apple Health Free form text - MAGI-based Apple Health 266 Noncooperation With TPL We did not get your form about other coverage for your medical bills. You cannot get medical benefits from DSHS until we have the information. Your children can still get medical assistance. See WAC rule (Washington Administrative Code): None required 182-503-0540 None required 275 No Longer Receiving SSI You no longer get SSI (Supplemental Security Income). 182-510-0005 182-510-0001 None required 276 DSHS doesn't define your medical condition as an emergency. HPF No Medical Emergency for AEM Your medical condition does not meet the emergency medical requirements for Washington Apple Health Alien Emergency Medical coverage. 182-507-0115 182-507-0110 182-507-0120 None required 279 QMB Start Date - Administrative Use Only None None required 280 Not Entitled to Medicare Part A DSHS cannot pay for your Medicare Part B premium because you are not eligible for Medicare Part A. If you have questions about your Medicare coverage, call your Social Security Office. See WAC rule (Washington Administrative Code): 182-517-0300 None required 281 Waiver Not Approved You need an approved plan of care before we can help pay for your care provider. See WAC rule (Washington Administrative Code): 182-515-1505 182-515-1510 182-515-1506 182-515-1511 We do not have a plan of care for your type of home or community based (HCB) program). 284 Failed To Meet Spenddown Requirement You didn't give us enough medical bills to meet your spenddown. You can reapply for medical at any time. See WAC rule (Washington Administrative Code): 182-519-0100 None required 288 Ineligible ESLMB Already Receiving MA You are not eligible for the Qualified Individual (QI-1) Program because you are receiving Medicaid Benefits. You are eligible for the State-funded Buy-In Program. We will pay for your Medicare Part A premiums, if you have any, as well as your Part B premiums, coinsurance, and deductibles. See WAC rule (Washington Administrative Code): 182-517-0300 None required 295 Dependent Has Creditable Medical Coverage (CHIP) Your child/children have other medical coverage. See WAC rule (Washington Administrative Code): HPF Your child/children have other creditable medical coverage. N/A 182-505-0215 None required 298 AU Stopped Employer Sponsored Health Care Coverage (CHIP) You stopped your employer sponsored health care coverage for your child/children. If you had a reason for stopping the coverage, contact us at Customer Service Support so we can determine if you meet the Good Cause reason for stopping the coverage. N/A 182-505-0215 None required 299 Premiums Not Paid (CHIP) You are losing CHIP coverage because you have not paid the premiums for 4 months or more. To keep CHIP, your past due premium must be paid before the ending date listed above. Mail your payment to the Office of Financial Recovery, PO Box 3951, Olympia, WA 98503. See WAC rule (Washington Administrative Code): N/A 182-505-0215 None required

300 Series Reason Code Protocols

Go to the Reason Code Link chart to link directly to a specific reason code or scroll through the list below. For ACES Procedures go to ACES Letters in the ACES User Manual.

On this page: 300-307 | 320-327 | 330-339 | 340-388

Reason code Reason code description WAC references - Classic Apple Health Free form text - Classic Apple Health WAC references - MAGI-Based Apple Health Free form text - MAGI-Based Apple Health 300 Nonpayment of Premium According to our records, you have not paid all required premiums. See WAC rule (Washington Administrative Code): None required 301 Exceeds Income Standard Your income is over the limit that is allowed for this program. See WAC rule (Washington Administrative Code): 388-478-0060 388-478-0055 388-450-0165 388-450-0162 388-450-0015 388-478-0090 The limit for your household size is $ __. 182-519-0050 182-505-0100 182-512-0010 182-517-0100 182-509-0001 306 Change In Unearned Income The amount of unearned income you get has changed. See WAC rule (Washington Administrative Code): 388-418-0020 388-450-0025 388-450-0162 182-512-0010 388-492-0020 388-492-0030 Your income from (source) has changed from $ __ to $ __. 307 Change In Gross Earned Income The amount of money that you earn has changed. See WAC rule (Washington Administrative Code): 388-450-0030 182-512-0010 388-418-0020 Your gross earned income has changed from $ __ to $ __.

Reason code Reason code description WAC references - Classic Apple Health Free form text - Classic Apple Health WAC references - MAGI-Based Apple Health Free form text - MAGI-Based Apple Health 320 Exceeds Gross Income Limit Your income is higher than the income limit for this program. See WAC rule (Washington Administrative Code): 388-450-0015 388-450-0165 388-478-0060 388-478-0090 The limit for your household size is $ __. 321 Change In Net Deemed Income The amount of income we consider available to you from an outside source has changed. See WAC rule (Washington Administrative Code): 388-450-0100 388-450-0105 388-450-0115 388-450-0120 388-450-0135 388-450-0155 388-450-0130 388-450-0150 388-450-0140 388-450-0160 388-450-0125 We are counting $ __ of (Name)'s income. 323 Change In Home Maintenance Exemption The income amount that you are allowed to keep to pay for home expenses is called a home maintenance allowance. Yours is changing because: You have been getting it for 6 months; Your doctor says you have to stay longer; or The amount of your home expense has changed. See WAC rule (Washington Administrative Code): 388-513-1380 Your home maintenance amount has changed because __. (add specific details, e.g. "Your rent has changed from $ __ to $ __. " Or "On __ (date) __ Dr. __ told us you can't return home before __ .") 327 Change In Recoupment We are taking a different amount from your benefits to repay an overpayment. See WAC rule (Washington Administrative Code): 388-410-0005 388-410-0010 388-410-0015 388-410-0030 None Required

Reason code Reason code description WAC references - Classic Apple Health Free form text - Apple Health WAC references - MAGI-Based Apple Health Free form text - MAGI-Based Apple Health 330 Lump Sum Your resources are over the limit for this month because of your lump sum payment. See WAC rule (Washington Administrative Code): 388-450-0245 388-470-0005 You got $ __ from __ on 00/00/00. Your countable resources are now $ __. Your resources cannot be more than $ __ (specify resource limit for household size). If the grant is suspended: We will be subtracting $ __ from next month's grant. This reduction is for one month only. If the grant is terminated: Your lump sum payment is more than the need standard for two months. You can reapply for a cash grant in (month). 332 Change In CPI Allowance Your Personal Needs Allowance (PNA) changed. See WAC rule (Washington Administrative Code): 388-513-1380 334 Your earned income is over the limit for this program 388-478-0035 The limit for your household size is $ __. 335 Change In Uncovered Medical Expense Allocation The amount you can use to pay medical expenses has changed. See WAC rule (Washington Administrative Code): 388-513-1380 The amount you can use to pay for the following medical expenses has changed: (Type of expense) from $ __ to $ __. 336 Change In CSMA / FMMA Allocation The amount we can allow for the maintenance of your family members at home has changed. See WAC rule (Washington Administrative Code): 388-513-1380 Your allocation changed from $ __ to $ __ because __. 339 Medical Extension Ends Your medical extension expired and we did not get your review form. If we get it before the end of the month, we will reconsider our decision. If you have already sent it, let me know. If your medical benefits stop and you decide that you still want them, you need to reapply. See WAC rule (Washington Administrative Code): 388-400-0035 182-523-0100 182-505-0115

Reason code Reason code description WAC references - Classic Apple Health Free form text - Classic Apple Health WAC references - MAGI-Based Apple Health Free form text - MAGI-Based Apple Health 340 QMB Ineligible - Client Is Not Institutional Related You are no longer eligible for assistance that pays for all or part of your Medicare costs and premiums. The department must count your income differently when you are no longer eligible for Long-Term Care Services, such as Nursing Facility Care, COPES or CAP/OBRA Services. See WAC rule (Washington Administrative Code): 388-450-0005 None Required 341 The state supplemental payment rate for all SSI recipients has changed. See WAC rule (Washington Administrative Code): 388-478-0055 None required 342 Medical coverage stopped because you are 3 months behind in premium payments. Medical can't start again until the premiums are paid. Premiums aren't required for a child who is pregnant, an American Indian or Alaska Native. If your family income decreases, medical coverage without a premium may be available. HPF Health care coverage stopped because you are three months behind in premium payments. Washington Apple Health with premiums coverage can't start again until the premiums are paid. 182-505-0225 None required 182-505-0225 None required 343 The amount of Third-Party Resources you get has changed. See WAC rule (Washington Administrative Code): 388-501-0200 The amount of your third party resource has changed from $ __ to $ __. 388 WA Fund CAP For Q1 Already Reached Washington gets a limited amount of money for the Qualified Individual (QI-1) Program. There are no more funds available for this year. You can reapply in December for next year. See WAC rule (Washington Administrative Code): 182-517-0300 None required

400 Series Reason Code Protocols

Go to the reason code chart to link directly to a specific reason code or scroll through the list below.

For ACES Procedures go to ACES Letters in the ACES User Manual.

Reason code Reason code description WAC references - Classic Medicaid Free form text - Classic Medicaid WAC references - MAGI-based Medicaid Free form text - MAGI-based Medicaid 401 Over resources: You have too many resources to get assistance right now. WAC 388-513-1350 WAC 388-470-0005 WAC 388-400-0070 Your resources cannot be more than $ __ (specify resource limit for household size). See the attachment for more information on how we figured out your resources. 410 You don't qualify for long-term care (LTC) services because the equity in your home is over the $500,000 limit. You may receive LTC services if we approve an undue hardship waiver. We approve hardship waivers when you can show that without LTC services: You will be deprived of housing, food, clothing or medical care. Your life or health will be endangered. Your request must: Tell us in writing the reason you need an undue hardship waiver. Be signed and returned within 30 days of the date of denial or termination of LTC services. Include the name, address and telephone number of the person writing the request. You may authorize your representative, guardian, or facility where you live to file an undue hardship waiver request for you. WAC 182-513-1350 WAC 182-513-1367 Explain the equity value we are counting and how we arrived at that number. 416 You have a penalty period because you gave something away or sold it for less than fair market value. You can only get benefits now if you prove you cannot pay for your housing, food, clothing, or health needs. WAC 388-488-0005 WAC 388-400-0070 Explain the equity value we are counting and how we arrived at that number 417 You transferred, gave away, or sold resources for less than fair market value. This is called uncompensated value. WAC 182-513-1363 WAC 182-513-1364 WAC 182-513-1365 None required 460 Payment standards are changing. You do not have administrative hearing rights based on a change in payment standards. WAC 388-478-0020 WAC 388-418-0020 None required

500 Series Reason Code Protocols

Go to the Reason Code Link chart to link directly to a specific reason code or scroll through the list below.

For ACES procedures go to ACES Letters in the ACES User Manual.

Reason code Reason code description WAC references - Classic Medicaid Free form text - Classic Medicaid WAC references - MAGI-Based Medicaid Free form text - MAGI-Based Medicaid 520 Change in Federal law There has been a change in the Federal law that regulates this program. None None required 182-518-0005 None required 525 No Eligibility Review Form - We haven't received your eligibility review or renewal form. HPF You have not completed your renewal for Washington Apple Health 388-434-0005 388-434-0010 388-492-0090 388-492-0110 388-492-0100 388-400-0070 None required 182-504-0035 None required 528 Eligibility Review Form incomplete The eligibility review or renewal form we received wasn't complete. HPF The renewal form that you sent to us was not complete. We need you to complete the form before we can determine your eligibility. 388-492-0110 388-492-0100 388-400-0070 388-434-0005 388-492-0090 You must return the completed form to us by 00/00/00 in order for your benefits to continue. 182-504-0035 None required 529 Termination/Denial due to nonpayment of premium Health coverage stopped for the children listed above because you are three months behind in premium payments. Washington Apple Health with premiums coverage can't start again until the premiums are paid. 182-505-0225 None required 531 Voluntary withdrawal for excess resources You withdrew your request for assistance because you have too many resources to get assistance right now. 388-513-1350 388-406-0050 None required 532 State-funded LTC - Program Full The state-funded long-term care services program is subject to caseload limits. The program is currently full. We aren’t enrolling new members at this time. See WAC rule (Washington Administrative Code): 182-507-0125 None required 534 Family Medical To 12-month medical extension Your cash benefits will stop because of earnings. Medical benefits for your family will continue under the Medical Extension Benefit program. You will get a separate letter to tell you about this program. See WAC rule (Washington Administrative Code): Not applicable Not applicable 535 Error in initial eligibility - Removed continuous tracking for child - For administrative use only None Specify the reason for termination and a WAC related to that reason. 538 TSOA Closure You can’t receive services under this program when you are eligible for certain Medicaid programs. See WAC rule (Washington Administrative Code): 182-513-1615 None required 542 We got your change report form. Some information is still missing. We sent you a letter telling you what you need to give to us. We did not get it. 388-418-0011 Specify what is missing. 544 Your bank didn't honor your premium payment. None None required 550 Voluntary withdrawal You withdrew your request for assistance. See WAC rule (Washington Administrative Code): HPF You withdrew your request for Washington Apple Health 388-406-0050 388-492-0020 None required 182-503-0080 None required 551 Whereabouts unknown We don’t know where you are. See WAC rule (Washington Administrative Code): 388-458-0030 388-492-0020 None required 182-518-0005 182-503-0520 182-503-0525 182-504-0105 552 Failed to provide verification You did not give us the information we needed. HPF You didn't give us the information we asked for. 182-503-0050 388-400-0070 388-472-0005 388-490-0005 388-458-0020 388-492-0020 On 00/00/00, I asked you to provide some information by 00/00/00. I still need: List of items 182-503-0050 __________??? 554 RCL Error in Initial Eligibility You didn’t meet Medicaid eligibility on the day of your discharge from a medical institution. See WAC rule (Washington Administrative Code): 182-513-1235 Describe the reason the client was not initially eligible for Medicaid. 555 Application opened in error - For administrative use only None None required 557 AU requests closure You asked us to stop your assistance. HPF You asked us to stop your Washington Apple Health coverage None None required 182-503-0080 None required 558 Failed to cooperate in securing other income and resources You have income or resources that you could use but you haven’t made a reasonable effort to get them. If there is a good reason why you have not done this, please tell us. See WAC rule (Washington Administrative Code): 388-400-0070 388-458-0020 388-472-0005 388-490-0005 388-492-0020 You told us that you have (type of income/resource). To become eligible, you must try to make it available by __ (specify what they must do to make income or resource available). 182-503-0050 559 Client already received assistance in another AU for this benefit month Although you can belong to more than one assistance unit, you can only get benefits from one at a time. 388-400-0005 388-400-0010 388-400-0025 388-400-0030 388-400-0040 388-400-0045 388-400-0060 388-400-0070 You are already getting medical assistance. 561 AU screened in error - System generated only None None required 562 Due to your child(ren)'s immigration status they do not qualify for Medicaid. The Children's Health Program is now full and your child(ren) are on a waiting list. When an opening occurs, you will be contacted to review family circumstances. See WAC rule (Washington Administrative Code) Specify which children. 182-505-0210 564 Noncooperation with TPL process You did not cooperate in obtaining another source of coverage for your medical care. See WAC rule (Washington Administrative Code): You told us that you could get help with medical from (specify TPL source). 566 Refused to cooperate with application process You refused to cooperate in the application process. Based on the information we have, we are unable to determine your eligibility. See WAC rule (Washington Administrative Code): HPF You have not cooperated with the application process. Based on the information we have, we are unable to determine your eligibility. 388-400-0070 388-406-0025 388-406-0035 388-406-0050 388-406-0060 388-452-0005 388-492-0020 388-406-0050 You did not __ . If you need help, let me know and I will try to assist you. 182-503-0080 572 User voided application - For administrative use only None None required 577 Missed application deadline - For administrative use only None None required 587 Already eligible for program in different AU - For administrative use only 388-408-0035 388-412-0005 The following persons aren't eligible for medical assistance for [MM/YYYY] because they already received medical assistance in another household: list name of ineligible persons NOTE: You may need to manually create a denial or termination letter or add text to the ACES system-generated letter. 588 Ineligible ESLMB already receiving MA You are not eligible for the ESLMB program because you are receiving Medicaid benefits. See WAC rule (Washington Administrative Code): You are not eligible for the Qualified Individual (QI-1) Program because you are receiving Medicaid Benefits. You are eligible for the State-funded Buy-In Program. We will pay for your Medicare Part A premiums, if you have any, as well as your Part B premiums, coinsurance, and deductibles. None required 182-517-0300 589 Based on your current medical information, you are no longer disabled under Social Security rules. See WAC rule (Washington Administrative Code): 388-511-1105 None required 590 You have a penalty period because you gave away a non exempt asset or sold it for less than fair market value. You, your representative or guardian, or with your consent, the facility where you live, may request an undue hardship waiver if you can show that without LTC services you will be deprived of housing, food, clothing or medical care and that your health or life will be endangered. The request must be: In writing State the basis for requesting the undue hardship waiver Be signed by the requestor and include the requestor's name, address and telephone number and Be made within 90 days of the date of denial or termination of LTC services. 388-513-1363 388-513-1364 388-513-1365 388-513-1367 Explain the amount of the transfer used to determine the penalty or penalties periods. Indicate the dates the penalty period starts and ends. 596 Failure to pursue Medicaid You aren't eligible for ABD cash or Housing and Essential Needs (HEN) Referral because you failed to pursue Medicaid. 388-400-0060 388-400-0070 (Social Service Specialist provides mandatory free form text via 14-118) 599 Other - For user generation only None None required (If used for ABD or HEN Referral denial or termination, Social Service Specialist provides mandatory free form text via 14-118)

600 Series Reason Code Protocols

Go to the Reason Code Link chart to find information regarding other series reason codes. This chart will be for codes 100 through 500.

Reason Code HCA Reason For Closure Washington Healthplanfinder Letters Text Washington Healthplanfinder Screen Text WAC References Forced Closure Code Required? 600 Due to incarceration You are not eligible for Washington Apple Health because you reported you are currently incarcerated. Not eligible for Washington Apple Health due to reported incarceration. 182-505-0210 182-505-0240 182-503-0505 182-505-0250 Yes 601 Due to residing in State hospital You are not eligible for Washington Apple Health because you are currently living in Eastern or Western State hospital and do not meet the age criteria for coverage. Not eligible for Washington Apple Health due to living in Eastern or Western State hospital and do not meet age criteria for coverage. 182-505-0210 182-505-0240 182-503-0505 182-505-0250 Yes 602 Not living in the household You are not eligible for Washington Apple Health because you are no longer living in the home. Not eligible for Washington Apple Health due to no longer living in the home. 182-506-0010 Yes 604 Other health insurance - Medicare You are not eligible for Washington Apple Health for Adults coverage because you have other health coverage through Medicare. Not eligible for Washington Apple Health due to other health coverage through Medicare. 182-505-0250 Yes 605 You must submit your own application You must submit your own application for Washington Apple Health coverage. Must submit separate application for Washington Apple Health due to age requirement. 182-503-0010 No 606 Age 65 or older You are not eligible for Washington Apple Health adult coverage because you are age 65 or older. Not eligible for Washington Apple Health due to age 65 or older. 182-505-0250 No

This section provides additional clarification regarding ACES coding for medical expenses for spenddown.

Medicare Part A, Part B, Part C, or Part D Premiums Copayments Coinsurance charges that are not covered under the Qualified Medicare Beneficiary (QMB) Medicare Savings Program (MSP) Deductibles

Premiums . Individuals typically pay premiums for Part B and Part D plans and sometimes for Part C plans. The charges are allowed towards spenddown as follows:

Allow premiums that the individual is or has been responsible to pay.

If S03, S05 or S06 is being approved to cover Part B premiums, allow the first two months premiums in the current base period.

Allow any premiums paid by the individual within the 3-month retroactive period if an MSP is not approved to cover this period. S05 or S06 can and should be approved for the retroactive period if requested – remember to notify the HCA Medicare Buy-In unit that you need retroactive coverage for Part B premiums.

Otherwise allow premiums as the expense is incurred.

Copayments . Individuals typically pay copayments for prescriptions under Part D, which vary depending on the drug and the Part D plan. These charges are allowed towards spenddown when the individual is responsible to pay for it. Medicaid only covers prescription drug costs for Medicare individuals if the drug is not covered by Medicare under the Part D plan but is covered by Medicaid.

Coinsurance . Individuals typically pay coinsurance charges under Parts A and B, which are generally 20% of the Medicare allowed charge. These charges are allowed towards spenddown unless the individual is also eligible for S03 coverage.

Example

An individual is on spenddown without QMB. Dr. Jones bills an individual $425. The Medicare allowed amount is $370 for this charge. Medicare pays 80% or $296 towards the bill, and the individual is legally obligated to pay the remaining 20% coinsurance amount of $74. Dr. Jones is not allowed to bill the individual for the remaining $55 -- the difference between $425 and the $370 that Medicare allowed. $74 is what is applied towards spenddown. The Explanation of Benefits (EOB) will show the allowed charges and the amount the individual is responsible for.

Deductibles . Individuals pay a standard deductible under Parts A and B, which are listed on the Washington Apple Health Income and resource standards chart . This amount is also typically shown on the individual's EOB. Deductibles are allowed towards spenddown unless the individual is also eligible for S03 coverage.

Private health insurance: Copayments (not premiums) Coinsurance charges Deductibles

Example

An individual has Regence Health insurance. He pays $15 copayment for each doctor’s visit and has a $250 yearly deductible to meet before coverage begins. The $15 copayment would be coded “CO” in ACES. He brings you an insurance statement showing that he had a hospital visit in January and he is responsible for the first $250 of the bill. This would also be coded as “CO” in ACES.

Private health insurance premiums

Do not code private health insurance premiums as "CO". Private health insurance premiums are coded on the MEDX screen, which reduces the total spenddown amount.

Certain expenses, such as: Transportation to medical appointments or to pick up prescriptions. Items prescribed by an allowable provider but not covered by Medicaid, such as hearing aids. Prior unpaid charges that were denied by HCA as an uncovered expense. Prescribed vitamins, supplements, or over-the-counter medications, such as prenatal vitamins Orthodontic or chiropractic treatments Laser eye surgery

It is not necessary to code the expenses of a nonapplying spouse or other household members as "MU" in order for ACES to treat their expenses as "uncovered". Code expenses for nonmembers the same as if the nonmember were applying for coverage based upon the expense type.

Inpatient or outpatient services provided in a hospital setting. This includes emergency room visits, physician charges for services provided in the hospital, lab fees, x-rays etc.

Use initial date of service

Always code hospital expense with the date the individual first entered the hospital. When reviewing hospital statements, use the initial date of service and not the statement date.

Any charges that are potentially payable by Medicaid, such as: Doctor’s visits Physical, speech or occupational therapy Specialist appointments Laboratory fees or X-rays Mental health services, etc.

See Scope of care for more information about services covered under the MN program. For questions regarding coverage for specific expenses, call the HCA Medical Assistance Customer Service Center at 1-800-562-3022.

Prescription pharmacy expenses for non-Medicare-eligible individuals.

Prescription drug name required

When entering an RX expense, it is a required field to enter the name of the prescription drug.

Enter each prescription separately – do not lump prescription drugs into one expense, even if paid for together.

Ensure the individual has provided a receipt showing payment and is not just providing a list of prescriptions they are waiting to fill.

Do not allow the following as prescription expenses:

Self-paid Medicare-covered drug. A Medicare eligible individual cannot choose to self-pay for a Medicare covered drug and then use the expense toward meeting a spenddown.

Prescription drug not on plan formulary. A prescription drug that is not on the individual’s Medicare Part D plan’s formulary cannot be allowed towards spenddown unless the individual has requested an exception from their plan and has received a written denial.

Prescribed items that are not pharmaceuticals.

This section describes the Achieving a Better Life Experience Act of 2014 (the ABLE Act) and its interaction with the Medicaid program. The establishment and use of an ABLE account enables certain individuals with disabilities to save money in tax-advantaged accounts, which they can later use for meeting their disability-related needs without affecting their Medicaid coverage.

Effective April 26, 2026

This rule describes a qualified achieving a better life experience (ABLE) account and its effect on the determination of eligibility for Washington apple health coverage.

A qualified ABLE account: Is established and maintained by a state, or its designated agency or entity; Meets federal requirements under 26 U.S.C. Sec. 529A; and Is used to save funds for the disability related expenses of the account's designated beneficiary.

This section applies to ABLE account beneficiaries who: Are entitled to benefits based on blindness or disability under Title II or XVI of the Social Security Act; or Meet the blindness or disability requirements under WAC 182-512-0050 (1)(b) and (c).

The disability or blindness described in subsection (2)(a) or (b) of this section must have occurred before age 46.

This section does not apply if the total combined annual contributions to an ABLE account exceed the limit under 26 U.S.C Sec. 529A.

When determining countable income for apple health programs for the account's designated beneficiary, the medicaid agency or the agency's designee does not: Count contributions made by a person other then the designated beneficiary to the ABLE account; Count funds distributed from the account; Count earnings generated by the account, such as accrued interest or dividends; or Reduce income used to determine eligibility by the amount of contributions made to the account, including any funds the designated beneficiary may contribute to it.

When determining eligibility for apple health programs, the agency or the agency's designee excludes as resources: The value of an ABLE account, including any earnings generated by the account; and Subject to subsection (8) of this section, distributions from the account for qualified disability expenses as long as the beneficiary: Maintains an ABLE account; Contributes to an ABLE account; or Receives distributions from such ABLE account.

"Qualified disability expense (QDE)" means any expense related to the beneficiary's blindness or disability that is made for the benefit of the beneficiary, including the following expenses: Education; Housing; Transportation; Employment training and support; Assistive technology and personal support services; Health; Prevention and wellness; Financial management; Legal fees; Expenses for oversight and monitoring; and Funeral and burial expenses.

Distributions under subsection (6)(b) of this section, which are retained into a subsequent calendar month: Remain excluded as resources as long as the distributions are identifiable and the beneficiary still intends to use the distribution for a QDE; Are available resources on the first day of a subsequent calendar month if the intent of the beneficiary changes such that the beneficiary will not use the distribution for a QDE; and Are available resources on the first day of any subsequent month when the distribution is actually used for a non-QDE.

The agency or the agency's designee counts as a resource on the first day of the following month any funds distributed for purposes other than paying a QDE expense described in subsection (7) of this section.

If the beneficiary has multiple ABLE accounts, the agency or the agency's designee applies this section to the first ABLE account established.

Funds remaining in the ABLE account when the beneficiary dies are subject to estate recovery under chapter 182-527 WAC, less any: Outstanding QDE debts; and Premium payments made from the ABLE account on behalf of the beneficiary to obtain coverage under the apple health care for workers with disabilities described in WAC 182-511-1000.

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 .

The ABLE Act amended the Internal Revenue Code of 1986 to create section 529A (“Qualified ABLE Programs”), permitting states to establish ABLE programs within which people with disabilities can open accounts that will generally be exempt from taxation. The purpose of the ABLE Act is to permit people with disabilities to save money in and withdraw funds from their ABLE accounts to pay for disability-related expenses, in support of their efforts to maintain health, independence and quality of life. The law states that ABLE accounts should “supplement, but not supplant” benefits available to ABLE account beneficiaries under Medicaid, the Supplemental Security Income program (SSI), and other programs.

Section 103 applies to individuals who have an ABLE account in a qualified ABLE program. Eligibility for an ABLE account is open to an individual of any age who has blindness or a disability, provided, however, that the individual’s blindness or disability occurred before the age of 26. An individual is permitted to have only one ABLE account. The individual may open the account in the program of the state of which the individual is a resident, or in another state’s ABLE program. The determination of eligibility for an ABLE account is the responsibility of the ABLE program in which an individual seeks to establish the account.

Under section 102(a) of the ABLE Act ( codified at 26 U.S.C. §529A(e) ), an individual is eligible for an ABLE account if the individual is receiving SSI or Social Security Disability Insurance (SSDI) benefits based on a disability or blindness that occurred before age 26. Alternatively, an individual (or a parent or guardian acting on the individual’s behalf) may establish eligibility by filing a disability certification (and obtaining a signed physician’s diagnosis) with the qualified ABLE program indicating that the individual has a medically determinable impairment meeting certain criteria that occurred before age 26. However, while sufficient to establish eligibility to participate in an ABLE program, section 102(a) of the ABLE Act provides that “no inference” may be drawn from a disability certification for purposes of establishing eligibility for Medicaid.

For MAGI and SSI-based eligibility determinations, under section 103, third party contributions to an ABLE account are disregarded in determining Medicaid eligibility. This is different from the treatment of such contributions in determining financial eligibility using SSI-based methodologies and, in narrow circumstances, different from the treatment of such contributions under MAGI-based methodologies.

Under SSI-based methodologies, applied to most non-MAGI eligibility groups, money contributed by a third party to an account which an individual can access generally is considered countable income in the month in which the contribution is received and, if not spent, a resource in the month following. Per section 103, however, third party contributions to an ABLE account are not either counted as income or included in total resources of the account beneficiary.

Some ABLE account beneficiaries may also be a beneficiary of a special needs trust (SNT) or pooled trust, as described in section 1917(d)(4) of the Act. Distributions from such trusts made on behalf of the trust beneficiary to the beneficiary’s ABLE account should be treated the same as contributions to ABLE accounts from any other third party. While disbursements from an SNT or pooled trust can be considered in some circumstances as income to the trust beneficiary, disbursements from an SNT or pooled trust to the ABLE account of the trust beneficiary are not counted as income under section 103. Therefore, states should disregard as income a distribution from an SNT or pooled trust that is deposited into the ABLE account of the SNT or pooled trust beneficiary.

Designated beneficiaries of an ABLE account can contribute their own income or resources to their ABLE account. If an ABLE account beneficiary transfers some of his or her own (otherwise countable) resources to his or her ABLE account, the effect would be a corresponding reduction in total countable resources. By contrast, if a beneficiary of an ABLE account transfers some of his or her income in the month received to his or her ABLE account, the effect would not be a reduction in countable income. This is because how an individual uses income generally does not change its designation as income at the point of its receipt, and there is nothing in the ABLE Act that supersedes this general rule.

A third party who has contributed to an ABLE account of someone else may apply for Medicaid and seek coverage of long-term services and supports (LTSS). Section 103 of the ABLE Act does not provide for any special treatment of contributions made to an ABLE account benefiting another person. For example, a contribution from a grandfather to the ABLE account of his grandchild, whether from the grandfather’s income or resources, would constitute a transfer of assets from the grandfather to his grandchild’s account. The transfer may need to be evaluated under the requirements in section 1917(c)(1) of the Act (depending on when the transfer occurred), if the grandfather subsequently seeks Medicaid coverage of LTSS. The amount transferred by the grandfather to his grandchild’s ABLE account would not be an exempt transfer by virtue of section 103 in the determination of the grandfather’s eligibility for Medicaid coverage of LTSS.

Like funds in and contributions to ABLE accounts, distributions from ABLE accounts are not included in the beneficiary’s taxable income or counted as income in eligibility determinations for federal programs such as Medicaid as long as they are used for “qualified disability expenses” (QDEs). Section 529A(e)(5) of the Internal Revenue Code broadly defines QDEs as any expenses related to the eligible individual’s blindness or disability which may include, but are not limited to, expenses incurred for education, housing, transportation, employment training and support, and assistive technology.

For individuals whose financial eligibility is determined using SSI-based methodologies, receipt of cash from a resource, whether the resource itself is counted or excluded, generally is not considered to be income, but rather the conversion of a resource from one form to another. The protection afforded under section 103, however, does not require that distributions from an ABLE account be used within the month the distribution is made, or within any particular timeframe. Accordingly, a distribution from an ABLE account may be countable as a resource only if (1) it is retained beyond the month in which the distribution is made and (2) it is used for something other than a QDE in that or a subsequent month. Section 103, then, means that ABLE account distributions retained after the month of receipt are disregarded unless used for a non-qualifying expense.

Example

If an SSI-based individual receives an ABLE account distribution in August, but does not spend the distribution until December (and uses the distribution for a QDE in that month), the amount of the distribution is not counted in any month. If the individual uses the distribution in December for a non-QDE, the distribution would be counted as a resource in the month of December.

Typically, all income is taken into account for purposes of post-eligibility treatment of income (PETI), including types or amounts of income that are not counted in making an initial eligibility determination. Distributions from an ABLE account that are used for a QDE, however, are disregarded when determining countable income for purposes of PETI.

The ABLE program that administers the program is responsible for facilitating an accurate determination of eligibility for an ABLE account. They also are involved in the process of the account holder’s use of funds in an ABLE account for qualified disability expenses (QDEs). Eligibility staff are not responsible for obtaining documentation of a client’s ABLE account, and will not monitor them for potential impact(s) on eligibility. If it becomes known that a client did not use funds withdrawn from their ABLE account for a QDE, the value amount is not counted retroactively. It would be counted only if it is anticipated and after advance notice could be given. There is no requirement that the client provide a copy of their ABLE account for the determination or renewal for eligibility. If one is received, see information on notifying the Office of Financial Recovery below.

Should staff receive a copy of a client’s ABLE account, notify Ken Washington of OFR via a Barcode tickler when any ABLE Account is imaged in the electronic case record. Set up the following DMS tickler:

Document type for tickler: TD

Subject: ABLE account

Site: 101

User: WAKE

Ready date: Default date is fine

Make sure the ABLE account is indicated on the appropriate person’s resource screen in ACES. Add in the remarks that OFR has been notified of the account in the ECR. An ABLE account is an excluded resource, but if the state files a claim, any amount remaining in the account is subject to estate recovery.

More information can be found on the Washington State ABLE Savings Plan website .

To describe the Address Confidentiality Program (ACP), run by the Office of the Secretary of State.

The ACP program is in place to protect the address of survivors of domestic violence, sexual assault, stalking or trafficking. Participants use a substitute address in place of their actual physical or mailing address.

Rules for the Address Confidentiality program are found in WAC 434-840-001 through WAC 434-840-310 and are governed by the Office of the Secretary of State.

The ACP provides the following services to victims of domestic violence, sexual assault, trafficking, or stalking:

Helps the participant maintain the secrecy of home, work, or school address.

Provides the participant a substitute mailing address.

Forwards first class mail from the substitute address.

Helps the participant obtain many state and local agency services without revealing the physical or mailing address.

Helps the participant to register to vote or obtain a marriage license without having those records available to the public.

Participants are given a laminated authorization card the size of a driver license. The card has the individual's signature, substitute address, expiration date, and a toll-free number to the ACP office for information. The toll-free number is 1-800-822-1065. The TTY number is 1-800-664-9677 (toll free).

