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Chapter 182-511 WAC

Last Update: 11/15/19

APPLE HEALTH FOR WORKERS WITH DISABILITIES (HWD)

WAC Sections

HTMLPDF182-511-1000Apple health for workers with disabilities (HWD)—Program description.
HTMLPDF182-511-1050Apple health for workers with disabilities (HWD)—Program requirements.
HTMLPDF182-511-1100Apple health for workers with disabilities (HWD)—Retroactive coverage.
HTMLPDF182-511-1150Apple health for workers with disabilities (HWD)—Disability requirements.
HTMLPDF182-511-1200Apple health for workers with disabilities (HWD)—Employment requirements.
HTMLPDF182-511-1250Apple health for workers with disabilities (HWD)—Premium payments.
DISPOSITION OF SECTIONS FORMERLY CODIFIED IN THIS TITLE
182-511-1060Washington apple health—Health care for workers with disabilities (HWD)—Income standard based on the federal poverty guidelines. [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, § 182-511-1060, filed 6/24/13, effective 7/25/13.] Repealed by WSR 19-23-063, filed 11/15/19, effective 1/1/20. Statutory Authority: RCW 41.05.021, 41.05.160 and 2019 c 70.

PDF182-511-1000

Apple health for workers with disabilities (HWD)—Program description.

This section describes the apple health for workers with disabilities (HWD) program.
(1) The HWD program provides categorically needy (CN) scope of care as described in WAC 182-501-0060.
(2) The HWD program also provides long-term services and supports described in chapters 182-513 and 182-515 WAC for a client who meets the functional requirements for those programs, are approved for those services, and choose to enroll in HWD.
(3) The medicaid agency approves HWD coverage for twelve months effective the first of the month in which a person applies and meets program requirements. See WAC 182-511-1100 for retroactive coverage for months before the month of application.
(4) A person who is eligible for another medicaid program may choose not to participate in the HWD program.
(5) A person is not eligible for HWD coverage for a month in which the person received medicaid benefits under the medically needy (MN) program.
[Statutory Authority: RCW 41.05.021, 41.05.160 and 2019 c 70. WSR 19-23-063, § 182-511-1000, filed 11/15/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-14-080, § 182-511-1000, filed 6/29/15, effective 7/30/15. WSR 11-24-018, recodified as § 182-511-1000, filed 11/29/11, effective 12/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 06-24-036, § 388-475-1000, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090, Section 1902 (a)(10)(A)(ii) of the Social Security Act, and 2001 c 7 § 209(5), Part II. WSR 02-01-073, § 388-475-1000, filed 12/14/01, effective 1/14/02.]


PDF182-511-1050

Apple health for workers with disabilities (HWD)—Program requirements.

This section describes requirements a person must meet to be eligible for the apple health for workers with disabilities (HWD) program.
(1) To qualify for the HWD program, a person must:
(a) Meet the general requirements for a medical program described in WAC 182-503-0505 (3)(a) through (f);
(b) Be at least age sixteen;
(c) Meet the federal disability requirements described in WAC 182-511-1150; and
(d) Be employed full or part time (including self-employment) as described in WAC 182-511-1200.
(2) The HWD program does not require a resource test.
(3) Once approved for HWD coverage, a person must pay the monthly premium in order to continue to qualify.
(a) The agency calculates the premium for HWD coverage according to WAC 182-511-1250.
(b) If a person does not pay four consecutive monthly premiums, the person is not eligible for HWD coverage for the next four months and must pay all premium amounts owed before HWD coverage can be approved again.
(c) Once approved for HWD coverage, a person who experiences a job loss can choose to continue HWD coverage through the original twelve months of eligibility, if the following requirements are met:
(i) The job loss results from an involuntary dismissal or health crisis; and
(ii) The person continues to pay the monthly premium.
[Statutory Authority: RCW 41.05.021, 41.05.160 and 2019 c 70. WSR 19-23-063, § 182-511-1050, filed 11/15/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-14-080, § 182-511-1050, filed 6/29/15, effective 7/30/15. WSR 11-24-018, recodified as § 182-511-1050, filed 11/29/11, effective 12/1/11. Statutory Authority: RCW 74.08.090, 34.05.353 and Section 1902 (a)(10)(A)(ii) of the Social Security Act. WSR 04-15-002, § 388-475-1050, filed 7/7/04, effective 8/7/04. Statutory Authority: RCW 74.08.090, Section 1902 (a)(10)(A)(ii) of the Social Security Act, and 2001 c 7 § 209(5), Part II. WSR 02-01-073, § 388-475-1050, filed 12/14/01, effective 1/14/02.]


