Medical Assistance Programs - Family Medical Programs
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Medical Assistance Programs - Family Medical Programs

Revised May 15, 2012

Purpose: This category describes the medical programs available for children and their caretakers.
WAC 388-505-0210Apple Health for kids and other children's medical assistance programs.
WAC 388-505-0211Premium requirements for premium-based healthcare coverage under programs included in apple health for kids.
WAC 388-505-0220Family medical eligibility.

CLARIFYING INFORMATION

  1. The family may:
    1. Receive a cash grant under the Temporary Assistance for Needy Families (TANF);
    2. Be eligible for TANF but choose not to receive cash assistance, such as recipients of diversion cash assistance; or
    3. Be determined ineligible for TANF cash assistance for a reason that does not apply to medical programs as described in WAC 388-505-0220.
  2. Consider the family as described in Assistance Units - Medical programs, including the establishment of separate medical assistance units (MAUs), if necessary.
  3. All family members may not be eligible for a medical program.  Some members may enroll in Healthy Options and others may not.
  4. For family members who are not eligible under this category, refer to the following categories:
    1. SSI-related Medical for children and adults who may meet SSI disability criteria services and is ineligible for any other medical program;
    2. Pregnancy for medical programs for pregnant women;
    3. Emergency Assistance: Alien Emergency Medical Program for an alien adult or child who is related to a Medicaid program, including the aged, blind, and disabled;
    4. Long Term Care for family members requiring nursing facility or home and community-based services;
    5. Medical Extensions for a family who has an increase in earned income, spousal support, or child support;
    6. Spenddown for a child, pregnant woman, or an SSI-related adult whose income exceeds program standards.  They may be eligible to receive Medically Needy (MN) coverage.

WAC 388-505-0210
WAC 388-505-0210

Effective December 16, 2011

WAC 388-505-0210 Apple Health for kids and other children's medical assistance programs.

Funding for coverage under Apple Health for Kids may come through Title XIX (medicaid), Title XXI (CHIP), or through state-funded programs. There are no resource limits for the Apple Health for Kids programs.  Apple Health for Kids coverage is free to children in households with incomes of no more than two-hundred percent of the federal poverty level (FPL), and available on a premium basis to children in households with incomes of no more than three-hundred percent FPL.

1.  Newborns are eligible for federally matched categorically needy (CN) coverage through  their first birthday when:

a.  The newborn is a resident of the state of Washington.

b.  The newborn's mother is eligible for medical assistance:

i. On the date of the newborn's birth, including a retroactive eligibility determination; or

ii.  Based on meeting a medically needy (MN) spenddown liability with expenses incurred on, or prior to, the date of the newborn's birth.

2. Children under the age of nineteen who are U.S. citizens, U.S. nationals, or lawfully present qualified or nonqualified aliens as described in WAC 388-424-0001, WAC 388-424-0010 (4), and WAC 388-424-0006 (1), (4) and (5)  are eligible for free federally matched CN coverage when they meet the following criteria:

a.  State residence as described in chapter 388-468 WAC;

b.  A social security number or application as described in chapter 388-476 WAC;

c.  Proof of citizenship or immigrant status and identity as required by WAC 388-490-0005 (11);

d.  Family income is at or below two-hundred percent Federal Poverty Level (FPL) as described in WAC 388-478-0075  at each application or review; or

e.  They received supplemental security income (SSI) cash payments in August 1996 and would continue to be eligible for those payments except for the August 1996 passage of amendments to federal disability definitions.

f.  They are currently eligible for SSI.

3.  Non-citizen children under the age of nineteen, who are not lawfully present qualified or nonqualified aliens as described in WAC as described in  WAC 388-424-0001,  WAC 388-424-0010 (4), and WAC 388-424-0006 (1), (4), and (5),  are eligible for free state-funded coverage when they meet the following criteria:

a.  State residence as described in chapter 388-468 WAC; and

b.  Family income is at or below two hundred percent FPL at each application or review.