When an individual states they are enrolled in ACP and have an assigned Private Mail Box (PMB) address:

If the individual is currently certified in the ACP: Use the ACP mailing address and participant code number (PMB number) as shown on the card in place of the individual's physical address on the ACES address screen or in Washington Healthplanfinder. Example: Jane Doe 1453 (PMB number) PO Box 257 Olympia, WA 98507-0257 Mail all correspondence for the individual to the substitute address. Do not ask the individual to provide their actual address. Do not record the individual's physical address in Automated Client Eligibility System (ACES) Online, Barcode, Healthplanfinder (HPF) or Customer Service Application (CSA) or retain copies of any documents that list the individual's physical address. When verifying residency, household composition, or shelter costs, do not ask the individual to provide documents that state their physical address. Accept any document that lists the ACP address and reasonably verifies the eligibility factor. See verification for instructions on determining reasonableness . If the individual provides a document that lists the physical address: Do not keep the document. Explain to the individual that if we have anything in the case record that lists their physical address, we may have to reveal that information if we are issued a subpoena. Document in the narrative: What documents were used as verification. What eligibility factor the documents verify; and Why copies of the document are not in the record. Allow the individual to provide any document that has the physical address concealed.

If the individual is not currently certified in the ACP: Do not enter the ACP mailing address and participant code into ACES. Require the individual to provide a current mailing address. Record the address in ACES or Washington Healthplanfinder; and Follow the normal verification procedures as described in Verification .

Verification of active ACP participant

If the individual's enrollment in ACP is questionable or we get returned mail from their ACP address, government agencies may call the ACP office at 360-753-2972 to verify that the individual is an active ACP participant.

To clarify the different types of orders and decisions that may be issued during an administrative hearing on eligibility for Apple Health programs.

Effective September 27, 2021

Unlike a prehearing meeting, a prehearing conference is a formal proceeding conducted on the record by an administrative law judge (ALJ) to address issues and prepare for a hearing. The ALJ must make an audio record of the prehearing conference. An ALJ may conduct the prehearing conference in person, by telephone, or in any other manner acceptable to the parties.

All parties must attend the prehearing conference. If the party who requested the hearing does not attend the prehearing conference, the ALJ may enter an order of default and an order dismissing the hearing.

The ALJ may require a prehearing conference. Any party may request a prehearing conference.

The ALJ must grant the appellant's, and may grant the managed care organization's or the agency representative's, first request for a prehearing conference if it is filed with the office of administrative hearings (OAH) at least seven business days before the scheduled hearing date.

When the ALJ grants a party's request for a prehearing conference, the ALJ must continue the previously scheduled hearing when necessary to comply with notice requirements in this section.

The ALJ may grant additional requests for prehearing conferences.

The office of administrative hearings (OAH) must schedule prehearing conferences for all cases which concern: The department's division of residential care services under Title XIX of the federal Social Security Act. Provider and vendor overpayment hearings. Estate recovery and predeath liens.

During a prehearing conference the parties and the ALJ may: Simplify or clarify the issues to be decided during the hearing; Agree to the date, time, and place of the hearing; Identify any accommodation or safety issues; Agree to postpone the hearing; Allow the parties to make changes in their own documents, including the notice or the hearing request; Agree to facts and documents to be entered during the hearing; Set a deadline to exchange names and phone numbers of witnesses and documents before the hearing; Schedule additional prehearing conferences; Resolve the dispute; Consider granting a stay if authorized by law or program rule; or Rule on any procedural issues and substantive motions raised by any party.

After the prehearing conference, the ALJ must enter a written order describing: The actions taken at the prehearing conference; Any changes to the documents; A statement of the issue or issues identified for the hearing; Any agreements reached; and Any ruling of the ALJ.

OAH must serve the prehearing order on the parties at least fourteen calendar days before the scheduled hearing.

A party may object to the prehearing order by notifying OAH in writing within ten calendar days after the mailing date of the order. The ALJ must issue a ruling on the objection within five days from the date a party files an objection.

If no objection is made to the prehearing order, the order determines how the hearing is conducted, including whether the hearing will be in person or held by telephone conference or other means, unless the ALJ changes the order for good cause.

The ALJ may take further appropriate actions to address other concerns raised by the parties.

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 .

Effective March 16, 2017

A notice of hearing or a notice of prehearing conference is a written notice issued by the office of administrative hearings (OAH) that must include the: Names of all parties to whom the notice is sent and, if known, the names and addresses of their representatives; Name, mailing address, and telephone number of the administrative law judge (ALJ), if known; Date, time, place, and nature of the hearing or prehearing conference; Legal authority and jurisdiction for the hearing; and Date of the hearing request. A notice of hearing or prehearing conference must include a statement that the appellant's failure to attend the prehearing conference or hearing may result in the loss of the right to a hearing. If the appellant fails to appear, the ALJ may enter an order of default.

Limited-English proficiency. The notice must include a statement that, if the appellant needs a qualified interpreter because they or any of their witnesses are people with limited-English proficiency, OAH will provide an interpreter at no cost to that party.

The notice must state whether the hearing or prehearing conference is to be held by telephone or in person, and how to request a change in the way it is held.

The notice of hearing or prehearing conference informs the appellant: How to indicate any special needs for the appellant or their witnesses, including the need for an interpreter in a primary language or for sensory impairments; How to contact OAH if a party has a safety concern; and That the appellant may request a qualified interpreter if the appellant or any of the appellant's witnesses are people with limited-English proficiency, and that OAH provides such interpreters at no cost to the appellant.

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 .

Effective January 5, 2018

Any party may request a continuance under this section either orally or in writing.

Before contacting the office of administrative hearings (OAH) to request a continuance, the party seeking the continuance must make a good faith effort to contact the other parties to find out if they agree to a continuance. The party making the request for a continuance must let OAH know whether the other parties agreed to the continuance.

Standard when less than sixty days . When a continuance request is made less than sixty days from the date OAH received the hearing request: If all parties agree to the continuance, the ALJ must grant the request unless the ALJ holds a prehearing conference and finds that good cause for a continuance does not exist under WAC 182-526-0020 . If the parties do not agree to the continuance, the ALJ must schedule a prehearing conference and determine if good cause for a continuance exists under WAC 182-526-0020 and under the following factors: Why the party is requesting a continuance; Why the other party or parties are objecting to the request; Whether a continuance in the case has previously been granted at the request of the same party who is now requesting the continuance and, if so, whether it was for the same reason; The extent to which the requesting or objecting parties could have prevented the need for delay; The number and duration of previous continuances in the case and who requested them; The legal or factual complexity of the case; The relative harm to the parties if the continuance is granted or denied, including the risk of harm to the appellant if he or she is not receiving continued benefits; The impact of a continuance on the parties' ability to adequately prepare and present their cases; Any need to provide accommodation, translation, or interpreter services; and The impact of a continuance on the ability of OAH to issue a timely initial decision; or Other relevant factors.

Standard when sixty days or greater . When a continuance request is made sixty days or more from the date OAH received the hearing request: The ALJ must not only consider whether there is good cause to continue the hearing but also must find a compelling reason for the continuance. Compelling reasons include: Medical evidence is required; Extraordinary circumstances exist, such as the sudden unforeseen onset of an illness or adverse event that was beyond the party's ability to prevent; The hearing format changes or the ALJ finds a compelling reason to change the way a witness appears at the hearing according to WAC 182-526-0360 ; The appellant needs more time to prepare or present evidence or argument because the agency issued an amended notice under WAC 182-526-0260 ; The need for more time was caused by another party's action or inaction, considering the relative capacity and resources of the parties; The need to provide accommodation, translation, or interpreter services; A party received notice of the date or deadline thirty days or more after OAH received the hearing request; Whether the continuance is needed to allow for effective assistance of counsel of record; or Other compelling reasons.

The ALJ must notify all parties whether a continuance was granted or denied orally on the record, or must do so in writing within five business days of the prehearing conference.

If the ALJ grants a continuance, OAH must serve a new notice of hearing on the parties at least fourteen calendar days before the new hearing date, unless the parties agree to a shorter time period.

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 .

Effective August 18, 2018

An order of dismissal may be entered when the appellant withdraws the request for hearing under WAC 182-526-0115 .

An appellant may file a petition (request) to vacate an order of dismissal under WAC 182-526-0290 .

An order of dismissal becomes a final order by operation of law, disposing of the appellant's request for a hearing under RCW 34.05.440 if: The appellant fails to appear at a prehearing conference scheduled to address the petition to vacate under WAC 182-526-0290 (3) and (4) (a).

The health care authority or managed care organization action stands after an order of dismissal becomes a final order.

The appellant may seek judicial review of a final order of dismissal to the superior court under WAC 182-526-0640 .

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 .

Effective March 16, 2017

In an initial order, the administrative law judge (ALJ) must:

Identify the matter as a health care authority appeal;

List the name and docket number of the case and the names of all parties and representatives;

Make findings concerning the facts used to resolve the dispute based on the hearing record;

Explain how the ALJ determined that evidence is credible or not credible when the facts or conduct of a witness is questioned;

State the law that applies to the dispute;

Apply the law to the facts of the case in the conclusions of law;

Discuss the reasons for the decision based on the facts and the law;

State the result and remedy ordered;

Explain how to request corrections to the initial order or petition for review by the board of appeals (BOA) and provide the deadlines for such requests;

State the date the initial order becomes final according to WAC 182-526-0525 ; and

Include any other information required by law or program rules.

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 .

Effective March 16, 2017

An initial order becomes a final order at 5:00 p.m. on the twenty-first calendar day after the office of administrative hearings (OAH) serves the initial order, unless:

Any party files a request for review of the initial order within twenty-one calendar days of the serving (mailing) of the initial order in accordance with WAC 182-526-0580 (1);

Any party files a request for extension of the deadline for filing a request for review which is granted by the review judge under WAC 182-526-0580 (2); or

Any party files a late request for review which is accepted by a review judge in accordance with WAC 182-526-0580 (3);

A managed care enrollee requests review by an independent review (IR) organization in accordance with RCW 48.43.535 prior to the initial order becoming final or a final order being entered by a review judge. See WAC 182-526-0200 for enrollee appeals.

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 .

Effective February 1, 2013

If a party disagrees with an administrative law judge's (ALJ) initial order because of a clerical error, the party may ask for a corrected initial order from the ALJ as provided in WAC 182-526-0540 through 182-526-0555 .

If a party disagrees with an initial order for a reason other than a clerical error and wants the initial order changed, the party must request review by a review judge as provided in WAC 182-526-0560 through 182-526-0595 .

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 .

Effective March 16, 2017

If a party does not agree with the final order and wants it reconsidered, the party may request the review judge to reconsider the decision.

The party must make the request in writing and clearly state why the party wants the final order reconsidered. The party must file the written reconsideration request with the BOA and it must be received by the deadline under WAC 182-526-0620 .

The party should send a copy of the request to all other parties or their representatives.

After receiving a reconsideration request, BOA serves a copy to the other parties and representatives and gives them time to respond.

The final order or the reconsideration decision is the final HCA decision. If a party disagrees with that decision, the party must petition for judicial review to change it.

If a party asks for reconsideration of the final order, the reconsideration process must be completed before a party requests judicial review. However, the party does not need to request reconsideration of a final order before requesting judicial review.

The party may ask the court to stay or stop the HCA action after filing the petition for judicial review.

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 .

The clarifying information on this page applies to eligibility decisions for Apple Health programs.

An administrative law judge (ALJ) is an impartial decision-maker who is an attorney and presides at an administrative hearing. ALJs are employed by the Office of Administrative Hearings (OAH), which is a separate state agency, as defined in RCW 34.05.010. ALJs are not Department of Social and Health Services (DSHS) or Health Care Authority (HCA) employees or representatives.

An appellant is a person or entity who requests a hearing about an action of HCA or its designee.

The hearing record is the official documentation of the hearing process. The record includes recordings or transcripts, admitted exhibits, decisions, briefs, notices, orders, and other filed documents.

Find out what the Office of Administrative Hearings (OAH) does in the appeals process.

Prehearing meeting ( WAC 182-526-0175 ): This is an informal meeting between HCA and the appellant and does not involve the ALJ. It can take place by phone, email, or in-person. The purpose is to:

Clarify the issue(s).

Exchange information.

Resolve any issues through an agreement or withdrawal.

Explain any rules or laws and answer questions.

Notice of hearing ( WAC 182-526-0255 ): This is a formal notice of the date, time, and location of the administrative hearing. This notice is sent to all parties, including the appellant and all agencies involved, such as HCA, DSHS (if the hearing is about a Classic Medicaid case), and OAH. It includes:

A copy of the request for an administrative hearing

Contact information for the parties

The docket numbers,

A summary of the appellant's legal rights

A referral to potentially free legal resources that are available.

Prehearing conference ( WAC 182-526-0195 ): This is a formal notice of a meeting mailed to all parties and includes HCA, the appellant, and an ALJ. This can be used to: Clarify any issues Set deadlines, Agree to a continuance, Resolve the dispute, Determine eligibility for continued coverage, Address other issues. If the appellant fails to show, the ALJ may issue an order of default and dismiss the hearing.

Order of dismissal ( WAC 182-526-0285 ): This is an order issued by an ALJ when an appellant withdraws the hearing request or does not appear for the hearing. The most common reasons for an order of dismissal are:

Default/no show: The appellant fails to appear.

Withdrawal: The appellant withdrew their request for hearing.

An appellant can request in writing that an Order of Dismissal be vacated (i.e., canceled) or set aside (see WAC 182-526-0290). A prehearing conference is scheduled. The ALJ issues a written order which will explain whether the appellant has established good cause (see WAC 182-526-0020) to have the hearing reinstated. If the ALJ determines good cause exists to vacate the dismissal order, the ALJ schedules a hearing.

Order of Continuance ( WAC 182-526-0280 ): A continuance is a rescheduling of a hearing to a later time or date. If a party would like a continuance, the party must see if the other parties agree. If so, an order of continuance is issued by OAH. If any of the other parties disagrees with the continuance, a prehearing conference is held. The ALJ either approves or denies the continuance request after the conference.

Initial decision ( WAC 182-526-0520 to WAC 182-526-0595 ): The decision issued by the ALJ who presided at the hearing. The initial decision becomes the final decision if it is not appealed by either party within 21 calendar days after OAH mails the order. The ALJ who conducted the hearing is responsible for writing the initial decision and mail a copy to all parties. The order will:

List all parties, witnesses, and exhibits (evidence).

Determine the facts of the case.

Explain why evidence or a witness is or is not credible.

State the applicable laws and rules that apply to the issue.

Discuss the reasons for the decision and how the laws apply to it.

State the result and remedy being ordered and

Explain the appeals process.

Request for Reconsideration ( WAC 182-526-0560 to WAC 182-526-0635 ): When the ALJ issues an initial order, any party may request the ALJ to reconsider the decision. The request for reconsideration must be received by OAH on or before the 10th calendar day after the initial order was mailed. The ALJ can only consider evidence that was presented in the hearing unless the ALJ reopens the hearing record (see WAC 182-526-0500 ). The ALJ will issue a written order in response to the request for reconsideration.

Judicial Review ( WAC 182-526-0640 to WAC 182-526-0650 ): Only the appellant has the right to request a judicial review of the final agency decision in superior court. Instructions regarding requesting judicial review are attached to the initial decision.

When a decision is received, document in the ACES narrative the docket number, the type of decision, and the date of mailing. Include any other information necessary, including the outcome of the hearing.

Default/no show: If the hearing notice was sent to the appellant's reported address and the appellant failed to appear:

Document the ACES narrative, and

File the decision with any related documents in the case record.

Hearing notice sent to address other than appellant's address

If the hearing notice was sent to an address other than the appellant's reported address or there is some other reason that the notice of hearing was not properly delivered, contact the OAH and provide the correct address or other information needed to deliver the notice.

Document the ACES narrative and send the decision, with the request for withdrawal and any other related documents, to be imaged into Barcode.

When the agency's decision is reversed, immediately:

Review the decision to determine if a request for reconsideration is needed. If so: Document in ACES the reason for the request for reconsideration. Send the request to OAH with a copy to the appellant.

If no request for reconsideration is needed: Reopen or approve coverage back to the date the action took place. Document the actions and decision and Send a letter to the household advising them of the hearing outcome and action taken to approve coverage.

When the agency's decision is affirmed, immediately:

Terminate continued coverage. Adequate notice must be provided to the appellant, but advance notice is not required.

Review the period of continued coverage, and establish overpayments as appropriate.

Document in ACES the decision.

After implementing the initial decision, determine if a review is appropriate:

Consult with a supervisor, administrator, or program manager, as appropriate.

Consult with training or program management staff (i.e., Office of Medicaid Eligibility and Policy), if necessary.

If the decision is made to petition for a review of the initial decision, prepare a memorandum for the Board of Appeals. Include:

Appellant's name and docket number.

All areas in which the agency believes the ALJ erred. See WAC 182-526-0575 for the review standard. The review judge usually only addresses areas that have been raised in the petition. Refer to findings of fact and conclusions of law by the number assigned in the decision.

Cite WACs, findings of fact, or evidence in the record that support the agency's argument.

New evidence which affects the decision and was not available for the initial hearing (even after reasonable diligence) can be brought up in the review.

A request for the review judge to find in the agency's favor.

Ensure the review is sent to the Board of Appeals and all other parties within the stated deadlines.

Do not reinstate continued coverage pending a review of the initial decision requested by the appellant.

Review the appellant's petition to determine an appropriate response.

If a response is required, prepare a memorandum to the Board of Appeals and include: The appellant's name and the docket number. A response which speaks only to the issues raised by the appellant. Argument which supports the finding in the initial decision.

Ensure the response is sent to the Board of Appeals and all other parties within the stated deadlines.

Implement the review decision immediately.

See WAC 182-526-0605 to determine if a request for reconsideration is appropriate.

If a reconsideration is appropriate, prepare a memorandum to the Board of Appeals including the specific reason why the department does not agree with the review decision.

This section gives a listing of allowable medical or remedial services and expenses that are allowed to reduce participation or used in MN spenddown. This is not a complete list, but an aid to use when determining whether a claimed medical expense is allowed to reduce participation or used to meet spenddown.

Away from home lodging costs related to medical treatment

Blood and its derivatives

Community case management in support of medical services or care

Cost of, or payments if rental or purchase contract for durable medical equipment, including aids to mobility, rehabilitative aids, prosthetic/orthotic devices, and Electronic Emergency Response Systems (EERS)

Food and other expenses for a medically necessary service animal

Hearing aids and related supplies

Hospital services, emergency room, clinic (including mental health clinics) and nursing facility expenses

In-home nursing care if need is documented with a physician's statement

Insulin and its necessary administration devices

Other services prescribed by an allowable medical practitioner

Out of State billings for medical services recognized under Washington State law

Oxygen

Medical/dental insurance deductibles and coinsurance charges incurred during the base period

Medically necessary improvements to the home to accommodate a disabled person

Medical supplies (e.g. syringes, adult diapers, etc.) and drugs, including OTC drugs prescribed by an M.D., D.O. or A.R.N.P.

Medical transportation by other means (e.g. bus, taxicab/rideshare, etc.) at the actual fare or fee. May include parking fees

Medical transportation by personal vehicle at the current state reimbursement rate

Remedial care such as dialysis helpers

Commercial diet clinics and gyms

Dietetics

Food, health food and nutritional supplements, unless prescribed

Health camps or retreats

In-home cooking/cleaning services

Massage Therapy, unless prescribed (must be provided by licensed practitioner)

OTC drugs and medications not prescribed, including medical cannabis, even if it is prescribed

Out-of-state billings for medical services not recognized under Washington State law

Physical fitness aids unless prescribed for medical services

Property maintenance

Services obtained out of the US

Telephone charges

Trips or retreats

Unpaid LTC participation incurred while active on an institutional Medicaid program

Eligibility for individuals in an alternate living facility

When an individual lives in an alternate living facility (ALF) and pays privately to the facility for their care, these charges are not considered a medical expense and cannot be allowed towards meeting spenddown. See WAC 182-513-1205 for rules on how to determine Medicaid eligibility for an individual who is living in a licensed, state contracted alternate living facility.

Allowable medical expenses is a chart that describes the allowable medical and remedial services allowed to reduce participation in post eligibility for long term care.

This section gives a listing of allowable medical or remedial services and expenses that are allowed to reduce participation or used in MN spenddown. This is not a complete list, but an aid to use to determine whether a claimed medical expense is allowed to reduce participation or used to meet spenddown.

WAC 182-513-1350 (6) (b) gives the criteria for allowable medical expenses used to reduce excess resources. DDA waivers , HCS CN waivers , hospice, and participation rules point to this WAC for allowable out-of-pocket medical expenses.

Premiums, deductibles, and coinsurance/copayment charges for health insurance and Medicare premiums

Necessary medical care recognized under state law, but not covered under the state's Medicaid plan;

Necessary medical care covered under the state's Medicaid plan incurred prior to Medicaid eligibility.

Expenses for nursing facility care are reduced at the state rate for the facility that the client owes the expense to

As long as the incurred medical expenses: Were not incurred more than three months before the month of the Medicaid application. Are not subject to third-party payment or reimbursement. Have not been used to satisfy a previous spend down liability. Have not previously been used to reduce excess resources . Have not been used to reduce client responsibility toward cost of care. Were not incurred during a transfer of asset penalty described in WAC 182-513-1363 . Are amounts for which the client remains liable.

Expenses not allowed to reduce excess resources or participation in personal care are: Unpaid expense(s) prior to HCBS Waiver eligibility to an adult family home (AFH) or boarding home is not a medical expense. Personal care cost in excess of approved hours determined by the CARE assessment described in 106 WAC is not a medical expense

Medical services covered by Medicare, Medicaid, or covered under a Apple Health managed care plan is not an allowable deduction from long-term care participation because it is considered "covered".

If the client's medical practitioner indicates an item or service is medically necessary (MN), and the item or service is denied, the client must file an appeal with Medicare, Medicaid, or the Apple Health managed care plan. The reduction of participation is the last resort after all other resources are pursued. Most medically necessary items should be covered by either Medicare, Medicaid fee-for-service or Apple Health managed care under the scope of care . This includes: transportation cost , over the counter items , cough and cold products , vitamins, topical and medical equipment and supplies , incontinent supplies , foot care, hearing aids , that are covered by Medicare, Medicaid, or Apple Health managed care.

See: Long-term care and Apple Health managed care See: Long-term care insurance and third party resources .

If a client chooses to go to a non-Medicaid contracted provider or outside the Apple Health managed care network, the charge is the client's responsibility as the service is covered under their Medicare, Medicaid, or Apple Health managed care plan. Health Care Authority (HCA) has an agreement to pay for health care services that is signed by the provider and client. HCA 13-879 The exception is when a client has "creditable" insurance coverage through their retirement, pension, employer sponsored plan or COBRA continuation plan. These client's may have copayments. These copayments are an allowable deduction only if Medicaid does not pay the copayments due the provider not having a Medicaid contract. Individuals with creditable insurance coverage are not limited to Medicaid contracted providers. An exception to rule (ETR) may be requested through the HCS Regional Designee for HCS cases or Marcie Birdsall for DDA cases if a client goes out of network due to special circumstances.

See the following pages for information on covered services.

Scope of care chart

Pharmacy information Drug lists Over the counter lists including cough/cold, vitamins

Apple Health basic covered services (rule of thumb, if it is covered under Medicaid it should be covered under Apple Health managed care)

Medical equipment and supplies

Noncovered services are an allowable deduction from participation

There are situations where a needed contracted Medicaid provider is not available within a reasonable distance. The most common situation is when a client is unable to find a Medicaid contracted dentist within a reasonable distance.

An exception to rule (ETR) may be requested. The reasoning must be documented. A medical expense is not allowed at the private rate if the care/expense is available under the Medicaid rate.

ETR requests for a medical deduction listed as a covered item under Medicare, Medicaid, or Apple Health must go through the HCS regional financial program manager for HCS offices. For DDA cases, an ETR request to reduce participation for a covered item must go through HCS HQ Marcie Birdsall.

Example

An exception to rule (ETR) can be considered for any medically necessary (MN) expense to reduce participation if an item is needed right away and the client has requested an appeal through Health Care Authority, Medicare or the Apple Health managed care plan.

A common expense turned in as a participation deduction is incontinence supplies.

Incontinence supplies are covered under Medicare/Medicaid. If the client is in need of more supplies than normally allowed, a medically necessary justification may be requested by Medicare or the Health Care Authority (HCA) in order to authorize more supplies.

Do not allow incontinence supplies as a participation deduction.

Bubble-packing prescription drugs is not an allowable expense from participation.

Facilities such as adult family homes, assisted living, and nursing facilities have specific regulations that ensure the proper labeling and organizing of a client's medication.

If a facility chooses to send the medications to a vendor to be bubble-packed, it is not an allowable deduction from participation.

Individuals on Medicare and Medicaid are called Full Benefit Dual Eligible (FBDE). Individuals on institutional Medicaid and HCB waivers do not have copayments toward Medicare services.

Individuals on institutional and HCBS waiver services on Medicare D for prescription drugs may have a premium cost that is an allowable medical deduction if the client has chosen a non-benchmark Medicare D PDP.

Drugs that are allowed under ANY PDP formulary under Medicare D, but not allowed in the specific PDP the client has chosen is not an allowable deduction from participation. Guidance from CMS has indicated if the drug is in any formulary it is a covered item.

Individuals on "credible coverage" for prescriptions are not enrolled in Medicare D. Prescription copayments due to credible coverage insurance is an allowable medical deduction from participation.

Medicare has a web tool to check for covered items under the Medicare program .

CMS notice to providers regarding QMB and Medicaid eligible clients. Providers are not allowed to charge QMB clients copayments.

If you have an institutional or HCB Waiver client being charged a Medicare D copayment, refer them back to the provider and indicate if the provider doesn't refund the copayment, the client will need to call the 1-800-MEDICARE helpline .

Medicare Savings Program (MSP) describes Medicare programs, buy-in, Medicare buy-in unit contact information, what is Medicare, and the different Medicare programs. This includes information on Medicare A, B, C, and D and referral numbers for help on Medicare related issues.

Medicaid Covered Drugs for Part D Dual Eligible

CMS guidance on expenses related to Medicare D for spenddown

Medicare and long-term services and supports (LTSS) has detailed information on Medicare and long-term care including participation issues.

Medicare and spenddown

Once a LTC client is eligible for Medicaid, the Medicare premiums are paid.

Allow a Medicare premium deduction that is considered out-of-pocket to the client. Don't allow a Medicare premium that will be covered under a Medicare Savings Program (MSP) or a state buy-in program.

S05/SLMB eligibility is effective up to 3 months prior to the date of application if eligible.

S03/QMB eligibility is effective the first of the following month the client is determined eligible. Allow the Medicare A/B premium as a participation reduction in the month(s) prior to the S03 opening.

Medicare D/Low income subsidy is for all active MSP or Medicaid clients. It is effective immediately. Client's can choose a nonbenchmark plan which may have additional premium costs that is allowed as a participation deduction. Institutional and HCB Waiver clients have no Medicare D copayments.

For individuals not eligible for a Medicare Savings Program (MSP), it takes approximately two months before the department begins paying state buy-in. Allow the Medicare A/B premium as a participation reduction. This should only occur when there is a retro or historical opening prior to MSP eligibility.

For questions related to insurance or Medicare premium payments, contact HCA Coordination of Benefits online via secure form , or call 1-800-562-3022, ext. 1-6129.

If using the contact us form , use the Client button. Indicate your contact information and question. Indicate you are a financial worker and your office. Include the ACES client ID.

HCA no longer pays Medicare C premiums with the exception of a small existing caseload subject to funding (these cases were grandfathered for Medicare C payment).

For more information on medical spenddown such as base periods, medical transportation, public programs and ACES screens, see the Apple Health for medically needy and spenddown overview page.

The spenddown clarifying information gives guidance as to allowable medical expenses, including

Expenses paid with a credit card.

Expenses sent to a collection agency.

The medical expense chart used for MN spenddown is the same basic guideline used to reduce participation for LTC programs.

There are situations that are unique to long term care programs.

Expenses incurred during a LTC transfer penalty are not allowed to reduce participation.

For LTC, a medical expense prior to eligibility must be unpaid. For spenddown, expenses incurred and paid 3 months prior to the application can be used.

Private personal care cost in excess of approved hours determined by the CARE assessment described in 106 WAC is not a medical expense.

Unpaid expenses prior to HCBS Waiver eligibility to an adult family home (AFH) or boarding home is not a medical expense. This applies to both participation and MN spenddown. These facilities are not medical facilities. Another term for AFH and boarding homes is alternate living facility (ALF).

Expenses of the community spouse or family members. This includes health insurance premiums. If the health insurance premium is for the couple, we allow one half of the expense for the LTC recipient if we are unable to determine the amount of the LTC recipient's share.

Health insurance premiums paid by a 3rd party including HCA COB unit are not used to reduce participation. Health insurance premiums paid on a client's behalf by COB are considered an income deduction for the MN Spenddown program.

Medical expense deduction from participation that is a covered item under the state plan is not allowed as a deduction if the client was on Medicaid during the date of service.

Medical expense deduction for copayments or deductibles from participation that is a covered item under Medicare is not allowed as a deduction if the client was on Medicaid and QMB during the date of service.

Medical expense deduction from participation that is a covered item under the Apple Health managed care plan is not allowed as a deduction if a client chooses the service outside of the network.

Liquid supplements (such as Ensure, Resource) are covered by Apple Health when medically necessary. Liquid supplements (enteral nutritional products) not approved by HCA are not considered a medical expense used to reduce participation even if the client has a medical prescription.

Effective 11/22/2012 reasonable limits on allowable medical expense deductions described in WAC 182-513-1350 was final. Expenses for nursing facility care are reduced at the state rate for nursing facility care that is owed by the client prior to Medicaid eligibility. It is based on the state rate for the particular facility the bill was incurred. Medical expenses incurred more than three months before the month of application is not an allocable medical deduction to reduce participation.

Expenses allowed only once

If an expense was used to meet a prior spenddown or to reduce excess resources for LTC programs, it cannot be used to reduce participation. This is the same rule as the spenddown program. An expense is allowed once.

A description of service animals is described in WAC 388-473-0040 food for service animals as an ongoing additional requirements. Although this section describes when to authorize food for services animals of an SSI or TANF recipient, it can also be used as a guideline when determining if expenses related to a service animal can be used as a medical expense.

In order for expenses related to a service animal to be used as a medical expense:

Consult CARE and the client's social service specialist/case manager as to whether the service animal is medically necessary. If the social service specialist is unable to determine if the service animal is medically necessary get a statement by the client's physician/practitioner as to why the expense is medically necessary.

The service animal must be performing a task that is necessary for the health and safety of the individual.

For LTC recipients with service animals that are on SSI, consider food for service animals as an ongoing additional requirement . If authorized, do not allow the food as a medical expense to reduce participation.

Noncovered necessary medical expenses is an allowable deduction to determine the client's participation. For HCBS waiver clients residing in alternate living facilities, it is not an allowable deduction from room and board without an exception to rule (ETR).

Submit an ETR request to the HCS regional designee for a medical expenses that would have been used to reduce participation if there had been available participation.

Room and board for ABD cash recipients is not reduced by medical expenses. Do not refer ABD cash cases for an ETR.

Reducing room and board is the last resort as it is state funded. If the expense can be deducted through participation, but takes a few months because of low participation, use that method rather than an ETR to reduce room and board.

Medicare supplements, called Medigap are not an allowable ETR from room and board if the client is eligible for a Medicare Savings Program (MSP), this is because MSP covers the same thing as a Medigap plan. For more information, see "What about Medicare Insurance Supplements, also called Medigap plans?" on the Medicare and long-term services and supports (LTSS) webpage (scroll down to find this section).

See also: HCS waivers, room and board, ETRs and bed holds .

DDA waiver has a process to reduce room and board for necessary medical expenses and guardianship fees. DDA has authorized the case manager as the designee to approve these costs from room and board. DDA case-managers notify the financial worker via the DSHS 15-345.

Any deduction from room and board must be coded as an ETR in ACES 3G in the decision tree under the Institutional Care/Expenses.

Medical assistance-third party liability

Long-term care and third-party resources, LTC insurance

Changes including medical expenses must be reported within the timeframes outlined in WAC 182-504-0110 . Changes that must be reported will be used for all medical including institutional medical programs. See WAC 182-504-0105 .

If a medical expense is not reported within required time frames, we are not able to use the expense as a post eligibility deduction for institutional Medicaid. For HCBS Waiver, we may allow a medical expense if unpaid as long it meets the criteria in WAC 182-513-1350 (6) and (7).

If a medical expense increases and is not reported within time frames, we can't go back historically and change the amount. If a medical expense ends, (such as a health insurance premium), and it is not reported timely, it is an overpayment.

In order to allow a medically necessary noncovered item, we will need verification:

Of the cost

Item is prescribed by an allowable practitioner and is considered a medically necessary item

Item is not covered by Medicare, Medicaid, or Apple Health managed care. Most medically necessary items should be covered for individuals receiving long-term care. Any item indicated on the pharmacy covered list , including over the counter items such as cough/cold medications or vitamins cannot be allowed as a participation deduction.

For medical equipment and supplies (MES) or environmental modifications, check with the social worker/case manager as to whether it should be covered under the HCBS waiver? Most MES is covered under the Medicaid scope of care or HCBS waiver. HCBS MB H13-030 dated June 24, 2013 has more information regarding MES vendors.

If the reported expense appears to be covered, send a letter explaining why the expense is not allowed using the text templates that include the rule.

Send the medical expense fact sheet to all new openings and clients that turn in expenses that are not allowed as a participation reduction.

Noncovered allowable medical expenses. Differences in how we apply the medical deduction in institutional medical and HCBS Waiver

Once it is determined the medically necessary expense is allowed as a deduction, there is differences in institutional and HCBS Waiver cases on when we allow the medical deduction.

Post eligibility participation ( WAC 182-513-1380 , WAC 182-515-1509 , WAC 182-515-1514 )

There are three methods of allowing expenses in post eligibility described in WAC 182-504-0120 (11) for institutional programs and WAC 182-504-0120 (12) for HCB Waivers. Federal guidance allows Method 1 or Method 2 for institutional cases (those residing in medical institutions). Federal option allows Method 3 for HCBS Waivers.

