Chapter 182-503 WAC
Last Update: 9/27/23PERSONS ELIGIBLE FOR MEDICAL ASSISTANCE
WAC Sections
| HTMLPDF | 182-503-0001 | Insurance affordability programs—Overview. |
| HTMLPDF | 182-503-0005 | Washington apple health—How to apply. |
| HTMLPDF | 182-503-0010 | Washington apple health—Who may apply. |
| HTMLPDF | 182-503-0040 | Washington apple health—Interview requirements. |
| HTMLPDF | 182-503-0050 | Verification of eligibility factors. |
| HTMLPDF | 182-503-0055 | Asset verification system. |
| HTMLPDF | 182-503-0060 | Washington apple health—Application processing times. |
| HTMLPDF | 182-503-0070 | Washington apple health (WAH)—When coverage begins. |
| HTMLPDF | 182-503-0080 | Washington apple health—Application denials and withdrawals. |
| HTMLPDF | 182-503-0090 | Washington apple health—Exceptions to rule. |
| HTMLPDF | 182-503-0100 | Washington apple health—Rights and responsibilities. |
| HTMLPDF | 182-503-0110 | Washington apple health—Limited-English proficient (LEP) services. |
| HTMLPDF | 182-503-0120 | Washington apple health—Equal access services. |
| HTMLPDF | 182-503-0130 | Authorized representative. |
| HTMLPDF | 182-503-0505 | Washington apple health—General eligibility requirements. |
| HTMLPDF | 182-503-0510 | Washington apple health—Program summary. |
| HTMLPDF | 182-503-0515 | Washington apple health—Social Security number requirements. |
| HTMLPDF | 182-503-0520 | Washington apple health—Residency requirements—Persons who are not residing in an institution. |
| HTMLPDF | 182-503-0525 | Washington apple health—Residency requirements for an institutionalized person. |
| HTMLPDF | 182-503-0535 | Washington apple health—Citizenship and immigration status. |
| HTMLPDF | 182-503-0540 | Assignment of rights and cooperation. |
| HTMLPDF | 182-503-0565 | Washington apple health—Age requirements for medical programs based on modified adjusted gross income (MAGI). |
DISPOSITION OF SECTIONS FORMERLY CODIFIED IN THIS TITLE
| 182-503-0530 | Citizenship and alien status—Definitions. [Statutory Authority: RCW 41.05.021, Patient Protection and Affordable Care Act (Public Law 111-148), 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 13-14-019, § 182-503-0530, filed 6/24/13, effective 7/25/13.] Repealed by WSR 15-10-002, filed 4/22/15, effective 5/23/15. Statutory Authority: RCW 41.05.021, 41.05.160. |
| 182-503-0532 | Citizenship requirements for the medical care services (MCS) and ADATSA programs. [Statutory Authority: RCW 41.05.021, 74.09.035, and 2011 1st sp.s. c 36. WSR 12-19-051, § 182-503-0532, filed 9/13/12, effective 10/14/12.] Repealed by WSR 14-16-019, filed 7/24/14, effective 8/24/14. Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. |
| 182-503-0555 | Age requirement for MCS and ADATSA. [Statutory Authority: RCW 41.05.021, 74.09.035, and 2011 1st sp.s. c 36. WSR 12-19-051, § 182-503-0555, filed 9/13/12, effective 10/14/12.] Repealed by WSR 14-16-019, filed 7/24/14, effective 8/24/14. Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. |
| 182-503-0560 | Impact of fleeing felon status on eligibility for medical care services (MCS). [Statutory Authority: RCW 41.05.021, 74.09.035, and 2011 1st sp.s. c 36. WSR 12-19-051, § 182-503-0560, filed 9/13/12, effective 10/14/12.] Repealed by WSR 14-16-019, filed 7/24/14, effective 8/24/14. Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. |
PDF182-503-0001
Insurance affordability programs—Overview.
(1) For the purposes of this chapter, "we" or "us" refers to the agency or its designee and "you" refers to the applicant for, or recipient of, health care coverage.
(2) A person may apply for all of the insurance affordability programs offered through the health care authority (HCA) or the Washington Healthplanfinder (as defined in WAC 182-500-0015):
(a) Washington apple health (WAH) programs (defined in WAC 182-500-0120). WAH includes medicaid programs (defined in WAC 182-500-0070), the children's health insurance program (CHIP) (defined in WAC 182-500-0020), and state-only funded health care programs. These programs are provided free or at low cost on a sliding scale to eligible persons based on their income. WAH program regulations for the application process and eligibility determination are found in chapters 182-503 through 182-527 WAC.
(b) Health insurance premium tax credits (defined in WAC 182-500-0045). This federal refundable tax credit partially offsets the cost of monthly premiums for qualified health plan (QHP) (defined in WAC 182-500-0090) insurance that an eligible person purchases through the Washington Healthplanfinder. Any advance payments of the tax credit are reconciled annually by the Internal Revenue Service (IRS) when the person files his or her federal tax return.
(c) Cost-sharing reductions. Cost-sharing reductions (defined in WAC 182-500-0020) are available to eligible persons enrolled in a silver-level QHP and to American Indians/Alaska Natives enrolled in any QHP.
(3) A person may also apply for and enroll in unsubsidized insurance with a QHP. This unsubsidized insurance is not an insurance affordability program.
(4) Persons choose whether or not to apply for insurance affordability programs. All persons who apply for an insurance affordability program are treated as an applicant for WAH coverage and receive an approval or denial of WAH. Applicants who are denied WAH are reviewed for other insurance affordability programs.
PDF182-503-0005
Washington apple health—How to apply.
(1) You may apply for Washington apple health at any time.
(2) 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:
(a) Online via the Washington Healthplanfinder at www.wahealthplanfinder.org;
(b) By calling the Washington Healthplanfinder customer support center and completing an application by telephone;
(c) By completing the application for health care coverage (HCA 18-001P), and mailing or faxing to Washington Healthplanfinder; or
(d) At a department of social and health services (DSHS) community services office (CSO).
(3) 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:
(a) Online via Washington Connection at www.WashingtonConnection.org;
(b) By completing the application for aged, blind, disabled/long-term care coverage (HCA 18-005) and mailing or faxing it to DSHS;
(c) By calling the DSHS customer service contact center and completing an application by telephone;
(d) In person at a local DSHS CSO or home and community services (HCS) office; or
(e) 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.
(4) You may receive help filing an application.
(a) For households containing people described in subsection (2) of this section:
(i) Call the Washington Healthplanfinder customer support center number listed on the application for health care coverage form (HCA 18-001P); or
(ii) Contact a navigator, health care authority volunteer assistor, or broker.
(b) 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:
(i) Call or visit a local DSHS CSO or HCS office; or
(ii) Call the DSHS community services customer service contact center number listed on the medicaid application form.
(5) To apply for tailored supports for older adults (TSOA), see WAC 182-513-1625.
(6) You must apply directly with the service provider for the following programs:
(a) The breast and cervical cancer treatment program under WAC 182-505-0120;
(b) The family planning only programs under chapter 182-532 WAC; and
(c) The kidney disease program under chapter 182-540 WAC.
(7) 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 website: www.hca.wa.gov/free-or-low-cost-health-care (search for "teen").
