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Chapter 182-504 WAC

Last Update: 9/25/24

CERTIFICATION PERIODS AND CHANGE OF CIRCUMSTANCE

WAC Sections

HTMLPDF182-504-0005Washington apple health—Retroactive certification period.
HTMLPDF182-504-0015Washington apple health—Certification periods for categorically needy programs.
HTMLPDF182-504-0020Certification periods for the noninstitutional medically needy program.
HTMLPDF182-504-0025Medicare savings program certification periods.
HTMLPDF182-504-0035Washington apple health—Renewals.
HTMLPDF182-504-0105Washington apple health—Changes that must be reported.
HTMLPDF182-504-0110Washington apple health—When to report changes.
HTMLPDF182-504-0120Washington apple health—Effective dates of changes.
HTMLPDF182-504-0125Washington apple health—Effect of reported changes.
HTMLPDF182-504-0130Washington apple health—Continued coverage pending an appeal.
DISPOSITION OF SECTIONS FORMERLY CODIFIED IN THIS TITLE
182-504-0030Medical certification periods for recipients of medical care services (MCS). [Statutory Authority: RCW 41.05.021, 74.09.035, and 2011 1st sp.s. c 36. WSR 12-19-051, § 182-504-0030, 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 Repealed by WSR 14-16-019, filed 7/24/14, effective 8/24/14.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.
182-504-0040Requirements for a midcertification review 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, § 182-504-0040, 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 Repealed by WSR 14-16-019, filed 7/24/14, effective 8/24/14.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.
182-504-0100Changes of circumstances—Changes that must be reported by a recipient of medical care services (MCS). [Statutory Authority: RCW 41.05.021, 74.09.035, and 2011 1st sp.s. c 36. WSR 12-19-051, § 182-504-0100, 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 Repealed by WSR 14-16-019, filed 7/24/14, effective 8/24/14.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.
182-504-0135Washington apple health—Reinstated coverage pending an appeal. [Statutory Authority: RCW 41.05.021, 41.05.160, 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 14-20-094, § 182-504-0135, filed 9/29/14, effective 10/30/14.] Repealed by WSR 16-22-060, filed 10/31/16, effective 12/1/16. Statutory Authority: RCW 41.05.021, 41.05.160.

PDF182-504-0005

Washington apple health—Retroactive certification period.

(1) The medicaid agency approves a retroactive Washington apple health (WAH) certification period for the three months immediately before the month of application when an individual:
(a) Requests retroactive WAH on his or her application, within the certification period following the retroactive period, or before the determination of benefits and any appeal process is final;
(b) Would have been eligible for WAH for any or all of the three months if he or she had applied during the retroactive period; and
(c) The individual received covered medical services as described in WAC 182-501-0060 and 182-501-0065.
(2) When an individual is eligible only during the three-month retroactive certification period, that period is the only period of certification, except when:
(a) A pregnant individual is eligible in one of the three months immediately before the month of application, but no earlier than the month of conception. Eligibility continues as described in WAC 182-504-0015(3).
(b) An individual who is applying within 12 months of their last pregnancy end date is eligible for after-pregnancy coverage in any of the three months immediately before the month of application. Continuous eligibility begins from the earliest month the individual is found eligible as described in WAC 182-504-0015 (3) and (4).
(c) A child is eligible for categorically needy (CN) WAH as described in WAC 182-505-0210 (1) through (5) and (7) in at least one of the three months immediately before the month of application. Eligibility after the retroactive period continues as described in WAC 182-504-0015(11).
(3) An individual applying for the medically needy (MN) spenddown program may be eligible for a retroactive certification period as described in WAC 182-504-0020.
(4) An individual applying for a medicare savings program may be eligible for a retroactive certification period as described in WAC 182-504-0025.
[Statutory Authority: RCW 41.05.021, 41.05.160, and 74.09.830. WSR 22-21-086, § 182-504-0005, filed 10/14/22, effective 11/14/22. 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, § 182-504-0005, filed 6/24/13, effective 7/25/13.]


PDF182-504-0015

Washington apple health—Certification periods for categorically needy programs.