Method 1: Allow the expense in the month it was incurred; or

Method 2: Estimate medical expense incurred in the preceding period, not to exceed 6 months if the expenses are expected to continue. At the end of the prospective period, or if there is a significant change of 25%, the expense is reconciled for the next time period. A reconciliation is required, at least every 6 months when using Method 2. Use barcode ticklers to track the expenses and reconciliation period. Use the Method 2 training instructions and calculator and document that Method 2 is being used to estimate medical expenses.

Method 3: When there is a change in income, or allowable expenses, that changes the amount of the cost of your care for a home and community-based waiver or service, we calculate the new participation amount effective the first of the month following the date the change was reported, except that the new participation amount will be effective the month the change occurs if the change is the loss of an income source that you report within thirty days of the change.

For additional information on Method 1, Method 2, and Method 3 go to the financial SharePoint site. See financial training under the policy and program changes.

If a Medicaid or Medicare/Medicaid client is turning in medical expense charges that appear to be covered, or the client is being charged the difference between the Medicaid or Medicare rate, you may need to refer the situation for an investigation.

Nursing facility, assistance living, group homes or adult family homes contact: Residential Care Services (RCS) complaint email box Complaint Resolution Unit (DSHS/RCS) .

All other Medicaid providers contact the Health Care Authority . Include your name, phone number, client and provider information and what the issue is.

Refer complaints regarding Medicare claims to 1-800-Medicare

If provider fraud is suspected, follow the procedures in HCS MB H13-011 issued 3/5/2013: procedures for report suspected fraud.

ARNP advanced registered nurse practitioners

CRN certified registered nurses

DC chiropractors

DDS dentists, denturist, orthodontist, periodontitis

Dental hygienists

DO osteopath

DPM podiatrists

Electrotherapist

Hydro therapist

Inhalation/respiratory therapists

MD physicians

Midwives

OD optometrist

Opticians

PA physicians assistants

Pharmacists

Physical Therapists

Psychologists/psychiatrists

Speech therapists

X-ray technicians

Acupuncturist

Dietitians

Licensed massage therapist

Naturopaths

Herbalists

Holistic healers

Homeopaths

Hypnotists

Masseurs or manipulators

Medical cannabis distributor

Practitioners not licensed under Washington State law

Psychic or faith healers

Sanipractors

Veterinarians (unless the expense is for a medically necessary service animal)

Services obtained out of the US

Interest and fees incurred on an unpaid medical bill

Durable medical equipment or modification approved under the HCBS Waiver program for individuals receiving Waiver services is not an allowable participation deduction

Insurance premiums for policies that pay a cash benefit to the insured and the benefit is not intended to reimburse a provider. These premiums are not health insurance but pay directly to the insurance holder under certain conditions. (usually a daily rate when the client is unable to work, in the hospital or has a certain type of medical condition). Contact the carrier to find out if it is a health insurance or one of these policies that pay a cash benefit to the client and not a provider because of a health condition. This does not include LTC insurance. LTC insurance premiums are an allowable deduction. LTC insurance policies waive the premiums when the client starts receiving benefits from the LTC insurance. Once the client is accessing LTC insurance, remove the premium as a deduction.

In home cooking/cleaning services/yard work/property maintenance

Telephone charges including long-distance charges

Commercial diet clinics, gyms and pools that are not monitored by a licensed physical therapist

Toiletries such as toothpaste, shampoo, personal grooming products

Private alternate living facility (ALF) charges are not considered a medical expense. See WAC 182-513-1205 for possible eligibility of Medicaid using rules for individuals living in state contracted ALFs.

Drugs not approved by the Federal Drug Administration (FDA)

Out of state billings for medical services not recognized under Washington State law.

Items covered under Medicare, Medicaid, or an Apple Health managed care plan is not an allowable deduction from long-term care participation. If a client chooses to go to a non-Medicaid/Medicare contracted provider or outside the healthy options managed care network, the cost is their responsibility.

Food/special diets is not a medical expense

Nutritional supplements unless prescribed as medically necessary . Examples are enteral liquid and powdered supplements.

For active Medicaid clients, liquid supplements that are medically necessary are covered by Health Care Authority (HCA). Liquid supplements (enteral supplements) not approved by HCA are not considered a medically necessary expense to be used to reduce participation.

Food items are covered under the basic food program, consider eligibility for basic food for individuals not in a facility claiming food items as a medical expense. AFH, Assisted living facilities, NF and RHCs are required to provide meals taking into account an individuals special dietary needs. Meals are included in the daily rate.

Over the counter drugs and medications not prescribed or considered not medically necessary . Many over the counter drugs , medications and vitamins are covered by Medicaid.

Health camps, trips or retreats

Medical cannabis. Cannabis is not an approved prescription drug under the Federal Food, Drug and Cosmetic Act and has not been approved by the FDA for treatment.

Unpaid participation incurred while active on a Medicaid program

Dietetics

Spouse's unpaid medical expenses are not allowed to reduce participation.

Where to indicate medical expenses

LTC medical expenses are indicated on the LTCX screen. The MEDX screen is used for recipients on other programs such as food assistance. Non-Medicare health insurance premiums are indicated on the MEDX screen for noninstitutional spenddown cases. Make sure the medical expense is indicated on the LTCX and MEDX screen when a LTC recipient is on food assistance.

Institutional Care in ACES 3G decision tree used in institutional Medicaid programs to indicate medical expenses.

Expenses in ACES 3G decision tree used to indicate health insurance premiums for spenddown. Used to indicate all medical expenses for food assistance including COPES HCBS Waivers participation.

ACES on line summary and detail used to indicate medical expenses for spenddown.

ACES-LTC

ACES-Medical expenses as a deduction

The following are a list of allowable practitioners for Classic (non-MAGI) Medicaid.

ARNP Advanced Registered Nurse Practitioner

CRN Certified Registered Nurse

D.C. Chiropractor

D.D.S. Dentist, Denturist, Orthodontist, Periodontist

D.O. Osteopath

D.P.M. Podiatrist

Dental Hygienist

Electrotherapist

Hydro therapist

Inhalation/Respiratory Therapist

LPN Licensed Practical Nurse

M.D. Physician

Midwife

Naturopath

O.D. Optometrist

Occupational therapist

Optician

P.A. Physician Assistant

Pharmacist

Psychologist/Psychiatrist

Speech therapist

X-ray Technician

Acupuncturist

Dietician

Herbalist

Homeopath

Holistic Healer

Hypnotist

Masseur or Manipulator

Psychic or Faith Healer

Sanipractor

Veterinarian

Practitioners not recognized under Washington State law

To describe and clarify rules on how annuities affect eligibility.

Effective March 2, 2018

A revocable annuity is considered an available resource.

An irrevocable annuity established prior to May 1, 2001, is not an available resource when issued by an individual, in­ surer, or other body licensed and approved to do business in the ju­risdiction in which the annuity is established.

The income from an irrevocable annuity that meets the requirements of this section is income for determining eligibility and the amount of participation in the total cost of care. The annuity itself is not a re­source.

Subject to subsection (5) of this section, an annuity established on or after May 1, 2001, and before April 1, 2009, is an available resource unless it: Is irrevocable; Is paid out in equal monthly amounts within the actuarial life expectancy of the annuitant; Is issued by an individual, insurer, or other body licensed and approved to do business in the jurisdiction in which the annuity is established; and Names the state of Washington as the benefi­ciary of the remaining funds up to the total of medicaid funds spent on the client during the client's lifetime. This subsection only ap­plies if the annuity is in the client's name.

If an irrevocable annuity is an availa­ble resource under subsection (4) of this section because it does not pay out in equal monthly amounts, it is an unavailable resource if: The full pay out is within the actuarial life expectancy of the client; and The client: Changes the scheduled pay out into equal monthly payments within the actuarial life expectancy of the annuitant; or Requests that the medicaid agency or the agency's designee calculate and budget the payments as equal monthly payments within the actuarial life expectancy of the annuitant. The income from the annuity remains unearned income to the annuitant.

An irrevocable annuity is unearned income when the annuitant is: The client; The spouse of the client; The blind or disabled child, as defined in WAC 182-512-0050 (1)(b) and (c), of the client; or A person designated to use the annuity for the sole benefit of the client, client's spouse, or a blind or disabled child, as de­ fined in WAC 182-512-0050 (1)(b) and (c), of the client.

An annuity is not an available resource when there is a joint owner, co-annuitant or an irrevocable beneficiary who will not agree to allow the annuity to be cashed, unless the joint owner or irrevocable beneficiary is the community spouse. In the case of a community spouse, the value of the annuity is an available resource and counts toward the maximum community spouse resource allowance.

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 .

Effective March 2, 2018

The medicaid agency or the agency's designee determines how an annui­ty, purchased by or on behalf of an annuitant and established on or after April 1, 2009, affects eligibility for medicaid.

General information. Clients of noninstitutional medicaid must disclose to the agency or the agency's designee any interest that client, or the fi­nancially responsible members of that client's assistance unit, has in an annuity. Clients of institutional or home and community-based (HCB) waiver services must disclose to the agency or the agency's designee any interest that client, or that client's community spouse, has in an annuity. Subject to (d) of this subsection, this section applies when the annuitant is: The client of medicaid; That client's spouse, if that spouse is financially respon­sible for that client; or That client's community spouse. If this section does not apply because of (c) of this subsec­tion, but the client of institutional or HCB waiver services, or that client's community spouse, is the owner of the annuity, then the pur­chase of the annuity is evaluated as an asset transfer under WAC 182-513-1363 . For the definition of "disabled," see WAC 182-512-0050 (1)(b) and (c). Actuarial life expectancy in this section is rounded up to the nearest whole year.

Annuities as resources. Subject to (b) of this subsection, a revocable annuity is an available resource. The following annuities are not available resources, even if revocable: An annuity described under 26 U.S.C. Sec. 408(b) or (q); or An annuity purchased with proceeds from: An account or trust described under 26 U.S.C. Sec. 408(a), (c), or (p); A simplified employee pension (within the meaning of 26 U.S.C. Sec. 408(k)); or A Roth IRA described under 26 U.S.C. Sec. 408A. An annuity not described under (b) of this subsection is an available resource unless the annuity: Is issued by an entity licensed and approved to issue annui­ties in the jurisdiction in which the annuity is established; Is immediate, irrevocable, nonassignable; and Is paid out, in equal monthly amounts with no deferral and no balloon payments, over a term: Of at least five years, if the actuarial life expectancy of the annuitant is at least five years; or Not less than the actuarial life expectancy of the annuitant, if the actuarial life expectancy of the annuitant is less than five years. If an annuity fails either the immediate requirement under (c)(ii) of this subsection or the monthly payout requirement under (c)(iii) of this subsection, the annuity is not a resource if: The annuity is fully paid out within the actuarial life ex­pectancy of the annuitant; and The annuitant: Changes the scheduled payout to equal monthly payments; or Asks the agency or the agency's designee to calculate and budget the periodic payments as equal monthly payments beginning the month of eligibility. Periodic payments made before the month of eli­gibility are not included in the calculation. Nothing under (d) of this subsection affects the deferral or balloon payment requirements under (c)(iii) of this subsection, or the payment term requirements under (c)(iii)(A) or (B) of this subsec­tion.

Annuities as income. If an annuity is not an available resource under subsection (3) of this section, the payments from the annuity are unearned income to the annuitant. If an annuity is an available resource under subsection (3) of this section, the payments from the annuity are not income to the annuitant.

An annuity as a transfer of assets. The purchase of an annuity is an uncompensated asset trans­fer, unless the annuity designates the state of Washington as remain­der beneficiary under subsection (6) of this section. The purchase of an annuity by the client of institutional or HCB waiver services is an uncompensated asset transfer, unless the an­nuity is an annuity under subsection (3)(b)(i) or (ii) of this sec­tion, or the annuity: Is issued by an entity licensed and approved to issue annui­ties in the jurisdiction in which the annuity is established; Is immediate, irrevocable, nonassignable; and Is paid out, in equal periodic amounts with no deferral and no balloon payments, over a term that is actuarially sound (i.e., a term that is not greater than the actuarial life expectancy of that client).

Beneficiary designation requirements. Subject to (b) of this subsection, to satisfy subsection (5)(a) of this section, when the client of institutional or HCB waiver services, or that client's community spouse, is the annuitant, the an­nuity must: Name the states as the remainder beneficiary, for at least the total amount of services covered under medicaid, paid on behalf of the client of institutional or HCB waiver services; and The remainder beneficiary must be listed in the annuity in the: First position; Next position, after the community spouse, and any minor or disabled children; or First position, if either the community spouse, or any minor or disabled children, or a representative for such children, named as beneficiary in the first position under (a)(ii)(B) of this subsection, transfers the right to receive payments from the annuity for less than fair market value. When the community spouse is the annuitant, the community spouse, or the community spouse's estate, cannot be named as remainder beneficiary under (a)(ii)(A) of this subsection. If a change of circumstance requires a change in beneficiary designation under (a) of this subsection, the agency or the agency's designee reevaluates the annuity's beneficiary designation.

Actuarial life expectancy is determined by tables that are published by the office of the chief actuary of the Social Security Administration.

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 .

In the Medicaid eligibility context, an annuity is a financial product someone purchases, with a lump sum of funds (called the “premium”), that guarantees a stream of payments for a certain period.

Because some annuities can be converted into cash (sold, assigned, or transferred), an annuity is evaluated to determine whether it is a resource or not.

Because all annuities provide a stream of payments, if an annuity is not a resource, then the stream of payments is unearned income.

Because the purchase of an annuity is an asset transfer, annuities are evaluated to determine whether there is uncompensated value for the purposes of long-term care (LTC) Medicaid penalties.

A revocable annuity is an available resource, unless it is established after April 1, 2009, and is the type of annuity described under WAC 182-516-0201 (3)(b). This includes irrevocable annuities in the cooling-off period – a grace period that allows an annuitant to cancel an annuity contract within the first several days, because the premium can be returned. Additionally, this includes “assignable” annuities – those can be pledged or promised as collateral in order to obtain goods, services, cash, or other valuable consideration.

An irrevocable annuity is also an available resource if the annuity fails the tests under WAC 182-516-0200 (4) and (5), or WAC 182-516-0201 (3).

The stream of payments from an annuity is unearned income when the annuity is not an available resource. If the annuity is an available resource, the stream of payments is not income, but a conversion of a resource into cash.

Example #1

Steve is applying for COPES. On April 25th, Steve’s spouse, Joan, purchased an annuity with $100,000 (Joan is the annuitant). Joan can cancel the contract with 15 days of purchase. As of May 1st, all the couple’s other resources total $5,000. The couple’s resources as of May 1st is $105,000 because Joan can cancel the contract and get the $100,000 returned.

Example #2

Same example as above, except the annuity was purchased on April 5th and the annuity can be used as collateral for a loan (can be assigned). The couple’s resources as of May 1st is $105,000 because Joan can use the annuity to obtain approximately the same value of the annuity as cash.

Example #3

Same example as above, except the annuity was determined to not be a resource. The annuity pays out $1,200 per month. That $1,200 is unearned income for Joan.

The only annuities subject to LTC transfer rules are those established after April 1, 2009, under WAC 182-516-0201 .

The entire purchase price of an annuity is uncompensated when the annuity:

Fails to name the state of Washington as remainder beneficiary, either in the first position, or second position as described under WAC 182-516-0201 (6).

Is not an annuity described under WAC 182-516-0201 (3)(b), and ANY condition below is not met. The annuity must be: Issued by an entity licensed and approved to issue annuities in the jurisdiction in which the annuity is established. Immediate. Irrevocable. Nonassignable. Not deferred. Paid out in equal periodic payments. Actuarially sound (the annuity must pay out within the annuitant’s life expectancy).

An annuity can be both a resource and an uncompensated transfer.

If a penalty will be applied, recall that it can only start once the client is otherwise eligible for LTC under WAC 182-513-1363 (7)(a). An annuity counting as a resource may make an applicant resource ineligible for LTC.

Example #4

Same example as above, except Joan named Steve as residual beneficiary, and the annuity was purchased within 5 years of Steve’s COPES application. The entire purchase price of the annuity is an uncompensated transfer because Washington is not named as residual beneficiary in the first position.

Example #5

Joanna is applying for COPES. On April 25th, Joanna’s spouse, Charlie, purchased an annuity with $100,000 (Charlie is the annuitant). Charlie’s life expectancy is 7 years, and the annuity pays out over 10 years. The entire purchase price of the annuity is an uncompensated transfer because the annuity pays out beyond the annuitant’s life expectancy.

Determine if an applicant or their spouse has disclosed any interests in an annuity. If so, determine whether the annuity is an available resource or not. If not, determine the amount of unearned income to the annuitant.

For LTC applicants and their spouses, determine whether the purchase of an annuity is an uncompensated transfer or not.

Notify Kevin Cavanaugh or Jessica Warrington of OFR via a Barcode tickler when any single premium immediate annuity (SPIA) that requires to name the State of Washington as beneficiary to the extent of Medicaid paid. Set up the following DMS tickler:

Document type for tickler: TD

Subject: Annuity

Site: 101

User: Kevin Cavanaugh barcode user CAVK; or Jessica Warrington barcode user WAJN

Ready date: Default date is fine

Make sure the annuity is indicated on the appropriate person's resource screen in ACES. Add in the remarks that OFR has been notified of the annuity in the ECR.

SSA Period Life Table (2015)

WAC 182-513-1363

Effective August 29, 2014.

Effective on or after January 1, 2014, a person is eligible for Washington apple health (WAH) modified adjusted gross income (MAGI)-based adult coverage when he or she meets the following requirements: Is age nineteen or older and under the age of sixty-five; Is not entitled to, or enrolled in, medicare benefits under Part A or B of Title XVIII of the Social Security Act; Is not otherwise eligible for and enrolled in mandatory coverage under one of the following programs: WAH SSI-related categorically needy (CN); WAH foster care program; or WAH adoption support program; Meets citizenship and immigration status requirements described in WAC 182-503-0535 ; Meets general eligibility requirements described in WAC 182-503-0505 ; and Has net countable income that is at or below one hundred thirty-three percent of the federal poverty level for a household of the applicable size.

Parents or caretaker relatives of an eligible dependent child as described in WAC 182-503-0565 are first considered for WAH for families as described in WAC 182-505-0240 . A person whose countable income exceeds the standard to qualify for family coverage is considered for coverage under this section.

Persons who are eligible under this section are eligible for WAH alternative benefit plan as defined in WAC 182-500-0010 coverage. A person described in this section is not eligible for medically needy WAH.

Other coverage options for adults not eligible under this section are described in WAC 182-508-0001 .

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 .

Adults who are over income for Apple Health for Families (N01) may be eligible for Apple Health for Adults (N05) as described in WAC 182-505-0250 .

Adults who are ineligible for Apple Health for Adults (N05) based on citizenship may be eligible for Alien Emergency Medical (N21/N25) as described in WAC 182-507-0110 . Learn about Health Care Authority's plan for Apple Health Expansion .

Individuals receiving or eligible for Medicare or who are age 65 or older, are not eligible for Apple Health for Adults (N05). Adults who are low income may qualify for Apple Health for Families and Caretakers even if they are 65+ or eligible for Medicare. See WAC 182-505-0240. Pregnant adults who are eligible for or receiving Medicare can get Apple Health for Pregnant Individuals. See WAC 182-505-0115.

Individuals may apply for MAGI Medicaid using the following options:

Online: Go to Washington Healthplanfinder - select the "Apply Now" button.

Phone: Call the Washington Healthplanfinder Customer Support Center at 855-923-4633.

Paper: Submit an Application for health care coverage ( 18-001P ).

In-person: Local resources who, at no additional cost, can help you apply for health coverage.

Local enrollment assistance

For assistance in applying for Apple Health through the Washington Healthplanfinder contact a navigator or call Healthplanfinder Customer Support at 855-923-4633.

To explain the Alien Medical Programs (commonly referred to as AEM) available to Washington State residents who are "Qualified Aliens" who have not met their 5-year bar, "Nonqualified Aliens", or undocumented individuals.

Effective March 31, 2014.

To qualify for an alien medical program (AMP) a person must: Be ineligible for federally funded Washington apple health (WAH) programs due to the citizenship/alien status requirements described in WAC 182-503-0535 ; Meet the requirements described in WAC 182-507-0115 , 182-507-0120 , or 182-507-0125 ; and Meet all categorical and financial eligibility criteria for one of the following programs, except for the Social Security number or citizenship/alien status requirements: An SSI-related medical program described in chapters 182-511 and 182-512 WAC; A MAGI-based program referred to in WAC 182-503-0510 ; or The breast and cervical cancer treatment program for women described in WAC 182-505-0120 ; or A medical extension described in WAC 182-523-0100 .

AMP medically needy (MN) health care coverage is available only for children, pregnant women and persons who meet SSI-related criteria. See WAC 182-519-0100 for MN eligibility and WAC 182-519-0110 for spending down excess income under the MN program.

The agency or its designee does not consider a person's date of arrival in the United States when determining eligibility for AMP.

For non-MAGI-based programs, the agency or its designee does not consider a sponsor's income and resources when determining eligibility for AMP, unless the sponsor makes the income or resources available. Sponsor deeming does not apply to MAGI-based programs.

A person is not eligible for AMP if that person entered the state specifically to obtain medical care.

A person who the agency or its designee determines is eligible for AMP may be eligible for retroactive coverage as described in WAC 182-504-0005 .

Once the agency or its designee determines financial and categorical eligibility for AMP, the agency or its designee then determines whether a person meets the requirements described in WAC 182-507-0115 , 182-507-0120 , or 182-507-0125 .

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 .

Effective February 17, 2023

A person nineteen years of age or older who is not pregnant and meets the eligibility criteria under WAC 182-507-0110 is eligible for the alien emergency medical program's scope of covered services described in this section if the person meets the requirements of (a) of this subsection, as well as the requirements of either (b), (c), or (d) of this subsection: (a) The medicaid agency determines that the primary condition requiring treatment is an emergency medical condition as defined in WAC 182-500-0030 , and the condition is confirmed through review of clinical records; and (b) The person's qualifying emergency medical condition is treated in one of the following hospital settings: (i) Inpatient; (ii) Outpatient surgery; (iii) Emergency room services, which must include an evaluation and management (E&M) visit by a physician; or (c) Involuntary Treatment Act (ITA) and voluntary inpatient admissions to a hospital psychiatric setting that are authorized by the agency's inpatient mental health designee (see subsection (5) of this section); or (d) For the assessment and treatment of the COVID-19 virus, the agency covers one physician visit provided in any outpatient setting, including the office or clinic setting, or via telemedicine, online digital or telephonic services to assess/evaluate and test, if clinically indicated, as follows: (i) If the test is positive, in addition to the services described in (b) of this subsection and subsection (2)(b) of this section, any medically necessary services to treat, including: (A) Follow-up office visits; (B) Medications, prior authorization requirements may apply; (C) Respiratory services and supplies; and (D) Medical supplies, prior authorization requirements may apply. (ii) If a test is negative, any treatment described in (d)(i)(A) through (B) of this subsection, as a precautionary measure for an anticipated positive test result. (e) The coverage described in (d) of this subsection is in effect only during the time period, as determined by the agency in its sole discretion, that a public health emergency related to COVID-19 exists. (2) If a person meets the criteria in subsection (1) of this section, the agency will cover and pay for all related medically necessary health care services and professional services provided: (a) By physicians in their office or in a clinic setting immediately prior to the transfer to the hospital, resulting in a direct admission to the hospital; and (b) During the specific emergency room visit, outpatient surgery or inpatient admission. These services include, but are not limited to: (i) Medications; (ii) Laboratory, x-ray, and other diagnostics and the professional interpretations; (iii) Medical equipment and supplies; (iv) Anesthesia, surgical, and recovery services; (v) Physician consultation, treatment, surgery, or evaluation services; (vi) Therapy services; (vii) Emergency medical transportation; and (viii) Nonemergency ambulance transportation to transfer the person from a hospital to a long term acute care (LTAC) or an inpatient physical medicine and rehabilitation (PM&R) unit, if that admission is prior authorized by the agency or its designee as described in subsection (3) of this section. (3) The agency will cover admissions to an LTAC facility or an inpatient PM&R unit if: (a) The original admission to the hospital meets the criteria as described in subsection (1) of this section; (b) The person is transferred directly to this facility from the community hospital; and (c) The admission is prior authorized according to LTAC and PM&R program rules (see WAC 182-550-2590 for LTAC and WAC 182-550-2561 for PM&R). (4) The agency does not cover any services, regardless of setting, once the person is discharged from the hospital after being treated for a qualifying emergency medical condition authorized by the agency and its designee under this program. Exceptions: (a) For admissions to treat COVID-19 or complications thereof, the agency will cover up to two postdischarge physician follow-up visits, regardless of how the visits are conducted or where they are conducted. (b) Pharmacy services, drugs, devices, and drug-related supplies listed in WAC 182-530-2000 , prescribed on the same day and associated with the qualifying visit or service (as described in subsection (1) of this section) will be covered for a one-time fill and retrospectively reimbursed according to pharmacy program rules. (5) Medical necessity of inpatient psychiatric care in the hospital setting must be determined, and any admission must be authorized by the agency's inpatient mental health designee according to the requirements in WAC 182-550-2600 . (6) There is no precertification or prior authorization for eligibility under this program. Eligibility for the AEM program does not have to be established before an individual begins receiving emergency treatment. (7)Under this program, certification is only valid for the period of time the person is receiving services under the criteria described in subsection (1) of this section. The exception for pharmacy services is also applicable as described in subsection (4) of this section. (a) For inpatient care, the period of eligibility is only for the period of time the person is in the hospital, LTAC, or PM&R facility the admission date through the discharge date. Upon discharge the person is no longer eligible for coverage. (b) For an outpatient surgery or emergency room services the period of eligibility is only for the date of service. If the person is in the hospital overnight, the eligibility period will be the admission date through the discharge date. Upon release form the hospital, the person is no longer eligible for coverage. (8) Under this program, any visit or service not meeting the criteria described in subsection (1) of this section is considered not within the scope of covered services as described in WAC 182-501-0060 . This includes, but is not limited to: (a) Hospital services, care, surgeries, or inpatient admissions to treat any condition which is not considered by the agency to be a qualifying emergency medical condition, including but not limited to: (i) Laboratory, x-ray, or other diagnostic procedures; (ii) Physical, occupational, speech therapy, or audiology services; (iii) Hospital clinic services; or (iv) Emergency room visits, surgery, or hospital admissions. (b) Any services provided during a hospital admission or visit (meeting the criteria described in subsection (1) of this section), which are not related to the treatment of the qualifying emergency medical condition; (c) Organ transplants, including preevaluations, postoperative care, and antirejection medication; (d) Services provided outside the hospital settings described in subsection (1) of this section including, but not limited to: (i) Office or clinic-based services rendered by a physician, an ARNP, or any other licensed practitioner; (ii) Prenatal care, except labor and delivery; (iii) Laboratory, radiology, and any other diagnostic testing; (iv) School-based services; (v) Personal care services; (vi) Physical, respiratory, occupational, and speech therapy services; (vii) Waiver services; (viii) Nursing facility services; (ix) Home health services; (x) Hospice services; (xi) Vision services; (xii) Hearing services; (xiii) Dental services; (xiv) Durable and non durable medical supplies; (xv) Nonemergency medical transportation; (xvi) Interpreter services; and (xvii) Pharmacy services, except as described in subsection (4) of this section. (9) The services listed in subsection (8) of this section are not within the scope of service categories for this program and therefore the exception to rule process is not available. (10) Providers must not bill the agency for visits or services that do not meet the qualifying criteria described in this section. The agency will identify and recover payment for claims paid in error.

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 .

Effective March 8, 2015

In addition to the provisions for emergency care described in WAC 182-507-0115 , the medicaid agency also considers the conditions in this section as an emergency, as defined in WAC 182-500-0030 .

A person nineteen years of age or older who is not pregnant and meets the eligibility criteria under WAC 182-507-0110 may be eligible for the scope of service categories under this program if the condition requires: Surgery, chemotherapy, and/or radiation therapy to treat cancer or life-threatening benign tumors; Dialysis to treat acute renal failure or end stage renal disease (ESRD); or Antirejection medication, if the person has had an organ transplant.

When related to treating the qualifying medical condition, covered services include but are not limited to: Physician and ARNP services, except when providing a service that is not within the scope of this medical program (as described in subsection (7) of this section); Inpatient and outpatient hospital care; Dialysis; Surgical procedures and care; Office or clinic based care; Pharmacy services; Laboratory, X ray, or other diagnostic studies; Oxygen services; Respiratory and intravenous (IV) therapy; Anesthesia services; Hospice services; Home health services, limited to two visits; Durable and nondurable medical equipment; Nonemergency transportation; and Interpreter services.

All hospice, home health, durable and nondurable medical equipment, oxygen and respiratory, IV therapy, and dialysis for acute renal disease services require prior authorization. Any prior authorization requirements applicable to the other services listed above must also be met according to specific program rules.

To be qualified and eligible for coverage for cancer treatment or treatment of life-threatening benign tumors under this program, the diagnosis must be already established or confirmed. There is no coverage for cancer screening or diagnostics for a workup to establish the presence of cancer or life-threatening benign tumors.

Coverage for dialysis under this program starts the date the person begins dialysis treatment, which includes fistula placement and other required access. There is no coverage for diagnostics or predialysis intervention, such as surgery for fistula placement anticipating the need for dialysis, or any services related to preparing for dialysis.

Certification for eligibility will range between one to twelve months depending on the qualifying condition, the proposed treatment plan, and whether the client if required to meet a spenddown liability.

The following are not within the scope of service categories for this program: Cancer screening or work-ups to detect or diagnose the presence of cancer or life-threatening benign tumors; Fistula placement while the person waits to see if dialysis will be required; Services provided by any health care professional to treat a condition not related to, or medically necessary to, treat the qualifying condition; Organ transplants, including preevaluations and post operative care; Health department services; School-based services; Personal care services; Physical, occupational, and speech therapy services; Audiology services; Neurodevelopmental services; Waiver services; Nursing facility services; Home health services, more than two visits; Vision services; Hearing services; Dental services, unless prior authorized and directly related to dialysis or cancer treatment; Mental health services; Podiatry services; Substance abuse services; and Smoking cessation services.

The services listed in subsection (7) of this section are not within the scope of service categories for this program. The exception to rule process is not available.

Providers must not bill the agency for visits or services that do not meet the qualifying criteria described in this section.

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 .

The Alien Medical Programs (AMP) includes:

The federally-funded Alien Emergency Medicaid (AEM) ( WAC 182-507-0110 ); and

The state-funded Long-Term Care (LTC) program ( WAC 182-507-0125 ).

Processing of AEM applications

AEM applications are ONLY processed by Community Service Division (CSD) and Health Care Authority (HCA) specialty staff. AMPs have the following program codes: K03, L04, L24, N21, N25, and S07.

AEM is for individuals who have a qualifying medical emergency and do not qualify for any other Apple Health program due to citizenship/immigration requirements under WAC 182-503-0535 . This includes qualified aliens who have not met the 5-year and are not exempt from the 5-year bar, nonpregnant nonqualified aliens, and undocumented individuals.

To qualify for AEM, an individual must have or need at least one of the following:

A qualifying emergent medical condition such as emergency room care, inpatient admission, or outpatient surgery;

A cancer treatment plan;

Dialysis treatment;

Antirejection medication for a post organ transplant;

Assessment and treatment of COVID-19 as a qualifying emergency ended with the public health emergency on May 11, 2023.

*LTC applications are coordinated and processed by Aging and Long-Term Services and Support (ALTSA).

Contact Emily Watts for all noncitizen LTC applications and referrals.

LTC for non citizens includes:

L04 for nursing facility, and

L24 for LTC in the home or in an alternative living facility.

Long-term care for noncitizens

The state-funded long-term care program for noncitizens has limited slots due to funding restrictions. A slot must be available and pre-authorized in order for this program to be considered. It covers nursing facility, in-home personal care, or residential services in an alternate living facility. All applications for state-funded long-term care services are coordinated and processed by Home and Community Living Administration (HCLA) and require prior authorization from the HCLA program manager. Specific instructions are in the clarifying information for the state-funded long-term care program for noncitizens.

The DSHS Specialized Medical Unit (SMU) or HCA MEDS Specialized Staff process applications as outlined below:

DSHS/CSD processes AEM cases under Classic Apple Health when:

Individual is age 65 or older and is not a caretaker for a child under age 19;

Individual is eligible for Medicare

HCA processes AEM applications under MAGI Medicaid when:

Individual is age 19 through 64

Individual is not eligible for Medicare; and

Follows MAGI rules established through the Healthplanfinder.

Applications must be submitted through Washington Connection or by completing a Washington Apple Health Application for ABD / LTC (18-005). Follow the instructions on the 18-005 form for submitting the application.

Apply online at Washington Healthplanfinder or by:

Submitting a paper application (HCA 18-001):

Write "AEM" on the top of the application

Write the date coverage needs to begin; and

Fax the completed application to: 866-841-2267

Routing Misdirected Applications (For internal HCA and DSHS AEM specialty staff only):

If the CSO, HCS or HCA receives a Form HCA 18-005 for AMP (non LTC): Route the application via DMS to CSO 132@AEM for processing.

If the CSO, HCS or HCA receives a Form HCA18-001 for AMP (non LTC): Route the application via DMS to @AEM076.

Both HCA MAGI-based and DSHS Classic AEM require the following supporting documents based on emergent condition:

Emergency room care: Emergency room treatment page(s) Copy of the completed hospital claim form (UB04)

Outpatient surgery care: Operative notes (description of procedure completed) Emergency room treatment page(s); and Copy of the completed hospital claim form (UB04)

Inpatient admission: History and physical Hospital discharge summary Copy of the completed hospital claim form (UB04)

Cancer treatment: Cancer treatment plan

Dialysis treatment: Current dialysis flow charts from dialysis center; Treatment plan from the attending physician

Antirejection treatment for a post organ transplant Treatment plan from the attending physician or provider

AEM applications cannot be approved without prior authorization from an HCA medical consultant.

The specialized eligibility worker makes the referral to the HCA medical consultant team via the AMP barcode referral system when:

Financial eligibility has been determined;

The required supported medical documents have been received; and

A NGMA approval has been received when required (only applies to DSHS Classic).