(8) As the primary applicant or head of household, you may start an application for apple health by providing your:
(a) Full name;
(b) Date of birth;
(c) Physical address, and mailing addresses (if different); and
(d) Signature.
(9) To complete an application for apple health, you must also give us all of the other information requested on the application.
(10) You may have an authorized representative apply on your behalf as described in WAC 182-503-0130.
(11) 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:
(a) 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
(b) Have limited-English proficiency as described in WAC 182-503-0110.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-11-007, § 182-503-0005, filed 5/4/23, effective 6/4/23; WSR 22-20-052, § 182-503-0005, filed 9/28/22, effective 10/29/22; WSR 18-11-071, § 182-503-0005, filed 5/15/18, effective 6/15/18; WSR 17-15-061, § 182-503-0005, filed 7/13/17, effective 8/13/17. Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-052, § 182-503-0005, filed 7/29/14, effective 8/29/14.]
PDF182-503-0010
Washington apple health—Who may apply.
(1) You may apply for Washington apple health for yourself.
(2) You may apply for apple health for another person if you are:
(a) A legal guardian;
(b) An authorized representative (as described in WAC 182-503-0130);
(c) A parent or caretaker relative of a child age 18 or younger;
(d) A tax filer applying for a tax dependent;
(e) A spouse; or
(f) 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.
(3) 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.
(4) You are automatically enrolled in apple health and do not need to submit an application if you are a:
(a) Supplemental security income (SSI) recipient;
(b) Person deemed to be an SSI recipient under 1619(b) of the SSA;
(c) Newborn as described in WAC 182-505-0210; or
(d) Child in foster care placement as described in WAC 182-505-0211.
(5) You are the primary applicant on an application if you complete and sign the application on behalf of your household.
(6) 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.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-01-117, § 182-503-0010, filed 12/16/19, effective 1/16/20; WSR 17-12-017, § 182-503-0010, filed 5/30/17, effective 6/30/17. Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-052, § 182-503-0010, filed 7/29/14, effective 8/29/14.]
PDF182-503-0040
Washington apple health—Interview requirements.
(1) 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.
(2) 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.
(3) A phone or in-person interview is required to determine initial financial eligibility for WAH long-term care services.
(4) The interview requirement described in subsection (3) of this section may be waived if the applicant is unable to comply:
(a) Due to his or her medical condition; or
(b) Because the applicant does not have a family member or another individual that is able to conduct the interview on his or her behalf.
[Statutory Authority: RCW 41.05.021, Patient Protection and Affordable Care Act (Public Law 111-148), 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 13-14-019, § 182-503-0040, filed 6/24/13, effective 7/25/13.]
PDF182-503-0050
Verification of eligibility factors.
(1) General rules.
(a) We may verify the information we use to determine, redetermine, or terminate your apple health eligibility.
(b) We verify the eligibility factors listed in WAC 182-503-0505(3).
(c) Before we ask you to provide records to verify an eligibility factor, we use information available from state databases, including data from the department of social and health services and the department of employment security, federal databases, or commercially available databases to verify the eligibility factor.
(d) We may require information from third parties, such as employers, landlords, and insurance companies, to verify an eligibility factor if the information we received:
(i) Cannot be verified through available data sources;
(ii) Did not verify an eligibility factor; or
(iii) Is contradictory, confusing, or outdated.
(e) We do not require you to submit a record unless it is necessary to determine or redetermine your eligibility.
(f) If you can obtain verification within three business days and we determine the verification is sufficient to confirm an eligibility factor, we base our initial eligibility decision upon that record.
(g) If we are unable to verify eligibility as described in (f) of this subsection, then we may consider third-party sources.
(h) If a fee is required to obtain a necessary record, we pay the fee directly to the holder of the record.
(i) We do not deny or delay your application if you failed to provide information to verify an eligibility factor in a particular type or form.
(j) Except for eligibility factors listed in WAC 182-503-0505 (3)(c) and (d), we accept alternative forms of verification. If you give us a reasonable explanation that confirms your eligibility, we may not require additional documentation.
(k) Once we verify an eligibility factor that will not change, we may not require additional verification. Examples include:
(i) U.S. citizenship;
(ii) Family relationships by birth;
(iii) Social Security numbers; and
(iv) Dates of birth, death, marriage, dissolution of marriage, or legal separation.
(l) If we cannot verify your immigration status and you are otherwise eligible for Washington apple health, we approve coverage and give additional time as needed to verify your immigration status.
(2) Submission timelines.
(a) We allow at least 10 calendar days for you to submit requested information.
(b) If you request more time to provide information, we allow the time requested.
(c) If the 10th day falls on a weekend or a legal holiday as described in RCW 1.16.050, the due date is the next business day.
(d) We do not deny or terminate your eligibility when we give you more time to provide information.
(e) If we do not receive your information by the due date, we make a determination based on all the information available.
(3) Notice requirements.
(a) When we need more information from you to determine your eligibility for apple health coverage, we send all notices according to the requirements of WAC 182-518-0015.
(b) If we cannot determine you are eligible, we send you a denial or termination notice including information on when we reconsider a denied application under WAC 182-503-0080.
(4) Equal access and limited-English proficiency services. If you are eligible for equal access services under WAC 182-503-0120 or limited-English proficiency services under WAC 182-503-0110, we provide legally sufficient support services.
(5) Eligibility factors for nonmodified adjusted gross income (MAGI)-based programs. If you apply for a non-MAGI program under WAC 182-503-0510(3), we verify the factors in WAC 182-503-0505(3). In addition, we verify:
(a) Household composition, if spousal or dependent deeming under chapter 182-512 WAC or spousal or dependent allowance under chapters 182-513 and 182-515 WAC applies;
(b) Income and income deductions;
(c) Resources, including:
(i) Trusts, annuities, life estates, and promissory notes under chapter 182-516 WAC;
(ii) Real property transactions; and
(iii) Financial records, as defined in WAC 182-503-0055, held by financial institutions.
(d) Medical expenses required to meet any spenddown liability under WAC 182-519-0110;
(e) All post-eligibility deductions used to determine cost of care for clients eligible for long-term services and supports under chapters 182-513 and 182-515 WAC;
(f) Transfers of assets under chapter 182-513 WAC and WAC 182-503-0055 when the program is subject to transfer of assets limitations;
(g) Shelter costs for long-term care cases where spousal and dependent allowances apply;
(h) Blindness or disability, if you claim either; and
(i) Social Security number for a community spouse if needed when you apply for long-term care.
(6) Verification for MAGI-based programs.
(a) After we approve your coverage based on your self-attestation, we may conduct a post-eligibility review to verify your self-attested information.
(b) When conducting a post-eligibility review, we attempt to verify eligibility factors using your self-attested information available to us through state, federal, and commercially available data sources, or other third parties, before requiring you to provide information.
(c) You may be required to provide additional information if:
(i) We cannot verify an eligibility factor through other data sources listed in subsection (b) of this section; or
(ii) The information received from the data source is not reasonably compatible with your self-attestation.
(7) Reapplication following post-eligibility review. If your eligibility for MAGI-based apple health terminates because of a post-eligibility review and you reapply, we may request verification of eligibility factors prior to determining eligibility.
