PDFWAC 182-508-0001
Washington apple health—Coverage options for adults not eligible under MAGI methodologies.
(1) This chapter provides information on eligibility determinations for adults who:
(a) Need a determination of eligibility on the basis of being aged, blind, or disabled;
(b) Need a determination of eligibility based on the need for long-term institutional care or home and community-based services;
(c) Are excluded from coverage under a modified adjusted gross income (MAGI)-based program as referenced in WAC 182-503-0510 on the basis of medicare entitlement;
(d) Are not eligible for health care coverage under chapter 182-505 WAC due to citizenship or immigration requirements; or
(e) Are not eligible for health care coverage under chapter 182-505 WAC due to income which exceeds the applicable standard for coverage.
(2) The agency determines eligibility for Washington apple health (WAH) noninstitutional categorically needy (CN) coverage under chapter 182-512 WAC for an adult who is age 65 or older, or who meets the federal blind or disabled criteria of the federal SSI program, and:
(a) Meets citizenship/immigration, residency, and Social Security number requirements as described in chapter 182-503 WAC; and
(b) Has CN countable income and resources that do not exceed the income and resource standards in WAC 182-512-0010.
(3) The agency determines eligibility for WAH health care for workers with disabilities (HWD) CN coverage for adults who meet the requirements described in WAC 182-511-1050, as follows:
(a) Are age 16 or older;
(b) Meet citizenship/immigration, residency, and Social Security number requirements as described in chapter 182-503 WAC;
(c) Meet the federal disability requirements described in WAC 182-511-1150; and
(d) Are employed full- or part-time (including self-employment) as described in WAC 182-511-1200.
(4) The agency determines eligibility for WAH long-term care CN coverage for adults who meet the institutional status requirements defined in WAC 182-513-1320 under the following rules:
(a) When the person receives coverage under a MAGI-based program and needs long-term care services in an institution, the agency follows rules described in chapter 182-514 WAC;
(b) When the person meets aged, blind, or disabled criteria as defined in WAC 182-512-0050 and needs long-term care services, the agency follows rules described in:
(i) Chapter 182-513 WAC, for an adult who resides in an institution; and
(ii) Chapter 182-515 WAC, for an adult who is determined eligible for WAH home and community-based waiver services.
(5) The agency determines eligibility for WAH noninstitutional CN or medically needy (MN) health care coverage for an adult who resides in an alternate living facility under rules described in WAC 182-513-1205.
(6) The agency determines eligibility for WAH-CN coverage under institutional rules described in chapters 182-513 and 182-515 WAC for an adult who:
(a) Has made a voluntary election of hospice services;
(b) Is not otherwise eligible for noninstitutional CN or MN health care coverage or for whom hospice is not included in the benefit service package available to the person; and
(c) Meets the aged, blind, or disabled criteria described in WAC 182-512-0050.
(7) The agency uses the following rules to determine eligibility for an adult under the WAH-MN program:
(a) Noninstitutional WAH-MN is determined under chapter 182-519 WAC for an adult with countable income that exceeds the applicable CN standard; and
(b) Non-SSI-related institutional WAH-MN long-term care coverage is determined under WAC 182-514-0263 for pregnant people and people age 20 and younger who:
(i) Meet institutional status requirements described in WAC 182-513-1320;
(ii) Do not meet blind or disabled criteria described in WAC 182-512-0050; and
(iii) Have countable income that exceeds the applicable CN standard.
(c) WAH-MN long-term care coverage is determined under WAC 182-513-1395 for an aged, blind, or disabled adult who resides in an institution and has countable income that exceeds the special income level (SIL).
(8) An adult is eligible for WAH-MN coverage when he or she:
(a) Meets citizenship/immigration, residency, and Social Security number requirements as described in WAC 182-503-0505;
(b) Has MN countable income that does not exceed the effective MN income standards in WAC 182-519-0050, or meets the excess income spenddown requirements in WAC 182-519-0110;
(c) Meets the countable resource standards in WAC 182-519-0050; and
(d) Is 65 years of age or older or meets the blind or disabled criteria of the federal SSI program.
(9) WAH-MN coverage is available for an aged, blind, or disabled ineligible spouse of an SSI recipient. See WAC 182-519-0100 for additional information.
(10) An adult who does not meet citizenship or alien status requirements described in WAC 182-503-0535 may be eligible for the WAH alien emergency medical program as described in WAC 182-507-0110.
(11) An adult is eligible for the state-funded medical care services (MCS) program when he or she meets the requirements under WAC 182-508-0005.
(12) A person who is entitled to medicare is eligible for coverage under a medicare savings program or the state-funded buy-in program when he or she meets the requirements described in chapter 182-517 WAC.
[Statutory Authority: RCW 41.05.021, 41.05.160, and 74.09.540. WSR 24-06-051, § 182-508-0001, filed 3/1/24, effective 4/1/24. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-11-009, § 182-508-0001, filed 5/4/23, effective 6/4/23. Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, 457, and 45 C.F.R. § 155. WSR 14-21-040, § 182-508-0001, filed 10/7/14, effective 11/7/14. Statutory Authority: RCW 41.05.021, 74.09.035, and 2011 1st sp.s. c 36. WSR 12-19-051, § 182-508-0001, filed 9/13/12, effective 10/14/12.]