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Chapter 182-505 WAC

Last Update: 11/8/23

FAMILY, CHILDREN, PREGNANCY AND ADULT MEDICAL PROGRAMS

WAC Sections

HTMLPDF182-505-0100Monthly income standards for MAGI-based programs.
HTMLPDF182-505-0115Washington apple health—Eligibility for pregnancy and after-pregnancy coverage.
HTMLPDF182-505-0117Washington apple health—Eligibility for pregnant minors.
HTMLPDF182-505-0120Washington apple health breast and cervical cancer treatment program for women—Client eligibility.
HTMLPDF182-505-0210Eligibility for children.
HTMLPDF182-505-0211Washington apple health—Foster care.
HTMLPDF182-505-0215Children's Washington apple health with premiums.
HTMLPDF182-505-0225Children's Washington apple health with premiums—Calculation and determination of premium amount.
HTMLPDF182-505-0240Parents and caretaker relatives.
HTMLPDF182-505-0250Washington apple health—MAGI-based adult medical.
HTMLPDF182-505-0300Hospital presumptive eligibility.
DISPOSITION OF SECTIONS FORMERLY CODIFIED IN THIS TITLE
182-505-0220Definitions for premium-based health care coverage under programs included in apple health for kids. [WSR 12-13-056, recodified as § 182-505-0220, filed 6/15/12, effective 7/1/12. 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, § 388-542-0050, 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, § 388-542-0050, filed 2/12/08, effective 3/14/08. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.522, 74.09.450, and 2004 c 276. WSR 04-16-064, § 388-542-0050, filed 7/30/04, effective 8/30/04. Statutory Authority: RCW 74.09.080, 74.08.510, [74.08.]522, 74.09.450, 1115 Waiver, 42 U.S.C. 1396. WSR 02-01-075, § 388-542-0050, filed 12/14/01, effective 1/14/02. Statutory Authority: RCW 74.08.090, 74.09.450. WSR 00-07-103, § 388-542-0050, filed 3/17/00, effective 4/17/00.] Repealed by WSR 14-16-052, filed 7/29/14, effective 8/29/14. 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.
182-505-0230Waiting period for premium-based health care coverage under programs included in apple health for kids following employer coverage. [WSR 12-13-056, recodified as § 182-505-0230, filed 6/15/12, effective 7/1/12. 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, § 388-542-0300, 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, § 388-542-0300, filed 2/12/08, effective 3/14/08. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.522, 74.09.450, and 2004 c 276. WSR 04-16-064, § 388-542-0300, filed 7/30/04, effective 8/30/04. Statutory Authority: RCW 74.09.080, 74.08.510, [74.08.]522, 74.09.450, 1115 Waiver, 42 U.S.C. 1396. WSR 02-01-075, § 388-542-0300, filed 12/14/01, effective 1/14/02. Statutory Authority: RCW 74.08.090, 74.09.450. WSR 00-07-103, § 388-542-0300, filed 3/17/00, effective 4/17/00.] Repealed by WSR 14-16-052, filed 7/29/14, effective 8/29/14. 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.
182-505-0235Washington apple health—Premium-based children's program—Order of payments. [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, § 182-505-0235, filed 7/29/14, effective 8/29/14. Statutory Authority: RCW 41.05.021, 74.04.050, 74.04.057, 74.09.500, and PPACA, § 2102 (b)(1)(A) of the Social Security Act, and Public Law 111-3 (CHIPRA). WSR 11-23-077, § 182-505-0235, filed 11/15/11, effective 12/16/11.] Repealed by WSR 17-12-018, filed 5/30/17, effective 6/30/17. Statutory Authority: RCW 41.05.021 and 41.05.160.
182-505-0237Premium-based Washington apple health for kids—Other rules that apply. [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, § 182-505-0237, filed 7/29/14, effective 8/29/14. WSR 12-13-056, recodified as § 182-505-0237, filed 6/15/12, effective 7/1/12. 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, § 388-542-0020, 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, § 388-542-0020, 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, § 388-542-0020, filed 2/12/08, effective 3/14/08. Statutory Authority: RCW 74.08.090 and 74.09.522. WSR 06-07-014, § 388-542-0020, filed 3/3/06, effective 4/3/06. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.522, 74.09.450, and 2004 c 276. WSR 04-16-064, § 388-542-0020, filed 7/30/04, effective 8/30/04.] Repealed by WSR 17-12-018, filed 5/30/17, effective 6/30/17. Statutory Authority: RCW 41.05.021 and 41.05.160.
182-505-0245Income and resource standards for family medical programs. [WSR 11-23-091, recodified as § 182-505-0245, filed 11/17/11, effective 11/21/11. Statutory Authority: RCW 74.04.050, 74.04.057, and 74.08.090. WSR 11-13-031, § 388-478-0065, filed 6/7/11, effective 7/8/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and 74.09.530. WSR 05-15-080, § 388-478-0065, filed 7/14/05, effective 8/14/05. Statutory Authority: RCW 74.08.090, 74.04.050, 74.04.057, 74.09.530, and Section 673(2) (42 U.S.C. 9902(2)). WSR 01-18-056, § 388-478-0065, filed 8/30/01, effective 9/30/01. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. WSR 98-16-044, § 388-478-0065, filed 7/31/98, effective 9/1/98. Formerly WAC 388-507-0710 and 388-508-0820.] Repealed by WSR 14-16-052, filed 7/29/14, effective 8/29/14. 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.
182-505-0510How a client is determined "related to" a categorical program. [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.] Decodified by WSR 12-13-056, filed 6/15/12, effective 7/1/12. Recodified as § 182-503-0510.
182-505-0515Medical coverage resulting from a cash grant. [WSR 12-02-034, recodified as § 182-505-0515, filed 12/29/11, effective 1/1/12. Statutory Authority: RCW 74.08.090, 74.08A.100, 74.09.080, and 74.09.415. WSR 02-17-030, § 388-503-0515, 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, § 388-503-0515, filed 7/31/98, effective 9/1/98.] Repealed by WSR 14-16-052, filed 7/29/14, effective 8/29/14. 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.

