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 October 1, 2013

WAC 182-503-0505 Washington apple health -- General eligibility requirements.



(1) Persons applying for Washington apple health (WAH) programs established under chapter 74.09 RCW must meet the eligibility criteria in chapters 182-500 through 182-527 WAC.

(2) Persons applying for WAH are considered first for federally funded or federally matched programs. State-funded programs are considered after the person is determined ineligible for federally funded and federally matched programs.

(3) Unless otherwise specified in a program specific WAC, the eligibility criteria for each WAH program are as follows:

(a) Age and identity (WAC 182-503-0050);

(b) Residence in Washington state (WAC 182-503-0520 and 182-503-0525);

(c) Citizenship or immigration status in the United States (WAC 182-503-0535);

(d) Possession of a valid Social Security account number (WAC 182-503-0515);

(e) Assignment of medical support rights to the state of Washington (WAC 182-503-0540);

(f) Application for medicare and enrollment into medicare's prescription drug program if:

(i) It is likely that the person is entitled to medicare; and

(ii) The state has authority to pay medicare cost sharing as described in chapter 182-517 WAC.

(g) For persons whose eligibility is not on the basis of modified adjusted gross income (MAGI) methodology, countable resources must be within specific program limits (chapters 182-512, 182-513, 182-515, 182-517, and 182-519 WAC); and

(h) Countable income within program limits:

(i) For MAGI-based WAH programs, see WAC 182-505-0100;

(ii) For the WAH refugee program, see WAC 182-507-0110;

(iii) For the WAH medical care services program, see WAC 182-508-0150;

(iv) For WAH for workers with disabilities (HWD), see WAC 182-511-0060;

(v) For the WAH SSI-related program, see WAC 182-512-0010;

(vi) For WAH long-term care programs, see WAC 182-513-1300 and 182-515-1500;

(vii) For WAH medicare savings programs, see WAC 182-517-0100; and

(viii) For the WAH medically needy program, see WAC 182-519-0050.

(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 in a public institution, including a correctional facility, are not eligible for WAH programs, except in the following situations:

(a) The person is under age twenty or over age sixty-five and is a patient in an institution for mental disease (see WAC 182-513-1315(13)); or

(b) The person receives inpatient hospital services outside of the public institution or correctional facility.

(6) Persons terminated from SSI or who lose eligibility for categorically needy (CN) coverage have their CN coverage continued while their eligibility for other health care programs is redetermined. See WAC 182-504-0125.

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