[Statutory Authority: RCW 41.05.021, 41.05.160, and 42 U.S.C. Sec. 1396w. WSR 19-21-007, § 182-503-0050, filed 10/3/19, effective 11/3/19. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-06-007, § 182-503-0050, filed 2/17/17, effective 3/20/17. Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (Public Law 111-148), 42 C.F.R. §§ 431, 435, 457 and 45 C.F.R. § 155. WSR 14-07-059, § 182-503-0050, filed 3/14/14, effective 4/14/14.]
PDF182-503-0055
Asset verification system.
(1) This rule implements the asset verification system (AVS) outlined in section 1940 of the Social Security Act.
(2) This rule applies to any client, or those financially responsible for them, who is subject to:
(a) The disclosure of resources, as defined in WAC 182-512-0200, to determine eligibility; or
(b) Provisions related to the transfer of assets, as described in WAC 182-513-1363.
(3) For the purposes of this section:
(a) "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:
(i) Banks; or
(ii) Credit unions.
(b) "Financial record" means any record held by a financial institution pertaining to a customer's relationship with the financial institution; and
(c) "Financial responsibility" is described in WAC 182-506-0015.
(4) You and any other financially responsible people must provide authorization for us to obtain any financial record held by a financial institution.
(a) 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.
(b) For a financially responsible spouse, authorization may be provided by the spouse, their legal guardian, or their attorney-in-fact.
(c) 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.
(5) The authorization, provided under subsection (4) of this section, will remain in effect until one of the following occurs:
(a) Your application for apple health is denied;
(b) Your eligibility for apple health is terminated; or
(c) You revoke your authorization in a written notification to us.
(6) We will:
(a) 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
(b) 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.
PDF182-503-0060
Washington apple health—Application processing times.
(1) We process applications for Washington apple health (medicaid) within 45 calendar days, with the following exceptions:
(a) If you are pregnant, we process your application within fifteen calendar days;
(b) If you are applying for a program that requires a disability decision, we process your application within 60 calendar days; or
(c) 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.
(2) 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).
(3) 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.
(4) If we need more information to decide if you can get apple health coverage, we will send you a letter within 20 calendar days of your initial application that:
(a) Follows the rules in chapter 182-518 WAC;
(b) States the additional information we need; and
(c) Allows at least 10 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.
(5) Good cause for a delay in processing the application exists when we acted as promptly as possible but:
(a) The delay was the result of an emergency beyond our control;
(b) The delay was the result of needing more information or documents that could not be readily obtained;
(c) You did not give us the information within the time frame specified in subsection (1) of this section.
(6) Good cause for a delay in processing the application does NOT exist when:
(a) We caused the delay in processing by:
(i) Failing to ask you for information timely; or
(ii) Failing to act promptly on requested information when you provided it timely; or
(b) We did not document the good cause reason before missing a time frame specified in subsection (1) of this section.
PDF182-503-0070
Washington apple health (WAH)—When coverage begins.
(1) 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.
(2) Sometimes we can start your coverage up to three months before the month you applied (see WAC 182-504-0005).
(3) 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:
(a) You are hospitalized during your confinement; and
(b) The hospital requires you to stay overnight.
(4) Your WAH coverage may not begin on the first day of the month if:
(a) Subsection (3) of this section applies to you. In that case, your coverage would start on the first day of your hospital stay;
(b) 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
(c) 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.
(5) For long-term care, the date your services start is described in WAC 388-106-0045.
PDF182-503-0080
Washington apple health—Application denials and withdrawals.
(1) We follow the rules about notices and letters in chapter 182-518 WAC. We follow the rules about timelines in WAC 182-503-0060.
(2) We deny your application for apple health coverage when:
(a) You tell us either orally or in writing to withdraw your request for coverage; or
(b) 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:
(i) We are unable to determine that you are eligible; or
(ii) We determine that you are not eligible.
(c) You are subject to asset verification and do not provide authorization as described in WAC 182-503-0055.
(3) We send you a written notice explaining why we denied your application (per chapter 182-518 WAC).
(4) We reconsider our decision to deny your apple health coverage without a new application from you when:
(a) We receive the information that we need to decide if you are eligible within 30 days of the date on the denial notice;
(b) You give us authorization to verify your assets as described in WAC 182-503-0055 within 30 days of the date on the denial notice;
(c) 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).
(5) 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.
[Statutory Authority: RCW 41.05.021, 41.05.160, and 42 U.S.C. Sec. 1396w. WSR 19-21-007, § 182-503-0080, filed 10/3/19, effective 11/3/19. Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-052, § 182-503-0080, filed 7/29/14, effective 8/29/14.]
PDF182-503-0090
Washington apple health—Exceptions to rule.
(1) A client or client's representative may request an exception to a Washington apple health financial eligibility rule in Title 182 WAC. The request for an exception to rule (ETR) may be submitted orally or in writing. The request must:
(a) Be received within ninety calendar days of the agency action with which the client disagrees or wants waived;
(b) Identify the rule for which an exception is being requested;
(c) State what the client is requesting; and
(d) Describe how the request meets subsection (2) of this section.
(2) The agency director or designee has the discretion to grant an ETR if they determine that the client's circumstances satisfy the conditions below:
(a) The exception would not contradict a specific provision of federal or state law; and
(b) The client's situation differs from the majority; and
(c) It is in the interest of the overall economy and the client's welfare, and:
(i) It increases opportunity for the client to function effectively; or
(ii) The client has an impairment or limitation that significantly interferes with the usual procedures required to determine eligibility and payment.
(3) A client does not have a right to an administrative hearing on ETR decisions under chapter 182-526 WAC.
(4) A client is mailed a decision in writing within ten calendar days when agency staff:
(a) Approve or deny an ETR request; or
(b) Request more information.
(5) If the ETR is approved, the notice includes information on what is approved and for what time frame.
(6) The agency designates staff at the aging and long-term support administration (ALTSA) and the developmental disabilities administration (DDA) to process all ETRs specifically relating to long-term services and supports programs described in Title 182 WAC.
(7) This section does not apply to requests that the agency pay for noncovered medical or dental services or related equipment. WAC 182-501-0160 applies to such requests.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 21-04-076, § 182-503-0090, filed 1/29/21, effective 3/1/21. Statutory Authority: RCW 41.05.021, Patient Protection and Affordable Care Act (Public Law 111-148), 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 13-14-019, § 182-503-0090, filed 6/24/13, effective 7/25/13.]
PDF182-503-0100
Washington apple health—Rights and responsibilities.
For the purposes of this chapter, "we" refers to the agency or its designee and "you" refers to the applicant for, or recipient of, health care coverage.