(1) A certification period is the period of time we determine that you are eligible for a categorically needy (CN) Washington apple health program. Unless otherwise stated in this section, the certification period begins on the first day of the month of application and continues through the end of the last month of the certification period.
(2) Newborn coverage begins on the child's date of birth and continues through the end of the month of the child's first birthday.
(3) If you are eligible for apple health based on pregnancy, the certification period continues through the last day of the month the pregnancy ends. After-pregnancy coverage begins the first day of the month, following the end of the pregnancy, and ends the last day of the 12th month from the time after-pregnancy coverage began.
(4) If you are newly eligible for apple health coverage and had a pregnancy end within the last 12 months, your certification period for after-pregnancy coverage:
(a) Begins the first day of the month you are eligible; and
(b) Ends the last day of the 12th month following the end of your pregnancy.
(5) If you are eligible for the refugee program, the certification period ends at the end of the 12th month following your date of entry to the United States.
(6) If you are a child under age six receiving apple health for kids without a premium, your certification period ends the last day of the month of your sixth birthday.
(7) If you are eligible for newborn coverage, your coverage continues through the last day of the month of your first birthday. Apple health for kids coverage begins automatically on the first day of the month after your newborn coverage ends and the certification period ends the last day of the month of your sixth birthday.
(8) For all other CN coverage, the certification period is 12 months.
(9) If you are a child, eligibility is continuous throughout the certification period regardless of a change in circumstances, unless you:
(a) Turn age 19;
(b) Move out-of-state; or
(c) Die.
(10) When you turn 19, the certification period ends after the redetermination process described in WAC 182-504-0125 is completed, even if the 12-month period is not over, unless:
(a) You are receiving inpatient services (described in WAC 182-514-0230) on the last day of the month you turn 19;
(b) The inpatient stay continues into the following month or months; and
(c) You remain eligible except for turning age 19.
(11) A retroactive certification period is described in WAC 182-504-0005.
(12) Coverage under premium-based programs included in apple health for kids as described in chapter 182-505 WAC begins no sooner than the month after creditable coverage ends.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-20-052, s 182-504-0015, filed 9/25/24, effective 10/26/24. Statutory Authority: RCW 41.05.021, 41.05.160, and 2023 c 475 § 211(36). WSR 23-23-057, § 182-504-0015, filed 11/8/23, effective 12/9/23. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-21-072, § 182-504-0015, filed 10/13/22, effective 11/13/22; WSR 22-12-033, § 182-504-0015, filed 5/24/22, effective 6/24/22; WSR 17-12-017, § 182-504-0015, 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, § 182-504-0015, filed 7/29/14, effective 8/29/14. WSR 11-24-018, recodified as § 182-504-0015, filed 11/29/11, effective 12/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, and 74.08.090, and Apple Health for Kids Act (ESHB 2128); 42 U.S.C. 1305; Public Law 111-3 (Children's Health Insurance Program Reauthorization Act of 2009). WSR 11-03-001, § 388-416-0015, filed 1/5/11, effective 2/5/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.402, 74.09.470, and 2008 session law. WSR 09-07-086, § 388-416-0015, filed 3/17/09, effective 4/17/09. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, 74.09.700, and 2007 c 5. WSR 08-05-018, § 388-416-0015, filed 2/12/08, effective 3/14/08. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 06-24-036, § 388-416-0015, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090, 74.09.530, and 74.09.415. WSR 05-19-031, § 388-416-0015, filed 9/12/05, effective 10/13/05. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.04.510, and 2004 c 54. WSR 04-21-064, § 388-416-0015, filed 10/18/04, effective 11/18/04. Statutory Authority: RCW 74.08.090, 74.09.530, and 2003 c 10. WSR 04-03-019, § 388-416-0015, filed 1/12/04, effective 2/12/04. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.08.090 and 74.09.450. WSR 00-08-002, § 388-416-0015, filed 3/22/00, effective 5/1/00. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. WSR 98-16-044, § 388-416-0015, filed 7/31/98, effective 9/1/98. Formerly 388-509-0970, 388-521-2105, 388-522-2210 and 388-522-2230.]


PDF182-504-0020

Certification periods for the noninstitutional medically needy program.