View a AEM process PDF .

Both HCA and DSHS process AEM applications, depending on whether the AEM is relatable to a MAGI-based Apple Health program or Classic Apple Health (aged, blind, or disabled) program.

HCA processes AEM MAGI-based Apple Health applications for: Applicants between ages 19 – 64 who are not entitled to Medicare.

DSHS processes AEM Classic Apple Health applications for: Applicants age 65 or older and not a caretaker for a child under age 19, Applicants receiving Medicare

Review the individual's immigration status to ensure they are not eligible for any other MAGI programs. AEM is a program of last resort and only available to the following: Undocumented individuals; Qualified aliens who have not met the 5-year bar and are not exempt from the 5-year bar; and Nonpregnant nonqualified aliens

Is the individual seeking or receiving long-term care services? If yes, refer to the Aging and Long-Term Support Administration (ALTSA). Send an email to Emily Watts at HCS indicating the name, client ID, type of LTC services needed, and dates services are needed. Continue processing the AEM request for medical assistance pending the result of the ALTSA prior authorization request. The HCS program manager will ensure the LTC request is followed up on if a slot is approved on the state-funded program. There is no need to forward documents in DMS to HCS or to the LTC Specialty Team If no, continue processing.

Complete the AEM referral/checklist in barcode as follows: If not already provided, send a request for information letter HCA 12-361 to the individual for required documents on referral/checklist. If the individual is still hospitalized at time of application and after contact with the hospital, the discharge date cannot be determined, refer to HCA medical consultant with the following: Admission history and physical (signed by the admission doctor); The most recent physician notes; and Note from the worker that the individual is still inpatient. Once all documents are provided, forward the referral/checklist and documents to the HCA medical consultant through the Barcode AEM Referral system. AEM applications cannot be approved until the HCA medical consultant has approved the AEM referral. The HCA medical consultant can be contacted at: Health Care Authority Health Care Benefits and Utilization Management MS 45506 Telephone: 800-562-3022 FAX: 360-586-1471 All communication pertaining to an AEM referral should be made through the Barcode AEM Referral system.

Once the AEM referral is returned by the medical consultant, follow these steps on processing the referral. Approval and denial letters must be manually generated out of the Washington Healthplanfinder. Add the following free-from text to approval letters: (Individual's name) has been approved Washington Apple Health, Alien Emergency Medical from (date) to (date). Add the following WAC and free-form text to denial letters: WAC 182-507-0110 - We have reviewed your case and you are not eligible for any HCA/DSHS medical program. We also reviewed your eligibility for the Alien Emergency Medical program and you do not meet the following: Have not had surgery to treat cancer, and are not receiving chemotherapy and/or radiation therapy to treat cancer; or Are not immediately starting or receiving dialysis to treat acute renal failure or end-stage renal disease; or Are not receiving antirejection medication for a post organ transplant. Do not have a qualifying emergency condition

ACES Online calculates the certification period.

If an AEM application is denied without having to make a referral to the HCA medical consultant, force close the application in the Washington Healthplanfinder with a 535 code and add the following WAC and free-form text: WAC 182-507-0110 We have reviewed your case and you are not eligible for any HCA/DSHS medical program. We also reviewed your eligibility for the Alien Medical program and you do not meet the following: Have not had surgery to treat cancer, and are not receiving chemotherapy and/or radiation therapy to treat cancer; or Are not immediately starting or receiving dialysis to treat acute renal failure or end-stage renal disease; or Are not receiving antirejection medication for a post organ transplant. Do not have a qualifying emergency condition

Referrals received by the HCA Medical Consultant

Referrals to the HCA Medical Consultant team without all required documentation will be considered incomplete and not accepted. They will be returned and will need to be resubmitted. Incomplete requests will not be pended by the medical consultant for completed documents.

Separate medical AUs

Separate medical AUs for each eligible individual should always be established even when an AU could have more than one eligible individual. Each individual needs their own AMP Barcode referral.

Ensure that the AEM application is relatable to a Classic Medicaid program. These would typically include: Individuals age 65 or older and not a caretaker for a child under age 19; Individuals eligible for Medicare;

Complete the AEM Referral/Checklist in Barcode as follows: If not already provided, send a request for information letter to the individual for the required supporting medical documents on referral/checklist. If the individual is still hospitalized at time of application and after contact with the hospital, the discharge date cannot be determined, refer to HCA medical consultant with the following: Admission History and Physical (signed by the admission doctor); The most recent physician notes; and Note from the worker that the individual is still inpatient. Once all documents are provided, forward the referral/checklist and documents to the HCA medical consultant through the Barcode AEM Referral system. AEM applications cannot be approved until the HCA medical consultant has approved the AEM Referral. The HCA medical consultant can be contacted at: Health Care Authority Health Care Benefits and Utilization Management MS 45506 Telephone: 800-562-3022 FAX: 360-586-1471 All communication pertaining to an AMP referral should be made through the Barcode AEM Referral system. Once the AEM referral is returned by the medical consultant, follow the ACES manual on how to process.

Approval Source field

Leaving the Approval Source field blank will result in the AU being denied. This field should only be left blank for applications being denied when a Barcode referral to the HCA medical consultant is not appropriate

Noncitizen children eligible for CN coverage

Noncitizen children are eligible for full-scope CN coverage through MAGI through the end of the month in which they turn 19. Young adults age 19-21 who are hospitalized for over 30 days may be eligible for either MAGI based new adult coverage OR Institutional Family coverage using K03. If the individual meets these criteria and is NOT eligible for MAGI-based new adult coverage, refer to the HCA for a K03 eligibility determination. The individual will still have to meet the criteria in Section 2 above. Send an email indicating the individual needs AEM under the K03 program.

ACES calculates a certification period for the individual. Verify the certification period and adjust in ACES accordingly, using the coverage end date given by the HCA medical consultant. Certification periods for AEM: Cannot be more than 12 months for non-spenddown AUs; Cannot be less than 1 month or more than 6 months for spenddown AUs; Won't be synchronized with other related AUs; and Won't continue beyond the end date when a renewal request (for instance, in the case of dialysis or cancer treatment) is initiated or received but not completed.

Renewal processing

During renewal processing, the system won't auto-extend the certification period in order to sync up renewal cycles. For certification periods less than 60 days, ACES does not send out renewal forms or notices because the renewal cycle is not triggered.

Approval dates

If the approval dates span more than one calendar month, the certification period shown in ACES includes all months within the approval period. However, the certification period in ACES for AEM does not show the actual approval period in ProviderOne. Coverage in ProviderOne will be for the actual dates approved.

Approval periods

Approval period is 6/5/xx - 7/12/xx. The certification period is 6/1/xx - 7/31/xx; however, eligibility is only established from 6/5/xx - 7/12/xx. If this is a spenddown AU, the AU begin date would be the date spenddown is met, which could be no earlier than 6/5/xx.

When the HCA medical consultant-approved coverage period expires

Once the HCA medical consultant-approved coverage period has expired, a new application, referral checklist, and medical documentation are required.

If an AEM application is denied, update the approval source field under Alien Medical on the ALAS screen in ACES with "N". ACES will deny the AU with reason code 276 - No Medical Emergency, with auto text reading: "Your medical condition doesn't meet the emergency requirements." You will need to add the following free-form text: We have reviewed your application and you are not eligible for any HCA/DSHS medical program. You are not eligible for the Alien Emergency Medical Program because you did not receive medically necessary treatment for a qualifying emergency medical condition.

If the client needs Long-Term Services and Supports (LTSS) at home, in a residential setting or in a nursing facility while processing the AMP request, a prior authorization request must be made to the HCS residential program manager.

For CSD or HCA staff who are processing an application which also includes a request for LTSS services, send an email referral to Emily Watts.

Indicate:

Name

Client ID

Where client is located

Type of LTSS service needed (in home, residential setting or nursing facility)

Dates of service needed

Region 1 HCS: Theresa Mayou Region 2 King County HS: Mathew Sipes Region 2 North HCS: Sherry Dennis, Tyler Ramsey Region 3 HCS: Tammy Hargrave, Laurie Alvarino

State-funded long-term care for noncitizens

Continue processing the AEM request for medical assistance pending the result of the HCS prior authorization request. If the HCA medical consultant:

Approves medical condition for AEM coverage, process the non institutional medical coverage using coverage group S07.

Denies medical condition. Deny the S07 and mark all documents complete.

The HCS program manager will coordinate the LTSS referral if a slot is approved for the state-funded program. There is no need to forward documents in DMS to HCS.

Apple Health Expansion is a state funded, capped enrollment (limited enrollment due to funding) program for individuals who do not meet the citizenship or immigration status requirements of other Apple Health programs.

Washington residents aged 19 or older,

Have countable income at or below 138% of the federal poverty level (FPL),

Do not qualify for other Apple Health programs based on immigration status ,

Are not pregnant or did not have a pregnancy end in the last 12 months, and

Are not eligible for qualified health plans with advance premium tax credits (APTC), federally funded medical assistance programs.

Are not eligible for another Apple Health program

There are no resource limits for the Apple Health Expansion program. Clients will need to have income at or below 138% of the FPL. For the current FPL income standards by household, visit the Apple Health Expansion program webpage .

Online : Go to Washington Connection . Select "Apply Now." Learn how to login to Washington connection . Learn how to complete your eligibility review .

Paper : Submit an Application for aged, blind, disabled/long-term care coverage (HCA 18-005) .

Phone : Request an application by calling 1-877-501-2233.

In-person : Visit your DSHS office. DSHS Community Services Office

Online : Go to Washington Healthplanfinder . Select "Apply Now".

Phone : Call the Washington Healthplanfinder Customer Support Center toll free at 1-855-923-4633.

Paper : Submit an Application for health care coverage (18-001P) .

In-person : Local resources who, at no additional cost, can help you apply for health coverage.

For more information, visit the Apple Health Expansion program webpage .

Both the Health Care Authority (HCA) and DSHS will process Apple Health Expansion applications. Clients aged 19-64 will be automatically processed in Washington Healthplanfinder (and all other acceptable application pathways) giving either an approval or denial based on the attested information of the client. For individuals aged 65+ DSHS will process their application coming through Washington Connection and all other acceptable application pathways and give either an approval or denial based on the confirmed information of the client.

What if the cap is on?

If the CAP is on, with EPICS approval, HCA and DSHS may manually process and approve applications for Apple Health Expansion.

HCA processes Apple Health Expansion applications under MAGI when:

Individual is age 19 through 64.

Individual is not eligible for Medicare, or any other federally funded Apple Health programs, and follows MAGI rules established through the Washington Healthplanfinder.

If Apple Health Expansion has open availability, individuals will be approved if they meet all eligibility requirements for the program.

Review the individual's income and immigration status to ensure they are not eligible for any other federally funded MAGI programs.

Is the client eligible for Apple Health Expansion based on attested information: If yes, continue with manual application processing If no, sends denial letter (If one has not already auto-generated from Washington Healthplanfinder dashboard) for Apple Health Expansion. Did client mark AEM? If yes client will be reviewed for AEM eligibility

If client is determined eligible for Apple Health Expansion staff manually approves client and sends approval letter.

"Submit information" letter

If attested income does not verify, verify important deadline to submit information letter generates.

Immigration status

If attested immigration status does not match information on file (i.e. attests to no immigration status but there is information on file, or attested immigration status does not verify), follow SAVE verification procedures.

Clients who are Federally Qualified (FQ) or Non-Federally Qualified (NF) are not eligible for Apple Health Expansion.

Clients who have not yet met their five-year bar are not eligible for Apple Health Expansion. This is due to being eligible for Qualified Health Plans with Advance Premium Tax Credits. These individuals could also be looked at for Alien Emergency Medical (AEM) .

There are no retro benefits for Apple Health Expansion. If retro is requested staff may look at AEM for retro months.

Apple Health Expansion does not include long-term services and supports (LTSS) authorized by the Developmental Disabilities Administration (DDA), Aging and Long-term Supports Administration (ALTSA), or Home and Community Services (HCS) in the scope of care benefit package.

Clients also currently active on Medical Care Services (MCS) coverage are not eligible for Apple Health Expansion coverage as they would be dual-enrolled in coverage.

Classic Apple Health Expansion applications are only processed by Community Services Division (CSD) specialized staff.

If the program cap has not been met, clients will be approved if eligible. If the limit (cap) is at capacity, eligible clients will be denied. Clients may qualify for other coverage including Alien Emergency Medical (AEM) and can purchase a QHP plan through the Health Benefits exchange (HBE).

DSHS-CSD processes Apple Health Expansion under Classic Apple Health when the individual is age 65 or older.

The following immigration status’ are eligible for Apple Health Expansion:

Undocumented / No immigration status

Applicants for asylum

Applicants for withholding of deportation/removal

Registry applicants

Order of supervision

Applicant for cancellation of removal / Suspension of deportation

Expired or revoked immigration status

Household composition-Apple Health Expansion (S20) will follow the same household composition rules as S02:

Income: Countable Earned and Unearned income types are the same as S02/S07 medical.

SSI recipient spouse: If an Apple Health Expansion applicant is married and their spouse is an SSI recipient, they are not eligible for Apple Health Expansion.

When there are two applying spouses on the same AU and they're eligible for different programs, only one spouse will be approved for coverage on the AU.

Example

John and Beth apply for medical on 7/1/26.

John is a 70-year-old citizen and Beth is 65 and does not have legal status.

A worker screens in S02 for John and S20 for Beth, with both clients having financial responsibility Applicant (PN).

During Finalize the S02 is approved for John with certification 7/1/26 - 6/30/27.

Beth's financial responsibility is changed from Applicant (PN) to Ineligible Spouse (SP).

During the finalize for the S20 John would be ineligible spouse (SP) and Beth would be applicant (PN).

If there is a spot available and Beth is eligible, she would be approved S20 on Apple Health Expansion.

The CSD specialized medical team has cap override access in ACES. This field is displayed on the AU details screen in ACES 3G

All S20 requests processed after the cap has been met shall be denied for Reason Code (171) Enrollment Cap regardless of the date of application or when it was received as long as the AEM indicator = N and they aren't eligible for a Classic Medical Program. (Trickle to pending AEM if AEM indicator = Y.)

S20 is not subject to asset test and therefore is required for AVS. S20 clients and AUs will not be included in the AVS application file. However, the AVS authorization field will display in ACES 3G when S20 is screened. If you have AVS authorization, update this field, if you do not, you are able to bypass.

AVS authorization field displays because if S20 trickles to S07. AVS authorization is required for S07 approval.

Staff screen in the application and can select the program code (S02, S20). Based on information entered in ACES, the program will trickle to the appropriate program. Example: S02 is screened, but client is eligible based on immigration status and income for S20- ACES will trickle to S20 Example: S20 is screened, but based on immigration status and income entered the client is eligible for Federal Medicaid. S20 trickles to S99.

Attestation acceptance

Client attestation of all eligibility factors will be accepted.

To explain the Family Planning Only (FPO) program.

Individuals have the option to apply for FPO through a family planning provider or by submitting their own application. All eligibility questions can be answered by contacting the Health Care Authority at 1-800-562-3022 ext. 12533 (translation services available). This program is confidential and information is only shared with the individual receiving the services or their designated authorized representative.

Example

Mary Sue is covered under Apple Health for Pregnant individuals. She has her baby and reports this in Healthplanfinder and is approved for After Pregnancy Coverage (APC) for 12 months following the end of her pregnancy. After her APC coverage ends, she does not qualify for other Apple Health programs because her income is too high (above 210% of FPL). She is potentially eligible for the FPO program.

The FPO program code in ACES is P06. Participation in the Family Planning Only program is confidential even when members of the same household are receiving the services.

For more information on FPO services, visit HCA's Family Planning Only webpage .

Staff do not need to take any action to close AUs for Apple Health for Pregnant Individuals. If an individual applies for Family Planning Only and is on an AU for pregnancy or after pregnancy coverage staff will deny the P06 as those programs offer full coverage and cover FPO services.

Effective January 1, 2026

The purpose of the family planning only programs is to provide family planning services to all clients capable of reproducing, regardless of gender, to:

Improve access to family planning and family planning-related services; and

Reduce unintended pregnancies;

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 .

Effective October 6, 2025

For the purposes of this section, "full-scope coverage" means coverage under either the categorically needy (CN) program, the broadest, most comprehensive scope of health care services covered or the alternative benefits plan (ABP), the same scope of care as CN, applicable to the apple health for adults program.

To be eligible for family planning only services, as defined in WAC 182-532-001, a client must: Provide a valid Social Security number (SSN) or proof of application to receive an SSN, be exempt from the requirement to provide an SSN as provided in WAC 182-503-0515, or meet good cause criteria listed in WAC 182-503-0515(2); Be a Washington state resident, as described under WAC 182-503-0520; Have an income at or below two hundred sixty percent of the federal poverty level, as described under WAC 182-505-0100; Need family planning services; and Have been denied apple health coverage within the last 30 days, unless the applicant: Has made an informed choice to not apply for full-scope coverage as described in WAC 182-500-0035 and 182-501-0060, including family planning; Is age 26 or younger and seeking services in confidence; Is a domestic violence victim who is seeking services in confidence; or Has an income of 150 percent to 260 percent of the federal poverty level, as described in WAC 182-505-0100.

A client is not eligible for family planning only medical if the client is: Pregnant; Sterilized; Covered under another apple health program that includes family planning services; or Covered by concurrent creditable coverage, as defined in RCW 48.66.020, unless they meet criteria in (1) (e) (ii) or (iii) of this section.

The agency does not limit the number of times a client may reapply for coverage.

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 .

The Kidney Disease Program (KDP) is a state-funded program that helps low-income, eligible clients with treatment costs for end-stage renal disease.

Client eligibility is determined by each contracted kidney center. Eligibility is based on the program's residential and medical criteria in addition to income and asset standards.

Contracted kidney centers require clients to apply for medical programs that provide medical coverage such as Medicaid, Medicare, supplemental insurance, or employer sponsored insurance.

KDP manual - effective January 1, 2025

KDP manual - effective January 1, 2024

KDP Washington Administrative Codes (WACs)

State Fiscal Year 2024 (SFY24) contract

Application eligibility form (Excel)

Application eligibility form (PDF)

Effective February 1, 2024

Effective February 1, 2023

For program questions, please email the Kidney Disease Program .

Effective June 9, 2025

General eligibility . For purposes of this section, a child must: Be a Washington state resident under WAC 182-503-0520 and 182-503-0525 ; Provide a Social Security number under WAC 182-503-0515 , unless exempt; and Meet program-specific requirements.

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. Newborn coverage . A child younger than age one is eligible for categorically needy (CN) coverage if the birth parent was eligible for Washington apple health on the date of delivery: Including a retroactive eligibility determination; or By meeting a medically needy (MN) spenddown liability with expenses incurred by the date of the newborn's birth: 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 . 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).

Continuous eligibility for children under age six . A child is eligible for Washington apple health continuous eligibility for children under age six when they: Have household income at or below 210 percent of the federal poverty level at the time of application; or On or after January 8, 2025, have household income greater than 210 percent but equal to or less than 312 percent of the federal poverty level at the time of application; or 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.

MAGI-based eligibility groups . A child age 18 or younger is eligible for CN coverage based on modified adjusted gross income (MAGI): At no cost when the child's countable income does not exceed the standard in WAC 182-505-0100 (6)(a); 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 ; 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 (MN) program if income exceeds the CN income standard for a person in an institution (special income level); Under WAC 182-505-0117 , if a child is pregnant; 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.

Non-MAGI-based children's programs . The agency determines eligibility for the: MN program according to WAC 182-519-0100 . A child age 18 or younger is eligible if the child: Is not eligible for MAGI-based coverage under subsection (3) of this section; Meets citizenship or immigration requirements under WAC 182-503-0535 (2)(a), (b), (c), or (d); and Meets any spenddown liability required under WAC 182-519-0110 . SSI-related program . A child age 18 or younger is eligible for CN or MN SSI-related coverage if the child meets: SSI-related eligibility under chapter 182-512 WAC; Citizenship or immigration requirements under WAC 182-503-0535 (2)(a), (b), (c), or (d); and Any MN spenddown liability under WAC 182-519-0110 . SSI-related long-term care program . A child age 18 or younger is eligible for home and community based (HCB) waiver programs under chapter 182-515 WAC if the child meets: SSI-related eligibility under chapter 182-512 WAC; Citizenship or immigration requirements under WAC 182-503-0535 (2)(a), (b), (c), or (d); and Program-specific age and functional requirements under chapters 388-106 and 388-845 WAC. A child age 18 or 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: Citizenship or immigration requirements under WAC 182-503-0535 (2)(a), (b), (c), or (d); Blindness or disability criteria under WAC 182-512-0050 ; and Nursing facility level of care under chapter 388-106 WAC.

Alien emergency medical program . A child age 20 or 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: The eligibility requirements of WAC 182-507-0110 ; and MN spenddown liability, if any, under WAC 182-519-0110 .

Other provisions . A child residing in an institution for mental disease (IMD) as defined in WAC 182-500-0050 is not eligible for inpatient hospital services, unless the child is unconditionally discharged from the IMD before receiving the services. A child incarcerated in a public institution as defined in WAC 182-500-0050 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 .

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 .

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.

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 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.

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.

Effective October 25, 2024.

For the purposes of this chapter, "premium" means an amount paid for health care coverage under WAC 182-505-0215 .

Premium requirement. The Washington apple health premium-based program under WAC 182-505-0215 requires payment of a monthly premium. The first monthly premium is due in the month following the determination of eligibility. There is no premium requirement for health care coverage received in the month eligibility is determined or in any prior month. A child who is American Indian or Alaska native is exempt from the monthly premium requirement.

Monthly premium amount. 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. The premium amount is as follows: 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. 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. The medicaid agency charges a monthly premium for no more than two children per household. Payment of the full premium is required. Partial payments cannot be designated for a specific child or month. 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. A change that affects the premium amount takes effect the month after the change is reported.

Nonpayment of premiums. 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 .

Medical coverage for parenting adults of minor dependent children has been "delinked" from cash assistance. Parenting adults need to complete a separate application for medical coverage.

Adults who are over income for Apple Health for Families (N01) may be eligible for Apple Health for Adults (N05) as described in WAC 182-505-0250 .

Adults who are ineligible for Apple Health for Families (N01) based on citizenship may be eligible for Alien Emergency Medical (N21) as described in WAC 182-507-0110 .

Parenting adults are eligible for Apple Health for Families (N01) even if they are eligible for Medicare and/or age 65 or older.

Individuals may apply for MAGI Medicaid using the following options:

Online: Washington Healthplanfinder

Paper: HCA Form 18-001 (Application for Health Care Coverage) , can be submitted via: Mail: Washington Healthplanfinder, PO Box 946, Olympia WA 98507 Fax: 1-855-867-4467

Phone: 1-855-923-4633

If an individual wants help applying for MAGI Medicaid, he or she can work with a Navigator or call Healthplanfinder Customer Support at 1-855-923-4633.

Describe the Health Care Extension (N02) available to parenting/caretaker (N01) adults when their N01 coverage ends due to increased earnings or collection of spousal support.

Effective December 28, 2019

A parent or caretaker relative who was eligible for and who received coverage under Washington apple health for parents and caretaker relatives, described in WAC 182-505-0240 , in any three of the last six months is eligible, along with all dependent children living in the household, for twelve months' extended health care coverage if the person becomes ineligible for coverage due to increased earnings or hours of employment.

A person remains eligible for apple health medical extension unless: The person: Moves out of state; Dies; or Leaves the household. The family: Moves out of state; Loses contact with the agency or its designee or the whereabouts of the family are unknown; or No longer includes an eligible dependent child as defined in WAC 182-503-0565 (2).

When a person or family is determined ineligible for apple health coverage under subsection (2)(a)(i) through (iii) or (b)(i) or (ii) of this section during the medical extension period, the agency or its designee redetermines eligibility for the remaining household members as described in WAC 182-504-0125 and sends written notice as described in chapter 182-518 WAC before apple health medical extension is terminated.

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 .

Health Care Extension (N02) is CN coverage given only to parent/caretaker adults who become ineligible for Washington Apple Health Family (N01) coverage because of an increase in earned income or spousal support.

To qualify the adult must be eligible for Washington Apple Health Family (N01) coverage in three of the preceding six months.

Health Care Extension (N02) coverage is certified for twelve months. However, eligibility is not continuous. Changes in household circumstances may effect eligibility.

There is no renewal of the Health Care Extension (N02).

Effective August 24, 2014

When the agency or its designee determines the family or an individual family member is ineligible during the medical extension period, the agency or its designee must determine if they are eligible for another medical program.

Children are eligible for twelve month continuous eligibility beginning with the first month of the medical extension period.

When a family reports a reduction of income, the family may be eligible for the Washington apple health for parents and caretaker relatives program (described in WAC 182-505-0240 ) instead of medical extension benefits.

When a medical extension period is ending, the family is required to complete a renewal of eligibility as described in WAC 182-504-0035 .

Postpartum and family planning extensions are described in WAC 182-505-0115 .

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 .

The individual receives a review at the end of the Health Care Extension certification period. Adults aren't eligible for consecutive N02 certifications.

To explain the medically needy (MN) program and spenddown.

WAC 182-500-0070 defines the medically needy program as follows:

"Medically needy (MN) or medically needy program (MNP)" is the state- and federally-funded health care program available to specific groups of persons who would be eligible as categorically needy (CN) except their monthly income is above the CN standard. Some long-term care individuals with income and/or resources above the CN standard may also qualify for MN.

Effective February 10, 2023

Changes to the Medically Needy Income Level (MNIL) occur on January 1st of each calendar year when the Social Security Administration (SSA) issues a cost-of-living adjustment.

Medically Needy (MN) standards for people who meet institutional status requirements are in WAC 182-513-1395 . The standard for a client who lives in an alternate living facility is in WAC 182-513-1205 .

The resource standards for institutional programs are in WAC 182-513-1350 . The institutional standard chart is found at Long Term Care Standards .

Countable resource standards for the noninstitutional MN program are: One person $2,000. A legally married couple $3,000. For each additional family member add $50.

People who do not meet institutional status requirements use the "effective" MNIL income standard to determine eligibility for the MN program. The "effective" MNIL is the one-person federal benefit rate (FBR) established by SSA each year, or the MNIL listed in the chart below, whichever amount is higher. The FBR is the supplemental security income (SSI) payment standard. For example, in 2023 the FBR is $914.

1 2 3 4 5 6 7 8 9 10 914 914 914 914 914 975 1125 1242 1358 1483

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 .

Effective January 27, 2019

A person who meets the following conditions may be eligible for medically needy (MN) coverage under the special rules in chapter 182-513 WAC and chapter 182-515 WAC : Meets the institutional status requirements of WAC 182-513-1320 ; Resides in a medical institution as described in WAC 182-513-1395 .

A supplemental security income (SSI)-related person who lives in a medicaid agency-contracted alternate living facility may be eligible for MN coverage under WAC 182-513-1205 .

A person may be eligible for MN coverage under this chapter when he or she is: Not covered under subsection (1) and (2) of this section; and Eligible for categorically needy (CN) medical coverage in all other respects, except that his or her CN countable income is above the CN income standard.

MN coverage may be available if the person is: A child; A pregnant woman; A refugee; An SSI-related person, including an aged, blind, or disabled person, with countable income under the CN income standard, who is an ineligible spouse of an SSI recipient; or A hospice client with countable income above the special income level (SIL).

A person who is not eligible for CN medical who applies for MN coverage has the right to income deductions in addition to, or instead of, those used to calculate CN countable income. These deductions to income are applied to each month of the base period to calculate MN countable income: The agency disregards the difference between the medically needy income level (MNIL) described in WAC 182-519-0050 and the federal benefit rate (FBR) established by the Social Security Administration each year. The FBR is the one-person SSI payment standard; All health insurance premiums, except for medicare Part A through Part D premiums, expected to be paid by the person or family member during the base period or periods; Any allocations to a spouse or to dependents for an SSI-related person who is married or who has dependent children. Rules for allocating income are described in WAC 182-512-0900 through WAC 182-512-0960 ; For an SSI-related person who is married and lives in the same home as his or her spouse who receives home and community-based waiver services under chapter 182-515 WAC , an income deduction equal to the MNIL, minus the nonapplying spouse's income; and A child or pregnant woman applying for MN coverage is eligible for income deductions allowed under temporary assistance for needy families (TANF) and state family assistance (SFA) rules and not under the rules for CN programs based on the federal poverty level. See WAC 182-509-0001 (4) for exceptions to the TANF and SFA rules that apply to medical programs and not to the cash assistance program.

The MNIL for a person who qualifies for MN coverage under subsection (1) of this section is based on rules in chapter 182-513 WAC and chapter 182-515 WAC .

The MNIL for all other people is described in WAC 182-519-0050 . If a person has countable income at or below the MNIL, the person is certified as eligible for up to 12 months of MN medical coverage.

If a person has countable income over the MNIL, the countable income that exceeds the agency's MNIL standards is called "excess income."

A person with "excess income" is not eligible for MN coverage until the person gives the agency or its designee evidence of medical expenses incurred by that person, their spouse, or family members living in the home for whom they are financially responsible. See WAC 182-519-0110 (8). An expense is incurred when: The person receives medical treatment or medical supplies, is financially liable for the medical expense, and has not paid the bill; or The person pays for the expense within the current or retroactive base period under WAC 182-519-0110 .

Incurred medical expenses or obligations may be used to offset any portion of countable income that is over the MNIL. This is the process of meeting "spenddown."

The agency or its designee calculates the amount of a person's spenddown by multiplying the monthly excess income amount by the number of months in the certification period under WAC 182-519-0110 . The qualifying medical expenses must be greater than or equal to the total calculated spenddown amount.

A person who is considered for MN coverage under this chapter may not spenddown excess resources to become eligible for the MN program. Under this chapter, a person is ineligible for MN coverage if the person's resources exceed the program standard in WAC 182-519-0050 . A person who is considered for MN coverage under WAC 182-513-1395 , WAC 182-514-0250 or WAC 182-514-0263 is allowed to spenddown excess resources.

There is no automatic redetermination process for MN coverage. A person must apply for each eligibility period under the MN program.

A person who requests a timely administrative hearing under WAC 182-518-0025 is not eligible for continued benefits beyond the end of the original certification date under the MN program.

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 .

Effective January 27, 2019

A person who applies for Washington apple health (WAH) and is eligible for medically needy (MN) coverage with a spenddown may choose a three-month or a six-month base period. A base period is a time period used to compute the spenddown liability amount. The months must be consecutive calendar months, unless a condition in subsection (4) of this section applies.

A base period begins on the first day of the month a person applies for WAH, unless a condition in subsection (4) of this section applies.

A person may request a separate base period to cover up to three calendar months immediately before the month of application. This is called a retroactive base period.

A base period may vary from the terms in subsections (1), (2), or (3) of this section if: A three-month base period would overlap a previous eligibility period; The person has countable resources over the applicable standard for any part of the required base period; The person is not or will not be able to meet the temporary assistance to needy families (TANF)-related or supplemental security income (SSI)-related requirement for the required base period; The person is eligible for categorically needy (CN) coverage for part of the required base period; or The person was not otherwise eligible for MN coverage for each month of the retroactive base period.

The medicaid agency or its designee calculates a person's spenddown liability. The MN countable income from each month of the base period is compared to the effective medically needy income level (MNIL) under WAC 182-519-0050 . Income over the effective MNIL standard (based on the person's household size) in each month in the base period is added together to determine the total spenddown amount.

If household income varies and a person's MN countable income falls below the effective MNIL for one or more months, the difference offsets the excess income in other months of the base period. See WAC 182-519-0100 (7) if a spenddown amount results in zero dollars and cents.

If a person's income decreases, the agency or its designee approves CN coverage for each month in the base period when the person's countable income and resources are equal to or below the applicable CN standards. Children age eighteen and younger and pregnant women who become CN eligible in any month of the base period are continuously eligible for CN coverage for the remainder of the certification, even if there is a subsequent increase in income.

Once a person's spenddown amount is determined, qualifying medical expenses are deducted. A qualifying medical expense must: Be an expense for which the person is financially liable; Not have been used to meet another spenddown; Not be the confirmed responsibility of a third party. The agency or its designee allows the entire expense if a third party has not confirmed its coverage of the expense within: Forty-five days of the date of service; or Thirty days after the base period ends. Be an incurred expense for the person: The person's spouse; A family member residing in the person's home for whom the person is financially responsible; or A relative residing in the person's home who is financially responsible for the person. Meet one of the following conditions: Be an unpaid liability at the beginning of the base period; Be for paid or unpaid medical services incurred during the base period; Be for medical services incurred and paid during the three-month retroactive base period if eligibility for WAH was not established in that base period. Paid expenses that meet this requirement may be applied towards the current base period; or Be for medical services incurred during a previous base period, either unpaid or paid, if it was necessary for the person to make a payment due to delays in the certification for that base period.

An exception to subsection (8) of this section exists for qualifying medical expenses paid on the person's behalf by a publicly administered program during the current or the retroactive base period. The agency or its designee uses the qualifying medical expenses to meet the spenddown liability. To qualify for this exception, the program must: Not be federally funded or make payments from federally matched funds; Not pay the expenses before the first day of the retroactive base period; and Provide proof of the expenses paid on the person's behalf.

Once the agency or its designee determines the expenses are a qualified medical expense under subsection (8) or (9) of this section, the expenses are subtracted from the spenddown liability to determine the date the person's eligibility for medical coverage begins. Qualifying medical expenses are deducted in the following order: First, medicare and other health insurance deductibles, coinsurance charges, enrollment fees, copayments, and premiums that are the person's responsibility under medicare Part A through Part D. (Health insurance premiums are income deductions under WAC 182-519-0100 (5)); Second, medical expenses incurred and paid by the person during the three-month retroactive base period if eligibility for WAH was not established in that base period; Third, current payments on, or unpaid balance of, medical expenses incurred before the current base period that were not used to establish eligibility for medical coverage in another base period. The agency or its designee sets no limit on the age of an unpaid expense; however, the expense must be a current liability and be unpaid at the beginning of the base period; Fourth, other medical expenses that are not covered by the agency's or its designee's medical programs, minus any third-party payments that apply to the charges. A licensed health care provider must provide or prescribe the items or services allowed as a medical expense; Fifth, other medical expenses incurred by the person during the base period that are potentially payable by the MN program (minus any confirmed third-party payments that apply to the charges). This deduction is allowed even if payment is denied for these services because they exceed the agency's or its designee's limits on amount, duration, or scope of care. Scope of care is described in WAC 182-501-0060 and WAC 182-501-0065 ; and Sixth, other medical expenses incurred by the person during the base period that are potentially payable by the MN program (minus any confirmed third-party payments that apply to the charges) and that are within the agency's or its designee's limits on amount, duration, or scope of care.