PDF182-505-0100

Monthly income standards for MAGI-based programs.

(1) Each year, the federal government publishes new federal poverty level (FPL) income standards in the Federal Register found at https://aspe.hhs.gov/topics/poverty-economic-mobility/poverty-guidelines/prior-hhs-poverty-guidelines-federal-register-references.
(a) The income standards for the following Washington apple health programs change on the first day of April every year based on the new FPL, except for subsections (2) and (3) of this section.
(b) The agency determines income eligibility by comparing countable income as determined of the person's medical assistance unit (MAU), as determined under WAC 182-506-0010 and 182-506-0012, to the applicable income standard. Rules for determining countable income are in chapter 182-509 WAC.
(2) Parents and caretaker relatives under WAC 182-505-0240 must have countable income equal to or below the following standards:
Medical Assistance Unit Size
1
2
3
4
5
6
7
8
9
10
11+
Income Standard
$511
$658
$820
$972
$1,127
$1,284
$1,471
$1,631
$1,792
$1,951
$1,951
(3) Parents and caretaker relatives with earned income above the limits in subsection (2) of this section are the only people who may be eligible for the transitional medical program described in WAC 182-523-0100.
(4) Adults described in WAC 182-505-0250 who are not eligible under subsection (2) or (3) of this section must have countable income equal to or below one hundred thirty-three percent of the FPL.
(5) Pregnant people described in WAC 182-505-0115 must have countable income equal to or below one hundred ninety-three percent of the FPL.
(6) Children with countable income:
(a) Equal to or below two hundred ten percent of the FPL as described in WAC 182-505-0210 (3)(a)(i) receive coverage at no cost.
(b) Greater than two hundred ten percent but equal to or less than three hundred twelve percent as described in WAC 182-505-0210 (3)(a)(ii) receive premium-based coverage. Premium amounts are described in WAC 182-505-0225.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-11-004, § 182-505-0100, filed 5/5/22, effective 6/5/22; WSR 17-12-018, § 182-505-0100, 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, § 182-505-0100, filed 7/29/14, effective 8/29/14. WSR 11-23-091, recodified as § 182-505-0100, filed 11/17/11, effective 11/21/11. 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, § 388-478-0075, 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, § 388-478-0075, filed 2/12/08, effective 3/14/08. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500 and 42 U.S.C. 9902(2). WSR 06-16-026, § 388-478-0075, filed 7/24/06, effective 8/24/06. Statutory Authority: RCW 74.08.090, 74.09.415, 74.09.530 and 2005 c 279. WSR 06-03-080, § 388-478-0075, filed 1/12/06, effective 2/12/06. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 42 U.S.C. 9902(2). WSR 05-17-157, § 388-478-0075, filed 8/22/05, effective 9/22/05. Statutory Authority: RCW 74.08.090, 74.04.057, 74.04.050, and 74.09.530. WSR 04-15-092, § 388-478-0075, filed 7/16/04, effective 8/16/04. Statutory Authority: RCW 74.08.090, 74.04.050, 74.04.057, 74.09.530, and 42 U.S.C. 9902(2). WSR 03-15-088, § 388-478-0075, filed 7/17/03, effective 7/17/03. Statutory Authority: RCW 74.08.090, 74.08A.100, 74.09.080, and 74.09.415. WSR 02-17-030, § 388-478-0075, filed 8/12/02, effective 9/12/02. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.500, 74.09.510, and Section 1902 (a)(10)(A)(ii)(XV) and (XVI) of the Social Security Act. WSR 02-07-090, § 388-478-0075, filed 3/19/02, effective 4/1/02. Statutory Authority: RCW 74.08.090, 74.04.050, 74.04.057, 74.09.530, and Section 673(2) (42 U.S.C. 9902(2)). WSR 01-18-056, § 388-478-0075, filed 8/30/01, effective 9/30/01; WSR 00-17-085, § 388-478-0075, filed 8/14/00, effective 9/14/00; WSR 99-19-005, § 388-478-0075, filed 9/3/99, effective 10/4/99. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. WSR 98-16-044, § 388-478-0075, filed 7/31/98, effective 9/1/98. Formerly WAC 388-507-0805, 388-508-0810, 388-509-0910, 388-509-0920, 388-509-0940 and 388-509-0960.]