(1) The certification period for the noninstitutional medically needy (MN) program for clients with countable income equal to or below the medically needy income level (MNIL):
(a) Begins on the first day of the month in which eligibility is established; and
(b) Is approved for twelve calendar months.
(2) The certification period for the noninstitutional MN program for clients with countable income above the MNIL:
(a) Begins on the day that spenddown is met; and
(b) Continues through the last day of the final month of the base period as described in WAC 182-519-0110.
(3) A retroactive MN certification period may be established for up to three months preceding the month of application.
(4) Expenses used to meet the spenddown liability for the current or the retroactive certification periods are the responsibility of the client. The agency is not responsible for paying any expense or portion of an expense which has been used to meet the spenddown liability. See WAC 182-519-0110.
(5) A new application must be submitted for each subsequent certification period for which medically needy coverage is requested.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-13-053, § 182-504-0020, filed 6/10/15, effective 7/11/15. WSR 11-24-018, recodified as § 182-504-0020, filed 11/29/11, effective 12/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and 74.09.500. WSR 08-21-108, § 388-416-0020, filed 10/16/08, effective 11/16/08. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. WSR 98-16-044, § 388-416-0020, filed 7/31/98, effective 9/1/98. Formerly WAC 388-521-2105 and 388-521-2130.]


PDF182-504-0025

Medicare savings program certification periods.

Certification periods for the different kinds of medicare savings programs are not all the same. The chart below explains the differences.
Medicare Savings Program
Certification
Period
Start Date
QMB (qualified medicare beneficiary)
S03
12 months
On the first day of the month following QMB eligibility determination
SLMB (Special low income medicare beneficiary)
S05
12 months
Up to three months prior to the certification period if on the first day of the first month of certification, the person:
• Is or has been enrolled in medicare Part B; and
• Meets SLMB eligibility requirements.
QDWI (Qualified disabled working individual)
S04
12 months
Up to three months prior to the certification period if on the first day of the first month of certification, the person:
• Is or has been enrolled in medicare Part A; and
• Meets QDWI eligibility requirements.
QI-1 (Qualified individual)
S06
Thru the end of the calendar year following QI-1 eligibility determination
Up to three months prior to the certification period if on the first day of the first month of certification, the person:
• Is or has been enrolled in medicare Part B; and
• Meets QI-1 eligibility requirements.
[WSR 11-24-018, recodified as § 182-504-0025, filed 11/29/11, effective 12/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530 and 42 U.S.C. 1396a(a) (Section 1902 (n)(2) of the Social Security Act of 1924). WSR 05-01-126, § 388-416-0035, filed 12/15/04, effective 1/15/05. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. WSR 98-16-044, § 388-416-0035, filed 7/31/98, effective 9/1/98. Formerly WAC 388-521-2150, 388-521-2155 and 388-521-2160.]


PDF182-504-0035

Washington apple health—Renewals.

