Change of Circumstances - Effect on Medical

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Revised December 14, 2011

Purpose:

WAC 182-504-0125

Effect of changes on medical program eligibility. (Emergency rule effective 11/18/11.)

WAC 182-504-0125

Effective November 18, 2011

WAC 182-504-0125 Effect of changes on medical program eligibility. (Emergency rule effective 2/29/12.)

1. An individual continues to be eligible for medical assistance until the agency or the agency's designee completes a review of the individual's case record and determines the individual is ineligible for medical assistance or is eligible for another medical program. This applies to all individuals who, during a certification period, become ineligible for, or are terminated from, or request termination from:

a. A categorically needy (CN) medicaid program;

b. A program included in apple health for kids; or

c. Any of the following cash grants:

i. Temporary assistance for needy families (TANF);

ii. Supplemental Security Income (SSI); or

iii. Aged, blind, disabled (ABD) cash assistance. See WAC 388-434-0005 for changes reported during eligibility review.

2. If CN medical coverage ends under one program and the individual meets all the eligibility requirements to be eligible under a different CN medical program, coverage is approved under the new program. If the individual's income exceeds the standard for CN medical coverage, the agency or the agency's designee considers eligibility under the medically needy (MN) program where appropriate.

3. If CN medical coverage ends and the individual does not meet the eligibility requirements to be eligible under a different medical program, the redetermination process is complete andmedical assistance is terminated giving advance and adequate notice with the following exception:

a. An individual who claims to have a disability is referred to the division of disability determination services for a disability determination if that is the only basis under which the individual is potentially eligible for medical assistance. Pending the outcome of the disability determination, medical eligibility is considered under the SSI-related medical program described in chapter 388-475 WAC.

b. An individual with countable income in excess of the SSI related CN medical standard is considered for medically needy (MN) coverage or medically needy (MN) with spenddown pending the final outcome of the disability determination.

4. An individual who becomes ineligible for refugee cash assistance is eligible for continued refugee medical assistance through the eight-month limit, as described in WAC 388-400-0035(4).

5. An individual who receives a TANF cash grant or family medical is eligible for a medical extension, as described under WAC 388-523-0100, when the cash grant or family medical program is terminated as a result of:

a. An increase in earned income; or

b. Collection of child or spousal support.

6. Changes in income during a certification period affects eligibility for all medical programs except:

a. Pregnant women's CN medical programs;

b. A program included in apple health for kids, except as specified in subsection (5) of this section; or

c. The first six months of the medical extension benefits described under chapter 388-523 WAC.

7. A child who receives premium-based coverage under a program included in apple health for kids described in WAC 388-505-0210 and chapter 388-542 WAC must be redetermined for a nonpremiumbased coverage when the family reports:

a. Family income has decreased to less than two hundred percent federal poverty level (FPL);

b. The child becomes pregnant;

c. A change in family size; or

d. The child receives SSI.

8. An individual who receives SSI-related CN medical coverage and reports a change in earned income which exceeds the substantial gainful activity (SGA) limit set by Social Security Administration no longer meets the definition of a disabled individual as described in WAC 388-475-0050, unless the individual continues to receive a Title 2 cash benefit, e.g., SSDI, DAC, or DWB. The agency or the agency's designee redetermines eligibility for such an individual under the health care for workers with disabilities (HWD) program which waives the SGA income test. The HWD program is a premium-based program and the individual must approve the premium amount before the agency or the agency's designee can authorize ongoing CN medical benefits under this program.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

CLARIFYING INFORMATION

1. Pregnant women and children found eligible for a CN medical program are continuously eligible through the end of their certification period. The only exceptions are aging out of the program, moving out of state, failing to pay a required premium, incarceration, or death. See WAC 182-504-0015.

NOTE:

Newborns approved SSI receives continuous CN for 12 months from the date of the SSI medical opening even if they are no longer eligible under the SSI program.

2. If mail is returned, see if a forwarding address is provided.

If one is provided, update the address. No further action is necessary.
If one is not provided, terminate the assistance for loss of contact/whereabouts unknown. Advance notice is not necessary.
If the client provides an updated Washington address at any time during the original certification period, the assistance unit is reinstated from the month of termination through the end of the original certification period. A new application is not necessary.

EXAMPLE

A household is receiving medical assistance for their children under the F06 program. The original certification period is January through December. In April, mail is returned with no forwarding address. The medical assistance is closed for loss of contact/whereabouts unknown effective 4/30/xx, and a termination letter is sent. In June, the client calls the worker and reports a new Washington address. The worker reinstates the assistance unit from May through December without requiring a new application.

3. When a child is terminated from a CN program because the head of household left the home, the child left the home, out of state residence, citizenship, whereabouts unknown, or no longer in institutional care, the system does not auto-open F06 but does track the 12 month eligibility for that child. When the child reapplies at any time during the remainder of the 12 calendar months of tracking and satisfies non-financial eligibility requirements, the system will approve CN under medical coverage group F06 for the remainder of the 12 month period regardless of income. A child who is no longer eligible for institutional medical coverage under the K01 program because they have discharged from the institutional setting is NOT required to submit a new application or review to receive the balance of the certification. Process the change in living arrangements as a change of circumstances and open an F06 AU for that child through the original certification date.

EXAMPLE

A child is in the hospital and receiving CN coverage under medical coverage group K01. The child is released to return home. The system does not have enough information on the household to automatically open the child on F06. Add an F06 AU to the active K01 AU and allow the system to close the K01 AU as the living arrangement code is updated in each process month. If parental income is not verified or known, code the parents' income verification field as "failed" and the system will not establish a new 12 month certification. It will recognize the continuous eligibility tracking from the K01 program and continue medical coverage for the child under the F06 program for the balance of their 12 month certification period. When a medical request for this child is screened into the system, the system looks at all eligibility factors. If non-financial and financial requirements are met, the system opens a new 12 month certification period and the child begins a new tracking period.

4. See WAC 388-505-0211 and WAC 388-542-0050 for information on closure of premium-based children's healthcare coverage for a client who:

a. Fails to pay their premiums, or

b. Had creditable health insurance coverage at the time of their application or review.

5. When a pregnancy ends, regardless of the reason, medical coverage continues through the end of the month containing the sixtieth day from the day pregnancy ends.

NOTE:

If the pregnant woman is pending spenddown when the baby is born and meets spenddown with the birth of the baby she is eligible for 60 days postpartum MN extension.

6. A working TANF recipient is eligible for family medical even when he/she chooses to terminate cash assistance to save cash TANF months. The client is eligible for family medical (F04) as long as countable income is less than the CNIL.

EXAMPLE

A mother and her two children receive TANF cash benefits. The mother starts working. To 'bank' cash assistance months she requests termination. Redetermine eligibility for TANF-related family medical (F04).

7. See MEDICAL EXTENSIONS for:

a. Medical Extension Report; or

b. A change resulting in eligibility for a medical extension.

8. If changes in income increase the spenddown liability, the change is effective the first of the month after the change. An increase in resources may affect MN eligibility.

WORKER RESPONSIBILITIES

If the client has not met the increased spenddown liability, terminate MN or MI giving advance and adequate notice. See SPENDDOWN.

ACES PROCEDURES

Interview:	See Interview
Add a Person:	See Add a Person
Add a Program:	See Add a Program
Update AU / Client Data:	See Update Assistance Unit / Client Data
Terminating an AUs / Client's Benefits:	See Close Assistance Unit / Client
Adverse Action:	See Update Assistance Unit / Client Data See Deny an Assistance Unit / Client
Trickling and Sprouting:	See Trickle and Sprout