4.  Children under the age of nineteen who are U.S. citizens, U.S. nationals, or lawfully present qualified or nonqualified aliens as described in WAC 388-424-0001, WAC 388-424-0010 (4),  and WAC 388-424-0006 (1), (4), and (5) are eligible for premium-based federally-matched CN coverage as described in chapter 388-542 WAC  when they meet the following criteria:

a.  State residence as described in chapter 388-468 WAC;

b.  Proof of citizenship or immigrant status and identity as required by WAC 388-490-0005 (11);

c.   Family income is over two-hundred percent FPL, as described in WAC 388-478-0075, but not over three-hundred percent FPL at each application or review;

d.  They do not have other creditable health insurance as described in WAC 388-542-0050; and

e.  They pay the required monthly premiums as described in WAC 388-505-0211.

5.  Noncitizen children under the age of nineteen, who are not lawfully present qualified or nonqualified aliens as described in WAC 388-424-0001, 388-424-0010 (4), and 388-424-0006 (1), (4), and (5), are eligible for premium-based state-funded coverage when they meet the following criteria:

a.  State residence as described in chapter 388-468 WAC;

b.  Family income is over two-hundred percent FPL, as described in WAC 388-478-0075, but not over three-hundred percent FPL at each application or review;

c.  They do not have other creditable health insurance as described in WAC 388-542-0050; and

d.  They pay the required monthly premium as described in WAC 388-505-0211.

 

 6.  Children under age 19 are eligible for the medically needy (MN) medicaid program when they meet the following criteria:

a.  Citizenship or immigrant status, state residence, and social security number requirements as described in subsection (2) (a), (b), and (c) of this section;

b.  Are ineligible for other federally-matched CN programs;

c. Have income that exceeds three hundred percent FPL; or

d. Have income less than three hundred percent FPL, but do not qualify for premium-based coverage as described in subsection (4) of this section because of creditable coverage; and

e. Meet their spenddown liability as described in WAC 388-519-0100  and WAC 388-519-0110.

7.  Children under the age of nineteen who reside or are expected to reside in a medical institution, intermediate care facility for the mentally retarded (ICF/MR), hospice care center, nursing home, institution for mental diseases (IMD) or inpatient psychiatric facility may be eligible for Apple Health for Kids healthcare coverage based upon institutional rules described in WAC 388-505-0260.  Individuals between the age of nineteen and twenty-one may still be eligible for healthcare coverage but not under Apple Health for Kids. See WAC 388-505-0230  "Family related institutional medical" and WAC 388-513-1320    "Determining institutional status for long-term care" for more information.

8.  Children who are in foster care under the legal responsibility of the state, or a federally recognized tribe located within the state, and who meet eligibility requirements for residency, social security number, and citizenship as described in subsection (2)(a), (b), and (c) of this section are eligible for federally-matched CN medicaid coverage through the month of their:

a.  Eighteenth birthday;

b.  Twenty-first birthday if the Children's Administration determines they remain eligible for continued foster care services; or

c.  Twenty-first birthday if they were in foster care on their eighteenth birthday and that birthday was on or after July 22, 2007.

9.  Children are eligible for state-funded CN coverage through the month of their eighteenth birthday if they:

a.  Are in foster care under the legal responsibility of the state or a federally-recognized tribe located within the state; and

b.  Do not meet social security number and citizenship requirements in subsection (2) (b) and (c) of this section.

10.  Children who receive subsidized adoption services are eligible for federally-matched CN coverage.

11.  Children under the age of nineteen not eligible for apple health for kids programs listed above may be eligible for one of the following medical assistance programs not included in apple health for kids:

a.  Family medical as described in WAC 388-505-0220;

b.  Medical extensions as described in WAC 388-523-0100; or

c.  SSI-related MN if they:

i.  Meet the blind and/or disability criteria of the federal SSI program, or the condition of subsection (2) (e) of this section; and

ii.  Have countable income above the level described in WAC 388-478-0070 (1).d.  Home and community based waiver programs as described in chapter 388-515 WAC; or

e. Alien medical as described in WAC 388-438-0110, if they:

    i. Have a documented emergency medical condition as defined in WAC 182-500-0030;

    ii. Have income more than three hundred percent FPL; or

    iii. Have income less than three hundred percent FPL, but do not qualify for premium-based coverage described in subsection (5) of this section because of creditable coverage.