(1) If you are applying for or receiving health care coverage, you have the right to:
(a) Have your rights and responsibilities explained to you and given in writing;
(b) Be treated politely and fairly without regard to your race, color, political beliefs, national origin, religion, age, gender (including gender identity and sex stereotyping), sexual orientation, disability, honorably discharged veteran or military status, or birthplace;
(c) Ask for health care coverage using any method listed under WAC 182-503-0010 (if you ask us for a receipt or confirmation, we will provide one to you);
(d) Get help completing your application if you ask for it;
(e) Have an application processed promptly and no later than the timelines described in WAC 182-503-0060;
(f) Have at least 10 calendar days to give the agency or its designee information needed to determine eligibility and be given more time if asked for;
(g) Have personal information kept confidential; we may share information with other state and federal agencies for purposes of eligibility and enrollment in Washington apple health;
(h) Get written notice, in most cases, at least 10 calendar days before the agency or its designee denies, terminates, or changes coverage;
(i) Ask for an appeal if you disagree with a decision we make. You can also ask a supervisor or administrator to review our decision or action without affecting your right to a fair hearing;
(j) Ask for and get interpreter or translator services at no cost and without delay;
(k) Ask for voter registration assistance;
(l) Refuse to speak to an investigator if we audit your case. You do not have to let an investigator into your home. You may ask the investigator to come back at another time. Such a request will not affect your eligibility for health care coverage;
(m) Get equal access services under WAC 182-503-0120 if you are eligible;
(n) Ask for support enforcement services through the division of child support; and
(o) Refuse to cooperate with us in identifying, using, or collecting third-party benefits (such as medical support) if you fear, and can verify, that your cooperating with us could result in serious physical or emotional harm to you, your children, or a child in your care. Verification may include one of the following:
(i) A statement you sign, outlining your fears and concerns;
(ii) Civil or criminal court orders (such as domestic violence protection orders, restraining orders, and no-contact orders);
(iii) Medical, police, or court reports; or
(iv) Written statement from clergy, friends, relatives, neighbors, or co-workers.
(2) You are responsible to:
(a) Report changes in your household or family circumstances as required under WAC 182-504-0105 and 182-504-0110;
(b) Give us any information or proof needed to determine eligibility. If you have trouble getting proof, we help you get the proof or contact other persons or agencies for it;
(c) Assign the right to medical support as described in WAC 182-505-0540, unless you can submit verification (which may include one of the items listed in subsection (1)(o) of this section) that your cooperating with us could result in serious physical or emotional harm to you, your children, or a child in your care;
(d) Complete renewals when asked;
(e) Apply for and make a reasonable effort to get potential income from other sources when available;
(f) Give medical providers information needed to bill us for health care services; and
(g) Cooperate with quality assurance or post enrollment review staff when asked.
[Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (P.L. 111-148), 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-06-068, § 182-503-0100, filed 2/28/14, effective 3/31/14.]
PDF182-503-0110
Washington apple health—Limited-English proficient (LEP) services.
(1) We provide interpreter and translation services (limited-English proficient or LEP services) free of charge to you if you have limited ability to read, write, and/or speak English. Interpreter services are those used for oral communication between two parties who do not speak the same language. Translation services are those used for written communication.
(2) We provide LEP services in your primary language.
(a) A primary language is the language you tell us that you wish to use when communicating with us. You may designate at least one primary language for oral communications and at least one primary language for written communications, and you may designate a different primary language for oral and for written communications.
(b) We note your primary languages in a record available to the agency, its designee, and health benefit exchange employees.
(3) We can provide LEP services through bilingual workers and/or contracted interpreters and translators who are expected to be competent. We consider a bilingual worker or a contracted interpreter or translator to be competent if he or she is:
(a) Certified for interpreting and/or translating in the language by the language testing and certification program of the department of social and health services;
(b) Certified or otherwise determined to be competent for interpreting and/or translating in the language by an association or organization with a regional or national reputation for certifying or determining the competence of interpreters and/or translators; or
(c) Determined competent for interpreting and/or translating in the language by us, taking into account his or her:
(i) Demonstrated proficiency in both English and the other language;
(ii) Orientation and training that includes the skills and ethics of interpreting;
(iii) Fundamental knowledge in both languages of any specialized terms or concepts peculiar to Washington apple health;
(iv) Sensitivity to cultural differences; and
(v) Demonstrated ability to convey information accurately in both languages.
(4) We provide notice of the availability of LEP services on printed applications and notices, in the Washington healthplanfinder website, and during contact with persons who appear to need LEP services.
(5) LEP services include:
(a) Spoken language interpreter (oral) services in person, over the telephone, or through other simultaneous audio or visual transmission (if available); and
(b) Translation of our forms, letters, and other text-based materials, whether printed in hard-copy or stored and presented by computer. These include, but are not limited to:
(i) Our pamphlets, brochures, and other informational material that describe our services and your health care rights and responsibilities;
(ii) Our applications and other forms you need to complete and/or sign; and
(iii) Notices of our actions affecting your eligibility for health care coverage.
(c) Direct provision of services by our bilingual employees.
(6) We provide interpreter services and translated documents in a prompt manner that allows the timely processing of your eligibility for health care coverage within time frames defined in WAC 182-503-0060, 182-503-0035, and 182-504-0125.
(7) If you believe that we have discriminated against you on the basis of race, color, national origin, birthplace, or another protected status, you may file a complaint with the U.S. Department of Health and Human Services at http://www.hhs.gov/ocr/civilrights/complaints or Regional Manager, Office of Civil Rights, U.S. Department of Health and Human Services, 2201 Sixth Ave. - M/S: RX-11, Seattle, WA 98121-1831 (voice phone 800-368-1019, fax 206-615-2297, TDD 800-537-7697).
[Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (P.L. 111-148), 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-06-068, § 182-503-0110, filed 2/28/14, effective 3/31/14.]
PDF182-503-0120
Washington apple health—Equal access services.
(1) When you have a mental, neurological, cognitive, physical or sensory impairment, or limitation that prevents you from receiving health care coverage, we provide services to help you apply for, maintain, and understand the health care coverage options available and eligibility decisions we make. These services are called equal access (EA) services.
(2) We provide EA services on an ongoing basis to ensure that you are able to maintain health care coverage and access to services we provide. EA services include, but are not limited to:
(a) Helping you to:
(i) Apply for or renew coverage;
(ii) Complete and submit forms;
(iii) Give us information to determine or continue your eligibility;
(iv) Ask for continued coverage;
(v) Ask for reinstated (restarted) coverage after your coverage ends; and
(vi) Ask for and participate in a hearing.
(b) Giving you additional time, when needed, for you to give us information before we reduce or end your health care coverage;
(c) Explaining our decision to change, reduce, end, or deny your health care coverage;
(d) Working with your authorized representative, if you have one, and giving that person copies of notices and letters we send you; and
(e) Providing you the services of a sign language interpreter/transliterator who is certified by the Registry of Interpreters for the Deaf at the appropriate level of certification.
(i) These services may include in-person sign language interpreter services, relay interpreter services, and video interpreter services, as well as other services; we decide which services to offer you based on your communication needs and preferences.
(ii) We offer these services as a reasonable accommodation, free of charge, if you are deaf, hard-of-hearing, or a deaf-blind person who uses sign language to communicate.
(f) Not taking adverse action in your case, or automatically reinstating your coverage for up to three months after the adverse action was taken, if we determine that your impairment or limitation was the cause of your failure to follow through on something you need to do to get or keep your Washington apple health coverage, such as:
(i) Applying for or renewing coverage;
(ii) Completing and submitting forms;
(iii) Giving us information to determine or continue your eligibility;
(iv) Asking for continued or reinstated coverage; or
(v) Asking for and participating in a hearing.
(3) We inform you of your right to EA services listed in subsection (2) of this section:
(a) On printed applications and notices, including the printed rights and responsibilities form;
(b) In the Washington healthplanfinder website, including the electronic rights and responsibilities form; and
(c) During contact with us.