(1) For all Washington apple health (WAH) programs, the following applies:
(a) You are required to complete a renewal of eligibility at least every 12 months with the following exceptions:
(i) If you are eligible for WAH medically needy with spenddown, then you must complete a new application at the end of each three- or six-month base period;
(ii) If you are eligible for WAH alien emergency medical, then you are certified for a specific period of time to cover emergency inpatient hospitalization costs only (see WAC 182-507-0115(8));
(iii) If you are eligible for WAH refugee coverage, you must complete a renewal of eligibility after 12 months; or
(iv) If you are a child on apple health for kids without premiums, your first renewal is due the month of your sixth birthday.
(b) You may complete renewals online, by phone, or by paper application that you mail or fax to us (the agency or its designee).
(c) If your WAH is renewed, we decide the certification period according to WAC 182-504-0015.
(d) We review all eligibility factors subject to change during the renewal process.
(e) We redetermine eligibility as described in WAC 182-504-0125 and send you written notice as described in WAC 182-518-0005 before WAH is terminated.
(f) If you need help meeting the requirements of this section, we provide equal access services as described in WAC 182-503-0120.
(2) For programs based on modified adjusted gross income (MAGI) as described in WAC 182-503-0510:
(a) Sixty days prior to the end of the certification period:
(i) When information from electronic sources shows income is reasonably compatible (as defined in WAC 182-500-0095), we administratively renew your coverage (as defined in WAC 182-500-0010) for a new certification period and send you a notice of renewal with the information used. You are required to inform us if any of the information we used is wrong.
(ii) If we are unable to complete an administrative renewal (as defined in WAC 182-500-0010), you must give us a signed renewal in order for us to decide if you will continue to get WAH coverage beyond the current certification period.
(iii) We follow the requirements described in WAC 182-518-0015 to request any additional information needed to complete the renewal process or to terminate coverage for failure to renew.
(b) If your WAH coverage is terminated because you did not renew, you have 90 days from the termination date to give us a completed renewal. If we decide you are still eligible to get WAH coverage, we will restore your WAH without a gap in coverage.
(3) For non-MAGI based programs (as described in WAC 182-503-0510):
(a) Forty-five days prior to the end of the certification period, we send notice with a renewal form. You must renew before the end of the certification period by either calling the department of social and health services at the number listed on the form to renew by telephone, renew online at www.washingtonconnection.org, or mailing or delivering to the department of social and health services a signed renewal form with the information required by WAC 182-503-0005.
(b) We follow the requirements in WAC 182-518-0015 to request any additional information needed to complete the renewal process or to terminate coverage for failure to renew.
(c) To complete your renewal, you must give us all the other information requested on the application that is needed to determine your eligibility.
(d) If you are terminated for failure to renew, you have 30 days from the termination date to submit a completed renewal. If still eligible, we will restore your WAH without a gap in coverage.
(4) If we determine that you are not eligible for renewal of your WAH coverage, we:
(a) Consider your eligibility for all other WAH programs before ending your WAH coverage; and
(b) Coordinate with the health benefit exchange any request for information that is necessary to determine your eligibility for:
(i) Other WAH programs; and
(ii) With respect to qualified health plans, health insurance premium tax credits (as defined in WAC 182-500-0045) and cost-sharing reductions (as defined in WAC 182-500-0020).
(5) We reconsider our decision that you are not eligible for WAH coverage without a new application from you when:
(a) We receive the information that we need to decide if you are eligible within 30 days of the date on the termination notice; or
(b) You request a hearing within 90 days of the date on the renewal denial letter and an administrative law judge (ALJ) or HCA review judge decides our decision was wrong (per chapter 182-526 WAC).
(6) If you disagree with our decision, you can ask for a hearing. If we decided that you are not eligible for renewal because we do not have enough information, the ALJ will consider the information we already have and anymore information you give us. The ALJ does not consider the previous absence of information or failure to respond in determining if you are eligible.
[Statutory Authority: RCW 41.05.021, 41.05.160, and 2023 c 475 § 211(36). WSR 23-23-057, § 182-504-0035, filed 11/8/23, effective 12/9/23. 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, § 182-504-0035, filed 7/29/14, effective 8/29/14.]


PDF182-504-0105

Washington apple health—Changes that must be reported.

(1) You must report changes in your household and family circumstances to us (the agency or its designee) timely according to WAC 182-504-0110.
(2) We tell you what you are required to report at the time you are approved for WAH coverage. We also will tell you if the reporting requirements change.
(3) You must report the following:
(a) Change in residential address;
(b) Change in mailing address;
(c) Change in marital status;
(d) When family members or dependents move in or out of the residence;
(e) Pregnancy;
(f) Incarceration;
(g) Change in institutional status;
(h) Change in health insurance coverage including medicare eligibility; and
(i) Change in immigration or citizenship status.
(4) If you are eligible for a WAH long-term care program described in chapter 182-513 or 182-515 WAC, you must also report changes to the following:
(a) Income;
(b) Resources;
(c) Medical expenses; and
(d) Spouse or dependent changes in income or shelter cost when expenses are allowed for either.
(5) If you get WAH parent or caretaker (as described in WAC 182-505-0240) or WAH modified adjusted gross income (MAGI)-based adult coverage (as described in WAC 182-505-0250), you must also report changes to the following:
(a) When total income increases or total deductions decrease by one hundred fifty dollars or more a month and the change will continue for at least two months;
(b) Your federal income tax filing status that you expect to use when you file your taxes for the current tax filing year (such as changing from "married filing separately" to "married filing jointly"); and
(c) The tax dependents you expect to claim when you file your federal income tax return for the current tax filing year.
(6) If you get WAH based on age, blindness, or disability (SSI-related medical), then you must also report changes to the following:
(a) Income; and
(b) Resources.
[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, § 182-504-0105, filed 7/29/14, effective 8/29/14.]


PDF182-504-0110

Washington apple health—When to report changes.