If a person submits verification of qualifying medical expenses with his or her application that meet or exceed the spenddown liability, the person is eligible for MN medical coverage for the remainder of the base period unless their circumstances change. See WAC 182-504-0105 to determine which changes must be reported to the agency or its designee. The beginning of eligibility is determined under WAC 182-504-0020 .

If a person cannot meet the spenddown amount when the application is submitted, the person is not eligible until he or she provides proof of additional qualifying expenses that meet the spenddown liability.

Each dollar of a qualifying medical expense may count once against a spenddown period that leads to eligibility for MN coverage. However, medical expenses may be used more than once if: The person did not meet his or her total spenddown liability and become eligible in a previous base period and the bill remains unpaid; or The medical expense was incurred and paid within three months of the current application, and the agency or its designee could not establish WAH eligibility for the person in the retroactive base period.

The person must provide the proof of qualifying medical expense information to the agency or its designee within thirty days after the base period ends, unless there is a good reason for delay.

Once a person meets the spenddown requirement and the certification begin date is established, newly identified expenses are not considered toward that spenddown unless: There is a good reason for the delay in submitting the expense; or The agency or its designee made an error when determining the correct begin date.

Good reasons for delay in providing medical expense information to the agency or its designee include, but are not limited to: The person did not receive a timely bill from his or her medical provider or insurance company; The person has medical issues that prevent him or her from submitting proof on time; or The person meets the criteria for needing equal access under chapter WAC 182-503-0120 .

The agency or its designee does not pay for any expense or portion of an expense used to meet a person's spenddown liability.

If an expense is potentially payable under the MN program, and only a portion of the medical expense is assigned to meet spenddown, the medical provider must not: Bill the person for more than the amount assigned to the remaining spenddown liability; or Accept or retain any additional amount for the covered service from the person. Any additional amount may be billed to the agency or its designee. See WAC 182-502-0160 , Billing a client.

The agency or its designee determines whether any payment is due to the medical provider on medical expenses partially assigned to meet a spenddown liability under WAC 182-502-0100 .

If the medical expense assigned to spenddown was incurred outside of a period of MN eligibility, or if the expense is not covered by WAH, the agency or its designee does not pay any portion of the bill.

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 .

The medically needy (MN) program provides Apple Health (Medicaid) health care coverage for aged, blind, or disabled persons, institutionalized individuals, hospice individuals, pregnant women, children, and refugees with income above Categorically Needy (CN) standards and countable resources below the applicable MN resource standard. Those standards are defined in the standards chapter of this manual. There is no MN program related to the Apple Health for Adults (N05) program.

MN program codes

The MN program has the following program codes: F99, G95, G99, K95, K99, L95, L99, P99, S95, and S99 .

An individual may qualify for the MN program with or without spenddown. When determining eligibility for the MN program, there may be a difference between CN countable income and MN countable income. This results from the extra income deductions which apply to MN (for more information, see WAC 182-519-0100 (5)). Decisions regarding CN eligibility and MN eligibility should be based on the appropriate calculation of countable income.

When determining countable income for individuals who are aged, blind or disabled, use SSI-related income rules and deeming methodologies.

When determining countable income for children and pregnant women, use family-related income rules and deeming methodologies.

If an individual's income goes down after the spenddown amount has been calculated, the individual may become eligible for CN coverage. See Change of circumstances for more information.

MN coverage for persons in institutions is determined according to WAC 182-513-1395 . See the long-term care section of the manual for more information.

MN without spenddown means that the individual receives MN coverage for 12 months from the month of application without first having to incur any medical costs.

MN with spenddown means that the individual needs to incur medical expenses greater than or equal to the spenddown amount before coverage can begin. The spenddown amount is calculated by subtracting the SSI-related MN income standard from the amount of countable income (after the $20 income disregard), then multiplying this difference by the number of months in the base period.

The base period is the number of months used to calculate the spenddown amount. The individual may choose either a 3-month or a 6-month base period. If the client incurs qualifying medical expenses before and during the base period, the individual meets the spenddown and receives MN coverage from the date the spenddown was met through the remainder of the base period.

The base period begins the first of the month in which the agency receives an application for medical benefits or may begin the first of the following month if the individual applies late in the month and chooses to withdraw their request for medical coverage in the initial month.

An individual may also request retroactive coverage for any or all of the 3 months prior to the month of application. These month(s) are referred to as a retroactive base period.

Example: retroactive coverage

We receive an application for benefits on March 10. The individual requests coverage for February only, as he was hospitalized from February 15 - February 21. The individual is eligible for coverage under MN with spenddown for February. The worker denies MN coverage for December and January and establishes a 1-month retroactive base period for February.

CN coverage during retroactive base period

Children and pregnant individuals who are found eligible for CN coverage in one of the months of a retroactive base period are continuously eligible for CN coverage for one year in the case of children or through the end of the postpartum period in the case of pregnant women.

There is no review for MN coverage. Each request for MN coverage is considered a separate application.

Before medical expenses can be used to reduce or meet spenddown, the individual must have incurred the legal obligation. This means that the individual must have received the medical service or product and have a legal obligation for the cost. The medical expenses used to meet spenddown are the individual's obligation and cannot be billed to Medicaid.

For an expense to be allowed towards spenddown, the expense must have been prescribed by a licensed provider. The following charts give some guidance on expenses that can be allowed towards a spenddown liability.

Allowable medical expenses chart

Allowable practitioners chart

Expenses that have been paid using a credit card are considered a paid expense. They are allowed as a paid expense within either the retroactive base period or the current base period in which they paid the bill with the credit card. They are no longer considered an unpaid expense as the provider has been paid and the individual has received the medical item or service. Current credit card payments on a bill that was paid prior to any period of eligibility are no longer considered a valid medical expense.

Medical expenses that are still owed and have not been written off or discharged by the collection agency are allowed as a medical expense and can be considered an unpaid bill for spenddown. The agency will confirm if the debt is still valid and will not allow any interest or fees charged by the collection agency to be counted toward the spenddown. The agency allows only the amount of the original unpaid debt (the medical expense), using the original date of service for the expense when coding it into ACES.

Premiums for private medical insurance are treated as income deductions and are not applied to spenddown. The agency allows private insurance premiums (not Medicare premiums) as an income deduction and reduces income prior to comparing income to the MNIL standard. In many cases, an individual may become eligible for MN coverage without spenddown using this methodology.

When the individual meets spenddown, the agency determines if it is cost-effective to pay the premiums to ensure the coverage continues. If it is cost effective and the individual meets spenddown, the agency pays the premium. If the individual does not meet spenddown, the agency does not pay the premiums.

For more information on the Premium Payment programs through the Medicaid Purchasing Administration, see Health Insurance Premium program .

Example: spenddown

The individual’s spenddown is $600 and the insurance premium is $100 a month. Since the base period is 6-months, the individual meets spenddown and becomes eligible for Medicaid. The agency determines if it is cost effective to pay the insurance premium. If it is, then the agency begins paying the insurance premiums.

Note: In this example, if the agency didn’t use the insurance premium since the agency had been paying it in the previous base period, then the individual will not meet spenddown. If the individual does not meet spenddown, the agency does not pay the insurance premium. Then, the worker allows the monthly premiums for the base period which makes the individual eligible for coverage. Once eligible, the agency begins paying the premiums.

View the following pages for clarifying information on specific spenddown topics:

Allowable expenses chart

Allowable medical practitioners

Public programs

Health Insurance Premium program

Medicare Savings Program

Changes of circumstance

ACES codes

Review the application to determine if the individual has applied for retroactive coverage. If not, contact the individual to determine if they have any unpaid or paid medical expenses that they incurred during that time period.

Explain to the individual that they have the option to use the expenses they incurred and paid during the 3-month period or any expenses they have incurred but which remain unpaid towards meeting spenddown in the retroactive base period, or that they may apply the expenses towards their spenddown liability in the current base period.

Explain the advantages or disadvantages of both options. If the individual chooses to use expenses that were incurred and paid within the 3-month retroactive period towards the current base period, we cannot then use the expenses towards establishing coverage in the retroactive period at a later date.

ACES defaults to a 6-month certification period, however, that may not be the best option for the individual. If possible, talk to the individual to determine their circumstances. Upcoming hospitalizations or other major expenses may make a difference in selecting a base period. If the spenddown amount is high, a 3-month base period may be to the individual's benefit. If the spenddown amount is low and the individual can easily meet it, a 6-month base period would provide medical coverage for a longer period of time.

Excess income

An individual has $30.00 per month in excess income. Spenddown in this example would be $90.00 for a 3-month base period and $180.00 for a 6 month base period.

If the individual has $250.00 in qualifying medical expenses, a 6-month base period would be beneficial to the individual since they would have a longer period of eligibility.

If the same individual has no qualifying medical expenses at the time of application and anticipates no large medical needs, a 3-month base period may be in the individual's best interests. It would enhance the individual's opportunity to meet spenddown and obtain coverage.

When spenddown is met and benefits authorized, notify the medical service providers affected by spenddown. Those whose bills remain the responsibility of the individual may continue to pursue collection for those bills.

Those provider bills which will be covered by the ProviderOne Card need to be billed to the Medicaid program, and the provider must cease billing the individual for those covered services.

The agency is authorized to release spenddown information to providers without a signed release of information form if it is information necessary for the provider to correctly bill HCA. This information includes: The amount of the spenddown assigned to their bill (if the bill is a split bill) The specific expenses and dollar amounts of their bill(s) that were used The total dollar amount of the spenddown liability The balance of spenddown remaining to be met.

If providers have questions related to spenddown for individuals who are pregnant or about children, refer them to the Medical Assistance Customer Service Center provider line toll free at 1-800-562-3022.

For other individuals on spenddown, refer them to the DSHS Specialty Unit toll free at 1-877-501-2233.

Effective July 1, 2017.

A person is eligible for Washington apple health categorically needy (CN) coverage when the person: Is a parent or caretaker relative of a dependent child who meets the criteria described in WAC 182-503-0565 (2); Meets citizenship and immigration status requirements described in WAC 182-503-0535 ; Meets general eligibility requirements described in WAC 182-503-0505 ; and Has countable income below the standard in WAC 182-505-0100 (2).

To be eligible for coverage as a caretaker relative, a person must be related to a dependent child who meets the criteria described in WAC 182-503-0565 (2).

A person must cooperate with the state of Washington in the identification, use and collection of medical support from responsible third parties as described in WAC 182-503-0540 .

A person who does not cooperate with the requirements in subsection (3) of this section is not eligible for coverage.

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 .

Individuals who are over income for Apple Health for Parents/Caretakers (N01) may be eligible for Apple Health for Adults (N05) as described in WAC 182-505-0250 .

Individuals who are ineligible for Apple Health for Parents/Caretakers (N01) based on citizenship may be eligible for Alien Emergency Medical (N21) as described in WAC 182-507-0110 .

Individuals are eligible for Apple Health for Parents/Caretakers (N01) even if they are eligible for Medicare and/or age 65 or older.

Individuals may apply for MAGI health care coverage using the following options:

Online : Go to Washington Healthplanfinder - select the "Apply Now" button.

Phone : Call the Washington Healthplanfinder Customer Support Center at 1-855-923-4633.

Paper : Submit an Application for health care coverage (18-001P) .

In-person : Local resources who, at no additional cost, can help you apply for health coverage.

Local enrollment assistance

Effective June 24, 2022.

A pregnant person is eligible for Washington apple health pregnancy coverage if the person: Meets citizenship or immigration status under WAC 182-503-0535 ; Meets Social Security number requirements under WAC 182-503-0115 ; Meets Washington state residency requirements under WAC 182-503-0520 and 182-503-0525 ; and Has countable income at or below the limit described in: WAC 182-505-0100 to be eligible for categorically needy (CN) coverage; or 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 .

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.

The assignment of medical support rights as described in WAC 182-503-0540 does not apply to pregnant people.

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.

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.

A person who does not meet the requirements in subsection (4) of this section may qualify for after-pregnancy coverage if they: Apply for and meet all requirements of the apple health pregnancy coverage program other than pregnancy; and 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 .

First Steps is the commonly used term for Maternity Support Services. It is a package of services for pregnant individuals who receive Apple Health. Sometimes the pregnant individual’s health care coverage is also referred to as First Steps. First Steps referrals are completed behind the scenes through the following process:

Pregnant individuals enrolled in a managed care plan are informed of the First Steps program through their Managed Care Organization (MCO). The MCO sends the HCA First Steps program manager at HCA a list of all the newly identified pregnant individuals.

Pregnant individuals who are not enrolled in a managed care plan are identified through ProviderOne.

The First Steps program manager sends the lists from i and ii to the First Steps providers.

Consider the unborn child(ren) when determining the household size. Add one person for each unborn child. This applies to all Apple Health programs.

Pregnant individuals with income over the MAGI standard of 210% FPL can choose between purchasing health care coverage through a Qualified Health Plan (QHP) or enroll in the medically needy program (MN).

There is no resource standard for MN (P99).

Apple Health pregnancy coverage has continuous eligibility. Changes in income do not affect Apple Health coverage for pregnant individuals during the certification period.

Changes in income are considered prior to the spenddown being met for MN (P99) coverage.

Accept self-attestation for pregnancy and estimated due date (EDD)

Applicants who apply after the pregnancy ends: As of June 2022, individuals who were not on an Apple Health program may now apply for postpartum coverage named After-Pregnancy Coverage (APC) if they had a pregnancy end within the last 12 months. The individual may be eligible for APC up to twelve months even if they are determined eligible retroactively to cover the pregnancy after the pregnancy ends.

When a pregnant individual applies for medical before the pregnancy ends but does not meet spenddown until the day the pregnancy ends, the individual is considered eligible for Apple Health coverage at the time the pregnancy ends. Therefore, the individual is eligible for After-Pregnancy Coverage.

Individuals who are receiving or eligible for Medicare and become pregnant may be eligible for Apple Health if their income is below the standard of 210% FPL.

Pregnant individuals are identified through a barcode report run by MEDS staff.

Send a letter through Healthplanfinder (HPF) offering medically needy (MN) coverage by meeting a spenddown. Included in this letter is the denial text if no response is received.

If the pregnant individual responds via phone call: Ask if they incur childcare costs, pay out child support, and if retroactive coverage is needed. Process P99 in ACES.

If the pregnant individual responds via mail: Process P99 in ACES.

For MAGI, click on the report a change link in the Healthplanfinder and update the pregnancy end date to the date the pregnancy ended.

For P99, if the pregnancy ends before the expected due date through birth, miscarriage, or termination, correct the estimated date of delivery on the DEM1 Screen in ACES to ensure a timely program change to After-Pregnancy Coverage. Adjust the review date to ensure the individual gets additional CN coverage if the pregnancy ends in a month later than the expected due date.

Add the newborn to N10 as soon as possible

It is important to add the newborn to Apple Health for Newborns (N10) as soon as possible after birth, so the baby has its own client identification number. This can avoid coverage problems for the baby.

If the birthing parent is on Apple Health (Medicaid) without a managed care plan (also known as fee-for-service) at the time of the baby's birth, the newborn will also be on fee-for-service under the birthing parent's client ID through the month of the newborn's 60th day of life.

Managed care organizations (MCOs) will only cover a newborn on the birthing parent’s client ID up to a maximum of 21 days after the birth of the baby. After that, a newborn must have their own client identification number, or the only medical coverage the newborn receives is fee-for-service, up through the month that includes the baby’s 60th day of life, or until the newborn is assigned their own client ID number, whichever is earlier.

Once the newborn has been issued their own client ID number, the newborn cannot use the birthing parent's client ID. Individuals who have questions regarding their eligibility for MAGI-based medical assistance should call the Medical Eligibility Determination Service at the Health Care Authority at 855-562-3022. Individuals who have questions about applying online for MAGI-based medical assistance should call the Health Benefit Exchange at 855-923-4633.

Effective June 24, 2022.

For the purposes of this rule, "minor" means a person under the age of 19.

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.

The medical assistance unit (MAU) of a pregnant minor is the pregnant minor.

There are no income standards and no resource tests for a pregnant minor to be eligible for apple health for kids.

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.

The assignment of rights as described in WAC 182-503-0540 does not apply to pregnant minors.

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 .

A pregnant teen in the Washington Apple Health for Pregnant Teens program will receive full scope health care coverage under Apple Health for Kids, with retroactive coverage to the estimated beginning of the pregnancy and with a certification period as follows:

If they remain under age 19 over the course of their pregnancy, they will be given a 1 year certification period.

If they turn 19 before the end of their pregnancy, their coverage will continue through the end of their pregnancy and they will be eligible for After-Pregnancy Coverage (APC) through the end of the twelfth month after the end of their pregnancy.

Any pregnant teen will be eligible for WAH for Pregnant Teens as long as they are under age 19 and meet residency requirements under WAC 182-503-0520 .

The pregnant teen will be treated as their own assistance unit, with no income or resource limits. As a result, pregnant teens in this program will not need to provide their parents’ income or asset information.

To apply, complete the paper application " Application for Pregnant Teen Health Care Coverage " (Form HCA 14-430) or submit by mail or fax to:

Medical Eligibility Determination Services (MEDS) PO Box 45531 Olympia, WA 98504-5531

Fax: 360-725-1898

Effective September 14, 2015

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: Has been screened for breast or cervical cancer under the department of health's breast, cervical, and colon health program (BCCHP); Requires treatment for breast cancer, cervical cancer, or a related precancerous condition; Is under sixty-five years of age; Is not eligible for other WAH-CN coverage, including coverage under the MAGI-based adult group; Is uninsured or does not otherwise have creditable coverage; Meets residency requirements under WAC 182-503-0520 ; Meets Social Security number requirements under WAC 182-503-0515 ; Is a U.S. citizen, U.S. national, qualifying American Indian born abroad, or qualified alien under WAC 182-503-0535 ; and Meets the income standard set by the BCCHP in DOH form 342-031.

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 .

The Department of Health (DOH) administers and determines eligibility for the CDC-BCCEDP program for the State of Washington through their Breast and Cervical Health Program. Although men may be diagnosed with breast cancer, the federal requirements of this program limit medical coverage for individuals whose sex assigned at birth is female.

This program provides breast and cervical cancer screening services for low-income individuals. In addition, CDC directly contracts with certain tribal entities for this screening service.

Access to this program is only available through the above channels. When an individual meets the eligibility criteria, prime contractors (via CDC-BCCEDP facilities) fax the DOH 345-214 consent form/application to Medical Eligibility Determination Services (MEDS) eligibility staff to screen, process, and maintain the S30 program in ACES.

Individuals not eligible for BCCTP due to citizenship or immigration status requirements (described in WAC 182-505-0120(1), are eligible for medical coverage under the Alien Emergency Medical Program rules. Individuals related to the BCCTP Medicaid program who require cancer treatment meet AEM condition criteria.

When contacted about this program, refer all inquiries to the nearest local DOH/Breast and Cervical Health provider for individuals requesting screening services for breast and cervical cancer and/or has not yet been diagnosed. The Department of Health website provides a list of screening clinics. At their website, click the appropriate county.

If an application/review is received in the local CSO indicating breast cancer; screen S02, determine eligibility for the SSI-related program and refer the individual to the local BCCTP provider.

Send an email when a woman is active on BCCTP (S30), applies, and is determined eligible for another CN medical program in order to terminate BCCTP (S30) coverage.

If an individual applies in the local CSO and is found eligible for ABD cash assistance, they continue to be eligible for CN coverage, however, not under the BCCTP program. Send an email to notify MEDS to terminate coverage under the BCCTP program. At incapacity review, determine whether the individual is still receiving the prescribed course of treatment for breast or cervical cancer.

To describe the program rules for the Refugee Medical Program (RMA).

Effective September 6, 2025

You are eligible for refugee medical assistance (RMA) if all the following conditions are met. You: Meet immigration status requirements of WAC 182-507-0135; Have countable resources below $2,000 on the date of application; Have countable income equal to or below 200 percent of the federal poverty level (FPL) on the date of application. The following income is not considered when determining eligibility for RMA: Resettlement cash payments made by a resettlement agency; Income of a sponsor is not counted unless the sponsor is also part of your assistance unit; and Income received after the date of application. Provide the name of the resettlement agency which helped bring you to the United States so that the department of social and health services (DSHS) can promptly notify the resettlement agency (or sponsor) about the medical application.

If you receive refugee cash assistance (RCA) you are eligible for RMA if you have countable resources below $2,000 on the date of application and you are not otherwise eligible for another medicaid or a children's health care program as described in WAC 182-505-0210. You do not have to apply for or receive RCA in order to qualify for RMA.

You are not eligible to receive RMA if you are: Already eligible for another medicaid or a children's health care program as described in WAC 182-505-0210; A full-time student in an institution of higher education unless the educational activity is part of a DSHS-approved individual responsibility plan (IRP); or A nonrefugee spouse of a refugee.

If approved for RMA, the agency or its designee issue an approval letter in both English and your primary language. The agency or its designee also sends a notice every time there are any changes or actions taken which affect your eligibility for RMA.

You may be eligible for RMA coverage of medical expenses incurred during the three months prior to the first day of the month of the application. Eligibility determination will be made according to medicaid rules.

If you are a victim of human trafficking you must provide the following documentation and meet the eligibility requirements in subsections (1) and (2) of this section to be eligible for RMA: Adults, 18 years of age or older, must provide the original certification letter from the United States Department of Health and Human Services (DHHS). No other documentation is needed. The eligibility period will be determined based on the entry date on your certification letter; A child victim under the age of 18 does not need to be certified. DHHS issues a special letter for children. Children also have to meet income eligibility requirements; A family member of a certified victim of human trafficking must have a T-2, T-3, T-4, T-5 or T-6 visa (derivative T-Visas), and the family member must meet eligibility requirements in subsections (1) and (2) of this section.

The entry date for an asylee is the date that asylum status is granted. For example, you entered the United States on December 1, 1999, as a tourist, then applied for asylum on April 1, 2000, interviewed with the asylum office on July 1, 2000, and were granted asylum on September 1, 2000. The date of entry is September 1, 2000, and that is the date used to establish eligibility for RMA.

RMA certification period. (a) RMA ends on either: The last day of the eighth month from the month the person entered the United States if they entered the United States on or before September 30, 2021. For example, if they entered the United States on September 30, 2021, they are eligible through April 30, 2022; The last day of the 12th month from the month the person entered the United States if they entered the United States on or after October 1, 2021, through May 4, 2025. For example, if they entered the United States on October 25, 2021, they are eligible through September 30, 2022; or The last day of the fourth month from the month the person entered the United States if they entered the United States on or after May 5, 2025. For example, if they entered the United States on June 20, 2025, they are eligible through September 30, 2025. The number of months you may receive RMA benefits could change if the federal Office of Refugee Resettlement changes the eligibility period.

If you are approved for RMA you are continuously eligible through the end of the initial RMA certification period, regardless of an increase in income.

The agency, or its designee, determines eligibility for medicaid and other medical programs for your spouse when the spouse arrives in the United States. If the spouse is not eligible for medicaid due to your countable income, the spouse is still eligible for RMA under subsection (8) of this section.

If you disagree with a decision or action taken on the case by the agency, or its designee, you have the right to request a review of the case action(s) or request an administrative hearing (see chapter 182-526 WAC). The request must be received by the agency, or its designee, within 90 days of the date of the decision or action.

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 .

Effective November 24, 2024

An individual is eligible for refugee medical assistance (RMA) if the individual provides documentation issued by the United States Citizenship and Immigration Services (USCIS) to show that the individual is: Admitted as a refugee under section 207 of the Immigration and Nationalities Act (INA); Paroled into the United States as a refugee or asylee under section 212 (d)(5) of the INA; Granted conditional entry under section 203 (a)(7) of the INA; Granted asylum under section 208 of the INA; Admitted as an Amerasian immigrant from Vietnam through the orderly departure program, under section 584 of the Foreign Operations Appropriations Act, incorporated in the FY88 continuing resolution P.L. 100-212; A Cuban-Haitian entrant who was admitted as a public interest parolee under section 212 (d)(5) of the INA; Certified as a victim of human trafficking by the federal Office of Refugee Resettlement (ORR); An eligible family member of a victim of human trafficking certified by ORR who has a T-2, T-3, T-4, or T-5 visa; Admitted as special immigrant from Iraq or Afghanistan under one of the following: Special immigrant status under section 101 (a) (27) of the INA; Special immigrant conditional permanent resident; or 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; 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; or 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 when: Granted parole into the United States between February 24, 2022, and September 30, 2024; or Granted parole into the United States after September 30, 2024, and is: The spouse or child of a person described in (k)(i) of this subsection; or The parent, legal guardian or primary caregiver of a person described in (k)(i) of this subsection who is determined to be an unaccompanied child under section 462 (g) (2) of the Homeland Security Act of 2002 or section 412 (d) (2) (B) of the Immigration and Nationality Act.

A permanent resident alien meets the immigration status requirements for RCA and RMA if the individual was previously in one of the statuses described in subsection (1) of this section.

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 .

Refugees and other humanitarian immigrants as described in WAC 182-507-0135 may be eligible for RMA if they are not eligible for Apple Health (Medicaid).

RMA eligibility is established based on an applicant's income and resources on the date of the application, rather than averaging income over the application processing period. Income received after the date of application for RMA is not considered when determining eligibility for RMA.

A student enrolled in an institution of higher education and carrying a full-time academic workload is considered a full-time student. A full-time student is eligible for RMA only if educational activity is a part of their WorkFirst personal employment plan.

For an overview of citizenship and immigration status eligibility rules, see the Citizenship and Immigration Status Guide .

For applicants as described in WAC 182-507-0135 who are under age 65, HCA determines eligibility for modified adjusted gross income (MAGI)-based Apple Health programs first.

Applications for medical assistance should be submitted through Healthplanfinder. If you experience an issue when submitting the application, complete a paper application and email it to HCA WAHRMA apps and include: Primary applicant name Healthplanfinder app ID Managed care organization (MCO) plan selection (optional) Error code (if any)

If an applicant is not eligible for MAGI-based Apple Health or they become ineligible during the certification period, HCA will determine eligibility for refugee medical assistance.

DSHS determines eligibility for medical assistance for clients over age 65 who are refugees or have other eligible immigration statuses.

For applicants age 65 or older, with blindness or disability, as described in WAC 182-507-0135 , complete applications:

In person at a local DSHS CSO.

Online at Washington Connection .

Faxed to CSD at 1-888-338-7410.

Mailed to DSHS - CSD Customer Service Center, PO Box 11699, Tacoma WA 98411-6699.

View a list of refugee resettlement agencies in Washington State .

The Apple Health for Workers with Disabilities program policy and procedures described here are effective January 1, 2020.

Purpose : This section describes the Apple Health for Workers with Disabilities (HWD) program. HWD recognizes the employment potential of people with disabilities. The enactment of the federal Ticket to Work and Work Incentives Improvement Act or the Ticket group of 1999 and the Balanced Budget Act (BBA) of 1997 enable many people with disabilities to work and keep their health care.

As a categorically needy (CN) Medicaid program, HWD provides access to Medicaid Personal Care services (MPC), Community First Choice (CFC), Medicaid Alternative Care (MAC) and Home and Community Based (HCB) waiver programs administered by the Developmental Disabilities Administration (DDA) and Home and Communities Services (HCS). To be approved for services, an individual must meet functional requirements as determined by DDA and HCS.

For more information see the Apple Health for workers with disabilities (HWD) fact sheet .

Effective January 1, 2020

This section describes the apple health for workers with disabilities (HWD) program.

The HWD program provides categorically needy (CN) scope of care as described in WAC 182-501-0060 .

The HWD program also provides long-term services and supports described in chapters 182-513 and 182-515 WAC for a client who meets the functional requirements for those programs, are approved for those services, and choose to enroll in HWD.

The medicaid agency approves HWD coverage for twelve months effective the first of the month in which a person applies and meets program requirements. See WAC 182-511-1100 for retroactive coverage for months before the month of application.

A person who is eligible for another medicaid program may choose not to participate in the HWD program.

A person is not eligible for HWD coverage for a month in which the person received benefits under the medically needy (MN) program.

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 .

Effective January 1, 2020

This section describes requirements a person must meet to be eligible for the apple health for workers with disabilities (HWD) program.

To qualify for the HWD program, a person must: Meet the general requirements for a medical program described in WAC 182-503-0505 (3)(a) through (f); Be at least age sixteen; Meet the federal disability requirements described in WAC 182-511-1150 ; Be employed full or part time (including self-employment) as described in WAC 182-511-1200 .

The HWD program does not require a resource test.

Once approved for HWD coverage, a person must pay the monthly premium in order to continue to qualify. The agency calculates the premium for HWD coverage according to WAC 182-511-1250 . If a person does not pay four consecutive monthly premiums, the person is not eligible for HWD coverage for the next four months and must pay all premium amounts owed before HWD coverage can be approved again. Once approved for HWD coverage, a person who experiences a job loss can choose to continue HWD coverage through the original twelve months of eligibility, if the following requirements are met: The job less results from an involuntary dismissal or health crisis; and The person continues to pay the monthly premium.

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 .

Effective January 1, 2020

This section describes requirements for retroactive coverage provided under the apple health for workers with disabilities (HWD) program.

Retroactive coverage refers to the period of up to three months before the month in which a person applies for the HWD program.

To qualify for retroactive coverage under the HWD program, a person must first: Meet all program requirements described in WAC 182-511-1050 for each month of the retroactive period; and Pay the premium amount for each month requested within one hundred twenty days of being billed for such coverage.

Payment must be received for each month requested of retroactive coverage before such coverage is approved.

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 .

HWD allows enrollees to earn and save more money and to purchase health care coverage with monthly premium based on a sliding scale.

Some people may be eligible for HWD, who are not eligible for other SSI-related medical programs, due to their having:

Monthly earnings at or above the Substantial Gainful Activity (SGA) level after deducting any impairment related or blind work expenses that have caused any Title II benefit to stop; or

Countable income or resources that exceed other program standards including coverage groups that use "institutional" rules to determine eligibility.

For more information go to the Apple Health SSI-related overview .

HWD functionality eligible and approved for services from the Developmental Disabilities Administration (DDA) or Home and Community Services (HCS), they pay a monthly premium for all services and do not participate in the cost of services under "institutional" rules. If residing in an alternate living facility, they continue to pay room and board; room and board cannot be paid for with Medicaid funds. As a result, the individual who is working may be able to keep more of his/her earned income. A monthly premium amount is most likely less than the participation amount when using institutional rules. One exception applies to DDA clients who live at home, who may be working, but do not have income and/or resources that require them to enroll in HWD to keep their coverage. They can keep up to the income standard for services at home for their personal needs allowance. DDA resource case managers review client circumstances on an individual basis to determine which option is better for them and communicate this information to designate HWD staff, using the DSHS 15-345 CSO/DDA Communication.

Waiver services may be subject to provisions

HCB waiver services received under HWD are subject to transfer of asset, annuity declaration, and excess home equity provisions that are specific to institutional programs. MPC and CFC program services are not subject to those provisions.

For additional information about HWD and DDA/HCS services, go to Working clients and LTC .

Like clients approved for coverage under other Apple Health programs, HWD clients may have access to other health insurance coverage. Some may even pay for such coverage out-of-pocket or have it taken out of their earnings. These costs may not be used to reduce countable income for determining eligibility or the monthly premium amount. However, the agency may be able to reimburse the monthly premium for the other insurance after HWD is approved. For related information, see Third Party Liability (TPL) .

It is critical to compare the options and determine which program costs less when an individual meets the requirements for more than one program.

Since HWD requires a monthly premium payment, the program of choice for someone eligible for both HWD and another CN program is the one that costs less. Compare HWD to the following programs to determine the most advantageous to the individual: Apple Health Adults Apple Health for Kids (the minimum age for HWD is 16 years) Apple Health for Pregnant Women The CN disability program (S02) for a disabled adult child (DAC) CN programs (L22 or G03) depending upon financial and functional requirements and place of residence

People who are eligible for both HWD and MN may prefer to receive Medicaid under the MN program. They do not have to enroll in HWD; enrollment is their choice. The HWD Award Letter provides people eligible for both with a comparison of their spenddown amount.

For most people, HWD is the preferred program because:

CN provides more extensive coverage than MN; and

The HWD monthly premium is likely to be less than the monthly amount used to determine a three or six month spenddown liability.

A person who is approved for MN (in active status) cannot be opened for HWD CN coverage until the first of the month after MN coverage is closed.

Individuals entitled to Medicare

Follow ACES procedures to screen for S03 and S05 when the individual is entitled to Medicare.

Part D expenses

HWD enrollees receiving Medicare get help with their Part D expenses. They receive "full subsidy" benefits. People with income above 135 percent FPL who choose MN instead of HWD receive only partial help with their Part D expenses, unless they meet their spenddown.

Effective January 1, 2020

This section describes the disability requirements for the following groups of individuals who may qualify for the apple health for workers with disabilities (HWD) program.

A person age sixteen through age sixty-four must meet the requirements of the Social Security Act in section 1902 (a) (10) (A) (ii): (XV) for the basic coverage group (BCG); or (XVI) for the medical improvement group (MIG).

The BCG consists of individuals who: Meet federal disability requirements for the Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) program; or Are determined by the department of social and health services (DSHS), division of disability determination services (DDDS), to meet federal disability requirements for the HWD program.

The MIG consists of individuals who: Were previously eligible and approved for the HWD program as a member of the BCG; and Are determined by DDDS to have a medically improved disability. The term "medically improved disability" refers to the particular status granted to persons described in subsection (1) (b). For these people, a continuation of HWD coverage is provided to help them maintain their employment.

A person sixty-five or older, must meet federal disability requirements as determined by the DSHS DDDS. Coverage under the MIG is not available under federal law for persons age sixty-five or older. Coverage for this age group is authorized under the Balanced Budget Act of 1997 as described under section 1902 (a)(10)(A)(ii)(XIII).