(4) We provide you the EA services listed in subsection (2) of this section if you ask for EA services, you are receiving services through the aging and long-term support administration, or we determine that you would benefit from EA services. We determine you would benefit from EA services if you:
(a) Appear to have or claim to have any impairment or limitation described in subsection (1) of this section;
(b) Have a developmental disability;
(c) Are disabled by alcohol or drug addiction;
(d) Are unable to read or write in any language;
(e) Appear to have limitations in your ability to communicate, understand, remember, process information, exercise judgment and make decisions, perform routine tasks, or relate appropriately with others (whether or not you have a disability) that may prevent you from understanding the nature of EA services or affect your ability to access our programs; or
(f) Are a minor not residing with your parents.
(5) If we determine that you are eligible for EA services, we develop and document an EA plan appropriate to your needs. The plan may be updated or changed at any time based on your request or a change in your needs.
(6) You may at any time refuse the EA services offered to you.
(7) We reinstate your coverage when:
(a) We end coverage because we were unable to determine if you continue to qualify; and
(b) You provide proof that you are still qualified for coverage within twenty calendar days from when we ended your coverage. We restore your coverage retroactive to the first of the month so there is no break in your coverage.
(8) If you believe that we have discriminated against you on the basis of a disability or another protected status, the person may file a complaint with the U.S. Department of Health and Human Services at http://www.hhs.gov/ocr/civilrights/complaints or Region Manager, Office for Civil Rights, U.S. Department of Health and Human Services, 2201 Sixth Ave. - M/S: RX-11, Seattle, WA 98121-1831 (voice phone 800-368-1019, fax 206-615-2297, TDD 800-537-7697).
[Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (P.L. 111-148), 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-06-068, § 182-503-0120, filed 2/28/14, effective 3/31/14.]
PDF182-503-0130
Authorized representative.
(1) Designating an authorized representative (AREP).
(a) 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.
(b) A court-appointed legal guardian with authority to make financial decisions on a person's behalf is that person's AREP.
(c) 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.
(d) 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).
(2) Serving as an AREP. To serve as an AREP, an individual or organization must:
(a) Have a good-faith belief that the information he or she provides to the agency is correct.
(b) 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.
(c) A provider, staff member, or volunteer of an organization must also comply with 42 C.F.R. 435.923(d-e).
(3) Terminating authorized representation.
(a) The person or the AREP may terminate the authorized representation at any time for any reason by notifying the agency verbally or in writing.
(b) Authorized representation terminates automatically when the person dies.
PDF182-503-0505
Washington apple health—General eligibility requirements.
(1) When you apply for Washington apple health programs established under chapter 74.09 RCW, you must meet the eligibility criteria in chapters 182-500 through 182-527 WAC.
(2) 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.
(3) Unless otherwise specified in a program specific WAC, the eligibility criteria for each program are as follows:
(a) Age (WAC 182-503-0050);
(b) Residence in Washington state (WAC 182-503-0520 and 182-503-0525);
(c) Citizenship or immigration status in the United States (WAC 182-503-0535);
(d) Possession of a valid Social Security account number (WAC 182-503-0515);
(e) Assignment of medical support rights to the state of Washington (WAC 182-503-0540);
(f) Application for medicare and enrollment into medicare's prescription drug program if:
(i) You are likely entitled to medicare; and
(ii) We have authority to pay medicare cost sharing as described in chapter 182-517 WAC.
(g) If your eligibility is not based on modified adjusted gross income (MAGI) methodology, your countable resources must be within specific program limits (chapters 182-512, 182-513, 182-515, 182-517, and 182-519 WAC); and
(h) Countable income within program limits:
(i) For MAGI-based programs, see WAC 182-505-0100;
(ii) For the refugee program, see WAC 182-507-0130;
(iii) For the medical care services program, see WAC 182-508-0005;
(iv) For the health care for workers with disabilities (HWD) program, see WAC 182-511-1000;
(v) For the SSI-related program, see WAC 182-512-0010;
(vii) For medicare savings programs, see WAC 182-517-0100; and
(viii) For the medically needy program, see WAC 182-519-0050.
(4) In addition to the general eligibility requirements in subsection (3) of this section, each program has specific eligibility requirements as described in applicable WAC.
(5) 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:
(a) If you are age 21 or younger or age 65 or older and are a patient in an institution for mental disease (see WAC 182-513-1317(5)); or
(b) You receive inpatient hospital services outside of the public institution or correctional facility.
(6) We limit coverage for people who become residents in a public institution, under subsection (5) of this section, until they are released.
(7) 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.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 19-08-029, § 182-503-0505, filed 3/27/19, effective 4/27/19; WSR 17-12-017, § 182-503-0505, filed 5/30/17, effective 6/30/17. Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-052, § 182-503-0505, filed 7/29/14, effective 8/29/14. WSR 12-13-056, recodified as § 182-503-0505, filed 6/15/12, effective 7/1/12. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and 74.09.530, 42 U.S.C., Section 1396a. WSR 07-21-005, § 388-503-0505, filed 10/4/07, effective 11/4/07. Statutory Authority: RCW 74.08.090, 74.09.530, and 2003 1st sp.s. c 25. WSR 04-07-141, § 388-503-0505, filed 3/22/04, effective 4/22/04. Statutory Authority: RCW 74.08.090, 74.08A.100, 74.09.080, and 74.09.415. WSR 02-17-030, § 388-503-0505, filed 8/12/02, effective 9/12/02. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. WSR 98-16-044, § 388-503-0505, filed 7/31/98, effective 9/1/98. Formerly WAC 388-501-0110, 388-503-0305 and 388-505-0501.]
PDF182-503-0510
Washington apple health—Program summary.
(1) The agency categorizes Washington apple health programs into three groups based on the income methodology used to determine eligibility:
(a) Those that use a modified adjusted gross income (MAGI)-based methodology described in WAC 182-509-0300, called MAGI-based apple health programs;
(b) Those that use an income methodology other than MAGI, called non-MAGI-based apple health programs, which include:
(i) Supplemental security income (SSI)-related apple health programs;
(ii) Temporary assistance for needy families (TANF)-related apple health programs; and
(iii) Other apple health programs not based on MAGI, SSI, or TANF methodologies.
(c) Those that provide coverage based on a specific status or entitlement in federal rule and not on countable income, called deemed eligible apple health programs.
(2) MAGI-based apple health programs include the following:
(a) Apple health parent and caretaker relative program described in WAC 182-505-0240;
(b) MAGI-based apple health adult medical program described in WAC 182-505-0250, for which the scope of coverage is called the alternative benefits plan (ABP) described in WAC 182-500-0010;
(c) Apple health for pregnant women program described in WAC 182-505-0115;
(d) Apple health for kids program described in WAC 182-505-0210 (3)(a);
(e) Premium-based apple health for kids described in WAC 182-505-0215;
(f) Apple health long-term care for children and adults described in chapter 182-514 WAC; and
(g) Apple health alien emergency medical program described in WAC 182-507-0110 through 182-507-0125 when the person is eligible based on criteria for a MAGI-based apple health program.
(3) Non-MAGI-based apple health programs include the following:
(a) SSI-related programs which use the income methodologies of the SSI program (except where the agency has adopted more liberal rules than SSI) described in chapter 182-512 WAC to determine eligibility:
(i) Apple health for workers with disabilities (HWD) described in chapter 182-511 WAC;
(iii) Apple health long-term care and hospice programs described in chapters 182-513 and 182-515 WAC;
(iv) Apple health medicare savings programs described in chapter 182-517 WAC; and
(v) Apple health alien emergency medical (AEM) programs described in WAC 182-507-0110 and 182-507-0125 when the person meets the age, blindness or disability criteria specified in WAC 182-512-0050.