    12.  Except for a child described in subsection (7) of this section, an inmate of a public institution, as defined in WAC 182-500-0050 (4), is not eligible for any Apple Health for Kids 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

    Apple Health for Kids Programs

    Children found eligible for a categorically needy scope of care medical program (F05, F06, F07, K01) are continuously eligible for Categorically Needy (CN) medical for 12 months regardless of changes; except for aging out of the program, moving out of state, failing to pay a required premium, incarceration, or death. (See WAC 182-504-0125.) The scope of coverage is identical for these programs regardless of the source of funding.  This Section describes:

    To contact MEDS for a case transfer:

    Before 2:00 pm call 1-800-562-3022, Ext 16136.

    After 2:00 pm E-Mail MEDSTRANSFER@HCA.WA.GOV.

    Apple Health for Kids

    1. Newborn Medical (F05): See WAC 388-505-0210 (1). Newborns are automatically entitled to receive CN Medicaid through their first birthday as long as:
      •  Their mother was eligible for medical (medicaid or CHIP) on the day of delivery, including through a retroactive eligibility determination. 
      • For MN spenddown pending on the day of delivery, spenddown was met with the labor and delivery expenses, and
      • The newborn is a Washington State resident. 

    It is important for the newborn to get its own client ID number as soon as possible after the day of delivery, to ensure there are no coverage problems.

    • If the mother is served fee-for-service on the date of the baby's birth, a newborn is covered by Medicaid fee-for-service under the mother's client ID through the month that includes the baby's 60th day of life.
    • Managed care organizations (MCOs, Healthy Options) only cover a newborn on the mother's client ID for the month(s) in which the first 21 days of life occur.  After that, a newborn must have its own client identification number, or the only medical coverage the newborn receives is fee-for-service, up through the month that includes its 60th day of life, or until the newborn is assigned its own client ID number, whichever is earlier.
    • Once the newborn has been issued its own client ID number, the newborn cannot use the mother's client ID number.

    NOTE:

    Due to continuous tracking in ACES there is no longer the need to open a newborn on F05 medical unless you do not have the required verification (SSN).  If you open the newborn on F06 or F05 you must use the newborns date of birth as the application date.  If the existing case is terminated at review for the previous members the newborn will continue on coverage for 12 months from the date added to the program.  If all children and newborn are eligible as one AU at next review (including SSN for newborn) combine children to one AU.   This will minimize the number of reviews to the household and issue a new 12 month certification for all children.

    EXAMPLE

    Client is on family medical with two children with certification through June.  Mom reports newborn born January 10 on an eligibility review.  Mom has also supplied verification she has applied for SSN for the newborn.  Worker adds the newborn to the existing F04 AU with January 10 date of birth as application date.  If at review in June family is now over income for family and children’s medical the AU should trickle to F06 for the newborn only through December.

    EXAMPLE

    Household has active F06 for two children with review due June and active F05 for newborn with review due September.  Review received in June. Client provides SSN for F05 child.  Household is income eligible for F06 for all children.  Add F05 child to existing F06 and complete review.  This will certify all children for a new 12 month certification.

    1. Apple Health for Kids CN coverage (F06):  See WAC 388-505-0210 (2)(3) These children receive federal or state funded CN Medicaid.  Federally funded children are enrolled in Healthy Options or Basic Health Plus (managed care) while state funded children remain fee-for-service.