PDF182-505-0115

Washington apple health—Eligibility for pregnancy and after-pregnancy coverage.

(1) A pregnant person is eligible for Washington apple health pregnancy coverage if the person:
(a) Meets citizenship or immigration status under WAC 182-503-0535;
(b) Meets Social Security number requirements under WAC 182-503-0115;
(c) Meets Washington state residency requirements under WAC 182-503-0520 and 182-503-0525; and
(d) Has countable income at or below the limit described in:
(i) WAC 182-505-0100 to be eligible for categorically needy (CN) coverage; or
(ii) WAC 182-505-0100 to be eligible for medically needy (MN) coverage. MN coverage begins when the pregnant person meets any required spenddown liability as described in WAC 182-519-0110.
(2) A noncitizen pregnant person who does not meet the requirements in subsection (1)(a) or (b) of this section is eligible for apple health pregnancy coverage if they meet countable income standards for CN or MN coverage as described in subsection (1)(d) of this section.
(3) The assignment of medical support rights as described in WAC 182-503-0540 does not apply to pregnant people.
(4) A person who was eligible for and covered under any CN or MN scope of coverage apple health program on the last day of pregnancy remains continuously eligible for after-pregnancy coverage for 12 months, beginning the month after their pregnancy ends. This includes people who meet an MN spenddown liability with expenses incurred no later than the date the pregnancy ends.
(5) Pregnancy coverage has CN scope of care for all people except those enrolled through the MN program who have MN scope of care. A person's after-pregnancy coverage has the same scope of coverage as their pregnancy coverage.
(6) A person who does not meet the requirements in subsection (4) of this section may qualify for after-pregnancy coverage if they:
(a) Apply for and meet all requirements of the apple health pregnancy coverage program other than pregnancy; and
(b) Apply any time during their 12-month postpartum period to receive ongoing medical coverage until the end of the 12th month after their pregnancy ends.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-12-033, § 182-505-0115, filed 5/24/22, effective 6/24/22. 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, § 182-505-0115, filed 7/29/14, effective 8/29/14. WSR 12-13-056, recodified as § 182-505-0115, filed 6/15/12, effective 7/1/12. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 42 U.S.C. 9902(2). WSR 05-07-032, § 388-462-0015, filed 3/9/05, effective 4/9/05. Statutory Authority: RCW 74.08.090, 74.08A.100, 74.09.080, and 74.09.415. WSR 02-17-030, § 388-462-0015, 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, § 388-462-0015, filed 7/31/98, effective 9/1/98. Formerly WAC 388-508-0820, 388-508-0830, 388-522-2230 and 388-508-0835.]


PDF182-505-0117

Washington apple health—Eligibility for pregnant minors.

(1) For the purposes of this rule, "minor" means a person under the age of 19.
(2) A pregnant minor who meets Washington state residency requirements under WAC 182-503-0520 and 182-503-0525 is eligible for the Washington apple health for kids program.
(3) The medical assistance unit (MAU) of a pregnant minor is the pregnant minor.
(4) There are no income standards and no resource tests for a pregnant minor to be eligible for apple health for kids.
(5) To ensure reimbursement from the U.S. Department of Health and Human Services, every pregnant minor applicant for apple health for kids must provide their Social Security number, unless they are exempt under WAC 182-503-0515, and must provide their citizenship or immigration status. The immigration status of a pregnant minor who is an undocumented alien (see WAC 182-503-0530) will not be disclosed to any third party.
(6) The assignment of rights as described in WAC 182-503-0540 does not apply to pregnant minors.
(7) A pregnant minor covered by the apple health for kids program has a one-year certification period. If a minor has their 19th birthday during their pregnancy, they are automatically enrolled in apple health for pregnancy coverage through the end of the month their pregnancy ends. They are eligible for after-pregnancy coverage for 12 months, beginning the first day of the month after their pregnancy ends.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-12-033, § 182-505-0117, filed 5/24/22, effective 6/24/22. Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, 457, and 45 C.F.R. § 155. WSR 14-21-040, § 182-505-0117, filed 10/7/14, effective 11/7/14.]


