Change of Circumstances - Effect on Medical
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Change of Circumstances - Effect on Medical


Revised April 18, 2013



Purpose:

WAC 182-504-0125Effect of changes on medical program eligibility.

WAC 182-504-0125
WAC 182-504-0125

Effective October 1, 2013

WAC 182-504-0125 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 (WAH) coverage until we decide if you can keep getting WAH coverage under a different WAH program.

(2) If your WAH categorically needy (CN) coverage ends due to a reported change and you meet all the eligibility requirements for a different WAH CN program, we will approve your coverage under the new WAH CN program. If you are not eligible for coverage under any WAH CN program but you meet the eligibility requirements for either WAH alternative benefits plan (ABP) coverage or WAH medically need (MN) coverage, we will approve your coverage under the program you are eligible for. If you are not eligible for coverage under any WAH CN program but you meet the eligibility requirements for both WAH ABP coverage and WAH MN coverage, we will approve the coverage that provides more appropriate coverage for your medical needs.

(3) If your WAH coverage ends and you are not eligible for a different WAH program, we stop your WAH coverage after giving you advance and adequate notice, unless the exception in subsection (4) applies to you.

(4) If you claim to have a disability and that is the only basis for you to be potentially eligible for WAH 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 WAH 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 WAH MN with spenddown as described in chapter 182-519 WAC, pending the final outcome of the disability determination.

(5) If you receive coverage under the WAH parent and caretaker relative program described in WAC 182-505-0240, you will be eligible for the WAH health care 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) WAH for pregnant women;

(b) WAH for kids, except as specified in subsection (7) of this section;

(c) WAH for SSI recipients;

(d) WAH refugee program; and

(e) WAH medical extension program.

(7) We redetermine eligibility for children receiving WAH for kids premium-based coverage described in WAC 182-505-0210 when the:

(a) Household's countable income decreases to less than two hundred percent federal poverty level (FPL);

(b) Child becomes pregnant;

(c) Family size changes; or

(d) Child receives SSI.

(8) If you get SSI-related WAH 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 individual as described in WAC 182-512-0050, due to work or earnings at the level of substantial gainful activity, we re-determine 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 188-511 WAC..

(9) Prior to a scheduled renewal or March 31, 2014, whichever is later, your WAH coverage will not end and you will not pay more for your WAH coverage as a result of an eligibility determination if:

(a) You are enrolled in WAH at the time of the eligibility determination;

(b) You were enrolled in WAH prior to October 1, 2013; and

(c) At the time of the eligibility determination, your enrollment in WAH is not yet based on MAGI methodologies.

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 receive 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 182-505-0225  and WAC 182-505-0220  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 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
Modification Date: April 18, 2013