When completing a disability determination for the HWD program, DDDS will not determine a person not disabled based only on earnings or the performance of substantial gainful activity (SGA). (See SSA POMS Section DI 10501.001, https://secure.ssa.gov/apps10/poms.nsf/Home?readform ).

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 .

For information on procedures to obtain a determination of disability or blindness that enables adult not receiving federal cash benefits to be related to Medicaid, see the Non-Grant Medical Assistance (NGMA) overview and Non-Grant Medical Assistance (NGMA) examples .

If the applicant is working and their income (gross income after deductions for impairment related work expenses or blind work expenses) is over the SGA standard or their resources exceed other program standards, forward the application, using the contact information below:

Address for all DDA and HCS documents: Home and Community Services PO BOX 45826 Olympia, WA 98504-5826 FAX: 1-855-635-8305

Maintains HWD cases on DDA services and those not on HCS services.

Phone: 1-800-871-9275 DDA LTC pool: @HWD 17

Brandy Sanchez ACES ID: BJSA

Jill Hamilton ACES ID: JIHA

Brian Dixon ACES ID: DIBR

Amy MacCalla Backup ACES ID: AMSC

Jeannie Valdez DDA HWD PBS Supervisor ACES ID: JEVA

Mark Smith DDA FHC ACES ID: MSMI

Danielle Lopez DDA SHPC ACES ID: DANL

Includes Pend Oreille, Grant, Adams, Lincoln, Okanogan, Ferry, Douglas, Whitman, Spokane, Klickitat, Yakima, Walla Walla, Franklin, Benton, Garfield, Columbia, Asotin, Kittitas, and Stevens counties.

Phone: 1-800-459-0421 TTY: 509-568-3697

Sean Cummings Phone: 509-601-2236 Spokane HCS ACE ID: CUSE

Alexandra (Alex) Stevens Phone: 509-564-9194 Backup, Ellensburg HCS ACES ID: AXSV

Michelle Bakken: Phone: 509-568-3788 Supervisor Spokane HCS ACES ID: BAKK

Mary Aspen: Phone: 509-306-5053 Supervisor Wenatchee HCS ACES ID: POLM

Includes King, Snohomish, Whatcom, Skagit, Island and San Juan counties.

Phone: 1-800-346-9257 or 206-341-7604 TTY: 1-800-833-6384

Emily Hill Phone: 206-341-7643 Backup, Holgate HCS, HWD Alpha A-Z ACES ID: HJCO

Includes Pierce, Kitsap, Clallam, Jefferson, Thurston, Mason, Lewis, Cowlitz, Clark, Pacific, Grays Harbor, Skamania, and Wahkiakum counties.

Phone: 253-476-7200 or 1-800-442-5129 TTY: 253-593-5471

Phone: 360-501-2540 or 1-800-605-7322 TTY: 711 for TTY-based Telecommunications Relay Service | Federal Communications Commission (fcc.gov)

Vacant HWD Alpha A-K ACES ID: AMLO

Vacant HWD Alpha L-Z ACES ID: TUJN

Steve Getman-Gerbec Supervisor

Roxanne LaRoy Supervisor backup

To continue eligibility for HWD as a member of the Medical Improvement Group (MIG), an individual must have been eligible and approved for the program as a member of the Basic Coverage Group (BCG). The HWD program manager determines whether an individual meets HWD MIG requirements and consults with DDS staff when appropriate.

Having the MIG option or coverage group ensures that an individual who continues to have a significant impairment may continue to receive health care services that support their employment.

For an individual receiving HWD benefits who appears to no longer meet the disability requirements for the BCG, use the following procedures.

Example #1

An HWD individual receives a letter from SSA that states he/she no longer meets the disability requirement to receive SSDI cash after completing his/her Trial Work Period (TWP) and has earnings at or above the substantial gainful activity (SGA) level for one subsequent month.

He/she will be eligible for and receive the SSDI benefit for that one month and the following two months. However, during any month in which earnings fall below the SGA level, the individual remains eligible for his/her SSDI cash benefit during the Extended Period of Eligibility (EPE). The EPE begins the month after the TWP ends. The individual should contact the Social Security Administration (SSA) to confirm when their TWP ended once their SSA cash benefit ends because of earning at or above the SGA level. To receive SSDI for a month in which earnings fall below SGA, the client must call SSA and document for them the amount of earnings; no application is necessary.

When an individual receives this letter from SSA, it might appear he/she does not continue to meet disability requirements for coverage under the HWD Basic Coverage Group (BCG). This is not true, since the client remains eligible for coverage under the BCG during the EPE. Staff need to recalculate the monthly premium amount and send proper notification. Staff should email the HWD program manager in Olympia, if they have questions about the client's coverage during the EPE.

For more information about this SSDI work incentives , see the SSA Red Book Extended Period of Eligibility .

Example: #2

An individual completes the EPE and remains enrolled in HWD. If medical improvement has occurred, the client's coverage continues until the completion of a disability determination for the Medically Improved Group (MIG) is completed. Email the HWD program manager to request a determination of eligibility under MIG and continue coverage until one is completed. .

To approve HWD coverage for a member of the MIG, use the new "Disability Source" (CD) code to indicate the client has a medically improved disability as determined by the HWD program manager.

For an individual receiving HWD benefits that no longer meets the eligibility requirements for BCG or MIG, continue HWD coverage until you redetermine eligibility for other medical programs.

Effective January 1, 2020

This section describes the employment requirements for the basic coverage group (BCG) and the medical improvement group (MIG) for the apple health for workers with disabilities (HWD) program.

For the purpose of the HWD program, employment means a person: Gets paid for working; Has earnings that are subject to federal income tax; and Has payroll taxes taken out of earnings received, unless self-employed.

To qualify for HWD coverage as a member of the BCG, a person must be employed full or part time.

To qualify for HWD coverage as a member of the MIG, a person must be: Working at least forty hours per month; and Earning at least the local minimum wage as described under section 6 of the Fair Labor Standards Act (29 U.S.C. 206).

For a person who is self-employed, the examples described in the Social Security Administration Program Operations Manual System (POMS) provide guidance when determining whether someone meets the HWD work requirements. (See SSA POMS Section SI 00820.200, https://secure.ssa.gov/apps10/poms.nsf/lnx/0500820200 ). The guidelines described in POMS for determining the existence of a trade or business may also be used when making this determination. (See SSA POMS Section RS 01802.010, https://secure.ssa.gov/apps10/poms.nsf/lnx/0301802010 ).

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 .

Individuals do not have to work a certain number of hours or earn a minimum amount of income to be eligible for HWD coverage under the BCG. Individuals who want to participate in the HWD program must provide proof they have earned income.

To satisfy the program requirement of being employed or self-employed, a person must provide proof that the work activity they perform is generating income subject to federal income tax rules. Individuals can meet this requirement by providing evidence that FICA and payroll taxes are taken out of their earnings.

When HWD may still be approved

If a person works for an employer that by law is not required to withhold FICA or payroll taxes or is prohibited from doing so, such as Tribal governments or certain sheltered workshops, HWD coverage may still be approved.

Individuals who are self-employed can meet this requirement by providing business records and a copy of Internal Revenue Services (IRS) forms completed and filed, e.g. IRS Schedule SE or IRS Form 1040, Schedule C or Schedule F, showing entries for net earnings or losses. If the person hasn't been in business long enough to file a tax return, detailed records, such as a combination of ledger sheets, receipt books, self-employment worksheets for tracking potential tax liability must be provided. A business license does not in and of itself provide evidence of self-employment.

Self-employment tax (SE tax) is a social security and Medicare tax primarily for individuals who work for themselves. Payments of SE tax contribute to an individual's coverage under the social security system. Social security coverage provides retirement, disability, survivor, and hospital insurance (Medicare) benefits. All deductions allowed by the IRS, including depreciation, may be used.

An individual must pay SE tax and file Schedule SE (Form 1040), if the individual has:

Net earnings from self-employment or $400 or more or church employee income of $108.28 or more.

The following examples are taken from the Social Security Administration (SSA) Program Operations Manual System to help determine whether a person meets the program requirement of employment.

Example: #3

Mrs. Bell reports she started babysitting for her grandchild while her daughter works. Sometimes the child comes to her home, but usually, she goes to her daughter's home because the child's toys and other items are there. She does not babysit for anyone else. She receives about $20 a week from her daughter.

Although a caregiver is a recognized occupation, Mrs. Bell is not holding herself out as a provider of daycare services, nor does she have intent to produce income. Therefore, Mrs. Bell is not considered self-employed when determining whether she meets the program requirement of employment.

However, if the income meets the definition of wages for the title II annual earnings test (e.g. an employer/employee relationship exists between Tina and Martha), it would be considered wages even though no Federal Insurance Contributions Act (FICA) taxes are being deducted. If a determination is made that the activity does not result in wages or Net Earnings from Self-employment Contributions Act (FICA) taxes are being deducted. If a determination is made that the activity does not result in wages or Net Earnings from Self-employment (NESE), then the income derived by the activity is unearned income, coded as type SW on the SSR.

Example: #4

Mrs. Simon files for SSA benefits. When asked about any income she receives, she says she babysits for various neighbors and friends, but does not consider herself self-employed. She does not file taxes for this income. She began babysitting when her own children were young to make some extra money. She gets new business by word of mouth.

Although Mrs. Simon does not consider herself to be in the daycare business, she meets all of the factors indicating the existence of a trade or business. Therefore, Mrs. Simon is considered to be self-employed when determining whether she meets the program requirement of employment.

Example: #5

Mr. Lyons, an SSDI recipient, reports that since he needed extra money to meet his rent and food expenses, he started collecting aluminum cans from the street. He redeems them at the recycle center for cash. Sometimes his neighbors or local organizations call him to pick up their cans. He does not file any tax returns, but he thinks he makes about $200 a month.

Since this is an ongoing, regular activity that includes some third-party collection pickups and was established with the intent of producing income, it is determined that Mr. Lyons is self-employed. To establish and document this eligibility criteria, Mr. Lyons must provide completed IRS forms or legitimate business records as described above.

Example: #6

Mr. Kent reports that he earned some money cutting the lawn for one of his neighbors. His car needed some repairs and he did not have the money. His neighbor told Mr. Kent that he could cut his lawn for the month of July for $80. Since he needed the cash to pay for the repair, he decided to cut the lawn. Mr. Kent is not holding himself out as a lawn service. Further, this is not an ongoing regular activity nor does Mr. Kent plan to do this activity to make a profit. He only did it to earn enough to pay for the car repair. Therefore, Mr. Kent is not considered to be self-employed when determining whether he meets the program requirement of employment.

However, even though there was no FICA withheld, the Claims Representative (CR) should explain whether the income is wages for annual earnings test purposes (e.g. does an employer/employee relationship exist). If a determination is made that the activity does not result in wages or NESE, then the income derived by the activity is unearned income.

When reviewing for continued HWD coverage under the MIG group, the 40 hours (per month) work requirement does not apply at this time. Enrollees must continue to meet the employment requirements of the Basic Coverage Group (BCG).

Do not use a personal check or pay stub that does not indicate tax withholdings as evidence of earnings gained through employment for HWD eligibility requirements.

Contact the individual’s employer when necessary to verify tax withholdings.

For individuals who are self-employed, but have not been in business long enough to file a tax return, accept business documents as evidence of self-employment. Advise them to maintain business records and provide a copy of their federal tax return.

Effective June 3, 2025

This section describes how the Medicaid agency calculates the premium amount a person must pay for apple health for workers with disabilities (HWD) coverage. This section also describes program requirements regarding the billing and payment of HWD premiums.

When determining the HWD premium amount, the agency counts only the income of the person approved for the program. It does not count the income of another household member.

When determining countable income used to calculate the HWD premium, the agency applies the following rules: Income is considered available and owned when it is: Received; and Can be used to meet the person's needs for food, clothing, and shelter, except as described in WAC 182-512-0600 (5) and 182-512-0650 . Income is considered unavailable when it is: Described in 20 C.F.R. Sec. 416.1103. Used to pay the fee described in WAC 182-512-0800 (5).

The HWD premium amount equals the lesser of the two following amounts: A total of the following (rounded down to the nearest whole dollar): Fifty percent of unearned income above the medically needy income level (MNIL) described in WAC 182-519-0050 ; plus Five percent of total unearned income; plus Two and one-half percent of earned income after first deducting $65; or Seven and one-half percent of countable income described in subsection (2) of this section, including both earned and unearned income.

When determining the premium amount, the agency will use the currently verified income amount until a change in income is reported and processed, unless good cause for delay in verifying changes exists.

A change in the premium amount is effective the month after the change in income is reported and processed.

For current and ongoing coverage, the agency will bill for HWD premiums during the month following the benefit month.

For retroactive coverage, the agency will bill the HWD premiums during the month following the month in which coverage is requested and necessary information that establishes eligibility is received by the agency.

If initial coverage for the HWD program is approved in a month that follows the month of application, the first monthly premium includes the costs for both the month of application and any following months that have passed during determination of eligibility.

As described in WAC 182-511-1050 (3)(b), the agency will close HWD coverage if premiums are not paid in full for four consecutive months.

The person must pay the monthly premium in full to avoid losing HWD coverage. If a person makes a partial payment, the payment does not count as a full payment toward the premium.

Payments received are applied to premiums owed in the following order: If retroactive coverage is requested, the retroactive coverage month(s); Past due months, beginning with the most delinquent month; The current coverage month that has been invoiced; then Future coverage months.

A person must pay a premium for any month that HWD coverage is provided. This includes months when a redetermination of coverage is made, and months when continued coverage that is requested, pending the outcome of an administrative hearing.

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 .

States have flexibility when determining the type and amount of cost sharing they require for enrollment in the HWD program with the following exception. States cannot require a premium amount that exceeds 7.5 percent of the enrollee's total income. Income used to calculate HWD premiums includes only that of the person enrolling in the program. If both spouses apply, their premiums are calculated separately using only the income of each spouse. ACES 3G calculates the HWD premium using the program formula and then compares that amount to 7.5 percent of the enrollee's total income. The lesser of the two is sent to the Office of Financial Recovery (OFR) for billing purposes.

Premium example:

A person earns $2,065 per month and receives $1,141 SSDI.

Income Premium calculation Monthly earned income $2,065 Monthly unearned income (Social Security) $1,141 Total monthly income $3,206

Calculations and premium amount Amount Subtract the MNIL* ($967) from unearned income ($1,141 - $967 = $174) Take 50% of the result (.5 x $174 = $87) * The MNIL amount is subject to change . $87 Calculate 5% of unearned income (.05 x $1141 = $57.05) $57.05 Subtract $65 from gross earned income ($2065 - $65 = $2000) Take 2.5% of the result (.025 x $2000 = $50) $50 PREMIUM AMOUNT (rounded down) - using first option ($87 + $57.05 + $50 = $194.05) $194.05

Calculation with premium amount v. actual premium Amount Calculate 7.5% of total monthly income (.075 x $3206 = $240.45) $240.45 PREMIUM AMOUNT (rounded down) - using second option. $240 ACTUAL PREMIUM (lesser of first and second calculation options) $194

If a person applies in one month for HWD coverage, but not approved until the next month, the first monthly premium include costs for both months. Purchasing the initial month is optional.

Example: #7

An individual applies for HWD on July 10 and provides information on August 6. HWD is approved on August 7 for coverage beginning July 1. The individual receives a bill for the initial premium, which includes charges for July and August.

Changes in the HWD premium takes effect the first of the following month in which the change is reported and processed as a change in circumstances. Individuals who experience a job loss may choose to continue HWD coverage as described in WAC 182-511-1050 (4)(c).

The interface between ACES and OFR is used to communicate information regarding premium payments. Nonpayment of premiums triggers the AU to close for Reason Code 342 - Termination/Denial Due to Nonpayment of Premium and imposes a four month sanction.

Explain to the individual they are not obligated to purchase coverage each month back to the date of application.

Encourage the individual who has paid for services received in the retroactive period that providers are not obligated to accept Medicaid reimbursement for those months.

Explain to the individual that premiums for retroactive coverage must be paid in advance. Premiums must be paid within 120 days or the retroactive coverage will be denied.

Premium billing invoice sent to Protective Payee

If the premium billing invoice is sent to a Protective Payee, a copy will not be sent to the client. Add free form text in a letter to the individual to let them know this.

American Indians/Alaska Natives (AI/AN)

Members of an American Indian/Alaska Native (AI/AN) population are exempt from HWD premiums. By entering the appropriate valid value for race, ACES automatically bills for a payment of $0.

Premium payment questions are managed by the CSO. Do not refer individuals to OFR or to HCA MACSC.

Individual did not receive bill

If the individual states they did not get the premium bill, check for returned mail.

Undelivered premium billings are returned to the HCA Imaging and Mail Services, not to OFR.

If the individual has lost the premium notice and asks where to send the payment, tell the individual to:

Make the check or money order out to DSHS:

Include the billing coupon that detaches from the monthly statement, or a written statement if the coupon has been lost, which states the payment is for Health Care for Workers with Disabilities or HWD premium; and Include their account number (the CLID of the head of household); and Mail the payment to: Office of Financial Recovery PO Box 9501 Olympia, WA 98507-9501

Pay premium from bank account

Individuals may pay their premium directly from their bank account. To set up an account, or for more information about this option, go to My Secure DSHS .

To clarify the Medicaid eligibility requirement to apply for Medicare.

Effective April 27, 2019.

When you apply for Washington apple health programs established under chapter 74.09 RCW, you must meet the eligibility criteria in chapter 182-500 WAC through chapter 182-527 WAC .

When you apply for apple health, we first consider you for federally funded or federally matched programs. We consider you for state-funded programs after we have determined that you are ineligible for federally funded and federally matched programs.

Unless otherwise specified in a program specific WAC, the eligibility criteria for each program are as follows: Age ( WAC 182-503-0050 ); Residence in Washington state ( WAC 182-503-0520 and WAC 182-503-0525 ); Citizenship or immigration status in the United States ( WAC 182-503-0535 ); Possession of a valid Social Security account number ( WAC 182-503-0515 ); Assignment of medical support rights to the state of Washington ( WAC 182-503-0540 ); Application for medicare and enrollment into medicare's prescription drug program if: You are likely entitled to medicare; and We have authority to pay medicare cost sharing as described in chapter 182-517 WAC . If your eligibility is not based on modified adjusted gross income (MAGI) methodology, your countable resources must be within specific program limits ( chapter 182-512 WAC , chapter 182-513 WAC , chapter 182-515 WAC , chapter 182-517 WAC , and chapter 182-519 WAC ); and Countable income within program limits: For MAGI-based programs, see WAC 182-505-0100 ; For the refugee program, see WAC 182-507-0130 ; For the medical care services program, see WAC 182-508-0005 ; For the health care for workers with disabilities (HWD) program, see WAC 182-511-1000 ; For the SSI-related program, see WAC 182-512-0010 ; For long-term care programs, see chapter 182-513 WAC and chapter 182-515 WAC ; For medicare savings programs, see WAC 182-517-0100 ; and For the medically needy program, see WAC 182-519-0050 .

In addition to the general eligibility requirements in subsection (3) of this section, each program has specific eligibility requirements as described in applicable WAC.

If you are in a public institution, including a correctional facility, you are not eligible for full scope apple health coverage, except in the following situations: If you are age twenty-one or younger or age sixty-five or older and are a patient in an institution for mental disease (see WAC 182-513-1317 (5)); or You receive inpatient hospital services outside of the public institution or correctional facility.

We limit coverage for people who become residents in a public institution, under subsection (5) of this section, until they are released.

If you are terminated from SSI or lose eligibility for categorically needy (CN) or alternative benefits plan (ABP) coverage, you receive coverage under the apple health program with the highest scope of care for which you may be eligible while we determine your eligibility for other health care programs. See WAC 182-504-0125 .

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 .

Application for and enrollment into Medicare is a condition of eligibility for individuals who apply for Apple Health coverage, as long as the agency is able to pick up the cost of the premiums on the individual's behalf. Every month Apple Health eligible individuals age 65 and older who are not already receiving Medicare are asked to provide proof of application for Medicare through an automated BarCode process.

The Medicare Buy-in Unit also sends letters requesting proof of application for Medicare under the End Stage Renal Disease Program (ESRD) to selected Medicaid kidney dialysis individuals who receive three consecutive months of treatment. The same process outlined above is used. The individual's letter is slightly different but still requires the individual to provide proof of application. The individual's kidney dialysis provider, (for example Northwest Kidney Dialysis Center), is also notified that they need to assist their individual with the Medicare/ESRD application process.

Individuals who fail to provide proof of application for Medicare to the Medicare Buy-in Unit under the authority of WAC 182-504-0505 and WAC 182-504-0540 can be terminated from Apple Health assistance, including individuals who receive SSI or long-term care services. Individuals closed for noncooperation with application to Medicare will show in ACES and ProviderOne as closed for reason code 266, noncooperation with TPL.

Timeline to termination request

The Medicare Buy-in Unit gives nearly 90 days in the two-letter process before they send an action request in BarCode to DSHS to propose termination of Apple Health coverage.

Every month Apple Health eligible individuals age 65 and older not already receiving Medicare are asked to provide proof of application for Medicare. The Medicare Buy-in unit in Olympia (call toll free 1-800-562-3022) manages this workload. The following process is followed:

Individuals are mailed a letter generated by barcode around the 20th of the month asking for proof of application for Medicare. The letter is provided in the individual's primary language and in English to the individual and to the individual's authorized representative. Only the English version is stored in DMS. All letters have a business reply postage paid return envelope addressed to the Medicare Buy-in Unit for returning the proof of Medicare application. Verification can be returned to any DSHS office or mailed to the DSHS Imaging Center.

Thirty days or more after the first letter is sent, the Medicare Buy-in Unit works the ticklers to review for proof of application for Medicare.

If no proof is received, a second letter is sent to the individual requesting proof of application for Medicare and again ticklers are set for the Medicare Buy-in Unit to review the case for proof.

If no proof is received from the second letter, the Medicare Buy-in Unit generates an action request to the worker of record asking that the individual be sent a termination of Medicaid notice under WAC 182-503-0505 General Eligibility and WAC 182-503-0540 Non Cooperation with Third Party Liability.

Proof Received After Termination – If the former recipient provides verification of application for Medicare their Medicaid case can be reactivated. If the verification comes in during the period of the original certification period the case should be opened with no further contact with the individual. If verification is received after the original certification period ends than a new application is necessary.

This section describes the application processes used by Aging and Long-term Supports Administration (ALTSA) when determining financial eligibility for Long-Term Services and Supports (LTSS).

Effective January 19, 2026

You may apply for Washington apple health at any time.

For apple health programs for children, pregnant people, parents and caretaker relatives, and adults age 64 and under without medicare, (including people who have a disability or are blind), you may apply: Online via the Washington Healthplanfinder at www.wahealthplanfinder.org ; By calling the Washington Healthplanfinder customer support center and completing an application by telephone; By completing the application for health care coverage ( HCA 18-001P ), and mailing or faxing to Washington Healthplanfinder; or At a department of social and health services (DSHS) community services office (CSO).

If you seek apple health coverage and are age 65 or older, have a disability, are blind, need assistance with medicare costs, or seek coverage of long-term services and supports, you may apply: Online via Washington Connection at www.WashingtonConnection.org ; By completing the application for aged, blind, disabled/long-term care coverage ( HCA 18-005 ) and mailing or faxing it to DSHS; By calling the DSHS customer service contact center and completing an application by telephone; In person at a local DSHS CSO or home and community services (HCS) office; or Effective January 19, 2026, with your consent when you complete an application for medicare Part D low-income subsidy (LIS) benefits, the social security administration (SSA) will transmit an LIS data file to us. We will use the LIS data file to initiate an application for you for benefits under the medicare savings program (MSP) without requiring you to submit a separate MSP application. As specified in subsection (2) of this section, if you are a child, pregnant, a parent or caretaker relative, or an adult age 64 and under without medicare.

You may receive help filing an application. For households containing people described in subsection (2) of this section: Call the Washington Healthplanfinder customer support center number listed on the application for health care coverage form ( HCA 18-001P ); or Contact a navigator, health care authority volunteer assistor, or broker. For people described in subsection (3) of this section who are not applying with a household containing people described in subsection (2) of this section: Call or visit a local DSHS CSO or HCS office; or Call the DSHS community services customer service contact center number listed on the medicaid application form.

To apply for tailored supports for older adults (TSOA), see WAC 182-513-1625 .

You must apply directly with the service provider for the following programs: The breast and cervical cancer treatment program under WAC 182-505-0120 ; The family planning only programs under chapter 182-532 WAC; and The kidney disease program under chapter 182-540 WAC.

For the confidential pregnant minor program under WAC 182-505-0117 and for minors living independently, you must complete a separate application directly with us (the medicaid agency). More information on how to give us an application may be found at the agency's web site: www.hca.wa.gov/free-or-low-cost-health-care (search for "teen").

As the primary applicant or head of household, you may start an application for apple health by providing your: Full name; Date of birth; Physical address, and mailing addresses (if different); and Signature.

To complete an application for apple health, you must also give us all of the other information requested on the application.

You may have an authorized representative apply on your behalf as described in WAC 182-503-0130 .

We help you with your application or renewal for apple health in a manner that is accessible to you. We provide equal access (EA) services as described in WAC 182-503-0120 if you: Ask for EA services, you apply for or receive long-term services and supports, or we determine that you would benefit from EA services; or Have limited-English proficiency as described in WAC 182-503-0110 .

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 .

Applications for LTSS may be submitted using any of the following methods:

Apply online at: www.WashingtonConnection.org if the client is age 65 or older, blind, disabled (ABD), or on Medicare.

Apply online at www.wahealthplanfinder.org . Applications for clients under age 65 or ineligible for Medicare should be submitted through this site and will have a real-time determination of Washington Apple Health medical coverage eligibility under the modified adjusted gross income (MAGI) methodology.

Apply by completing the HCA 18-005 - Washington Apple Health Application for Aged, Blind, Disabled/Long-Term Care coverage and mail or fax into HCS, or

Apply by completing the HCA 18-008 - Washington Apple Health for Tailored Supports for Older Adults (TSOA) , which is a program that provides supports to caregivers, or

Apply in-person at a local Home and Community Services office. To find an HCS office near you, use the DSHS Office Locator , or

Call the HCS intake line in the area in which you reside to schedule an assessment. See "How to request an LTSS assessment" below.

Mail to: Home and Community Services - LTSS PO Box 45826 Olympia WA 98504-5826; or FAX to: 1-855-635-8305

Always include the client's full name and the DSHS client id (if known) on any document mailed or faxed to DSHS.

An HCS social worker must complete a functional assessment for home and community services (in-home care, in a residential facility, and nursing facility coverage).

To request an assessment contact the HCS Intake and Referral Team by:

Phone: 1-877-429-7019

Fax: 1-855-635-8305

A new application isn't required for clients active on ABD SSI-related Apple Health who need LTSS as long as the Public Benefit Specialist (PBS) is able to determine institutional eligibility using information in the current case record. Examples are the SSI or SSI-related programs or Apple Health for Workers with Disabilities (HWD). Use the original eligibility review date to open institutional coverage. Center for Medicare and Medicaid Services (CMS) requires an annual review at least once a year for categorically needy (CN) Medicaid.

Review excess home equity, annuity and transfer of resource provisions that are specific to institutional and home and community-based (HCB) waivers.

SSI recipients who need institutional services, or HCB waiver, must complete and sign an application, or the DSHS 14-416 - Eligibility Review for Long Term Services and Supports and complete an interview. Don't hold up eligibility for long-term care awaiting a signed review. If an application, eligibility review, or LTSS review is in the electronic case record within the past year, a new review form isn't needed.

Ensure an Asset Verification System (AVS) Authorization is on file, and if not, follow these procedures.

Clients active on MAGI except AEM N21 and N25, don't need to submit an additional application if they are functionally eligible for, and in need of the following:

Nursing Facility (NF) services

Community First Choice (CFC)

Medicaid Personal Care (MPC)

Medicaid Alternative Care (MAC)

If a client needs waiver services they must submit an application and may need a disability determination.

The PBS will:

Complete a Financial Communication to Social Services (07-104) referral when an application is received on an active MAGI case.

Add text stating that unless an assessment is completed and determines HCB Waiver is needed, the client will remain on MAGI.

Send a general correspondence letter to the client indicating the application was received and because the client is currently receiving Medicaid services, additional information isn't needed for financial eligibility.

MAGI and nursing facilities (NF)

If an 18-005 is received on an active MAGI case and the client is in a NF or hospice care center, no action is needed by the PBS. MAGI covers NF and Hospice under the scope of care. Exception is N21/N25 AEM MAGI.

Effective January 16, 2020.

You may apply for Washington apple health for yourself.

You may apply for apple health for another person if you are: A legal guardian; An authorized representative (as described in WAC 182-503-0130 ); A parent or caretaker relative of a child age eighteen or younger; A tax filer applying for a tax dependent; A spouse; or A person applying for someone who is unable to apply on their own due to a medical condition and who is in need of long-term care services.

If you reside in an institution of mental diseases (as defined in WAC 182-500-0050 (1)) or a public institution (as defined in WAC 182-500-0050 (4)), including a Washington state department of corrections facility, city, tribal, or county jail, or secure community transition facility or total confinement facility (as defined in RCW 71.09.020 ), you, your representative, or the facility may apply for you to get the apple health coverage for which you are determined eligible.

You are automatically enrolled in apple health and do not need to submit an application if you are a: Supplemental security income (SSI) recipient; Person deemed to be an SSI recipient under 1619(b) of the SSA; Newborn as described in WAC 182-505-0210 ; or Child in foster care placement as described in WAC 182-505-0211 .

You are the primary applicant on an application if you complete and sign the application on behalf of your household.

If you are an SSI recipient, then you, your authorized representative as defined in WAC 182-500-0010 , or another person applying on your behalf as described in subsection (2) of this section, must turn in a signed application to apply for long-term care services as described in WAC 182-513-1315 .

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 .

Effective July 25, 2013

An individual applying for Washington apple health (WAH) (as defined in WAC 182-500-0120 ) is not required to have an in-person interview to determine eligibility.

The agency or its designee may contact an individual by phone or in writing to gather any additional information that is needed to make an eligibility determination.

A phone or in-person interview is required to determine initial financial eligibility for WAH long-term care services.

The interview requirement described in subsection (3) of this section may be waived if the applicant is unable to comply: Due to his or her medical condition; or Because the applicant does not have a family member or another individual that is able to conduct the interview on his or her behalf.

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 .

An interview with the applicant or authorized representative is required to determine eligibility for institutional, HCB waiver services, or TSOA services. The PBS may waive the interview requirement. If the client is unable to complete the interview due to a medical condition or because no one is available to assist the client.

Asset verification, if not already authorized on the application by the client and financially responsible people (if applicable), may be authorized during the interview process.

Use Equal Access - Necessary Supplemental Accommodation (NSA) and long-term services and supports policies for LTSS applicants and recipients.

The interview can be conducted in person or by phone. Call the client or their representative to complete an interview. If they can't be reached, or are unavailable, send an appointment letter (DSHS 0011-01) and a request for verification letter for what is needed to determine eligibility, based only on what was declared on the application.

The PBS must:

Go over the application, particularly what was declared in the income and resource sections. Ask about other resources not declared on the application. General open-ended questions about resources and income should also be asked. Family members and other representatives are often just learning about the client's income and resources when they apply. Open-ended questions often reveal that additional sources of income and assets may exist.

Document in ACES remarks, in detail, all eligibility factors discussed during the interview and included on the application.

If not already authorized, request authorization for AVS for the client and any applicable financially responsible people. Ensure AVS procedures are followed.

Ask about any transfers, gifts, or property sales during the 5-year look back and the circumstances of why they were made. Request verification of transfers, gifts or property sales, if applicable.

Ask about other medical coverage. If there is other medical coverage and you can obtain the information during the interview, complete a 14-194 medical coverage form in Barcode.

Ask if there are unpaid medical expenses and request verification if medical expenses exist. Ask if any of these bills were incurred within the last 3 months.

Explain the financial and social service functional eligibility process. Explain to the applicant that there is a Public Benefits Specialist (PBS) and a social service manager making determinations concurrently for LTSS eligibility.

For in-home service applicants, discuss the food assistance program and inquire if the household would like to apply for food benefits.

Explain the medical service card, automatic Medicare D enrollment if not on a creditable coverage or Medicare D Prescription Drug Plan.

Explain the Medicare Savings Program (MSP). If the applicant is eligible for an MSP based on income and resource guidelines and all information is received to determine eligibility for MSP, don't hold up processing this program while the LTSS medical is pending.

Explain participation and room and board, how the amount is determined, and that it must be paid to the provider.

Explain Estate Recovery and mail the Estate Recovery fact sheet.

Explain what changes of circumstances need to be reported

In the case of the community spouse, explain how all resources in excess of the $2,000 resource limit must be transferred to the spouse within 1 year and the requirement to provide verification of this by the first annual review.

Summarize what verification is needed to complete the application and send a request for information letter. Encourage the applicant to gather documents as soon as possible to expedite the process. Explain how to request an extension if more time is needed.

Summarize the interview and items still needed to determine eligibility in the ACES narrative.

Type of client interaction (phone, in-person, etc.)

Statements made by the client and/or their representative.

Case actions and why the actions were taken, and

Eligibility decisions made, or next steps.

When working on a case that has ACES Equal Access (EA) requirements: Document how the plan was followed, If changing ACES EA requirements, clearly document the reason.

Use remarks to document information specific to the ACES page:

Details of how eligibility factor(s) were verified, When using Collateral Contact (CC) or Other (OT) valid value, document the details of how it was verified, When information is verified using an electronic source (such as BENDEX, AVS, etc.),

Include remarks to reconcile any discrepancies, or important information not otherwise captured, including required questions left blank on the application or eligibility review form.

Documentation provides:

An ongoing permanent history of actions and decisions made;

A support of eligibility, ineligibility and benefit determination;

Credibility for decisions when used as evidence in legal matters;

A trail for reviewers to determine the accuracy of the benefits issued.

Follow these principles when documenting:

Clear - Use readily understood language. Acronyms utilized should be DSHS/HCA approved

Concise - Documentation is subject to public review. Stick to the facts relevant to determining eligibility or benefit level.