PDF182-505-0120

Washington apple health breast and cervical cancer treatment program for women—Client eligibility.

(1) Effective April 1, 2014, a woman is eligible for categorically needy (CN) coverage under the Washington apple health (WAH) breast and cervical cancer treatment program (BCCTP) only when she:
(a) Has been screened for breast or cervical cancer under the department of health's breast, cervical, and colon health program (BCCHP);
(b) Requires treatment for breast cancer, cervical cancer, or a related precancerous condition;
(c) Is under sixty-five years of age;
(d) Is not eligible for other WAH-CN coverage, including coverage under the MAGI-based adult group;
(e) Is uninsured or does not otherwise have creditable coverage;
(f) Meets residency requirements under WAC 182-503-0520;
(g) Meets Social Security number requirements under WAC 182-503-0515;
(h) Is a U.S. citizen, U.S. national, qualifying American Indian born abroad, or qualified alien under WAC 182-503-0535; and
(i) Meets the income standard set by the BCCHP in DOH form 342-031.
(2) The certification period for breast and cervical cancer treatment covered under this section is twelve months, as provided in WAC 182-504-0015. To remain continuously enrolled, the client must renew her eligibility before the certification period ends. Eligibility for BCCTP coverage under subsection (1)(b) of this section continues throughout the course of treatment as certified by the BCCHP. Retroactive coverage may be available under WAC 182-504-0005.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-17-056, § 182-505-0120, filed 8/14/15, effective 9/14/15. Statutory Authority: RCW 41.05.021, 41.05.160, 2014 c 221. WSR 14-21-075, § 182-505-0120, filed 10/10/14, effective 11/10/14. WSR 12-02-034, recodified as § 182-505-0120, filed 12/29/11, effective 1/1/12. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.08.090. WSR 04-15-057, § 388-462-0020, filed 7/13/04, effective 8/13/04. Statutory Authority: RCW 74.08.090, 74.04.050, 74.04.057, 74.09.530, 74.09.510, and Public Law 106-354. WSR 02-01-134, § 388-462-0020, filed 12/19/01, effective 1/19/02.]


PDF182-505-0210

Eligibility for children.