PDF182-511-1100

Apple health for workers with disabilities (HWD)—Retroactive coverage.

This section describes requirements for retroactive coverage provided under the apple health for workers with disabilities (HWD) program.
(1) Retroactive coverage refers to the period of up to three months before the month in which a person applies for the HWD program.
(2) To qualify for retroactive coverage under the HWD program, a person must first:
(a) Meet all program requirements described in WAC 182-511-1050 for each month of the retroactive period; and
(b) Pay the premium amount for each month requested within one hundred twenty days of being billed for such coverage.
(3) Payment must be received for each month requested of retroactive coverage before such coverage is approved.
[Statutory Authority: RCW 41.05.021, 41.05.160 and 2019 c 70. WSR 19-23-063, § 182-511-1100, filed 11/15/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-14-080, § 182-511-1100, filed 6/29/15, effective 7/30/15. WSR 11-24-018, recodified as § 182-511-1100, filed 11/29/11, effective 12/1/11. Statutory Authority: RCW 74.08.090, Section 1902 (a)(10)(A)(ii) of the Social Security Act, and 2001 c 7 § 209(5), Part II. WSR 02-01-073, § 388-475-1100, filed 12/14/01, effective 1/14/02.]


PDF182-511-1150

Apple health for workers with disabilities (HWD)—Disability requirements.

This section describes the disability requirements for the following groups of individuals who may qualify for the apple health for workers with disabilities (HWD) program.
(1) A person age sixteen through age sixty-four must meet the requirements of the Social Security Act in section 1902(a)(10)(A)(ii):
(a) (XV) for the basic coverage group (BCG); or
(b) (XVI) for the medical improvement group (MIG).
(2) The BCG consists of individuals who:
(a) Meet federal disability requirements for the supplemental security income (SSI) or Social Security Disability Insurance (SSDI) program; or
(b) Are determined by the department of social and health services (DSHS), division of disability determination services (DDDS), to meet federal disability requirements for the HWD program.
(3) The MIG consists of individuals who:
(a) Were previously eligible and approved for the HWD program as a member of the BCG; and
(b) Are determined by DDDS to have a medically improved disability. The term "medically improved disability" refers to the particular status granted to persons described in subsection (1)(b). For these people, a continuation of HWD coverage is provided to help them maintain their employment.
(4) A person age sixty-five or older, must meet federal disability requirements as determined by the DSHS DDDS. Coverage under the MIG is not available under federal law for persons age sixty-five or older. Coverage for this age group is authorized under the Balanced Budget Act of 1997 as described under section 1902 (a)(10)(A)(ii)(XIII).
(5) When completing a disability determination for the HWD program, DDDS will not determine a person not disabled based only on earnings or the performance of substantial gainful activity (SGA). (See SSA POMS Section DI 10501.001, https://secure.ssa.gov/apps10/poms.nsf/lnx/0410501001).
[Statutory Authority: RCW 41.05.021, 41.05.160 and 2019 c 70. WSR 19-23-063, § 182-511-1150, filed 11/15/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 19-08-025, § 182-511-1150, filed 3/27/19, effective 4/27/19; WSR 15-14-080, § 182-511-1150, filed 6/29/15, effective 7/30/15. WSR 11-24-018, recodified as § 182-511-1150, filed 11/29/11, effective 12/1/11. Statutory Authority: RCW 74.08.090, Section 1902 (a)(10)(A)(ii) of the Social Security Act, and 2001 c 7 § 209(5), Part II. WSR 02-01-073, § 388-475-1150, filed 12/14/01, effective 1/14/02.]


PDF182-511-1200

Apple health for workers with disabilities (HWD)—Employment requirements.