Complete - The documentation must support the eligibility decision and allow a reviewer to determine what was done and why.

Consistent - Explain how conflicts or inconsistencies of information were addressed. Demonstrate the reasonableness of decisions. Ensure what you document accurately describes what happened with the case.

Effective August 8, 2021

We process applications for Washington apple health medicaid within forty-five calendar days, with the following exceptions: If you are pregnant, we process your application within fifteen calendar days; If you are applying for a program that requires a disability decision, we process your application within sixty calendar days; or The modified adjusted gross income (MAGI)-based apple health application process using Washington Healthplanfinder may provide faster or real-time determination of eligibility for medicaid.

For calculating time limits, "day one" is the day we get an application from you that includes at least the information described in WAC 182-503-0005 (8). If you give us your paper application during business hours, "day one" is the day you give us your application. If you give us your paper application outside of business hours, "day one" is the next business day. If you experience technical difficulties while attempting to give us your application in Washington Healthplanfinder, "day one" is the day we are able to determine, based on the evidence available, that you first tried to submit an application that included at least the information described in WAC 182-503-0005 (8).

We determine eligibility as quickly as possible and respond promptly to applications and information received. We do not delay a decision by using the time limits in this section as a waiting period.

If we need more information to decide if you can get apple health coverage, we will send you a letter within twenty calendar days of your initial application that: Follows the rules in chapter 182-518 WAC; States the additional information we need; and Allows at least ten calendar days to provide it. We will allow you more time if you ask for more time or need an accommodation due to disability or limited-English proficiency.

Good cause for a delay in processing the application exists when we acted as promptly as possible but: The delay was the result of an emergency beyond our control; The delay was the result of needing more information or documents that could not be readily obtained; You did not give us the information within the time frame specified in subsection (1) of this section.

Good cause for a delay in processing the application does NOT exist when: We caused the delay in processing by: Failing to ask you for information timely; or Failing to act promptly on requested information when you provided it timely; or We did not document the good cause reason before missing a time frame specified in subsection (1) of this section.

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 .

Document standard of promptness for all medical applications pending more than 45 days:

Day one is the date the application was received.

Update a good cause code when changing a program from an SSI-related assistance unit (AU) to an LTSS AU to prevent the case from being incorrectly reported as a new application.

A good cause code must be used when finalizing any medical (AU) historically beyond 45 days.

Cases without a delay reason code or updated with "No Good Cause (NG)" to the DSHS secretary.

Effective August 29, 2014.

Your Washington apple health (WAH) coverage starts on the first day of the month you applied for and we decided you are eligible to receive coverage, unless one of the exceptions in subsection (4) of this section applies to you.

Sometimes we can start your coverage up to three months before the month you applied (see WAC 182-504-0005 ).

If you are confined or incarcerated as described in WAC 182-503-0010 , your coverage cannot start before the day you are discharged, except when: You are hospitalized during your confinement; and The hospital requires you to stay overnight.

Your WAH coverage may not begin on the first day of the month if: Subsection (3) of this section applies to you. In that case, your coverage would start on the first day of your hospital stay; You must meet a medically needy spenddown liability (see WAC 182-519-0110 ). In that case, your coverage would start on the day your spenddown is met; or You are eligible under the WAH alien emergency medical program (see WAC 182-507-0115 ). In that case, your coverage would start on the day your emergent hospital stay begins.

For long-term care, the date your services start is described in WAC 388-106-0045 .

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 .

There are two start dates for LTSS, the Medicaid eligibility date and the LTSS start date:

Medicaid eligibility begins, the first day of the month the client is eligible for LTSS.

The LTSS authorization date, which is described in WAC 388-106-0045 , WAC 388-106-0360 and RCW 74.42.056 . If there is a transfer penalty as described in WAC 182-513-1363 , the LTSS start date begins the day after the transfer penalty ends.

The LTSS start date is the date the client is both financially and functionally eligible. The authorization can't be backdated for HCB waiver, CFC, or MPC unless social services has fast-tracked services and the client is subsequently found financially eligible. Social services indicates the start date for HCB waiver on the DSHS 14-443 (communication from social services to HCS PBS), or the DSHS 15-345 (communication from DDA case manager to the DDA PBS).

For Hospice as a Medicaid program, the hospice authorization date is based on the receipt of the 13-746 (HCA/Medicaid hospice notification). The hospice provider is required to submit this form within 5 business days of a hospice election on all active and pending Medicaid cases. If the 13-746 is not received timely, count back 5 business days from the date of receipt to determine the authorization date.

The LTSS authorization date can be backdated for nursing facility services up to 3 months prior to the date of application for a new applicant of Medicaid as long as the client is nursing facility level of care (NFLOC) and financially eligible.

The LTSS start date for nursing facility services on an active Medicaid recipient is based on the first date the admission is reported to DSHS as long as the client meets all other eligibility factors. If the nursing facility admission is on a weekend or holiday, the authorization date is the date of admission as long as DSHS is notified by the next business day.

Effective November 3, 2019.

We follow the rules about notices and letters in chapter 182-518 WAC. We follow the rules about timelines in WAC 182-503-0060 .

We deny your application for apple health coverage when: You tell us either orally or in writing to withdraw your request for coverage; or Based on all information we have received from you and other sources within the time frames stated in WAC 182-503-0060 , including any extra time given at your request or to accommodate a disability or limited-English proficiency: We are unable to determine that you are eligible; or We determine that you are not eligible. You are subject to asset verification and do not provide authorization as described in WAC 182-503-0055.

We send you a written notice explaining why we denied your application (per chapter 182-518 WAC).

We reconsider our decision to deny your apple health coverage without a new application from you when: We receive the information that we need to decide if you are eligible within thirty days of the date on the denial notice; You give us authorization to verify your assets as described in WAC 182-503-0055 within thirty days of the date on the denial notice; You request a hearing within ninety days of the date on the denial letter and an administrative law judge (ALJ) or HCA review judge decides our denial was wrong (per chapter 182-526 WAC).

If you disagree with our decision, you can ask for a hearing. If we denied your application because we do not have enough information, the ALJ will consider the information we already have and any more information you give us. The ALJ does not consider the previous absence of information or failure to respond in determining if you are eligible.

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 .

If an applicant has withdrawn their request for medical benefits and then decides they want to pursue the application, we will redetermine eligibility for benefits without a new application as long as the client has notified the department within 30 days of the withdrawal. The PBS should review the original application to ensure there are no changes and proceed to determine eligibility.

The application process begins and the application date is established when the request for benefits is received. These are the forms used in the application process for LTSS.

HCA forms , including translations are found on the HCA forms website.

DSHS forms , including translations are found on the DSHS forms website.

HCA 18-003 - Rights and responsibilities (translations can be found at Health Care Authority (HCA) forms under 14-113 )

HCA 18-005 - Washington Apple Health application for aged, blind, disabled/long-term care coverage

HCA 18-008 - Washington Apple Health application for tailored supports for older adults (TSOA)

DSHS 14-00 - Application for cash or food assistance1 (used for any cash, food, or medical care services [MCS] request as MCS is tied to ABD cash/HEN eligibility)

HCA 14-194 - Medical coverage information (used to report third party insurance coverage including LTC insurance)

DSHS 14-539 - Revocable burial fund provision for SSI-related health care

DSHS 14-540 - Irrevocable burial fund provision for SSI-related health care

DSHS 14-454 - Estate recovery fact sheet (repaying the state for medical and long-term services and supports)

DSHS 14-501 - Community resource declaration (used to evaluate resources [assets] for an applicant and their spouse based on date of institutionalization under WAC 182-513-1350 )

DSHS 14-532 - Authorized representative release of information .

DSHS 10-438 - Long-term care partnership (LTCP) asset designation form (used to designate assets [resources] for those with a long-term care partnership insurance policy)

DSHS 14-012 - Consent (release of information form) (used for all DSHS programs)

DSHS 27-189 - Asset Verification Authorization

HCA release of information and DSHS consent forms

The HCA 80-020 - Authorization for Release of Information is for medical benefits under the Health Care Authority (HCA) and will be accepted as a release of information for all medical programs including LTSS programs. The DSHS consent form is preferred as it is used for all programs including medical, food, and cash.

PBS determines financial eligibility by comparing the client's income, resources and circumstances to program criteria. The PBS also determines maximum client responsibility.

Social service staff and case managers determine functional eligibility and what services to authorize based on a complete and comprehensive CARE assessment.

For HCS clients, both functional and financial eligibility are determined concurrently. Functional eligibility for DDA is determined prior to the submission of a financial application. LTSS can begin once a client is found financially and functionally eligible and an approved provider is in place.

For ABD, SSI-related Apple Health programs:

Department-designated social service staff:

Assess the client's functional eligibility for institutional care.

Screen all clients to determine potential for HCB services.

Determine if the client is likely to attain institutional status and be likely to reside at the nursing facility for 30 days or longer WAC 182-513-1320, or notifies the facility when the client doesn't appear to meet the need for nursing facility care.

Determine if a housing maintenance allowance (HMA) is appropriate (current rule states HMA is the amount of the Federal Poverty Level).

Provide PBS staff with the following information: Date of NF admission, Whether the client meets nursing facility level of care (NFLOC), For Medicaid recipients, the first date DSHS was notified of the admission by the nursing facility, If the client is likely to attain institutional status, Whether there is a housing maintenance allowance and the start date, if appropriate.

Public benefit specialist (PBS) staff:

Refer the client to social services for a care assessment if the client contacts the PBS first and document the date the client first requested NF care.

Determine the client's financial eligibility for LTSS and noninstitutional medical assistance including three months retroactive medical coverage if financially eligible.

Authorize payment for NF care if the client is both functionally and financially eligible. For Medicaid applicants, institutional services are approved based on the date the client is eligible up to 3 months prior to the date of application. For Medicaid recipients, institutional services are approved based on the first date the admission is known to DSHS as long as the client meets all other eligibility factors. If the NF admission is on a weekend or holiday, the NF has until the first business day to report the admission.

Issue the NF award letter to the applicant/recipient and the nursing facility.

This process applies to SSI-related programs only MAGI-based clients are not eligible for HCB waiver.

Department-designated social service staff:

Assess the client's functional eligibility for in home or residential care.

Provide the PBS staff with the following information: Service start date Type of service Residential facility name and address, including room number, if applicable.

Public Benefits Specialists:

Refer the client to social service intake for a CARE assessment if the client contacts the PBS first and document the date the client first requested in-home or residential care.

Give a projected client responsibility amount to the case worker using the LTSS referral 07-104. Clearly indicate this is a projection and the financial application is in process.

Determine the client's financial eligibility for LTSS Medicaid and/or noninstitutional medical assistance including a request for retro medical if needed.

Authorize in ACES for in-home or residential HCB waiver if the client is both functionally and financially eligible.

Issue the award letter to the applicant/recipient.

Backdating services

Services can't be backdated prior to the date of the authorization until the date that financial eligibility is established.

Clients switching from private pay to Medicaid are advised to apply for benefits 30 to 45 days before being resource eligible for the program. There is good information on the Washington LawHelp website that explains the timing of an LTSS application.

Fast Track is a social service process that allows the authorization of LTSS prior to a financial eligibility determination. The HCS case manager coordinates and consults with the PBS to see if Fast Track is appropriate.

The PBS should make a Fast Track recommendation based on the information, verifications and cross-matches available, and send this determination via 07-104 to social services.

Questions to consider when making a Fast Track recommendation:

What resources is the client reporting on the application or past applications?

Are transfers indicated?

Did you receive verification of resources with the application?

Have you received Accurint and/or AVS results and reviewed the assets reported?

Is the client single or married, and which resource standard is being used to make a recommendation?

Social services can’t begin Fast Track until a CARE assessment is completed. The determination of Fast Track is ultimately up to social services.

Clients receiving services during the Fast Track period won't receive a medical services card until financial eligibility is established. Services may be authorized using Fast Track for a maximum of 90 days.

Don’t open a case in ACES until you have everything needed to establish financial eligibility.

If the client isn't financially eligible, notify social services. Social services will state fund Fast Track services when the client isn't financially eligible during the fast track period. An overpayment isn't established.

This chapter includes rules and procedures for processing applications for Apple Health. It includes the following sections and rules:

WAC 182-503-0010 Who can apply for Apple Health?

WAC 182-503-0005 How to apply for Apple Health?

WAC 182-503-0060 What is the date of my application and how does it affect my health care coverage?

Online submission:

Applications submitted through Washington Healthplanfinder: day one is the day the application is received by the system.

Applications submitted through Washington Healthplanfinder Connection: day one is the day the application is received during business hours. If submitted after business hours, day one is the next business day.

Telephonic submission: day one is the day the application was signed telephonically.

Paper submission (including fax): day one is the day the application was received during business hours.

WAC 182-503-0050 Do I need to submit other information after I apply for health care coverage?

WAC 182-503-0060 How long does the department have to process my application?

WAC 182-503-0070 When does my health coverage begin?

WAC 182-518-0005 What happens when my application is denied?

WAC 182-503-0080 Can I still get health care coverage even after my application is denied?

For LTSS services, an ACES award letter is required in order for the provider to bill correctly and receive the correct amount of participation from the individual. Each change in service, participation or living arrangement requires a new award letter. Authorized representative (AREP) screens are also completed when the individual has an AREP such as a guardian, power of attorney, attorney, protective payees or other representative handling the individual's affairs. In addition to the individual's representative and advocates, some institutions need to be indicated on the AREP screen for correct payment and billing through SSPS, or Provider One. State Institutions that bill through Financial Service Administration (FSA) are also indicated on the AREP screen.

Effective November 25, 2023

"Administrative renewal" means the agency uses electronically available income and resources data sources to verify and recertify a person's Washington apple health benefits for a subsequent certification period. A case is administratively renewed when the person's self-attested income and resources are reasonably compatible (as defined in WAC 182-500-0095 ) with the information available to the agency from the electronic data sources and the person meets citizenship, immigration, Social Security number, and age requirements.

"After-pregnancy coverage (APC)" means full-scope Washington apple health (medicaid) health care coverage for people up to 12 months after the month their pregnancy ends under WAC 182-505-0115 .

"Agency" or "medicaid agency" means the Washington state health care authority (HCA).

"Agency's designee" means any entity expressly designated by the agency to act on its behalf.

"Allowable costs" are the documented costs as reported after any cost adjustment, cost disallowances, reclassifications, or reclassifications to nonallowable costs which are necessary, ordinary and related to the outpatient care of medical care clients or not expressly declared nonallowable by applicable statutes or regulations. Costs are ordinary if they are of the nature and magnitude which prudent and cost-conscious management would pay.

"Alternative benefits plan" means the range of health care services included within the scope of service categories described in WAC 182-501-0060 available to persons eligible to receive health care coverage under the Washington apple health modified adjusted gross income (MAGI)-based adult coverage described in WAC 182-505-0250 .

"Ancillary services" means additional services ordered by the provider to support the core treatment provided to the patient. These services may include, but are not limited to, laboratory services, radiology services, drugs, physical therapy, occupational therapy, and speech therapy.

"Apple health for kids" is the umbrella term for health care coverage for certain groups of children that is funded by the state and federal governments under Title XIX medicaid programs, Title XXI Children's Health Insurance Program, or solely through state funds (including the program formerly known as the children's health program). Funding for any given child depends on the program for which the child is determined to be eligible. Apple health for kids programs are included in the array of health care programs available through Washington apple health (WAH).

"Attested income" or "attested resources" means a self-declared statement of a person's income or resources made under penalty of perjury to be true. (See also "self-attestation.")

"Authorization" means the agency's or the agency's designee's determination that criteria are met, as one of the preconditions to the agency's or the agency's designee's decision to provide payment for a specific service or device. (See also "expedited prior authorization" and "prior authorization.")

"Authorized representative" is defined under WAC 182-503-0130 .

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 .

"Authorized representative" means a family member, friend, organization, or someone acting responsibly on behalf of a person who is designated by the person to act on his or her behalf in all matters relating to an application or renewal of Washington apple health or other ongoing communications with agency or its designee. The authorization must be made in writing, including on an application or eligibility review form, and signed by the person unless the person's medical condition prevents such written authorization. Authority to act on behalf of an applicant or beneficiary under state law can substitute for the person's authorization. The power to act as an AREP ends when the person or a court-appointed guardian of the person informs the agency or its designee that the representative is no longer authorized to act on his or her behalf, or when the agency learns of a change in the legal authority upon which the authorization is based.

For the following facilities, notices are generated based on the provider number indicated on the INST screen in ACES. Do not indicate these facilities on the AREP screen in ACES:

Nursing facilities

State veteran nursing facilities

Hospice care centers (includes hospice agencies and care centers)

Hospice agencies when the individual is residing in a nursing home.

HCS Waiver, CFC or MPC services case managed by HCS social worker, AAA or Developmental Disabilities Administration case manager do not need to be listed on the AREP screen. These notices are generated to the HCS SW, AAA, or DDA CM electronically via the barcode system. The HCS SW, DDA, and AAA CM receives the notice via their ECR To Do list. The SW or CM makes necessary changes to SSPS based on the notice received The DSHS 14-443 indicates who is case managing the case.

In addition to the individual's representative and advocates, some facilities or case managers need to be indicated on the AREP screen for correct payment and billing.

Hospice outside of a nursing facility or hospice care center when an individual is receiving hospice outside of a medical institution and not on a DDA or HCS Waiver. Find additional information about hospice including the hospice care center addresses.

New Freedom: King and Pierce County

Program of All-Inclusive Care for the Elderly (PACE) - King County on the AREP screen indicate: Providence Elder Place Attn: PEP Biller PO Box 389672 Seattle WA 98138-9672

The DSHS Economic Services Administration Office of Financial Recovery PO Box 9768 Olympia WA 98507 must be on the AREP screen if the client is residing in one of the following state owned facilities: Fircrest School Shoreline, Washington (DDA Residential Habilitation Centers-RHC) Lakeland Village Medical Lake, Washington (DDA RHC) Rainier School Buckley, Washington (DDA RHC) Yakima Valley School Selah, Washington (DDA RHC) Eastern State Hospital, (Institution for the Mental Disease-IMD) Western State Hospital, (IMD) Child Study and Treatment Center (IMD)

It is important to update or remove the information on the AREP screen if the individual changes services. (Example DDA individual at RHC discharges home to a DDA Waiver).

Effective November 25, 2023

"Administrative renewal" means the agency uses electronically available income and resources data sources to verify and recertify a person's Washington apple health benefits for a subsequent certification period. A case is administratively renewed when the person's self-attested income and resources are reasonably compatible (as defined in WAC 182-500-0095 ) with the information available to the agency from the electronic data sources and the person meets citizenship, immigration, Social Security number, and age requirements.

"After-pregnancy coverage (APC)" means full-scope Washington apple health (medicaid) health care coverage for people up to 12 months after the month their pregnancy ends under WAC 182-505-0115 .

"Agency" or "medicaid agency" means the Washington state health care authority (HCA).

"Agency's designee" means any entity expressly designated by the agency to act on its behalf.

"Allowable costs" are the documented costs as reported after any cost adjustment, cost disallowances, reclassifications, or reclassifications to nonallowable costs which are necessary, ordinary and related to the outpatient care of medical care clients or not expressly declared nonallowable by applicable statutes or regulations. Costs are ordinary if they are of the nature and magnitude which prudent and cost-conscious management would pay.

"Alternative benefits plan" means the range of health care services included within the scope of service categories described in WAC 182-501-0060 available to persons eligible to receive health care coverage under the Washington apple health modified adjusted gross income (MAGI)-based adult coverage described in WAC 182-505-0250 .

"Ancillary services" means additional services ordered by the provider to support the core treatment provided to the patient. These services may include, but are not limited to, laboratory services, radiology services, drugs, physical therapy, occupational therapy, and speech therapy.

"Apple health for kids" is the umbrella term for health care coverage for certain groups of children that is funded by the state and federal governments under Title XIX medicaid programs, Title XXI Children's Health Insurance Program, or solely through state funds (including the program formerly known as the children's health program). Funding for any given child depends on the program for which the child is determined to be eligible. Apple health for kids programs are included in the array of health care programs available through Washington apple health (WAH).

"Attested income" or "attested resources" means a self-declared statement of a person's income or resources made under penalty of perjury to be true. (See also "self-attestation.")

"Authorization" means the agency's or the agency's designee's determination that criteria are met, as one of the preconditions to the agency's or the agency's designee's decision to provide payment for a specific service or device. (See also "expedited prior authorization" and "prior authorization.")

"Authorized representative" is defined under WAC 182-503-0130 .

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 .

In addition to the individual's representative and advocates, some facilities or case managers need to be indicated on the AREP screen for correct payment and billing.

Hospice outside of a nursing facility or Hospice Care Center when an individual is receiving Hospice outside of a medical institution and not on a DDA or HCS Waiver. The Department of Health website has additional information about Hospice Care Centers including the Hospice Care Center addresses.

New Freedom-King and Pierce Co.

Program of All-inclusive Care for the Elderly (PACE) - King Co. on the AREP screen indicate: Providence Elder Place Attn: PEP Biller PO Box 389672 Seattle WA 98138-9672

The DSHS Office of Financial Recovery PO Box 9768 Olympia WA 98507 must be on the AREP screen if the client is residing in one of the following state owned facilities: Fircrest School Shoreline, Washington (DDA Residential Habilitation Centers-RHC) Lakeland Village Medical Lake, Washington (DDA RHC) Rainier School Buckley, Washington (DDA RHC) Yakima Valley School Selah, Washington (DDA RHC Eastern State Hospital, (Institution for the Mental Disease-IMD) Western State Hospital, (IMD) Child Study and Treatment Center (IMD)

It is important to update or remove the information on the AREP screen if the individual changes services. (Example: DDA individual at RHC discharges home to a DDA Waiver).

To explain the asset verification system (AVS) and new program requirements for applicants and recipients of long-term care services.

Effective September 12, 2020

This rule implements the asset verification system (AVS) outlined in section 1940 of the Social Security Act.

This rule applies to any client, or those financially responsible for them, who is subject to: The disclosure of resources, as defined in WAC 182-512-0200 , to determine eligibility; or Provisions related to the transfer of assets, as described in WAC 182-513-1363 .

For the purposes of this section: "Financial institution" means the same as defined in section 1101 of the Right to Financial Privacy Act, and may include, but is not limited to: Banks; or Credit unions. "Financial record" means any record held by a financial institution pertaining to a customer's relationship with the financial institution; and "Financial responsibility" is described in WAC 182-506-0015 .

You and any other financially responsible people must provide authorization for us to obtain any financial record held by a financial institution. For you, the authorization may be provided by anyone described in WAC 182-503-0010 (1) and (2)(a), (b), or (c), except in the case of an authorized representative who must be designated by the client. For a financially responsible spouse, authorization may be provided by the spouse, their legal guardian, or their attorney-in-fact. The agency may grant an exception to rule as described in WAC 182-503-0090 if authorization is not provided by those listed in (a) and (b) of this subsection.

The authorization, provided under subsection (4) of this section, will remain in effect until one of the following occurs: Your application for apple health is denied; Your eligibility for apple health is terminated; or You revoke your authorization in a written notification to us.

We will: Use the authorization provided under subsection (4) of this section to electronically verify your financial records and those of any other financially responsible person to determine or renew your eligibility for apple health; or Inform you in writing at the time of application and renewal that we will obtain and use information available through AVS to determine your eligibility for apple health.

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 .

Section 1940 of the Social Security Act 2008 (42 USC 1396w), requires all states to implement a system to verify resources/assets of aged, blind, or disabled applicants and recipients of Medicaid, including long-term services and supports (LTSS), through the use of an asset verification system.

The AVS searches client financial institution accounts via several methods:

Automatically searches for accounts at the largest financial institutions in the United States.

Automatically searches for accounts at specific financial institutions based on the client's residential address, via a geographic search algorithm.

Allows financial eligibility staff to directly search for accounts at financial institutions where we believe the applicant/recipient has an account.

AVS reports on the following account types:

Burial accounts

Certificate of deposit

Checking accounts

Christmas club accounts

IRA accounts

Keogh accounts

Money market accounts

Rent security

Savings accounts

Trusts

Financial eligibility staff review the information received from financial institutions and resolve discrepancies with the client prior to the eligibility determination.

AVS does not change how financial eligibility staff handles questionable situations; AVS is another tool to use to determine eligibility.

Clients, and those financially responsible for them, must provide authorization before an AVS search is submitted.

Once a client or financially responsible person gives authorization for use of AVS, it remains in place until the client or the financially responsible person cancels the authorization in writing, they are no longer eligible for coverage, or the application is withdrawn or denied.

For more information

Please refer to your agency's AVS procedures documentation.

Staff must receive authorization in order to run an AVS search. Tickles will be generated approximately 90 days prior to the end of the renewal month for clients who do not have an AVS authorization in place.

Staff should review the case record to determine whether authorization was granted on an application or review form previously received, or authorization was granted and documented in the ACES narrative.

If authorization was granted , update the AVS authorization field to "AVS Authorized."

If authorization is not provided , request AVS authorization from the client.

If there has been a break in medical coverage for more than 30 days, a new authorization is required.

AVS will provide banking information for the month the AVS search is submitted.

Approximately 60 days prior to the end of the renewal month, if an AVS authorization is in place for the client and financially responsible people (if applicable), an AVS request will be sent overnight via batch process. Fifteen days after submission AVS results will populate in the AVS portal.

For Medicaid programs that do not have a 60-month look-back period, the AVS will provide 4 months of financial institution account balance data from the application date.

For Medicaid programs that have a 60-month look-back period, the AVS will review accounts balances and transfers for the 60 month period from the application date.

An AVS request is sent after both the client and financially responsible person (if applicable) have a status of "AVS authorized." At that point, all financial institutions on the ACES resource page that have been added through the financial institution search, will be sent to the AVS vendor to directly search for records at that those financial institutions. An AVS2 tickle will be set for 16 days following submission.

Financial staff must contact the applicant or recipient and give them the opportunity to provide the needed information to resolve a discrepancy and determine ongoing eligibility when AVS returns information that indicates:

Inconsistent withdrawals during the look-back period (for LTSS programs with a transfer look-back period).

Bank accounts that are over the resource standard.

Accounts not listed on the application, or disclosed during the interview (if an adverse action may be necessary).

Any other questionable information.

Financial eligibility staff cannot deny or terminate a case based solely on the information received from AVS or LexisNexis. Alternate verification must be requested.

If the client is ineligible due to transfers in the 60-month look-back period, determine if there is eligibility for another medical program without a look-back period:

S-series AH if client is resource eligible

HWD if the client is disabled and working

TSOA eligibility

At application or eligibility review, once AVS results are received, document the client's resources in ACES.

Once results are reviewed in the portal and documented in ACES, the AVS case must be closed in the portal using closed/withdrawn.

To explain what an authorized representative (AREP) is, how to designate someone as AREP, and what information the agency may disclose to AREPs.

Effective August 17, 2015

Designating an authorized representative (AREP). A person may designate an AREP to act on his or her behalf in eligibility-related interactions with the medicaid agency by completing the agency's Authorized Representative Designation Form (DSHS 14-532), or through any of the methods described in 42 C.F.R. 435.907(a) and 42 C.F.R. 435.923. The Authorized Representative Designation Form is available online at https://www.dshs.wa.gov/fsa/forms . A court-appointed legal guardian with authority to make financial decisions on a person's behalf is that person's AREP. An agreement creating power of attorney (POA) that grants decision-making authority regarding the person's financial interactions with the agency establishes the POA as the AREP. If a person is unable to designate an AREP due to a medical condition, an individual may designate himself or herself as the AREP by signing the agency's Authorized Representative Designation Form (DSHS 14-532).

Serving as an AREP. To serve as an AREP, an individual or organization must: Have a good-faith belief that the information he or she provides to the agency is correct. Report any change in circumstance required under WAC 182-504-0105 unless doing so would exceed the scope of authorized representation or violate state or federal law. A provider, staff member, or volunteer of an organization must also comply with 42 C.F.R. 435.923(d-e).

Terminating authorized representation. The person or the AREP may terminate the authorized representation at any time for any reason by notifying the agency verbally or in writing. Authorized representation terminates automatically when the person dies.

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 .

Defined in WAC 182-503-0130 , an AREP is a person or organization who is authorized by an applicant or recipient to get only the information needed to determine the applicant's or recipient's eligibility for Apple Health programs and other information related to Apple Health coverage such as certification periods, renewals, etc. An AREP assists the applicant/recipient with the application, recertification, and general eligibility processes. Designating an AREP is never required.

An AREP can be any adult (including anyone who is not a member of the household/medical assistance unit) or organization (including any department, division, or other subset of an organization) who is both:

Sufficiently aware of the applicant's or recipient's household circumstances, and

Authorized by the applicant or recipient to act on behalf of him or her for eligibility purposes.

If an AREP is an organization, other individuals of that organization may also act as AREPs. If an AREP is a division or another part of a larger organization, only individuals in that division or part may act as AREPs.

AREPS

King County Public Health is a large organization. If the Access and Outreach department of King County Public Health is designated an AREP, only those individuals in that department may act as AREPs. Individuals from other departments in King County Public Health are not AREPs.

An AREP is not authorized to receive health information about individuals unless they have power of attorney or have been named on the completed and signed DSHS 14-012 consent form .

An AREP can share any information relevant to eligibility; however, the department can only share information with the AREP that is necessary for the purposes of determining financial eligibility.

An AREP can receive letters, including the income computation sheet, renewal forms, and ProviderOne services cards if the individual has authorized the sharing of such correspondence.

The table below describes the forms used by HCA and DSHS for the following purposes:

Designating an AREP

Authorizing consent to share information

Releasing agency records

Type of form and questions Authorized representative Consent to use and share confidential information Authorization to release agency records HCA forms 18-001 (14-430 for pregnant teens) * See note 80-020 DSHS forms 14-532 or 18-005 ** 14-012 17-063 When to use? To authorize the agency to exchange with the AREP only the information needed to determine eligibility for Apple Health programs. HIPAA restrictions prevent us from discussing the person's individual health information with an AREP unless a current signed DSHS 14-012 consent form is in the record. To give consent for the agency to exchange more information with health care providers or other agencies (as identified on the form) than the basic eligibility information that can be shared with an AREP. DSHS Form 14-012 is HIPAA-compliant. To authorize the agency to release agency records and other information (as identified on the form) to the person or organization (as identified on the form). DSHS Form 17-063 and HCA Form 80-020 are HIPAA-compliant. Who processes the request? If the individual designates an AREP in Healthplanfinder (which the individual can do anytime), Healthplanfinder accepts the request when submitted. Outside of Healthplanfinder, the AREP designation is received and entered into ACES or Healthplanfinder as follows: HBE staff process HCA Form 18-001 (Medicaid paper application). HCA medical assistance specialist (MAS) staff process HCA Form 18-001 and DSHS Form 14-532 sent to HCA. DSHS public benefit specialist (PBS) staff process all HCA Form 18-005 (Classic Medicaid paper application) and DSHS Form 14-532 sent to DSHS. DSHS receives DSHS Form 14-012 and uploads it into the Electronic Case Record (ECR). Only the Public Disclosure Unit at HCA or DSHS can approve or deny requests to release agency records, whether on HCA Form 80-020 or DSHS Form 17-063 or by other correspondence. How long is the designation effective? An AREP designation on HCA Form 18-001 or HCA Form 18-005 or DSHS Form14-532 is effective until applicant/recipient revokes or AREP notifies they are no longer the AREP An AREP designation is effective until revoked by the client or authorized representative unless otherwise designated by the applicant/recipient and automatically terminates when a person dies. The consent on DSHS Form 14-012 is effective for the period of time specified on the form. The authorization to release records on HCA Form 80-020 or DSHS Form 17-063 is effective for the period of time specified on the form.

* The consent to Use and Share Confidential information form is not required for HCA to obtain information from a provider.

**To designate an authorized representative complete DSHS forms 14-532 or designate your authorized representative on the completed Washington Apple Health Application for Aged, Blind, Disabled/Long-Term Services and Supports ( 18-005 , page 16).

Carefully review consent forms

Every signed consent form is unique, so it is critical that the authorized information, designated parties, and effective dates be carefully reviewed before releasing information.

DSHS Form 14-532 and DSHS Form 14-012 are not required when the AREP has Power of Attorney or Legal Guardianship. Power of Attorney/Legal Guardianship must be verified. For medical assistance programs, legal guardianship is designated by coding the AREP screen Rep Type field in ACES with CG or GN and power of attorney is designated by coding the AREP screen Rep Type field in ACES with AD or NA.

When a child aged 18 or younger is institutionalized and the facility is applying on their behalf, the DSHS 14-532 AREP form or the designation of the facility as an AREP on the application or eligibility review is not required when the individual is:

In a court ordered, out-of-home placement under chapter 13.34 RCW ; or

Involuntarily committed to an inpatient treatment program by a court order under chapter 71.34 RCW .

For information regarding AREP screens for long-term care cases .

Depending on what an Apple Health recipient chooses, an AREP may:

Receive letters/notices/forms/ProviderOne cards; or

Have permission only to discuss the case; or

Both.

For Classic Medicaid:

The worker records on the AREP screen in ACES the representative's name and address and the REP Type code, which determines what forms, letters, etc. they receive.

If the individual is completing their review over the phone and they are designating a new AREP, the individual should complete a DSHS 14-532 AREP form . The worker should not add the new AREP until they receive the completed DSHS 14-532 AREP form or written confirmation from the individual. Completing the DSHS 14-532 AREP form is not required if the individual is confirming or making changes to their current AREP.

For MAGI-based Medicaid, the applicant or worker clicks the box in Washington Healthplanfinder to choose whether the AREP will receive letters/notices/form/ProviderOne cards. This information is then transferred to ACES.

Initial designation of an AREP by an individual should be made on the application, review or DSHS 14-532 AREP form . Changes to an existing AREP can be made verbally but must be well documented in the remarks behind the AREP screen in ACES.