    NOTE:

    A pregnant minor should be left on an F06 or F07 program unless the family income  is over 300% FPL (pregnancy is an exemption from premiums, be sure to document pregnancy on the DEM1 screen).  If family income is over 300% put the pregnant minor on the P02 program.  On P02, only the income contributed by the parents to the pregnant minor is considered available to her..  This applies whether or not the pregnant minor is living in the parent’s home.

    1. Apple Health for Kids CN Coverage (F07): See WAC 388-505-0210 (4). These children receive federal or state funded CN medical, but are required to pay a premium see WAC 388-505-0211.Federally funded children are enrolled in managed care, while state funded children remain fee-for-service.
    2. Apple Health for Kids (MN) Medically Needy coverage (F99, S99, K99):  See WAC 388-505-0210 (5). These children receive slightly less coverage than CN Medicaid and do not enroll in managed care.  They must meet a spenddown before DSHS will pay for any services.  See Spenddown  for more information.
    3. Children's Institutional coverage (K01, K95, K99):  See WAC  388-505-0230 - 388-505-0265: These children are approved for medical assistance based on institutional rules once they reside, or are expected to reside:

      a.  30 days or longer in a medical institution; or

      b.  30 days or longer if they are admitted to an inpatient psychiatric treatment program and they are aged eighteen or older; or

        c.  90 days or longer if they are admitted to an inpatient psychiatric treatment program and they are age seventeen or younger.

        6.  Children's Alien Medical Program (AMP) coverage (F99):   See WAC 388-505-0210 (10): These alien children are eligible for MN coverage for emergency medical services only.

    Age

    1. Ensure eligibility runs through the end of the month of the appropriate birthday, by program (i.e., age one for newborns, eighteenth, nineteenth or twenty-first birthday if considering an institutional program).
    2. When a client applies in the same month they reach the age limit for the specific program, they can still be approved for the month of application even though they may have already had their birthday.
    3. When a client is a Medicaid recipient in the month of their twenty-first birthday and they receive active inpatient psychiatric treatment which extends beyond their twenty-first birthday, they remain eligible for CN or MN coverage under the family institutional medical program (K01, K95) until the date they discharge from the facility or until their twenty-second birthday, whichever happens first.

    EXAMPLE

    The client turns nineteen on March 15 and applies for medical assistance on March 20. If the client meets all other eligibility factors for children's CN medical assistance, the application can be authorized for the entire month of March. (If the client had medical needs during the prior three months, determine eligibility for the retroactive period.)

    Household Composition for Apple Health for Kids programs

    Children may live with parents, relatives, non-relatives, or on their own and receive Apple Health for kids.


    EXAMPLE

     Client 17 years old is homeless and living with friends applies for medical assistance.  Client eligibility is determined for Apple Health for Kids based on the child’s income only.  A child does not need to be living with a parent or guardian to be eligible. 

    When a child meets institutional status because they have been admitted to a medical institution or inpatient psychiatric treatment program for 30 days or longer (or 90 days for psychiatric care for a child age seventeen or younger), the department no longer considers the income of their parents, spouse or in some cases, their own dependent children. Eligibility is determined based on the individual’s income and resources only.

    Medical Eligibility Determination Services (MEDS)

    For case transfers from MEDS before 2:00 pm, call 1-800-562-3022 x 16136.

    For case transfers from MEDS after 2:00 pm, E-Mail MEDSTRANSFER@HCA.WA.GOV   Medical Eligibility Determination Services (MEDS) staff determine the eligibility for:

      1. Children for BH Plus (F06).
      2. Non BH plus children (F06) with no associated cash, food or family medical.
      3. Pregnant BH members (P02/P04).
      4. Premium-based Apple Health for Kids program (F07).
      5. Children's MN spenddown (F99).
      6. Breast and Cervical Cancer Treatment program (S30).
      7. Foster Care medical (D01/D02).
        To contact Foster Care call 1-800-562-3022 x 15480
      8. Take Charge Family Planning Waiver (P06). 
        To contact Take Charge call 1-800-562-3022 x 15481 
    2. MEDS will process and maintain stand alone applications/reviews for Apple Health for Kids (no associated cash, food or family medical) mailed by the client to the MEDS office or any associated with another active 076 case.