This section describes the employment requirements for the basic coverage group (BCG) and the medical improvement group (MIG) for the apple health for workers with disabilities (HWD) program.
(1) For the purpose of the HWD program, employment means a person:
(a) Gets paid for working;
(b) Has earnings that are subject to federal income tax; and
(c) Has payroll taxes taken out of earnings received, unless self-employed.
(2) To qualify for HWD coverage as a member of the BCG, a person must be employed full or part time.
(3) To qualify for HWD coverage as a member of the MIG, a person must be:
(a) Working at least forty hours per month; and
(b) Earning at least the local minimum wage as described under section 6 of the Fair Labor Standards Act (29 U.S.C. 206).
(4) For a person who is self-employed, the examples described in the Social Security Administration Program Operations Manual System (POMS) provide guidance when determining whether someone meets the HWD work requirements. (See SSA POMS Section SI 00820.200, http://secure.ssa.gov/poms.nsf/lnx/0500820200). The guidelines described in POMS for determining the existence of a trade or business may also be used when making this determination. (See SSA POMS Section RS 01802.010, https://secure.ssa.gov/apps10/poms.nsf/lnx/0301802010).
[Statutory Authority: RCW 41.05.021, 41.05.160 and 2019 c 70. WSR 19-23-063, § 182-511-1200, filed 11/15/19, effective 1/1/20. WSR 11-24-018, recodified as § 182-511-1200, filed 11/29/11, effective 12/1/11. Statutory Authority: RCW 74.08.090, Section 1902 (a)(10)(A)(ii) of the Social Security Act, and 2001 c 7 § 209(5), Part II. WSR 02-01-073, § 388-475-1200, filed 12/14/01, effective 1/14/02.]


PDF182-511-1250

Apple health for workers with disabilities (HWD)—Premium payments.

This section describes how the medicaid agency calculates the premium amount a person must pay for apple health for workers with disabilities (HWD) coverage. This section also describes program requirements regarding the billing and payment of HWD premiums.
(1) When determining the HWD premium amount, the agency counts only the income of the person approved for the program. It does not count the income of another household member.
(2) When determining countable income used to calculate the HWD premium, the agency applies the following rules:
(a) Income is considered available and owned when it is:
(i) Received; and
(ii) Can be used to meet the person's needs for food, clothing, and shelter, except as described in WAC 182-512-0600(5), 182-512-0650, and 182-512-0700(1).
(b) Certain receipts are not income as described in 20 C.F.R. Sec. 416.1103.
(3) The HWD premium amount equals the lesser of the two following amounts:
(a) A total of the following (rounded down to the nearest whole dollar):
(i) Fifty percent of unearned income above the medically needy income level (MNIL) described in WAC 182-519-0050; plus
(ii) Five percent of total unearned income; plus
(iii) Two and one-half percent of earned income after first deducting sixty-five dollars; or
(b) Seven and one-half percent of countable income described in subsection (2) of this section, including both earned and unearned income.
(4) When determining the premium amount, the agency will use the currently verified income amount until a change in income is reported and processed, unless good cause for delay in verifying changes exists.
(5) A change in the premium amount is effective the month after the change in income is reported and processed.
(6) For current and ongoing coverage, the agency will bill for HWD premiums during the month following the benefit month.
(7) For retroactive coverage, the agency will bill the HWD premiums during the month following the month in which coverage is requested and necessary information that establishes eligibility is received by the agency.
(8) If initial coverage for the HWD program is approved in a month that follows the month of application, the first monthly premium includes the costs for both the month of application and any following months that have passed during determination of eligibility.
(9) As described in WAC 182-511-1050 (3)(b), the agency will close HWD coverage if premiums are not paid in full for four consecutive months.
(10) The person must pay the monthly premium in full to avoid losing HWD coverage. If a person makes a partial payment, the payment does not count as a full payment toward the premium.
(11) Payments received are applied to premiums owed in the following order:
(a) If retroactive coverage is requested, the retroactive coverage month(s);
(b) Past due months, beginning with the most delinquent month;
(c) The current coverage month that has been invoiced; then
(d) Future coverage months.
(12) A person must pay a premium for any month that HWD coverage is provided. This includes months when a redetermination of coverage is made, and months when continued coverage that is requested, pending the outcome of an administrative hearing.
[Statutory Authority: RCW 41.05.021, 41.05.160 and 2019 c 70. WSR 19-23-063, § 182-511-1250, filed 11/15/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-14-080, § 182-511-1250, filed 6/29/15, effective 7/30/15. WSR 11-24-018, recodified as § 182-511-1250, filed 11/29/11, effective 12/1/11. Statutory Authority: RCW 74.08.090, 34.05.353 and Section 1902 (a)(10)(A)(ii) of the Social Security Act. WSR 04-15-002, § 388-475-1250, filed 7/7/04, effective 8/7/04. Statutory Authority: RCW 74.08.090, Section 1902 (a)(10)(A)(ii) of the Social Security Act, and 2001 c 7 § 209(5), Part II. WSR 02-01-073, § 388-475-1250, filed 12/14/01, effective 1/14/02.]