(1) All changes you report to us (the agency or its designee), as required by WAC 182-504-0105, are used to decide if you can receive or keep receiving Washington apple health (WAH) coverage.
(2) You must report changes during your certification period within thirty days of when the change happened.
(3) You must report all changes during application, renewal, or redetermination of your WAH eligibility, regardless of when the change happened.
(4) For a change in income, the date a change happened is the first date you received income based on the change. For example, the date you receive your first paycheck for a new job or the date you got a paycheck with a wage increase is the date the change happened.
(5) If you do not report a change or you report a change late, we will decide if you can receive or keep receiving WAH coverage based on the date the change was required to be reported.
(6) If you do not report a change or you report a change late, and if it affects the amount you must pay toward your cost of care as described in WAC 182-513-1380 or chapter 182-515 WAC, you may become liable for overpayments we make on your behalf and you may need to pay more to your care provider.
(7) If you do not report a change or you report a change late, it may result in us overpaying you and you having to pay us back for the health care costs we overpaid. See chapter 182-520 WAC.
[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, § 182-504-0110, filed 7/29/14, effective 8/29/14.]


PDF182-504-0120

Washington apple health—Effective dates of changes.

(1) We (the agency or its designee) determine the date a change affects your Washington apple health (WAH) coverage based on:
(a) The date you report the change to us;
(b) The date you give us the requested verification; and
(c) The type of WAH you or your family is receiving.
(2) When you report a change after you submit your application, but before your application is processed, the change is considered when processing your application.
(3) If another person, agency, or data source reports a change in circumstances, the information may be used in determining your eligibility. We will not rely on information received from a person, agency, or data source to terminate your WAH coverage without requesting additional information from you.
(4) A change in income affects your ongoing eligibility only if it is expected to continue beyond the month when the change is reported, and only if it is expected to last more than two months.
(5) A change that results in termination of your WAH coverage takes effect the first of the month following the advance notice period.
(6) The advance notice period:
(a) Begins on the day we send the letter about the change to you; and
(b) Is determined according to the rules in WAC 182-518-0025.
(7) A change that results in a decreased scope of care takes effect on the first of the month following the advance notice period. Examples of a decreased scope of care are:
(a) Termination of WAH categorically needy (CN) medical and approval for other WAH coverage with a lesser scope of care such as WAH medically needy (MN) medical;
(b) WAH-MN recipient with a change that increases the spenddown liability amount;
(c) WAH-MN recipient with no spenddown liability with a change that results in WAH-MN with a spenddown liability.
(8) A change that results in an increased scope of care takes effect on the first of the month following the date the change was reported, when you provide the required verification:
(a) Within ten days of the date we requested the verification; or
(b) By the end of the month of your change report, whichever is later.
If you are a WAH-MN applicant with a spenddown liability that has not yet been met and you report a change that results in your becoming eligible for WAH-CN medical or WAH for adults, your change report will be treated as a new application for purposes of retroactive WAH coverage as described in WAC 182-504-0005.
(9) If you do not provide the required verification timely under subsection (8) of this section, we make the change effective the first of the month following the month in which you provide the verification. We may terminate your WAH coverage if you do not provide the required verification.
(10) When a law or regulation requires a change in WAH, the date specified by the law or regulation is the effective date of the change.
(11) When a change in income or allowable expenses is reported timely (within thirty days) and changes the amount you pay towards the cost of your care for institutional programs (residing in a medical institution), we calculate your new participation amount based on:
(a) Either actual income received in a month or allowable deductions incurred in a month, or both; or
(b) An estimate of your monthly or allowable expenses in a prospective period of six months or less, based on both actual income received in a preceding period of six months or less and income expected to be received during the prospective period. At the end of the prospective period or when any significant change occurs, we reconcile this estimate for the period with income received during the same period.
(12) When a change in income, or allowable expenses, changes the amount you pay towards the cost of your care for a home and community-based waiver or service, we calculate your 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.
(13) We use the following rules to determine the effective date of change for the health care for workers with disabilities (HWD) program:
(a) HWD coverage begins the month after coverage in another medical program ends and the premium amount has been approved by the eligible person; and
(b) If a change in income increases or decreases the monthly premium, the change is effective the first of the month after the change is reported. For more information on premium requirements for this program, see WAC 182-511-1250.
[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, § 182-504-0120, filed 7/29/14, effective 8/29/14.]


PDF182-504-0125

Washington apple health—Effect of reported changes.