    Maintenance of a BH Plus, Premium-based Apple Health for Kids, Breast and Cervical Cancer or Take Charge AU is the responsibility of MEDS.  However, when CSO's open other type of assistance which include any of these AU member(s) it may result in a "case" being shared between MEDS and CSO's.


    Basic Health (BH) and BH Plus

    1. BH provides affordable health insurance to any Washington resident, and is administered by the Washington State Health Care Authority (HCA).
    2. An application for BH is only considered a joint application for BH Plus Medicaid) when the family applying for BH coverage also requests BH plus for their child on the application.
    3. BH Plus is CN medical (F06) for federally qualified children of BH members.  Non qualified children (F06) are not eligible for BH plus.  It is called BH Plus because the children receiving CN medical get more medical coverage than adult BH members. The children are enrolled in  a Basic Health managed care plan and can also be identified as BH plus by the coding on the ACES MISC screen.  The process of authorizing CN medical to BH children is intended to appear seamless and transparent to the BH family.
    4. DSHS pays the BH premium for the child. There are no co-payments or deductibles for the child. Medical Eligibility Determination Services (MEDS) staff determines and maintains the eligibility for children in BH Plus.
    5. If a family applies for other benefits in the local office the BH plus case will need to be transferred to the local CSO but the BH plus AU is still maintained by MEDS.
    6. To request a transfer of a BH plus case contact MEDS before 2:00 pm at 1-800-562-3022 x 16136 or after 2:00 pm E-mail MEDSTRANSFER@HCA.WA.GOV.

    Shared Case processing / Transfers

    CSO and MEDS staff must coordinate actions taken on shared cases. Shared cases only exist when MEDS has a BH Plus (F06, F05 or P02), Premium –based Apple Health for Kids (F07) or Breast and Cervical (S30) AU and the CSO has other assistance active for the household.


    NOTE:

    All non BH Plus stand-alone medical cases will be transferred to and maintained by the CSO if cash, food or family medical is requested. 

    1. Before taking action on an open case:

    a.  CSO staff needs to examine the STAT screens to determine if the household includes an F07 or S30 AU or the ACES "MISC" screen to determine if there is a BH Plus AU in the household. BH Plus is identified with a “Y” in the BH Plus indicator field in the upper right section of the MISC screen.

    b.  MEDS staff needs to examine the STAT screens to determine if the household is receiving other benefits in the CSO.

    2.  For the CSO if the action taken closes or changes household size to a shared AU in the ongoing month, verify on the DONE screen warning message 1737 or 1738 appears. This will verify alert 405 will be generated.

    1. If these messages do not appear send a DMS tickler to the MEDS worker.
    2. Do not close a shared MEDS AU while the CSO AU is still pending.

    3.  If the CSO needs a shared case transferred before 2:00 pm call 1-800-562-3022 Ext. 16136, or after 2 :00 pm e-mail MEDSTRANSFER@HCA.WA.GOV.

    4.  For MEDS if the shared case is for any program other than F06, prior contact with the CSO is required before making any change.

    5.  If MEDS staff is unable to reach the CSO to take action on a shared case they will contact the CSO supervisor of record for action.

    6.  When a change is made in the ongoing month to a shared case ACES generates alerts 404 and 405 to the CSO or MEDS. These alerts are only generated when a shared user accesses the case, a change to the AU composition occurs and no transfer of CSO has occurred in the ongoing month.

    How To Contact MEDS:

    Mail:
    MEDS
    PO Box or Mail Stop 45531
    Olympia, Washington 98504-5531
    Phone:
    General Information: 1-800-562-3022 x 16136 before 2:00 pm daily.
    FAX: (866) 720-2892 or (360) 586-2042

    E-Mail:

    Case transfers MEDSTRANSFER@HCA.WA.GOV  


    Children’s Alien Medical Program (AMP)

    Applications received in the CSO or MEDS with clients eligible for AMP are forwarded to the Specialized Medical Unit (SMU) in site 157 if AMP is for a client age 19 or older, or under age 19 with family income over 300% FPL.  The application should be reassigned in DMS to @AEM in CSO 157.