(1) General eligibility. For purposes of this section, a child must:
(a) Be a Washington state resident under WAC 182-503-0520 and 182-503-0525;
(b) Provide a Social Security number under WAC 182-503-0515, unless exempt; and
(c) Meet program-specific requirements.
(2) Deemed eligibility groups. A child is automatically eligible for coverage without an application if the child meets the program-specific requirements in (a) through (c) of this subsection.
(a) Newborn coverage. A child under age one is eligible for categorically needy (CN) coverage if the birth parent was eligible for Washington apple health on the date of delivery:
(i) Including a retroactive eligibility determination; or
(ii) By meeting a medically needy (MN) spenddown liability with expenses incurred by the date of the newborn's birth:
(b) Washington apple health for supplemental security income (SSI) recipients. A child who is eligible for SSI is automatically eligible for CN coverage under WAC 182-510-0001.
(c) Foster care coverage. A child age 20 and younger is eligible for CN coverage under WAC 182-505-0211 when the child is in foster care or receives subsidized adoption services. For children who age out of the foster care program, see WAC 182-505-0211(3).
(3) Continuous eligibility for children under age six. Children are eligible for Washington apple health continuous eligibility for children under age six when they:
(a) Have household income at or below 215 percent of the federal poverty level at the time of application; or
(b) Received coverage under subsection (5) of this section and are no longer eligible for deemed coverage under subsection (5)(b) or (c) of this section.
(4) MAGI-based eligibility groups. A child age 18 and younger is eligible for CN coverage based on modified adjusted gross income (MAGI):
(a) At no cost when the child's countable income does not exceed the standard in WAC 182-505-0100 (6)(a);
(b) With payment of a premium when the child's countable income does not exceed the standard in WAC 182-505-0100 (6)(b), and the child meets additional eligibility criteria in WAC 182-505-0215;
(c) Under chapter 182-514 WAC, if the child needs long-term care services because the child resides or is expected to reside in an institution, as defined in WAC 182-500-0050, for 30 days or longer. An institutionalized child is eligible for coverage under the medically needy program if income exceeds the CN income standard for a person in an institution (special income level);
(d) Under WAC 182-505-0117, if a child is pregnant.
(5) Non-MAGI-based children's programs. The agency determines eligibility for the:
(a) Medically needy (MN) program according to WAC 182-510-0001(6) and 182-519-0100. A child age 18 and younger is eligible if the child:
(i) Is not eligible for MAGI-based coverage under subsection (4) of this section;
(ii) Meets citizenship or immigration requirements under WAC 182-503-0535 (2)(a), (b), (c), or (d); and
(iii) Meets any spenddown liability required under WAC 182-519-0110.
(b) SSI-related program. A child age 18 and younger is eligible for CN or MN SSI-related coverage if the child meets:
(i) SSI-related eligibility under chapter 182-512 WAC;
(ii) Citizenship or immigration requirements under WAC 182-503-0535 (2)(a), (b), (c), or (d); and
(iii) Any MN spenddown liability under WAC 182-519-0110.
(c) SSI-related long-term care program.
(i) A child age 18 and younger is eligible for home and community based (HCB) waiver programs under chapter 182-515 WAC if the child meets:
(A) SSI-related eligibility under chapter 182-512 WAC;
(B) Citizenship or immigration requirements under WAC 182-503-0535 (2)(a), (b), (c), or (d); and
(C) Program-specific age and functional requirements under chapters 388-106 and 388-845 WAC.
(ii) A child age 18 and younger who resides or is expected to reside in a medical institution as defined in WAC 182-500-0050 is eligible for institutional medical under chapter 182-513 WAC if the child meets:
(A) Citizenship or immigration requirements under WAC 182-503-0535 (2)(a), (b), (c), or (d);
(B) Blindness or disability criteria under WAC 182-512-0050; and
(C) Nursing facility level of care under chapter 388-106 WAC.
(6) Alien emergency medical program. A child age 20 and younger who does not meet the eligibility requirements for a program described under subsections (2) through (5) of this section is eligible for the alien emergency medical (AEM) program if the child meets:
(a) The eligibility requirements of WAC 182-507-0110; and
(b) MN spenddown liability, if any, under WAC 182-519-0110.
(7) Other provisions.
(a) A child residing in an institution for mental disease (IMD) as defined in WAC 182-500-0050(1) is not eligible for inpatient hospital services, unless the child is unconditionally discharged from the IMD before receiving the services.
(b) A child incarcerated in a public institution as defined in WAC 182-500-0050(4) is only eligible for inpatient hospital services.
[Statutory Authority: RCW 41.05.021, 41.05.160, and 2023 c 475 § 211(36). WSR 23-23-057, § 182-505-0210, filed 11/8/23, effective 12/9/23. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-12-018, § 182-505-0210, filed 5/30/17, effective 6/30/17; WSR 16-01-034, § 182-505-0210, filed 12/8/15, effective 1/8/16; WSR 15-15-153, § 182-505-0210, filed 7/21/15, effective 8/21/15. 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, § 182-505-0210, filed 7/29/14, effective 8/29/14. WSR 12-13-056, recodified as § 182-505-0210, filed 6/15/12, effective 7/1/12. Statutory Authority: RCW 41.05.021, 74.04.050, 74.04.057, 74.09.500, and PPACA, § 2102 (b)(1)(A) of the Social Security Act, and Public Law 111-3 (CHIPRA). WSR 11-23-077, § 388-505-0210, filed 11/15/11, effective 12/16/11. 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, § 388-505-0210, 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, § 388-505-0210, 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, § 388-505-0210, filed 2/12/08, effective 3/14/08. Statutory Authority: RCW 74.08.090, 74.09.530, and 74.09.415. WSR 05-23-013, § 388-505-0210, filed 11/4/05, effective 1/1/06. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.08.090. WSR 04-15-057, § 388-505-0210, filed 7/13/04, effective 8/13/04. Statutory Authority: RCW 74.08.090 and 74.04.050. WSR 03-14-107, § 388-505-0210, filed 6/30/03, effective 7/31/03. Statutory Authority: RCW 74.08.090, 74.08A.100, 74.09.080, and 74.09.415. WSR 02-17-030, § 388-505-0210, filed 8/12/02, effective 9/12/02. Statutory Authority: RCW 74.08.090, 74.04.050, [74.04.]055, and [74.04.]057. WSR 01-11-110, § 388-505-0210, filed 5/21/01, effective 6/21/01. Statutory Authority: RCW 74.08.090 and 74.08A.100. WSR 99-17-023, § 388-505-0210, filed 8/10/99, effective 9/10/99. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. WSR 98-16-044, § 388-505-0210, filed 7/31/98, effective 9/1/98. Formerly WAC 388-509-0905, 388-509-0910 and 388-509-0920.]


PDF182-505-0211

Washington apple health—Foster care.