(1) If you report a change required under WAC 182-504-0105 during a certification period, you continue to be eligible for Washington apple health coverage until we decide if you can keep getting apple health coverage under your current apple health program or a different apple health program.
(2) If your apple health categorically needy (CN) coverage ends due to a reported change and you meet all the eligibility requirements for a different apple health CN program, we will approve your coverage under the new apple health CN program. If you are not eligible for coverage under any apple health CN program but you meet the eligibility requirements for either apple health alternative benefits plan (ABP) coverage or apple health medically needy (MN) coverage, we will approve your coverage under the program you are eligible for. If you are not eligible for coverage under any apple health CN program but you meet the eligibility requirements for both apple health ABP coverage and apple health MN coverage, we will approve the apple health ABP coverage unless you notify us that you prefer apple health MN coverage.
(3) If your apple health coverage ends and you are not eligible for a different apple health program, we stop your apple health coverage after giving you advance and adequate notice unless the exception in subsection (4) of this section applies to you.
(4) If you claim to have a disability and that is the only basis for you to be potentially eligible for apple health coverage, then we refer you to the division of disability determination services (within the department of social and health services) for a disability determination. Pending the outcome of the disability determination, we also determine if you are eligible for apple health coverage under the SSI-related medical program described in chapter 182-512 WAC. If you have countable income in excess of the SSI-related categorically needy income level (CNIL), then we look to see if you can get coverage under apple health MN with spenddown as described in chapter 182-519 WAC pending the final outcome of the disability determination.
(5) If you are eligible for and receive coverage under the apple health parent and caretaker relative program described in WAC 182-505-0240, you may be eligible for the apple health medical extension program described in WAC 182-523-0100, if your coverage ends as a result of an increase in your earned income.
(6) Changes in income during a certification period do not affect eligibility for the following programs:
(a) Apple health for pregnant women;
(b) Apple health for children, except as specified in subsection (7) of this section;
(c) Apple health for SSI recipients;
(d) Apple health refugee program; and
(e) Apple health medical extension program.
(7) We redetermine eligibility for children receiving apple health for kids premium-based coverage described in WAC 182-505-0210 when the:
(a) Household's countable income decreases to a percentage of the federal poverty level (FPL) that would result in either a change in premium for apple health for kids with premiums or the children becoming eligible for apple health for kids (without premiums);
(b) Child becomes pregnant;
(c) Family size changes; or
(d) Child receives SSI.
(8) If you get SSI-related apple health CN coverage and report a change in work or earned income which results in a determination by the division of disability determination services that you no longer meet the definition of a disabled person as described in WAC 182-512-0050 due to work or earnings at the level of substantial gainful activity (SGA), we redetermine your eligibility for coverage under the health care for workers with disabilities (HWD) program. The HWD program is a premium-based program that waives the SGA work or earnings test, and you must approve the premium amount before we can authorize coverage under this program. For HWD program rules, see chapter 182-511 WAC.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-18-024, § 182-504-0125, filed 8/28/17, effective 10/1/17. 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, § 182-504-0125, 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, § 182-504-0125, filed 9/13/12, effective 10/14/12.]


PDF182-504-0130

Washington apple health—Continued coverage pending an appeal.

(1) Continued coverage is when you continue to receive Washington apple health benefits while appealing a medicaid agency adverse action to terminate, suspend, or reduce your:
(a) Medicaid eligibility; or
(b) Authorization for a covered service.
(2) To qualify for continued coverage, you must request a hearing on the adverse action no later than:
(a) The tenth day after we (the medicaid agency or its designee) sent a notice of the action to you; or
(b) The last day of the month before the action takes effect.
(3) If your last day to request a hearing and still qualify for continued coverage falls on a Saturday, Sunday, or a designated holiday under WAC 357-31-005, you have until 5:00 p.m. on the next business day to request the hearing.
(4) Continued coverage ends when:
(a) You state in writing you no longer wish to receive continued coverage;
(b) You withdraw the appeal;
(c) You default and an order of dismissal is entered;
(d) An administrative law judge or a review judge issues an adverse ruling or written decision:
(i) Terminating your continued coverage; or
(ii) Ruling you do not qualify for benefits.
(5) You cannot receive continued coverage if the adverse action was due solely to a change in statute, federal regulation, or administrative rule, unless there is a question about whether you are in the class of people affected by the change.
(6) If you are receiving medically needy coverage, you cannot receive continued coverage past the end of the certification period described in WAC 182-504-0020.
(7) If you are receiving coverage under an alien medical program, you cannot receive continued coverage past the end of the certification period described in chapter 182-507 WAC.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-22-060, § 182-504-0130, filed 10/31/16, effective 12/1/16. 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, § 182-504-0130, filed 2/28/14, effective 3/31/14.]