    NOTE:

    Non-qualified children under age 19 with family income under 300% FPL are related to and approved for the appropriate Apple Health for Kids program not AMP.

    How To Contact the SMU:

    Mail:                                                                         
    DSHS
    CSD - Customer Service Center
    PO Box 11699
    Tacoma, Washington 98411-6699

    Phone:
    1-877-501-2233

    DMS:
    AMP Applications
    forward in DMS to CSO 157@AEM.


    WAC 388-505-0211

    WAC 388-505-0211

    Effective December 16, 2011

    WAC 388-505-0211 Premium requirements for premium-based healthcare coverage under programs included in apple health for kids.

    1. For the purposes of this chapter, "premium" means an amount paid for coverage under programs included in apple health for kids as described in WAC 388-505-0210  (4) and (5).
    2. Payment of a premium is required as a condition of eligibility for premium-based coverage under programs included in apple health for kids, as described in WAC 388-505-0210 (4)  and (5),  unless the child is:
      1. Pregnant; or
      2. An American Indian or Alaska Native.
    3. The premium requirement begins the first of the month following the determination of eligibility.  There is no premium requirement for medical coverage received in a month or months before the determination of eligibility.
    4. The premium amount for the assistance unit (AU) is based on the net countable income as described in WAC 388-450-0210 and the number of children in the (AU).  If the household includes more than one (AU), the premium amount billed for the AUs may be different amounts.
    5. The premium amount is limited to a monthly maximum of two premiums for households with two or more children.
    6. The premium amount for each U. S. citizen or lawfully present alien child described in WAC 388-505-0210  (4) is:
      1. Twenty dollars per month per child for households with income above two hundred percent FPL, but not above two hundred and fifty percent FPL;
      2. Thirty dollars per month per child for households with income above two hundred and fifty percent FPL, but not above three hundred percent FPL.
    7. The premium amount for each noncitizen child described in WAC 388-505-0210  (5) who is not a lawfully present qualified or nonqualified alien is no greater than the average of the state-share of the per capita cost for state-funded children's health coverage.  The premium amount is set every two years, based on the forecasted per capita costs for that period.
    8. All children in an AU are ineligible for healthcare coverage when the head of household fails to pay required premium payments for three consecutive months.
    9. When the agency or the agency's designee terminates the medical coverage of a child due to nonpayment of premiums, the child's eligibility is restored only when the:
      1. Past due premiums are paid in full prior to the end of the certification period; or
      2. The child becomes eligible for coverage under a nonpremium-based CN healthcare program.
    10. The agency or the agency's designee writes off past-due premiums after twelve months.
    11. If all past due premiums are paid after the certification period is over:
      1.  Eligibility for prior months is not restored; and
      2. Children are not eligible for premium-based coverage under apple health for kids until:

                        i.  The month the premiums are paid or the agency writes off the debt; and

                        ii. The family reapplies and is found eligible.

        12.  A family cannot designate partial payment of the billed premium amount as payment for a specific child in the AU. The full premium amount is the obligation of the head of household of the AU. A family can decide to request healthcare coverage only for certain children in the AU, if they want to reduce premium obligation.

         13.  A change that affects the premium amount is effective the month after the change is reported  and processed.

         14.  A sponsor or other third party may pay the premium on behalf of the child or children in the AU. The premium payment requirement remains the obligation of head of household of the AU. The failure of a sponsor or other third party to pay the premium does not eliminate the obligation of the head of household to pay past due premiums.

    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

    When the household fails to pay the required premium for three months, all premium-based assistance units are closed through the end of the certification period.  If the household pays the entire 3 months’ delinquent premiums within the certification period, then the assistance unit is reinstated back to the month of termination. The household will not be charged a premium for the reinstated months and will enter the premium billing cycle with the ongoing month.