(1) A client under the age of 18 is eligible for Washington apple health foster care coverage when they:
(a) Are in foster care, as determined by the department of children, youth, and families (DCYF), under the legal responsibility of the state, or a federally recognized tribe located within the state; and
(b) Meet Washington residency requirements as described in WAC 182-503-0520 or 182-503-0525.
(2) A client age 20 or younger is eligible for coverage when the client meets:
(a) Washington residency requirements as described in WAC 182-503-0520 or 182-503-0525;
(b) Citizenship or immigration status requirements as described in WAC 182-503-0535;
(c) Social Security number requirements as described in WAC 182-503-0515; and
(d) One of the following requirements:
(i) Is in foster care, or is eligible for continued foster care services as determined by DCYF, under the legal responsibility of the state, or a federally recognized tribe located within the state; or
(ii) Receives subsidized adoption services through DCYF; or
(iii) Is enrolled in the unaccompanied refugee minor (URM) program as authorized by the office of refugee and immigrant assistance (ORIA); or
(iv) Is living in a community facility (as defined in WAC 110-700-0005) operated or contracted by DCYF's juvenile rehabilitation.
(3) A client age 18 or older but under age 26 is eligible for Washington apple health coverage when the client:
(a) Was in foster care under the legal responsibility of any state or a federally recognized tribe located within any state:
(i) On the client's 18th birthday; or
(ii) At such higher age as to when the state or tribe extends foster care coverage; and
(b) Meets residency, Social Security number, and citizenship requirements as described in subsection (2) of this section.
(4) A client described in subsections (1) through (3) of this section is not eligible for full-scope coverage if the client is confined to a public institution as defined in WAC 182-500-0050, except:
(a) If the client is under age 21;
(b) Resides in an institution for mental disease (IMD); and
(c) Meets the institutional status requirements in WAC 182-513-1320, 182-514-0250, or 182-514-0260.
[Statutory Authority: RCW 41.05.021, 41.05.160, and P.L. 115-271, Sec. 1002. WSR 22-20-049, § 182-505-0211, filed 9/28/22, effective 1/1/23. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-12-017, § 182-505-0211, filed 5/30/17, effective 6/30/17. Statutory Authority: RCW 41.05.021, Patient Protection and Affordable Care Act (P.L. 111-148), 42 C.F.R. §§ 431, 435, 457, and 45 C.F.R. § 155. WSR 14-01-021, § 182-505-0211, filed 12/9/13, effective 1/9/14.]


PDF182-505-0215

Children's Washington apple health with premiums.

(1) A child is eligible for Washington apple health with premiums if the child:
(a) Meets the requirements in WAC 182-505-0210(1);
(b) Has countable income below the standard in WAC 182-505-0100 (6)(b); and
(c) Pays the required premium under WAC 182-505-0225, unless the child is exempt under WAC 182-505-0225 (2)(c).
(2) A child is not eligible for Washington apple health with premiums if the child:
(a) Is eligible for no-cost Washington apple health; or
(b) Has creditable health insurance coverage as defined in WAC 182-500-0020.
(3) A child with creditable health insurance coverage may be eligible for Washington apple health with premiums if the child:
(a) Is eligible for either:
(i) Public employees benefits board (PEBB) health insurance coverage based on a family member's employment with a Washington state agency, or a Washington state university, community college, or technical college; or
(ii) School employees benefits board (SEBB) health insurance coverage based on a family member's employment with a Washington school district, charter school, or educational service district; and
(b) Meets the requirements in subsection (1) of this section.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 21-01-207, § 182-505-0215, filed 12/23/20, effective 1/23/21. Statutory Authority: RCW 41.05.021, 41.05.160, 41.05.050, 41.05.065, 34.05.010, 74.09.500 and 42 C.F.R. 457.310. WSR 19-21-103, § 182-505-0215, filed 10/16/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-12-018, § 182-505-0215, 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, § 182-505-0215, filed 7/29/14, effective 8/29/14. WSR 12-13-056, recodified as § 182-505-0215, filed 6/15/12, effective 7/1/12. 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, § 388-542-0010, 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, § 388-542-0010, filed 2/12/08, effective 3/14/08. Statutory Authority: RCW 74.08.090, 74.09.050, and Title XXI of the Social Security Act. WSR 06-15-134, § 388-542-0010, filed 7/19/06, effective 8/19/06. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.522, 74.09.450, and 2004 c 276. WSR 04-16-064, § 388-542-0010, filed 7/30/04, effective 8/30/04.]


PDF182-505-0225

Children's Washington apple health with premiums—Calculation and determination of premium amount.