(b) TANF-related programs which use the income methodologies based on the TANF cash program described in WAC 388-450-0170 to determine eligibility, with variations as specified in WAC 182-509-0001(5) and program specific rules:
(i) Refugee medical assistance (RMA) program described in WAC 182-507-0130; and
(ii) Apple health medically needy (MN) coverage for pregnant women and children who do not meet SSI-related criteria.
(c) Other programs:
(i) Breast and cervical cancer program described in WAC 182-505-0120;
(ii) Family planning only programs described in chapter 182-532 WAC;
(iii) Medical care services described in WAC 182-508-0005;
(iv) Apple health for pregnant minors described in WAC 182-505-0117;
(v) Kidney disease program described in chapter 182-540 WAC; and
(vi) Tailored supports for older adults described in WAC 182-513-1610.
(4) Deemed eligible apple health programs include:
(a) Apple health SSI medical program described in chapter 182-510 WAC, or a person who meets the medicaid eligibility criteria in 1619b of the Social Security Act;
(b) Newborn medical program described in WAC 182-505-0210(2);
(c) Foster care program described in WAC 182-505-0211;
(d) Medical extension program described in WAC 182-523-0100; and
(e) Family planning extension described in WAC 182-505-0115(5).
(5) A person is eligible for categorically needy (CN) health care coverage when the household's countable income is at or below the categorically needy income level (CNIL) for the specific program.
(6) If income is above the CNIL, a person is eligible for the MN program if the person is:
(a) A child;
(b) A pregnant woman; or
(c) SSI-related (aged 65, blind or disabled).
(7) MN health care coverage is not available to parents, caretaker relatives, or adults unless they are eligible under subsection (6) of this section.
(8) A person who is eligible for the apple health MAGI-based adult program listed in subsection (2)(b) of this section is eligible for ABP health care coverage as defined in WAC 182-500-0010. Such a person may apply for more comprehensive coverage through another apple health program at any time.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-11-007, § 182-503-0510, filed 5/4/23, effective 6/4/23. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 1st sp.s. c 36 § 213 (1)(e), section 1115 of the Social Security Act, and 42 C.F.R. §§ 431.400 through 431.428. WSR 17-12-019, § 182-503-0510, filed 5/30/17, effective 7/1/17. Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (P.L. 111-148), 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-06-068, § 182-503-0510, filed 2/28/14, effective 3/31/14. WSR 12-13-056, recodified as § 182-503-0510, filed 6/15/12, effective 7/1/12. WSR 12-02-034, recodified as § 182-505-0510, filed 12/29/11, effective 1/1/12. Statutory Authority: RCW 34.05.353 (2)(d), 74.08.090, and chapters 74.09, 74.04 RCW. WSR 08-11-047, § 388-503-0510, filed 5/15/08, effective 6/15/08. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and 74.09.530. WSR 05-07-097, § 388-503-0510, filed 3/17/05, effective 4/17/05. Statutory Authority: RCW 74.08.090, 74.08A.100, 74.09.080, and 74.09.415. WSR 02-17-030, § 388-503-0510, filed 8/12/02, effective 9/12/02. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. WSR 98-16-044, § 388-503-0510, filed 7/31/98, effective 9/1/98.]
PDF182-503-0515
Washington apple health—Social Security number requirements.
(1) To be eligible for Washington apple health (medicaid), or tailored supports for older adults (TSOA) described in WAC 182-513-1610, you (the applicant or recipient) must provide your valid Social Security number (SSN) or proof of application for an SSN to the medicaid agency or the agency's designee, except as provided in subsections (2) and (6) of this section.
(2) An SSN is not required if you are:
(a) Not eligible to receive an SSN or may only be issued an SSN for a valid nonwork reason described in 20 C.F.R. 422.104;
(b) A household member who is not applying for apple health coverage, unless verification of that household member's resources is required to determine the eligibility of the client;
(c) Refusing to obtain an SSN for well-established religious objections as defined in 42 C.F.R. 435.910 (h)(3); or
(d) Not able to obtain or provide an SSN because you are a victim of domestic violence.
(3) If you are receiving coverage because you meet an exception under either subsection (2)(c) or (d) of this section, we (the agency) will confirm with you at your apple health renewal, consistent with WAC 182-503-0050, that you still meet the exception.
(4) If we ask for confirmation that you continue to meet an exception in subsection (2) of this section and you do not respond in accordance with subsection (3) of this section, or if you no longer meet an exception and do not provide your SSN, we will terminate your apple health coverage according to WAC 182-518-0025.
(5) If you are not able to provide your SSN, either because you do not know it or it has not been issued, you must provide:
(a) Proof from the Social Security Administration (SSA) that you turned in an application for an SSN; and
(b) The SSN when you receive it.
(i) Your apple health coverage will not be delayed, denied, or terminated while waiting for SSA to send you your SSN. If you need help applying for an SSN, assistance will be provided to you.
(ii) We will ask you every 90 days if your SSN has been issued.
(6) An SSN is not required for the following apple health programs:
(a) Refugee medical assistance program described in WAC 182-507-0130;
(c) Newborn medical program described in WAC 182-505-0210 (2)(a);
(d) Foster care program for a child age 18 and younger as described in WAC 182-505-0211(1);
(e) Medical programs for children and pregnant women who do not meet citizenship or immigration status described in WAC 182-503-0535 (2)(e)(ii) and (iii); or
(f) Family planning only program described in WAC 182-532-510 if you do not meet citizenship or immigration status for Washington apple health or you have made an informed choice to apply for family planning services only.
(7) If you are required to provide an SSN under this section, and you do not meet an exception under subsection (2) of this section, failure to provide your SSN may result in:
(a) Denial of your application or termination of your coverage because we cannot determine your household's eligibility; or
(b) Inability to apply the community spouse resource allocation (CSRA) or monthly maintenance needs allowance (MMNA) for a client of long-term services and supports (LTSS).
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 21-19-142, § 182-503-0515, filed 9/22/21, effective 10/23/21; WSR 18-10-014, § 182-503-0515, filed 4/23/18, effective 5/24/18. Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-052, § 182-503-0515, filed 7/29/14, effective 8/29/14.]
PDF182-503-0520
Washington apple health—Residency requirements—Persons who are not residing in an institution.
(1) A resident is a person (including an emancipated person under age 18 and a married person under age 18 who is capable of indicating intent) who currently lives in Washington and:
(a) Intends to reside here, including persons without a fixed address; or
(b) Entered the state looking for a job; or
(c) Entered the state with a job commitment.
(2) A person does not need to live in the state for a specific period of time prior to meeting the requirements in subsection (1) of this section before being considered a resident.
(3) A child under age eighteen who is not covered by subsection (1) of this section, is a resident if:
(a) The child lives in the state, with or without a fixed address, including with a custodial parent or caretaker; or
(b) The child's parent or caretaker is a resident as defined in subsection (1) of this section.