Authorized Representative/Protective Payee

Codes on this page:

A01-A24 | D01-D26 | F99 | G01-G99 | K01-K99 | L01-L99 | M99 | N01-N33 | P06-P99 | R02-R03 | S01-S99 | T02

Scope legend: CNP = Categorically Needy Program MNP = Medically Needy Program ERSO = Emergency Related Services Only (AEM) MSP = Medicare Savings ABP = Alternative Benefit Plan

ACES Program Description Scope A01 Medical care services and ABD cash with CN Medicaid State funded Medical Care Services and ABD Cash Aged/Blind/Disabled State funded A05 Medical care services and ABD cash with CN Medicaid Medical Care Services non citizen (under 65, incapacitated) State funded A24 Medical care services and ABD cash with CN Medicaid Medical Care Services non citizen SFA for survivors of certain crimes State funded

ACES Program Description Scope D01 Foster Care SSI Recipient Foster Care or Adoption Support or Juvenile Rehabilitation CNP D02 Foster Care Foster Care or Adoption Support or Juvenile Rehabilitation CNP D26 Federal Foster Care Former Foster Care expansion to age 26 years CNP

ACES Program Description Scope F99 Family related medical assistance Medically needy children spenddown MNP

ACES Program Description Scope G01 Medical care services and ABD cash with CN Medicaid MCS Medical care services (ended 8/31/2014) State funded G02 Medical care services and ABD cash with CN Medicaid ABD cash plus either: ABD-X Presumptive SSI Federally funded CN Medicaid (ended 12/31/2013) ABD-A Federally funded CNP - AGED (ended 8/31/2014) ABD-D Federally funded CNP - NGMA disability determination (ended 8/31/2014) CNP G03 SSI Related living in an Alternative Living Facility (Non Medical Institution) Adult Family Home, boarding home or DDD Group Home Non Institutional Medical in ALF CNP income under the SIL plus under state rate x 31 days + 38.84 CNP G95 SSI Related living in an Alternative Living Facility (Non Medical Institution) Adult Family Home, boarding home or DDD Group Home Medically Needy Non Institutional in ALF no Spenddown MNP G99 SSI Related living in an Alternative Living Facility (Non Medical Institution) Adult Family Home, boarding home or DDD Group Home Medically Needy Non Institutional in ALF with Spenddown MNP

ACES Program Description Scope K01 Institutional family/children Categorically Needy family in medical institution CNP K03 Institutional family/children Undocumented Alien family in medical institution - Emergency Related Service Only ERSO K95 Institutional family/children Family LTC Medically Needy no Spenddown in Medical Institution MNP K99 Institutional family/children Family LTC Medically Needy with Spenddown - in Medical Institution MNP

ACES Program Description Scope L01 Institutional SSI - related Residing in a medical institution 30 days or more SSI recipient in a Medical Institution - Residing in a medical institution 30 days or more CNP L02 Institutional SSI - related Residing in a medical institution 30 days or more SSI related CNP in a medical institution income under the SIL CNP L04 Institutional SSI - related Residing in a medical institution 30 days or more Undocumented alien/non-citizen LTC must be preapproved by ADSA program manager. Emergency related service only (45 slots) ERSO - CNP L21 Institutional HCBS Waivers (HCS/DDD) and hospice DDD/HCS Waiver on SSI CNP L22 SSI and SSI related DDD/HCS Waiver - gross income under the SIL CNP L24 SSI and SSI related Undocumented alien/noncitizens LTC - residential placement; must be preapproved by ADSA program manager; Emergency related service only (45 slots) ERSO - CNP L31 SSI and SSI related PACE or Hospice on SSI (effective 10/1/2015) CNP L32 SSI and SSI related PACE or Hospice - SSI related (effective 10/1/2015) CNP L41 SSI and SSI related Roads to Community Living (RCL) on SSI (effective 10/1/2015) CNP L51 Noninstitutional community first choice Personal care services in the community Community First Choice CFC on SSI (effective 10/1/2015) CNP L52 Noninstitutional community first choice Personal care services in the community Community First Choice - SSI-Related at home or in an ALF (effective 10/1/2015) CNP L95 Institutional SSI - related Residing in a medical institution 30 days or more SSI related Medically Needy no Spenddown Income over the SIL; Income under the state rate MNP L99 SSI and SSI related Roads to Community Living - SSI related (effective 10/1/2015) CNP L99 Institutional SSI - related Residing in a medical institution 30 days or more SSI related Medically Needy with Spenddown; Income over the SIL; income over the state rate but under the private rate; locks into state NF rate MNP

ACES Program Description Scope M99 Psychiatric inpatient Psychiatric indigent inpatient spenddown (MI prior to 7/2003) Mental health ONLY (ended 12/31/2013) Inpatient psychiatric hospital only

ACES Program Description Scope N01 Modified Adjusted Gross Income (MAGI) MAGI Parent/Caretaker Medicaid; Adult CNP N02 Modified Adjusted Gross Income (MAGI) 12 Month Transitional MAGI Parent/Caretaker Medicaid; Adult CNP N03 Modified Adjusted Gross Income (MAGI) MAGI Pregnancy CNP N04 Modified Adjusted Gross Income (MAGI) After Pregnancy ABP N05 Modified Adjusted Gross Income (MAGI) MAGI Adult Medicaid; Income =<133% (Medicaid Expansion) ABP N07 Modified Adjusted Gross Income (MAGI) After pregnancy; not Medicaid eligible during pregnancy CNP N08 Modified Adjusted Gross Income (MAGI) After pregnancy state funded; eligible during pregnancy, > 193% and = < 210% FPL N10 Modified Adjusted Gross Income (MAGI) MAGI Newborn Medical Birth to One Year CNP N11 Modified Adjusted Gross Income (MAGI) MAGI Children's Medicaid/Age Under 19 CNP N13 Modified Adjusted Gross Income (MAGI) MAGI Children's Health Insurance Program (CHIP) Children Under 19; Premium Payment Program CNP N20 Modified Adjusted Gross Income (MAGI) MAGI Adult Medical 19 - 64; Income = < 138% Apple Health Expansion Apple Health Expansion - State funded N21 Modified Adjusted Gross Income (MAGI) MAGI Parents/Caretaker; Alien Emergency Related Service Only ERSO N23 Modified Adjusted Gross Income (MAGI) MAGI Pregnancy; Not Lawfully Present CNP N24 Modified Adjusted Gross Income (MAGI) After pregnancy; not lawfully present CNP N25 Modified Adjusted Gross Income (MAGI) MAGI Adult - Alien Emergency Related Service Only ERSO N27 Modified Adjusted Gross Income (MAGI) After pregnancy; not lawfully present; not Medicaid eligible during pregnancy CNP N31 Modified Adjusted Gross Income (MAGI) MAGI Children's Medical; Under 19; Noncitizen State funded CNP N33 Modified Adjusted Gross Income (MAGI) MAGI Children's Health Insurance Program (CHIP): Under 19; Premium Payment Program, Noncitizen State funded CNP

ACES Program Description Scope P06 Family Planning Only Family Planning Only P99 Pregnancy Medically Needy Pregnant Spenddown MNP

ACES Program Description Scope R02 Refugee medical assistance Transitional 4 month extension CNP R03 Refugee medical assistance Refugee Categorically needy CNP

ACES Program Description Scope S01 SSI and SSI Related SSI Recipients CNP S02 SSI and SSI Related ABD Categorically Needy CNP S03 SSI and SSI Related QMB Medicare Savings Program (MSP) Medicare premium and Medicare copays MSP S04 SSI and SSI Related QDWI Medicare Savings Program MSP S05 SSI and SSI Related SLMB Medicare Savings Program. Medicare Premium only MSP S06 SSI and SSI Related QI-1 (SLMB) Medicare Savings Program MSP S07 SSI and SSI Related Undocumented Alien - Emergency Related Service Only ERSO S08 SSI Related Health Care for Workers w/disability Health Care for Workers with Disability CNP Premium based program - Substantial Gainful Activity (SGA) not a factor in Disability determination. CNP S20 Apple Health Eligibility Classic Adult Medical 65+; Income = < 138% Apple Health Expansion Apple Health Expansion - State Funded S30 Breast and Cervical Cancer Program Breast and Cervical Cancer (Health Department Approval) CNP S95 SSI and SSI Related Medically Needy no Spenddown MNP S99 SSI and SSI Related Medically Needy with Spenddown MNP

ACES Program Description Scope T02 Tailored supports for older adults (TSOA) HCS maintains TSOA cases TSOA - No medical benefits and no Medicaid services card issued Pre- Medicaid benefit for the caregiver of a person 55 or older to support the caregiver. For those not eligible for a CN or ABP Medicaid program and not needing or eligible for other LTSS services because of resources. Must meet NFLOC. No medical benefits

This section describes determining available income for an SSI-related single client for long-term care and determining available income for legally married couples for long-term care services.

Effective February 20, 2017

This section describes income the agency or its designee determines available when evaluating an SSI-related single client's eligibility for long-term care (LTC) services.

See WAC 182-513-1330 for rules related to available income for legally married couples.

The agency or its designee applies the following rules when determining income eligibility for SSI-related LTC services: WAC 182-512-0600 SSI-related medical—Definition of income; WAC 182-512-0650 SSI-related medical—Available income; WAC 182-512-0700 SSI-related medical—Income eligibility; WAC 182-512-0750 SSI-related medical—Countable unearned income; WAC 182-512-0840 (3) self-employment income-allowable expenses WAC 182-512-0785 , 182-512-0790 , and 182-512-0795 for sponsored immigrants and how to determine if sponsors' income counts in determining benefits.

In initial categorically needy income eligibility for LTC, the agency does not allow any deductions listed in 1612(b) of the Social Security Act, for example: Twenty dollars per month income exclusion under WAC 182-512-0800 ; The first $65 and the remaining one-half earned income work incentive under WAC 182-512-0840 ; and Impairment related work expense or blind work expense under WAC 182-512-0840 .

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 .

Effective August 26, 2018

This section describes income the agency or its designee determines available when evaluating a legally married person's eligibility for long-term care (LTC) services.

The agency or the agency's designee applies the following rules when determining income eligibility for LTC services: WAC 182-512-0600 SSI-related medical—Definition of income; WAC 182-512-0650 SSI-related medical—Available income; WAC 182-512-0700 SSI-related medical—Income eligibility; WAC 182-512-0750 SSI-related medical—Countable unearned income; WAC 182-512-0840 (3), self-employment income-allowance expenses; WAC 182-512-0960 SSI-related medical —Allocating income—Determining eligibility for a spouse when the other spouse receives long-term services and supports (LTSS); WAC 182-512-0785, 182-512-0790, and 182-512-0795 for sponsored immigrants and how to determine if the sponsors' income counts in determining benefits.

In initial categorically needy income eligibility for LTC, the agency does not allow any deductions listed in 1612(b) of the Social Security Act, for example: Twenty dollars per month income exclusion under WAC 182-512-0800 ; The first $65 and the remaining one-half earned income work incentive under WAC 182-512-0840 ; and Impairment related work expense or blind work expense under WAC 182-512-0840 .

The following income is available to an institutionalized spouse, unless subsections (5) and (6) apply: Income received in the institutionalized spouse's name; Income paid to a representative on the institutionalized spouse's behalf; and One-half of the income received in the names of both spouses.

The following income is unavailable to an institutionalized spouse: Separate income received in the name of the community spouse; and Income established as unavailable through a court order.

For the determination of eligibility only, if available income under subsection (3)(a) through (c) of this section, minus income exclusions under WAC 182-513-1340 , exceeds the special income level (SIL), defined under WAC 182-513-1100 , the agency or its designee: Follows Washington state community property law when determining ownership of income; Presumes all income received after the marriage by either spouse to be community income; Considers one-half of all community income available to the institutionalized spouse.

If the total of subsection (5)(c) of this section plus the institutionalized spouse's separate income is over the SIL, determine available income using subsection (3) of this section.

A stream of income, not generated by a transferred resource, is available to the institutionalized spouse, even if the institutionalized spouse transfers or assigns the rights to the stream of income to one of the following: The community spouse; or A trust for the benefit of the community spouse.

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 .

When one member of a married couple applies for LTC services, the department applies the "name on the check" rule (see below) to determine the individual’s available income. If the individual is not income eligible for services under the Categorically Needy (CN) program, the department applies the "community income" rule (see below). If the application of both rules results in income above the CN standard, the department determines the individual’s eligibility for institutional or hospice services under the Medically Needy (MN) program.

When both spouses are applying at the same time, or when one has already been determined eligible for LTC services, the department establishes eligibility for them as it does for single individuals with the following exceptions: If the two are living together in a medical institution or alternate living facility, their eligibility can be determined together as a couple, if doing so would be to their advantage. If one spouse is applying for CN LTC services, the department does not use the community income rule to establish an income amount as a single person, when doing so would be to their disadvantage. The department uses the "name on the check" rule for each spouse, when doing so allows an otherwise eligible client to be approved for CN services. The total amount of income benefits to which a person is entitled is treated as available unearned income even when benefits are; Reduced through the withholding of a portion of the benefit amount to repay a legal obligation; or Garnished to repay a debt, other legal obligation, or make any other payment such as payment of Medicare premiums. See WAC 182-512-0750 .

This rule presumes that income received in the spouse’s name is their separate income

Income paid to one spouse on their behalf is presumed to be that spouse’s income

One-half of income paid to both spouses is assigned to each spouse

With no documentation of ownership, one-half of all income is assigned to each spouse

Income received in the name of either or both spouses and another person(s) is assigned according to their proportionate share

This rule presumes that income received in the name of either or both spouses is the income of both, unless it meets the definition of separate income

Consider income, including but not limited to wages, pensions, and retirement funds the spouse earned the right to receive during the marriage as community income

SSI payments or income legally established as separate income

Income from a source that required the spouse to earn the right to receive it, including but not limited to, retirement funds the spouse earned the right to receive before the marriage

Income from separate property acquired before the marriage or during the marriage, if purchased with separate income and kept separately

Income that has been commingled is not separate income, unless it can be traced to its separate source

This section describes resource eligibility for institutional medicaid programs including HCBS Waiver programs.

Effective February 25, 2023

General information. This section describes how the agency or the agency's designee defines the resource standard and countable or excluded resources when determining a person's eligibility for SSI-related long-term care (LTC) services. "Resource standard" means the maximum amount of resources a person can have and still be resource eligible for program benefits. For a person not SSI-related, the agency applies program specific resource rules to determine eligibility.

Resource standards. The resource standard for the following people is $2000: A single person; or An institutionalized spouse. The resource standard for a legally married couple is $3000, unless subsection (3)(b)(ii) of this section applies. The resource standard for a person with a qualified long-term care partnership policy under WAC 182-513-1400 may be higher based on the dollar amount paid out by a partnership policy. Determining the amount of resources that can be allocated to the community spouse when determining resource eligibility is under WAC 182-513-1355 .

Availability of resources. General. The agency or the agency's designee applies the following rules when determining available resources for LTC services: WAC 182-512-0300 SSI-related medical—Resources eligibility; WAC 182-512-0250 SSI-related medical—Ownership and availability of resources; and WAC 182-512-0260 SSI-related medical—How to count a sponsor's resources. Married couples. When both spouses apply for LTC services, the resources of both spouses are available to each other through the month in which the spouses stopped living together. When both spouses are institutionalized, the agency or the agency's designee determines the eligibility of each spouse as a single person the month following the month of separation. If the agency or the agency's designee has already established eligibility and authorized services for one spouse, and the community spouse needs LTC services in the same month, but after eligibility has been established and services authorized for the institutionalized spouse, then the agency applies the standard under subsection (2)(a) of this section to each spouse. If doing this would make one of the spouses ineligible, then the agency applies subsection (2)(b) of this section for the couple. The resources of the community spouse are unavailable to the institutionalized spouse the month after eligibility for LTC services is established, unless (v) or (vi) of this subsection applies. When a single institutionalized individual marries, the agency or the agency's designee redetermines eligibility applying the resource and income rules for a legally married couple. A redetermination of the couple's resources under this section is required if: The institutionalized spouse has a break of at least 30 consecutive days in a period of institutional status; The institutionalized spouse's countable resources exceed the standard under subsection (2)(a) of this section, and WAC 182-513-1355 (2)(b) applies; or The institutionalized spouse does not transfer the amount, under WAC 182-513-1355 (3) or (5), to the community spouse by either: The end of the month of the first regularly scheduled eligibility review; or A reasonable amount of time necessary to obtain a court order for the support of the community spouse.

Countable resources. The agency or the agency's designee determines countable resources using the following sections: WAC 182-512-0200 SSI-related medical—Definition of resources. WAC 182-512-0250 SSI-related medical—Ownership and availability of resources. WAC 182-512-0260 SSI-related medical—How to count a sponsor's resources. WAC 182-512-0300 SSI-related medical—Resources eligibility. WAC 182-512-0350 SSI-related medical—Property and contracts excluded as resources; WAC 182-512-0400 SSI-related medical—Vehicles excluded as resources; WAC 182-512-0450 SSI-related medical—Life insurance excluded as a resource; and WAC 182-512-0500 SSI-related medical—Burial funds, contracts and spaces excluded as resources. Chapter 182-516 WAC, Trusts, annuities, life estates, and promissory notes—Effect on medical programs. The agency or the agency's designee determines excluded resources based on federal law and WAC 182-512-0550 , except: For institutional and HCB waiver programs, pension funds owned by a nonapplying spouse are counted toward the resource standard. For long-term services and supports (LTSS), based on the need for either nursing facility level of care or intermediate care facility for the intellectually disabled level of care, one home is excluded only if it meets the home equity limits of subsection (8) of this section. See WAC 182-512-0350 (1)(b). The agency or the agency's designee adds together the countable resources of both spouses if subsections (3)(b)(i) and (iv) apply, but not if subsection (3)(b)(ii) or (iii) apply. For a person with a community spouse, see WAC 182-513-1355 .

Excess resources. For LTC programs, a person may reduce excess resources by deducting incurred medical expenses under subsection (6) of this section; The amount of excess resources is limited to the following amounts: For LTC services provided under the categorically needy (CN) program: In a medical institution, excess resources and available income must be under the state medicaid rate based on the number of days the person spent in the medical institution in the month. For HCB waiver eligibility, incurred medical expenses must reduce resources within allowable resource standards. The cost of care for the HCB waiver services cannot be allowed as a projected expense. For LTC services provided under the medically needy (MN) program, see: WAC 182-513-1395 for LTC programs; and WAC 182-513-1245 for hospice. Excess resources not otherwise applied to medical expenses will be applied to the projected cost of care for services in a medical institution under WAC 182-513-1380 .

Allowable medical expenses. The following incurred medical expenses may be used to reduce excess resources: Premiums, deductibles, coinsurance, or copayment charges for health insurance and medicare; Medically necessary care defined under WAC 182-500-0070 , but not covered under the state's medicaid plan. Information regarding covered services is under chapter 182-501 WAC; Medically necessary care defined under WAC 182-500-0070 incurred prior to medicaid eligibility. Expenses for nursing facility care are reduced at the state rate for the specific facility that provided the services. To be allowed, the medical expense must: Have been incurred no more than three months before the month of the medicaid application; Not be subject to third-party payment or reimbursement; Not have been used to satisfy a previous spenddown liability; Not have been previously used to reduce excess resources; Not have been used to reduce participation; Not have been incurred during a transfer of asset penalty under WAC 182-513-1363 ; and Be an amount for which the person remains liable.

Nonallowable expenses. The following expenses are not allowed to reduce excess resources: Unpaid adult family home (AFH) or assisted living facility expenses incurred prior to medicaid eligibility; Personal care cost in excess of approved hours determined by the CARE assessment under chapter 388-106 WAC; and Expenses excluded by federal law.

Excess home equity. A person with an equity interest in a primary residence in excess of the home equity limit is ineligible for long-term services and supports (LTSS) that are based on the need for either nursing facility level of care or intermediate care facility for the intellectually disabled level of care, unless one of the following persons lawfully resides in the home: That person's spouse; or That person's dependent child under age 21, blind child, or disabled child. The home equity provision applies to all applications for LTSS received on or after May 1, 2006. The excess home equity limit is the federal maximum allowed. On January 1st of each year, this standard may change by the percentage in the consumer price index for all consumers (CPI-U). The current maximum home equity limit is posted by the Centers for Medicare and Medicaid Services. (See subsection (9) of this section for institutional resource standards.) A person who is denied or terminated LTC services due to excess home equity may apply for an undue hardship waiver under WAC 182-513-1367 .

Institutional resource standards are found at www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/program-standard-income-and-resources .

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 .

Effective February 25, 2023

The agency or its designee uses this section to calculate the resource allocation from the institutionalized spouse to the community spouse for the determination of the institutionalized spouse's resource eligibility under WAC 182-513-1350 (2)(a)(ii).

If the institutionalized spouse's most recent continuous period of institutionalization (MRCPI) began: Before October 1, 1989, the agency adds together one-half the total amount of countable resources, as determined under WAC 182-513-1350 (4), held in the name of: The institutionalized spouse; and Both spouses. On or after October 1, 1989, the agency or its designee adds together the total amount of countable resources, as determined under WAC 182-513-1350 (4), held in the name of: Either spouse; and Both spouses.

If subsection (2)(b) of this section applies, the agency or its designee determines the amount of resources allocated to the community spouse, before determining the amount of countable resources used to establish eligibility for the institutionalized spouse under WAC 182-513-1350 : If the institutionalized spouse's MRCPI began on or after October 1, 1989, and before August 1, 2003, the agency or its designee allocates the federal spousal resource maximum; If the institutionalized spouse's MRCPI began on or after August 1, 2003, the agency or its designee allocates the greater of: A spousal share equal to one-half of the couple's combined countable resources, up to the federal spousal resource maximum; or The state spousal resource standard.

Countable resources under subsection (3)(b) of this section determined as of the first day of the month in which MRCPI began.

The agency or its designee uses a community spouse evaluation to determine the amount of the spousal share under subsection (3)(b)(i) of this section.

The agency or its designee completes a community spouse resource evaluation: Upon request by the institutionalized spouse, or the institutionalized spouse's community spouse; At any time between the date that the MRCPI began and the date that eligibility for long-term care (LTC) is determined; and Upon receipt of any verification required to establish the amount of the couple's resources in the month of MRCPI.

The community spouse resource evaluation can be completed prior to an application for LTC or as part of the LTC application if: The beginning of the MRCPI was prior to the month of application; and The spousal share exceeds the state spousal resource standard.

The amount of allocated resources under subsection (3) of this section can be increased, but only if: A court has entered an order against the institutionalized spouse for the support of the community spouse or a dependent of either spouse; or A final order is entered under chapter 182-526 WAC, ruling that the institutionalized spouse or community spouse established that the income generated by the resources allocated under subsection (3) of this section is insufficient to raise the community spouse's income to the monthly maintenance needs allowance (MMNA) determined under WAC 182-513-1385 , but only after the application of the income-first rule under 42 U.S.C. 1396r–5(d)(6).

If a final order establishes that the conditions identified in subsection (8)(b) of this section have been met, then an amount of allocated resources under subsection (3) of this section will be substituted by an amount adequate to provide such an MMNA.

The institutionalized spouse has until the end of the month of the first regularly scheduled eligibility review to transfer countable resources in excess of $2000 to the community spouse.

Standards in this section are found at www.hca.wa.gov/free-or-low-cost-health-care/program-administration/program-standard-income-and-resources .

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 .

Resource ownership and availability : describes how the department defines resources, determines ownership and availability of resources, property and contracts, vehicles, life insurance, burial funds and other excluded resources.

Resource eligibility and excess resource eligibility specific to long-term care is described in WAC 182-513-1350 .

Standards - LTSS

The individual must be resource eligible on the first day of the month to be eligible for any day or days of that month. A resource determination is made on the first moment of the first day of the month. Changes in the amount of an individual's countable resources during a month do not affect eligibility or ineligibility for that month. See WAC 182-512-0300 (1).

See WAC 182-513-1350 (8) (d) (e) and (f).

Excess resources for any historical month will first be reduced by qualifying medical expenses coded on the LTCX screen. Then, for individuals in a medical institution, any remaining excess resources will be applied to the individual's participation. If the individual's resources cannot be reduced to the program limit through this process, the assistance unit will be terminated or denied. The remaining excess resources do not carry forward for use in any months beyond the months in which they are entered.

Excess Resources will not be reduced by medical expenses or applied to the individual's participation in any month beyond the current calendar month. When excess resources exist in any benefit month beyond the current calendar month, the assistance unit will be terminated or denied.

The following long term care expense types are considered incurred medical expenses and will be used to reduce excess resources in this order:

UB – Outstanding Nursing Home Bill

UO – Old Medical Bill

UA – Adult Day Health

UM – Medical Necessity MA Not Covered

UH – Hearing Aids

OH – Health Insurance

UD – Prescription Expenses Not Covered By Medicare Part D

OP – Medicare Part D Copayments

OL – LTC Insurance

OD – Medicare Part D Premiums

OC – Medicare Part C Premiums

OB – Medicare Part B Premiums

OA – Medicare Part A Premiums

Multiple expenses of the same type are deducted in order of highest amount to lowest amount.

All other expense types are not considered medical expenses and can't be used to reduce excess resources.

ACES will compare the individual's income plus excess resources to the cost of care

In a full calendar month it will use the state daily rate x 30.42

In a partial month, it will use the state daily rate x the actual number of days

If the income plus the remaining excess resources is not more than the cost of care, the case will open and assign the excess.

If the income plus remaining excess resources is more than the cost of care, the case will deny.

Income only determines CN versus MN. Excess resources do not affect the scope of care the individual is eligible to receive.

If excess resources causes a case to go into L99 spenddown, the case needs to be denied.

For CN Waiver eligibility, incurred medical expenses must reduce resources within the allowable resource limits for CN-Waiver eligibility. The cost of care for waiver services cannot be allowed as a projected expense.

If medical expenses do not reduce the excess to the applicable resource standard, the case will deny.

If medical expenses do reduce the excess to the applicable resource standard, the case will open.

Set a barcode tickler to check resource eligibility on the first of the month when appropriate.

Ensure the excess is in the first month of eligibility only

Adjust the resource amount in the remaining processing months to the applicable standard

ACES will deny if excess is coded in the ongoing month.

A review does not need to be initiated

Update the resource information in the current or historical month

Case will process as described

Excess will not be assigned to the cost of care for days coded on the STAY screen

Excess will be applied if the facility is coded using INST

An individual may also reduce excess resources by using funds to establish a burial fund, if appropriate. Care must be taken to ensure that excess resources are spent during the month of application. See SSI-related rules regarding burial funds.

An individual is not eligible if they have excess resources that must be assigned toward cost of care (medical institution) when there is no obligation to pay the facility for that month because Medicare or another TPL source is covering 100% of the cost. Deny eligibility for that month as there isn't a cost of care the individual is obligated to pay. Consider eligibility for the following month.

This is only for issues where the individual has excess resources and other coverage. If the individual doesn't have excess resources, Medicare or other TPL coverage does not affect eligibility.

For months where there is other coverage for only a part of a month, eligibility with excess resources will be based on the cost for the number of days the individual is obligated to pay, similar to a partial month with excess resources:

If the assigned excess plus income is greater than the cost for the number of days of individual's obligation, the individual isn't eligible.

If the assigned excess plus income is no greater than the cost for the number of days of individual's obligation, the individual is eligible and must pay the excess toward care.

Code the date the client starts having an obligation to pay as the payment authorization date.

Example #1: Excess, not eligible

Arlo is single and his monthly income is $2,000. On 2/1 his resources were $2500 after reducing for out-of-pocket medical expenses. He admits to the nursing home under Medicare on 2/19 and applies for Medicaid. Medicare is paying the cost at $100%. Because he has no obligation toward his cost of care, his excess resources cannot be assigned to an actual medical obligation. He is not resource eligible. Deny February for being over resources and consider eligibility for March.

Example #2: Excess, is eligible

Milly is single and her monthly income is $2,000. On 2/1 her resources were $2,000 after reducing for out-of-pocket medical expenses. She enters the nursing home under Medicare on 2/19 and applies for Medicaid. Medicare is paying the cost at 100%. She is eligible because her resources do not need to be assigned toward the cost of care.

If excess resources were assigned but never paid and the client is still over resources in a subsequent month, you cannot assign the same excess again. The only alternative is to terminate the case.

Determine if the excess is the same funds previously assigned

If it is the same funds, do not assign them again

Find out if they have paid but it is not yet reflected in the accounts by discussing with the institution bookkeeper

If it has not been paid, advise the individual they are not eligible as their eligibility was contingent upon them paying that excess toward care

Determine if/when they are going to pay it and follow up

If individual fails to pay it after allowing a reasonable time (10 days) propose termination

Advise HQ there is a situation where an active medical institution case starts receiving Medicare coverage at 100% (nursing home readmit after a hospital stay) and has excess resources. This will be very rare and most likely will be an overpayment.

When a client becomes ineligible due to excess resources and notifies the agency timely, and the notification is beyond the time for 10 day notice to be given. We do not terminate the case. We must give 10 day notice, unless the client verbally waives the notice to prevent an overpayment. See WAC 182-518-0025 .

Example #1: 10 day notice

Client received a lump sum on 4/25/2015. They have 30 days to report and report the change of 5/10/2015. Their combined resources on 5/1/2015 were $4000. In this example we would propose termination effective 5/31/2015 and indicate if the client's resources are at or below $2000. We would need verification, see Verification requirements . We could reinstate eligibility if reported within 30 days

See how annuities affect eligibility for information on how annuities, trusts, and life estates affect SSI-related and LTC eligibility.

View definitions related to trusts, annuities and life estates .

Use the Individual Annuity (Life Expectancy) Tables in Appendix IV to determine whether annuity payments will exceed a time frame based on the actuarial life expectancy of the individual. If they do, establish a period of ineligibility described in the transfer of asset section.

Determine whether a life estate can be excluded as a resource. If not, determine its value as a nonexcluded resource by using Appendix II - Determining the Value of Life Estates. If the life estate is jointly owned, divide the value by the number of joint owners to determine the individual’s share.

View details about reverse mortgages, promissory notes, and loans .

WAC 182-513-1350 (8) (b) states:

For an SSI-related client one automobile per household is excluded regardless of value if it is used for transportation of the eligible individual/couple.

For an SSI-related individual with a community spouse, the value of one automobile is excluded regardless of its use or value.

Vehicles not meeting the definition of automobile is a vehicle that has been junked or a vehicle that is used only as a recreational vehicle.

What this means is one vehicle is excluded for SSI-related programs if used for transportation. For institutional programs with a community spouse a vehicle is excluded regardless of it's use.

This does not mean there are two vehicle exclusions for institutional Medicaid.

Example #1

Single individual in a nursing home has a vehicle that is not being used to transport the individual. In this example the vehicle is not excluded as it is not used to transport the individual.

Example #2

Married individual in a nursing home. Community spouse cannot drive. The vehicle is still excluded because the value of one automobile is excluded regardless of use.

The exclusion for SSI-related individuals with a community spouse supersedes the exclusion for an SSI-related individual being transported described in WAC 182-512-0400 (2). You cannot get both exclusions. There is 1 vehicle exclusion for institutional SSI-related medical.

An individual can establish a patient trust account in a nursing facility, if the individual is not capable of handling personal funds or has requested in writing that one be established.

The Nursing Facility is required to: Maintain an interest bearing account for balances above $49.99 Keep a ledger of the trust account balance of each individual Notify the HCS/CSO FSS when the trust account is close to the resource standard

If the individual leaves a medical facility, the facility returns these funds to the individual. If the individual dies, the facility sends these funds to the Office of Financial Recovery. If the individual leaves and his/her whereabouts are unknown, the facility sends these funds to the Department of Revenue.

See WAC 182-513-1350 .

The individual's home with equity less than $500,000 is an excluded resources. This includes the land on which the dwelling is located and all contiguous property and related out buildings in which the individual has ownership interest, when:

The individual uses the home as his or her primary residence.

The individual's spouse lives in the home.

The individual does not currently live in the home but the individual or his/her representative has stated the individual intends to return to the home.

When the home cannot be excluded the individual must make a reasonable attempt to convert the property to an available resource. Providing one of the following does this:

Current real estate listing

Advertisement showing property is for sale

Other verification to show reasonable effort to sell the property

Excess home equity value over the excess home equity standard is a provision specific to long-term care services. If an individual has excess home equity, there is no eligibility for payment of long-term care services.

See Excess home equity .

Resources of a married couple-one spouse institutionalized. The rules regarding resources for married couples are different depending on when the institutionalized spouse began the current period of institutional status. If the current period of institutional status began before October 1, 1989, the determination of eligibility does not include any resources of the community spouse that are owned and maintained separately from community resources. Once eligibility has been established, this rule remains in effect unless a break of at least thirty consecutive days occurs. If the current period of institutional status began on or after October 1, 1989, the spousal impoverishment count all nonexcluded resources owned by either or both spouses, separately or jointly. The department then allocates the amount set aside for the community spouse The amount that is allocated is based upon the onset date of the current period of institutional status. One set of rules covers married clients who become institutionalized before 8/1/03. A separate set of rules covers married individuals who become institutionalized on or after 8/1/03. The amount of allocation allowed, based on the appropriate set of rules, can be increased only as described in WAC 182-513-1350 : Pursuant to a court order for spousal support When an administrative law judge (ALJ) approves a determination by Home and Community Services (HCS) that the excess resources are needed to produce income to provide the community spouse the minimum maintenance allocation. Once eligibility has been established, this resource determination remains in effect unless a break of at least thirty consecutive days occurs, or if the institutionalized spouse acquires resources above the program standard. If the onset date of the current period of institutional status is after October 1, 1989 and before August 1, 2003, the federal Community Spouse Resource maximum that was in place at the time of the application is used as the Community Spouse Resource Allocation. See Example #1. If the onset date of the current period of institutional status is on or after August 1, 2003, the State Spousal Resource Standard that was in place at the time of the application is used as the Community Spouse Resource Allocation, unless: The individual or community spouse requests an evaluation of their community resources; and The results of the evaluation show the spousal share of the community resources at the onset of institutional status, or 1/2 of the couple’s total nonexcluded resources, was greater than the State Spousal Resource Standard. See Example #2.

Married clients who become institutionalized on or after 8/1/03 and have a community spouse can request HCS to evaluate their resources. This evaluation is used to determine if they are eligible for a higher spousal resource allocation than the State Spousal Resource Allocation standard. When evaluating community resources, consider the value of all nonexcluded resources owned by either spouse separately or jointly as of the first day of the month that institutionalization began. Resource Evaluations can be requested and completed prior to the LTC Medicaid application or at the time of the LTC Medicaid application. Verification of all resources is required to complete the evaluation.