(1) For the purposes of this chapter, "premium" means an amount paid for health care coverage under WAC 182-505-0215.
(2) Premium requirement. Eligibility for Washington apple health premium-based program under WAC 182-505-0215 requires payment of a monthly premium.
(a) The first monthly premium is due in the month following the determination of eligibility.
(b) There is no premium requirement for health care coverage received in the month eligibility is determined or in any prior month.
(c) A child who is American Indian or Alaska native is exempt from the monthly premium requirement.
(3) Monthly premium amount.
(a) The premium amount for the medical assistance unit (MAU) is based on countable income under chapter 182-509 WAC and the number of people in the MAU under chapter 182-506 WAC.
(b) The premium amount is as follows:
(i) If the MAU's countable income exceeds two hundred ten percent of the federal poverty level (FPL) but does not exceed two hundred sixty percent of the FPL, the monthly premium for each child is $20.
(ii) If the MAU's countable income exceeds two hundred sixty percent of the FPL but does not exceed three hundred twelve percent of the FPL, the monthly premium for each child is $30.
(iii) The medicaid agency charges a monthly premium for no more than two children per household.
(iv) Payment of the full premium is required. Partial payments cannot be designated for a specific child or month.
(v) Any third party may pay the premium on behalf of the household. Failure of a third party to pay the premium does not eliminate the obligation of the household to pay past due premiums.
(c) A change that affects the premium amount takes effect the month after the change is reported.
(4) Nonpayment of premiums.
(a) Premium-based coverage ends for all children in the household if the required premiums are not paid for three consecutive months.
(b) Premium-based coverage is restored back to the month coverage ended if the unpaid premiums are fully paid before the certification period ends.
(c) The household may reapply for premium-based coverage ninety days after the coverage ended for nonpayment.
(d) The agency writes off past-due premiums after twelve months.
[Statutory Authority: RCW 41.05.021 and, 41.05.160. WSR 17-12-018, § 182-505-0225, filed 5/30/17, effective 6/30/17. WSR 12-13-056, recodified as § 182-505-0225, filed 6/15/12, effective 7/1/12. Statutory Authority: RCW 41.05.021, 74.04.050, 74.04.057, 74.09.500, and PPACA, § 2102 (b)(1)(A) of the Social Security Act, and Public Law 111-3 (CHIPRA). WSR 11-23-077, § 388-505-0211, filed 11/15/11, effective 12/16/11. 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, § 388-505-0211, 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, § 388-505-0211, 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, § 388-505-0211, filed 2/12/08, effective 3/14/08. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.522, 74.09.450, and 2004 c 276. WSR 04-16-064, § 388-505-0211, filed 7/30/04, effective 8/30/04. Statutory Authority: RCW 74.08.090, 74.09.055, 2004 c 276. WSR 04-08-125, § 388-505-0211, filed 4/7/04, effective 5/8/04.]


PDF182-505-0240

Parents and caretaker relatives.

(1) A person is eligible for Washington apple health categorically needy (CN) coverage when the person:
(a) Is a parent or caretaker relative of a dependent child who meets the criteria described in WAC 182-503-0565(2);
(b) Meets citizenship and immigration status requirements described in WAC 182-503-0535;
(c) Meets general eligibility requirements described in WAC 182-503-0505; and
(d) Has countable income below the standard in WAC 182-505-0100(2).
(2) To be eligible for coverage as a caretaker relative, a person must be related to a dependent child who meets the criteria described in WAC 182-503-0565(2).
(3) A person must cooperate with the state of Washington in the identification, use and collection of medical support from responsible third parties as described in WAC 182-503-0540.
(4) A person who does not cooperate with the requirements in subsection (3) of this section is not eligible for coverage.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-12-018, § 182-505-0240, 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, § 182-505-0240, filed 7/29/14, effective 8/29/14. WSR 12-13-056, recodified as § 182-505-0240, filed 6/15/12, effective 7/1/12. Statutory Authority: RCW 74.04.050, 74.04.057, and 74.08.090. WSR 11-13-031, § 388-505-0220, filed 6/7/11, effective 7/8/11. Statutory Authority: RCW 74.04.050 and 74.08.090. WSR 08-19-099 and 08-20-014, § 388-505-0220, filed 9/17/08 and 9/18/08, effective 10/18/08 and 10/19/08. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.04.510, and 74.08.090. WSR 08-14-105, § 388-505-0220, filed 6/30/08, effective 8/1/08. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and 74.09.530. WSR 05-16-127, § 388-505-0220, filed 8/3/05, effective 9/3/05. Statutory Authority: RCW 74.08.090, 74.08A.100, 74.09.080, and 74.09.415. WSR 02-17-030, § 388-505-0220, filed 8/12/02, effective 9/12/02. Statutory Authority: RCW 74.08.090, 74.04.050, [74.04.]055, and [74.04.]057. WSR 01-11-110, § 388-505-0220, filed 5/21/01, effective 6/21/01; WSR 98-16-044, § 388-505-0220, filed 7/31/98, effective 9/1/98. Formerly WAC 388-507-0740 and 388-522-2210.]