(4) A resident applying for or receiving health care coverage can temporarily be out of the state for more than one month without their health care coverage being denied or terminated, if the person:
(a) Intends to return to the state once the purpose of his or her absence has been accomplished and provides adequate information of this intent after a request by the agency or its designee; and
(b) Has not been determined eligible for medicaid or state-funded health care coverage in another state (other than coverage in another state for incidental or emergency health care).
(5) A person who enters Washington state only for health care is not a resident and is not eligible for any medical program. The only exception is for a person who moves from another state directly into an institution in Washington state. Residency rules for institutionalized persons are described in WAC 182-503-0525.
(6) A person of any age who receives a state supplemental payment (SSP) is considered a resident of the state that is making the payment.
(7) A person who receives federal payments for foster or adoption assistance is considered a resident of the state where the person physically resides even if:
(a) The person does not live in the state that is making the foster or adoption assistance payment; or
(b) The person does not live in the state where the adoption agreement was entered.
(8) In a dispute between states, the state of residence is the state in which the person is physically located.
[Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-052, § 182-503-0520, filed 7/29/14, effective 8/29/14. Statutory Authority: RCW 41.05.021, 74.09.035, and 2011 1st sp.s. c 36. WSR 12-19-051, § 182-503-0520, filed 9/13/12, effective 10/14/12.]
PDF182-503-0525
Washington apple health—Residency requirements for an institutionalized person.
(1) An institutionalized person is a person who resides in an institution as defined in WAC 182-500-0050. The term "person" used in this section means an "institutionalized person" unless otherwise indicated. It does not include persons who receive services under a home and community-based waiver program. When a state is making a placement for a person in another state, the term institution also includes foster care homes, licensed as described in 45 C.F.R. 1355.20.
(2) The agency must determine whether a person is capable of indicating their intent to reside in Washington state when deciding whether that person is a resident of the state. The agency determines that persons who meet the following criteria are deemed incapable of indicating intent to reside in the state:
(a) The person is judged legally incompetent by a court of law;
(b) A physician, psychologist or licensed medical professional in the field of intellectual disabilities has determined that the person is incapable of indicating intent; or
(c) The person is incapable of declaring intent due to a documented medical condition.
(3) When a person is placed in an out-of-state institution by the agency, its designee or by a department of social and health services-contracted agency, the state arranging the placement is considered the person's state of residence, unless the person is capable of expressing intent and:
(a) Indicates a desire to change his or her state of residence; or
(b) Asks the current state of residence for help in relocating. This may include assistance in locating an institutional placement in the new state of residence.
(4) If another state has not authorized the placement in the institution, as described in subsection (3) of this section, the agency or its designee uses one of the following criteria to determine the state of residence for a person who is age 20 or younger:
(a) The state of residence is the state where the parent or legal guardian is a resident at the time of the placement in the institution. To determine a parent's or legal guardian's place of residence, follow rules described in WAC 182-503-0520 for a noninstitutionalized person.
(b) The state of residence is the state where the parent or legal guardian currently is a resident if the person resides in an institution in that state.
(c) If the parents of the person are separated and live in different states, the state of residence is that of the parent filing the application.
(d) If the parental rights are terminated and the person has a legal guardian, the state of residence is where the legal guardian is a resident.
(e) If the person has both a guardian of the estate and a guardian of the person, the state of residence is where the guardian of the person is a resident, unless the state has laws which delegate guardianship to a state official or agency for persons who are admitted to state institutions. In that case, the state of residence for the person is the state where the institution is located (unless another state has authorized the placement).
(f) If the person has been abandoned by the parents or legal guardian, and an application is filed on their behalf by another party, the state of residence is the state where the person is institutionalized. The term abandoned also includes situations where the parents or legal guardian are deceased.
(5) A person age 21 or older that is capable of indicating intent is considered a resident of the state where he or she is living and intends to reside.
(6) A person age 21 or older who became incapable of indicating intent at age 21 or older is considered a resident of the state where the person is physically residing, unless the person has been placed in the institution by another state.
(7) A person age 21 or older who became incapable of indicating intent before the age of 21 is considered a resident of the state where the parents or legal guardian were residents at the time of the placement in the institution.
(8) If a noninstitutionalized person moves directly from another state to an institution in Washington state, it is not necessary for the person to establish residency in Washington state prior to entering the facility. The person is considered a resident if he or she intends to reside in the state unless the placement was made by the other state.
(9) A person of any age who receives a state supplemental payment (SSP) is considered a resident of the state that is making the payment.
(10) In a dispute between states, the state of residence is the state in which the person is physically located.
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Washington apple health—Citizenship and immigration status.
(1) Definitions.
(a) Nonqualified alien means someone who is lawfully present in the United States (U.S.) but who is not a qualified alien, a U.S. citizen, a U.S. national, or a qualifying American Indian born abroad.
(b) Qualified alien means someone who is lawfully present in the United States and who is one or more of the following:
(i) A person lawfully admitted for permanent residence (LPR).
(ii) An abused spouse or child, a parent of an abused child, or a child of an abused spouse who no longer resides with the person who committed the abuse, and who has one of the following:
(A) A pending or approved I-130 petition or application to immigrate as an immediate relative of a U.S. citizen or as the spouse of an unmarried LPR younger than 21 years of age.
(B) Proof of a pending application for suspension of deportation or cancellation of removal under the Violence Against Women Act (VAWA).
(C) A notice of prima facie approval of a pending self-petition under VAWA. An abused spouse's petition covers his or her child if the child is younger than 21 years of age. In that case, the child retains qualified alien status even after he or she turns 21 years of age.
(iii) A person who has been granted parole into the U.S. for one year or more, under the Immigration and Nationality Act (INA) Section 212 (d)(5), including public interest parolees.
(iv) A member of a Hmong or Highland Laotian tribe that rendered military assistance to the U.S. between August 5, 1964, and May 7, 1975, including the spouse, unremarried widow or widower, and unmarried dependent child of the tribal member.
(v) A person who was admitted into the U.S. as a conditional entrant under INA Section 203 (a)(7) before April 1, 1980.
(vi) A person admitted to the U.S. as a refugee under INA Section 207.
(vii) A person who has been granted asylum under INA Section 208.
(viii) A person granted withholding of deportation or removal under INA Section 243(h) or 241 (b)(3).
(ix) A Cuban or Haitian national who was paroled into the U.S. or given other special status.
(x) An Amerasian child of a U.S. citizen under 8 C.F.R. Section 204.4(a).
(xi) A person from Iraq or Afghanistan who has been granted one of the following:
(A) Special immigrant status under INA Section 101 (a)(27);
(B) Special immigrant conditional permanent resident; or
(C) 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.
(xii) An Afghan who, under Section 2502 of the Extending Government Funding and Delivering Emergency Assistance Act of 2021, is evaluated as a qualified alien until March 31, 2023, or the end of their parole term, whichever is later, when granted parole:
(A) Between July 31, 2021, and September 30, 2023; or
(B) After September 30, 2022, and is:
(I) Their spouse or child; or
(II) The parent or guardian of an unaccompanied minor described under this subsection.
(xiii) A citizen or national of Ukraine (or a person who last habitually resided in Ukraine) who, under section 401 of the Additional Ukraine Supplemental Appropriations Act, 2022 (AUSAA), is evaluated as a qualified alien until the end of their parole term when:
(A) Granted parole into the United States between February 24, 2022, and September 30, 2023; or
(B) Granted parole into the United States after September 30, 2023, and is:
(I) The spouse or child of a person described in (b)(xiii)(A) of this subsection; or
(II) The parent, legal guardian, or primary caregiver of a person described in (b)(xiii)(A) 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.
