General Eligibility requirements for Medical Programs
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General Eligibility requirements for Medical Programs

Revised April 22, 2013

WAC 182-503-0505General eligibility requirements for medical programs.

WAC 182-503-0505

WAC 182-503-0505

Effective July 1, 2012

WAC 182-503-0505 General eligibility requirements for medical programs.

  1. Persons applying for benefits under the medical coverage programs established under chapter 74.09 RCW must meet the eligibility criteria established by the department in chapters 388-400 through 388-555 WAC. 

  2. Persons applying for medical coverage are considered first for federally funded or federally matched programs. State-funded programs are considered after federally funded programs and are not available to the client except for brief periods when the state-funded programs offer a broad scope of care which meet a specific client need.

  3. Unless otherwise specified in program specific WAC, the eligibility criteria for each medical program is as follows:

    1. Verification of age and identity (chapters 388-404, 388-406, and 388-490 WAC); and

    2. Residence in Washington state (chapter 388-468 WAC); and

    3. Citizenship or immigration status in the United States (chapter388-424 WAC); and

    4. Possession of a valid Social Security Account Number (chapter 388-476 WAC); and

    5. Assignment of medical support rights to the state of Washington (388-505-0540); and

    6. Cooperation in securing medical support (chapter 388-422 WAC); and

    7. Application for Medicare and enrollment into Medicare's prescription drug program if:

      1. It is likely that the individual is entitled to Medicare; and

      2. The state has authority to pay Medicare cost sharing as described in chapter 388-517 WAC.

    8. Countable resources within program limits (chapters 388-470 and 388-475 and 388-478 WAC); and

    9. Countable income within program limits (chapters 388-450 and 388-475 and 388-478 WAC).

  4. In addition to the general eligibility requirements in subsection (3) of this section, each program has specific eligibility requirements as described in applicable WAC.

  5. Persons living in a public institution,  including a correctional facility, are not eligible for the department's medical coverage programs.  For a person under age twenty or over age sixty-five who is a patient in an institution for mental disease, see WAC 388-513-1315 (13)  for exception.

  6. Persons terminated from SSI or TANF cash grants and those who lose eligibility for categorically needy (CN) medical coverage have their CN coverage continued while their eligibility for other medical programs is redetermined. This continuation of medical coverage is described in chapter 388-434 WAC.

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

Application for Medicare

Application for and enrollment into Medicare is a condition of eligibility for clients who apply for Medicaid coverage, as long as the department is able to pick up the cost of the premiums on the client's behalf.  

Compliance Process

Every month 600 Medicaid clients age 65 and older are asked to provide proof of application for Medicare.  The number of clients is limited to 600 by agreement with the Social Security Administration.  This is intended to limit the number of applications that they receive in a month.  The Medicare Buy-in unit in Olympia (call 1-800-562-3022) manages this workload.  The following process is followed:

  1. The selected 600 clients are mailed a letter generated by barcode around the 20th of the month asking for proof of application for Medicare.
  2. The letter is provided in the client's primary language and in English to the client and to the client's authorized representative(s).  Only the English version is stored in DMS.
  3. All letters have a stamped return envelope addressed to the Medicare Buy-in Unit for returning the proof of Medicare application.
  4. Thirty days or more after the first letter is sent, the Medicare Buy-in Unit works the ticklers to review for proof of application for Medicare.
  5. If no proof is received, a second letter is sent to the client requesting proof of application for Medicare and again ticklers are set for the Medicare Buy-in Unit to review the case for proof.
  6. If no proof is received from the second letter, the Medicare Buy-in Unit generates an action request to the worker of record asking that the client be sent a termination of Medicaid notice under WAC 182-503-0505 General Eligibility and WAC 182-503-0540  Non Cooperation with Third Party Liability.

End Stage Renal Disease

The Medicare Buy-in Unit also sends letters requesting proof of application for Medicare under the End Stage Renal Disease Program (ESRD) to selected Medicaid kidney dialysis clients who receive three consecutive months of treatment.  The same process outlined above is used.  The client's letter is slightly different but still requires the client to provide proof of application.  The client's kidney dialysis provider, (for example Northwest Kidney Dialysis Center), is also notified that they need to assist their client with the Medicare/ESRD application process.

All clients who fail to provide proof of application for Medicare to the Medicare Buy-in Unit under the authority of the above listed WAC citations, can be terminated from Medicaid assistance, including clients who receive SSI or long-term care services. 


NOTE:

The Medicare Buy-in Unit is careful to give nearly 90 days in the two-letter process before they send an action request to the field to propose termination of Medicaid assistance.
Modification Date: April 22, 2013