PDF182-505-0250

Washington apple health—MAGI-based adult medical.

(1) Effective on or after January 1, 2014, a person is eligible for Washington apple health (WAH) modified adjusted gross income (MAGI)-based adult coverage when he or she meets the following requirements:
(a) Is age nineteen or older and under the age of sixty-five;
(b) Is not entitled to, or enrolled in, medicare benefits under Part A or B of Title XVIII of the Social Security Act;
(c) Is not otherwise eligible for and enrolled in mandatory coverage under one of the following programs:
(i) WAH SSI-related categorically needy (CN);
(ii) WAH foster care program; or
(iii) WAH adoption support program;
(d) Meets citizenship and immigration status requirements described in WAC 182-503-0535;
(e) Meets general eligibility requirements described in WAC 182-503-0505; and
(f) Has net countable income that is at or below one hundred thirty-three percent of the federal poverty level for a household of the applicable size.
(2) Parents or caretaker relatives of an eligible dependent child as described in WAC 182-503-0565 are first considered for WAH for families as described in WAC 182-505-0240. A person whose countable income exceeds the standard to qualify for family coverage is considered for coverage under this section.
(3) Persons who are eligible under this section are eligible for WAH alternative benefit plan as defined in WAC 182-500-0010 coverage. A person described in this section is not eligible for medically needy WAH.
(4) Other coverage options for adults not eligible under this section are described in WAC 182-508-0001.
[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, § 182-505-0250, filed 7/29/14, effective 8/29/14.]


PDF182-505-0300

Hospital presumptive eligibility.

(1) Purpose. The hospital presumptive eligibility (HPE) program provides temporary Washington apple health coverage to HPE-eligible persons who enroll through an HPE-qualified hospital.
(2) HPE-eligible persons. To be HPE-eligible:
(a) A person must:
(i) Be younger than age 65; and
(ii) Meet the eligibility requirements for one or more of the following programs:
(A) Washington apple health for pregnant women (chapter 182-505 WAC);
(B) Washington apple health for kids (chapter 182-505 WAC);
(C) Washington apple health for foster care (chapter 182-505 WAC);
(D) Washington apple health for parents and caretaker relatives (chapter 182-505 WAC);
(E) Washington apple health for adults (chapter 182-505 WAC); or
(F) Family planning only services (chapter 182-532 WAC).
(b) A person must not:
(i) Be an apple health beneficiary;
(ii) Be a supplemental security income beneficiary; or
(iii) Have received HPE coverage within the preceding 24 months.
(3) HPE-qualified hospitals. To be HPE-qualified, a hospital must:
(a) Operate in Washington state;
(b) Submit a signed core provider agreement (CPA) to the agency;
(c) Submit a signed HPE agreement to the agency;
(d) Comply with the terms of the CPA and HPE agreements;
(e) Determine HPE eligibility using only those employees who have successfully completed the agency's HPE training;
(f) Agree to provide HPE-application assistance to anyone who requests it; and
(g) Agree to be listed on the agency's website as an HPE-application assistance provider.
(4) Limitations.
(a) An HPE-qualified hospital must attempt to help the person complete a regular apple health application before filing an HPE application. If the person cannot indicate whether they expect to file a federal tax return or be claimed as a tax dependent, the HPE-qualified hospital may treat the person as a nonfiler under WAC 182-506-0010 (5)(c) for HPE purposes.
(b) HPE coverage begins on the earlier of:
(i) The day the HPE-qualified hospital determines the person is eligible; or
(ii) The day the HPE-qualified hospital provides a covered medical service to the person, but only if the hospital determines the person is eligible and submits the decision to the agency no later than five calendar days after the date of service.
(c) HPE coverage ends on the earlier of:
(i) The last day of the month following the month in which HPE coverage began; or
(ii) The day the agency determines the person is eligible for other apple health coverage.
(d) HPE coverage does not qualify a person for continuous eligibility under WAC 182-504-0015.
(e) If HPE coverage is based on pregnancy, the pregnant person is eligible for HPE coverage only once for that pregnancy.
(f) The HPE program covers only those services included in the programs listed in subsection (2)(e) of this section, except that pregnancy-related services are limited to ambulatory prenatal care.
(g) A child born to a person with HPE coverage is ineligible for apple health under WAC 182-505-0210(2). An HPE-qualified hospital must complete a separate HPE determination for the newborn child.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-11-007, § 182-505-0300, filed 5/4/23, effective 6/4/23; WSR 17-12-018, § 182-505-0300, filed 5/30/17, effective 6/30/17. Statutory Authority: RCW 41.05.021, 41.05.160, Patient Protection and Affordable Care Act established under Public Law 111-148. WSR 15-06-039, § 182-505-0300, filed 2/26/15, effective 3/29/15.]
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