    If the household pays the delinquent premium after the end of the certification period, the assistance unit remains closed.  The household will need to reapply in order to have eligibility for premium-based coverage redetermined.

    If the household reapplies within twelve months of their case closing for failing to pay the required premium, they are ineligible for premium-based coverage until:

    1. They pay the delinquent premium, or
    2. Twelve months have elapsed and the department writes off the delinquent balance.

     

    WORKER RESPONSIBILITIES

    When the assistance unit is closed for failing to pay the required premium:

    1. Send the client a letter explaining that coverage may be reinstated if the delinquent premium is paid in full by the end of the certification period.
    2. Document the closure, that the letter was sent, and the date that the delinquent premium must be paid by in order for coverage to be reinstated.

    If the household pays the delinquent premium in full prior to the end of the certification period:

    1. Reinstate eligibility for all months since the termination of the au for non-payment of the premium.
    2. Document the reinstatement, months reinstated, and send the client a reinstatement letter that includes the months reinstated, and the last month of the certification period.

    If the household pays the delinquent premium in full after the end of the certification period:

    1. Note that the payment was received, but do not reinstate the assistance unit.
    2. Send the household a letter with an application and explain that they will need to reapply in order to have ongoing eligibility determined.

    If the household reapplies for medical assistance within twelve months of termination for failing to pay the required premium:

    1. Review the household’s income eligibility for nonpremium-based Apple Health for Kids (e.g. F06).  If eligible for such a program, authorize that program. 
    2. If not eligible for a nonpremium-based program review the record to see if there is a delinquent balance on their premium account.

    a.  If there is a delinquent balance, contact the client and explain they are not eligible for premium-based Apple Health for Kids until their delinquent account is paid in full, or the department writes of the delinquent balance.

    b.  Give the household the amount of the delinquent premium and contact information for mailing the delinquent premium to FSA.  The household should:

    i.   Make the check or money order payable to: DSHS

    ii.   Include a statement that the payment is for their delinquent Apple Health premium.

    iii.  Include their account number (HOH client ID number)

    iv.  Mail the payment to:

    DSHS
    Office of Financial Recovery
    PO Box 9501
    Olympia, WA 98507-9726

     

      3.  If there are questions about the delinquent account; that a payment has been made, or  it appears the delinquency is over twelve months old, the worker should contact the FSA representative.  Do not refer clients to FSA.  

     

    FSA CONTACTS

    E-mail address

    Melody Green

    		 ofrpremium@dshs.wa.gov

    WAC 388-505-0220

    WAC 388-505-0220

    Effective July 7, 2011

    WAC 388-505-0220 Family medical eligibility.

    1. A person is eligible for categorically needy (CN) medical assistance when they are:

      1. Receiving temporary assistance for needy families (TANF) cash benefits;

      2. Receiving Tribal TANF; 

      3. Receiving cash diversion assistance, except SFA relatable families described in WAC 388-400-0010 (2);

      4. Eligible for TANF cash benefits but choose not to receive; or

      5. Over the TANF cash payment standard but under the family medical payment standard as described in WAC 388-478-0065; or

      6. Not eligible for or receiving TANF cash assistance, but meet the eligibility criteria for aid to families with dependent children (AFDC) in effect on July 16, 1996 except that:

        1. Earned income is treated as described in WAC 388-450-0210; and

        2. Resources are treated as described in WAC 388-470-0005  for applicants and WAC 388-470-0026  for recipients.

    2. An adult cannot receive a family medicaid program unless the household includes a child who is eligible for:

      1. Family Medicaid;

      2. SSI; or

      3. Children’s Medicaid.

    3. A person is eligible for CN family medical coverage when the person is not eligible for or receiving cash benefits solely because the person:

      1. Received sixty months of TANF cash benefits or is a member of an assistance unit which has received sixty months of TANF cash benefits;