(xiv) A person who has been certified or approved as a victim of trafficking by the federal office of refugee resettlement, or who is:
(A) The spouse or child of a trafficking victim of any age; or
(B) The parent or minor sibling of a trafficking victim who is younger than 21 years of age.
(xv) A person from the Federated States of Micronesia, the Republic of Palau, or the Republic of the Marshall Islands living in the United States in accordance with the Compacts of Free Association.
(c) U.S. citizen means someone who is a United States citizen under federal law.
(d) U.S. national means someone who is a United States national under federal law.
(e) Undocumented person means someone who is not lawfully present in the U.S.
(f) Qualifying American Indian born abroad means someone who:
(i) Was born in Canada and has at least 50 percent American Indian blood, regardless of tribal membership; or
(ii) Was born outside of the United States and is a member of a federally recognized tribe or an Alaska Native enrolled by the Secretary of the Interior under the Alaska Native Claims Settlement Act.
(2) Eligibility.
(a) A U.S. citizen, U.S. national or qualifying American Indian born abroad may be eligible for:
(i) Apple health for adults;
(ii) Apple health for kids;
(iii) Apple health for pregnant women; or
(iv) Classic medicaid.
(b) A qualified alien who meets or is exempt from the five-year bar may be eligible for:
(i) Apple health for adults;
(ii) Apple health for kids;
(iii) Apple health for pregnant women; or
(iv) Classic medicaid.
(c) A qualified alien who neither meets nor is exempt from the five-year bar may be eligible for:
(i) Alien medical programs;
(ii) Apple health for kids;
(iii) Apple health for pregnant women; or
(iv) Medical care services.
(d) A nonqualified alien may be eligible for:
(i) Alien medical programs;
(ii) Apple health for kids;
(iii) Apple health for pregnant women; or
(iv) Medical care services.
(e) An undocumented person may be eligible for:
(i) Alien medical programs;
(ii) State-only funded apple health for kids; or
(iii) State-only funded apple health for pregnant women.
(3) The five-year bar.
(a) A qualified alien meets the five-year bar if he or she:
(i) Continuously resided in the U.S. for five years or more from the date he or she became a qualified alien; or
(ii) Entered the U.S. before August 22, 1996, and:
(A) Became a qualified alien before August 22, 1996; or
(B) Became a qualified alien on or after August 22, 1996, and has continuously resided in the U.S. between the date of entry into the U.S. and the date he or she became a qualified alien.
(b) A qualified alien is exempt from the five-year bar if he or she is:
(i) A qualified alien as defined in subsection (1)(b)(vi) through (xv) of this section;
(ii) An LPR, parolee, or abused person, who is also an armed services member or veteran, or a family member of an armed services member or veteran, as described below:
(A) An active-duty member of the U.S. military, other than active-duty for training;
(B) An honorably discharged U.S. veteran;
(C) A veteran of the military forces of the Philippines who served before July 1, 1946, as described in Title 38 U.S.C. Section 107; or
(D) The spouse, unremarried widow or widower, or unmarried dependent child of an honorably discharged U.S. veteran or active-duty member of the U.S. military.
[Statutory Authority: RCW 41.05.021, 41.05.160, and Section 1501, Consolidated Appropriations Act, 2023; P.L. 117-328, div. M, Title V, § 1501. WSR 23-20-043, § 182-503-0535, filed 9/27/23, effective 10/28/23. Statutory Authority: RCW 41.05.021, 41.05.160, and P.L. 117-128. WSR 22-20-074, § 182-503-0535, filed 9/30/22, effective 10/31/22. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-08-002, § 182-503-0535, filed 3/23/22, effective 4/23/22; WSR 21-19-029, § 182-503-0535, filed 9/9/21, effective 10/10/21; WSR 15-10-002, § 182-503-0535, filed 4/22/15, effective 5/23/15. Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-052, § 182-503-0535, filed 7/29/14, effective 8/29/14.]
PDF182-503-0540
Assignment of rights and cooperation.
(1) When you become eligible for any of the agency's health care programs, you assign certain rights to the state of Washington. You assign all rights to any type of coverage or payment for health care that comes from:
(a) A court order;
(b) An administrative agency order; or
(c) Any third-party benefits or payment obligations for medical care which are the result of subrogation or contract (see WAC 182-501-0100).
(2) When you sign the application you assign the rights described in subsection (1) of this section to the state for:
(a) Yourself; and
(b) Any eligible person for whom you can legally make such assignment.
(3) You must cooperate with us in identifying, using or collecting third-party benefits. If you do not cooperate, your health care coverage may end unless you can show good reason not to cooperate with us. Examples of good reason include, but are not limited to:
(a) Your reasonable belief that cooperating with us would result in serious physical or emotional harm to you, a child in your care, or a child related to you; and
(b) Your being incapacitated without the ability to cooperate with us.
(4) Your WAH coverage will not end due solely to the noncooperation of any third party.
(5) You will have to pay for your health care services if you:
(a) Received and kept the third-party payment for those services; or
(b) Refused to give to the provider of care your legal signature on insurance forms.
(6) The state is limited to the recovery of its own costs for health care costs paid on behalf of a recipient of health care coverage. The legal term which describes the method by which the state acquires the rights of a person for whom the state has paid costs is called subrogation.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 19-02-046, § 182-503-0540, filed 12/27/18, effective 1/27/19. Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-052, § 182-503-0540, filed 7/29/14, effective 8/29/14. WSR 12-13-056, recodified as § 182-503-0540, filed 6/15/12, effective 7/1/12. Statutory Authority: RCW 74.08.090. WSR 01-02-076, § 388-505-0540, filed 12/29/00, effective 1/29/01. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. WSR 98-16-044, § 388-505-0540, filed 7/31/98, effective 9/1/98. Statutory Authority: RCW 74.08.090 and 74.09.522. WSR 97-04-005, § 388-505-0540, filed 1/24/97, effective 2/24/97. Statutory Authority: RCW 74.08.090. WSR 94-10-065 (Order 3732), § 388-505-0540, filed 5/3/94, effective 6/3/94. Formerly WAC 388-83-012, 388-501-0170 and 388-505-0560.]
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Washington apple health—Age requirements for medical programs based on modified adjusted gross income (MAGI).
The following age requirements apply to persons whose eligibility for Washington apple health (WAH) is based on modified adjusted gross income (MAGI) methodology per WAC 182-509-0305.
(1) You must be age 64 or younger to be eligible for WAH MAGI-based adult coverage as described in WAC 182-505-0250.
(2) Your household must include an eligible dependent child age seventeen or younger to be eligible for WAH parent or caretaker relative coverage as described in WAC 182-505-0240. For purposes of this subsection, an "eligible dependent child" is a child related to you in one of the ways described in WAC 182-500-0020.
(3) A child must be age 18 or younger to be eligible for WAH for kids as described in WAC 182-505-0210 with the following exceptions:
(a) An institutionalized child may still qualify under a children's health care program through the age of 21 (see WAC 182-514-0230);
(b) A foster care child may qualify for WAH foster care coverage through the age of 26 (see WAC 182-505-0211).