Medical Re-Determination
DSHS Home Page

EAZ
Search     for:
DSHS HomeACES ManualEAZ ManualSocial Services ManualWork First Manual
Acronyms  Revisions  WAC Number Index  Site Map  WCCC  DSHS Home

Medical Re-Determination

Revised November 10, 2009

Purpose: To define medical re-determination, describe when a medical re-determination is required, and to provide step by step directions through the process.
WAC 388-418-0025Effect of changes on medical program eligibility.
WAC 388-434-0005How often does the department review my eligibility for benefits?

  

When eligibility ends for a CN Medicaid program, the department is required to look at eligibility for other Medicaid programs before terminating CN coverage.  Re-determination is the point at which the department considers eligibility for other Medicaid programs and documents in ACES that the reconsideration has been completed.

If the re-determination process is not documented, the case will be found in error even if the correct action has been taken.


NOTE:  

CN eligbility may end at the point of re-determination even when we find the individual eligible for SSI-related medical, because income may cause the CN medical (S02) to trickle to medically needy (MN) medical (S95/S99).

 

 

WAC 388-434-0005

WAC 388-434-0005

Effective October 1, 2004

WAC 388-434-0005 How often does the department review my eligibility for benefits?

  1. If you receive cash assistance, the department reviews your eligibility for assistance at least once every twelve months.   

  2. When it is time for your eligibility review, the department requires you to complete a review.  We use the information that you provide to determine your eligibility for all assistance programs. 

  3. If you complete an interview for assistance with a department representative and sign the printed Application for Benefits (AFB) form, you do not have to complete a separate review form.

  4. For cash assistance, an eligibility review form or the AFB must be dated and signed by both husband and wife, or both parents of a child in common when the parents live together.

  5. For medical assistance, a signature is not required to complete your review.

  6. We may review your eligibility at any time if we decide your circumstances need to be reviewed sooner.

  7. At your review, we look at:

    1. All eligibility requirements under WAC 388-400-0005 through 388-400-0035, 388-503-0505 through 388-503-0515, and 388-505-0210 through 388-505-0220.

    2. Changes since we last determined your eligibility; and

    3. Changes that are anticipated for the next review period.

  8. If you receive medical assistance, we set your certification period according to 388-416-0010, 388-416-0015, 388-416-0020, and 388-416-0035.

  9. You are responsible for attending an interview if one is required under 388-452-0005.

  10. If you do not complete the eligibility review for cash assistance, we consider you to be withdrawing your request for continuing assistance:

    1. Your cash assistance benefits will end.

    2. Your medical benefits will continue for twelve consecutive months from the month we received your most recent application or eligibility review.

  11. We will send you written notice as described under chapter 388-458 WAC before assistance is suspended, terminated or a benefit error is established as a result of your eligibility review.

  12. If you currently receive Categorically Needy (CN) medical assistance, and you are found to no longer be eligible for benefits, we will determine if you are eligible for another program.  Until we decide if you're eligible for any other programs, your CN medical assistance will continue per 388-418-0025

  13. When you need a supplemental accommodation under 388-472-0010, we will help you meet the requirements of this section.

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.



WAC 388-418-0025

WAC 388-418-0025

Effective April 17, 2009

WAC 388-418-0025 Effect of changes on medical program eligibility.

  1. You continue to be eligible for medical assistance until the department determines your ineligibility or eligibility for another medical program.  This applies to you if, during a certification period, you become ineligible for, or are terminated from, or request termination from:

    1. A CN Medicaid program;

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

    3. Any of the following cash grants:

      1. TANF;

      2. SSI; or

      3. GA-X.  See  WAC 388-434-0005  for changes reported during eligibility review.

  2. If you become ineligible for refugee cash assistance, refugee medical assistance can be continued through the eight month limit, as described in  WAC 388-400-0035(4).

  3. If you receive a TANF cash grant or family medical, you are eligible for a medical extension, as described under WAC 388-523-0100, when your cash grant or family medical program is terminated as a result of:

    1. Earned income; or

    2. Collection of child or spousal support.

  4. A change in income during a certification period does affect eligibility for all medical programs except:

    1. Pregnant women's medical programs;

    2. A program included in apple health for kids,  except as specified in subsection (5);

    3. The first six months of the medical extension benefits.

  5. For a child receiving premium-based coverage under a program included in apple health for kids as described in WAC 388-505-0210 and chapter 388-542 WAC, the department must redetermine eligibility for nonpremium-based coverage when the family reports:

    1. Family income has decreased to less than two hundred percent Federal Poverty Level (FPL);

    2. The child becomes pregnant;

    3. A change in family size; or

    4. The child receives SSI.

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

This section provides a brief overview of when a medical re-determination is required.

WORKER RESPONSIBILITIES - Continuous Eligibility

This section discusses medical re-determination when a client remains eligible for medicaid under continuous eligibility rules.

WORKER RESPONSIBILITIES - Individuals Related to a Medical Coverage Group

This section discusses the medical re-determination process for clients who are automatically related to a medical coverage group: they are aged, blind or disabled, pregnant or are the parent or responsible relative caring for a dependent child.  

WORKER RESPONSIBILITIES - Ex-parte Review

This section discusses the medical re-determination process for clients who are not automatically related to a medical coverage group and situations when the department needs more information in order to establish whether the client may qualify for medicaid under a different program.

SSI REDETERMINATION

This section discusses the re-determination process for clients who lose eligibility under the Supplemental Security Income (SSI) cash assistance program.  This section includes an overview of the automated re-determination process which ACES uses to generate reviews and notices to the client and to the department.

SSI REDETERMINATION - SSI RELATED SPECIAL INCOME DISREGARDS

This section discusses the ACES re-determination process for clients who lose eligibility under the SSI program but who remain eligible for CN medicaid due to the SSI-related special income disregards:  Pickle, Disabled Adult Child or under the Disabled Widow(er) provisions. More information on this can be found in Clarifying Information under WAC 388-475-0880.  

Back to top

Modification Date: November 10, 2009
Have comments on the manual? Please e-mail us. You can also use this link to report broken links or content problems.