      2. Failed to meet the school attendance requirement in chapter 388-400 WAC;

      3. Is an unmarried minor parent who is not in a department-approved living situation;

      4. Is a parent or caretaker relative who fails to notify the department within five days of the date the child leaves the home and the child's absence will exceed one hundred eighty days;

      5. Is a fleeing felon or fleeing to avoid prosecution for a felony charge, or is a probation and parole violator;

      6. Was convicted of a drug related felony;

      7. Was convicted of receiving benefits unlawfully;

      8. Was convicted of misrepresenting residence to obtain assistance in two or more states;

      9. Has gross earnings exceeding the TANF gross income level; or

      10. Is not cooperating with WorkFirst requirements.

    4. An adult must cooperate with the division of child support in the identification, use, and collection of medical support from responsible third parties, unless the person meets the medical exemption criteria described in WAC 388-505-0540 or the medical good cause criteria described in Chapter 388-422 WAC.

    5. Except for a client described in WAC 388-505-0210 (6 ), a person who is an inmate of a public institution, as defined in WAC 388-500-0005, is not eligible for CN or MN medical coverage.

    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

    Family Medical Programs

    A family may be eligible for one of the following programs:

    1. Family medical attached to TANF cash (F01):  All family members eligible for this cash program are eligible for CN medical, with the exception of an adult under DCS sanction.  F01 clients may enroll in Healthy Options.


    NOTE:

    Effective October 1, 2002, children and adults who do not meet federal Medicaid criteria do not have family medical coverage unless they are pregnant or meet the criteria for the Alien Emergency Medical Program.

    1. Family medical (F04): Families who do not want cash assistance or who are ineligible due to the reasons described in WAC 388-505-0220 (2) may be eligible for family medical.

      1. A family must include an “eligible dependent child” meeting the Age Requirements described in WAC 388-404-0005 (1).


    NOTE: School attendance of children under the age of eighteen is not an eligibility requirement for a family medical program. For the purposes of a family medical program, a child who is age eighteen and has already graduated or who does not meet the criteria of WAC 388-404-0005(1) is not considered an “eligible dependent child”. When the only child in the household is NOT an “eligible dependent child”, the family is not eligible for a family medical program. The child may still be eligible under a medical program for children. Determine whether the adults are eligible for another medical program.

    EXAMPLE

    A family applying for Family Medical (F04) includes a citizen father and a mother with “qualified alien” status that has resided in the country for many years. The only child in the home is undocumented. The family meets eligibility criteria except the child is not eligible to receive benefits. The adults in the family cannot be certified as eligible for (F04).

    EXAMPLE

    A mother and her son are receiving Family Medical (F04). The son graduates in June and has his 18th birthday in July. The son no longer meets the definition of an eligible “dependent child”. Effective August 1, the mother is not eligible for F04. However, the Children’s Medical program (F06) covers the child until he reaches age 19. In this situation, the mother is not eligible based on the age of the child, even though the child is eligible to receive benefits under another program.

    1. Family Medical MN coverage is not available for caretaker adults. If the caretaker adult in the household is pregnant, review for a pregnancy program. If the caretaker adult is aged, blind, or disabled, review for an SSI-related program.
    2. Adults may be eligible for Family Medical (F04) as a separate MAU when certain conditions exist. See Assistance Units for those conditions and instructions concerning financial responsibility and the establishment of separate MAUs as required by the Sneede V. Kizer Ninth Circuit Court decision.

    NOTE: A family eligible for TANF cash diversion is eligible for Family Medical (F04) with a twelve-month certification period.  Should the family report a change in the family's circumstances, refer to the Change of Circumstances category.

    1. Alien Emergency Medical Program (F09):  A child under age 19 or an adult who is the caretaker of a dependent child may be eligible for the Alien Emergency Medical Program when they meet the financial criteria for the program and have an acute emergency medical condition.  See the Alien Emergency Medical (AEM) Program  section for more information. 

    ACES PROCEDURES

    See Medical

    Modification Date: May 15, 2012