Medical Re-Determination
DSHS Home Page
 
Search     for:
DSHS Home    Acronyms    Revisions    WAC Number Index    Site Map    WCCC

Medical Re-Determination


Revised December 31, 2013



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 182-504-0125Washington apple health -- Effect of reported changes.
WAC 388-434-0005How often does the department review my eligibility for benefits?

Definition:  When eligibility ends for a CN Medicaid program, federal law requires the Agency (or its designee) to look at eligibility for other Medicaid programs before terminating CN coverage.  Re-determination is complete at the point the agency  considers eligibility for other Medicaid programs and documents in ACES that the reconsideration has been completed.

Without documentation of the re-determination process, the case will be found in error even if the correct action has been taken.


NOTE:

CN eligibility may end at the point of re-determination, even while waiting on a final disability determination, if income causes the CN medical (S02) to trickle to medically needy (MN) medical (S95/S99).  

 


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.

WAC 388-434-0005

WAC 388-434-0005

Effective October 1, 2013

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

    a. All eligibility requirements under WAC 388-400-0005 through 388-400-0030

    b.Changes since we last determined your eligibility; and

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

  7. You are responsible for attending an interview if one is required under WAC 388-452-0005.
  8. If you do not complete the eligibility review for cash assistance, we consider you to be withdrawing your request for continuing assistance and your cash assistance benefits will end.
  9. 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.
  10. When you need a supplemental accomodation under WAC 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.

*** As a result of implementation of the Affordable Care Act (ACA), this clarifying page may no longer be effective for medical coverage applications received on or after 10/01/2013. Please see the ACA Transition Plan for more information. Clients under 65 years of age who need to apply for medical coverage on or after 10/01/2013 should be referred to Washington Healthplanfinder. Applications for medical coverage for households where all members are 65 years of age and older should be referred to Washington Connection. ***

 

 

CLARIFYING INFORMATION

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

WORKER RESPONSIBILITIES

This section discusses the medical re-determination processes for the following. Clients who:

  • Remain eligible for medicaid under continuous eligibility rules;
  • Are automatically related to a medical coverage group; they are age 65 or older, blind or disabled; pregnant or the parent or responsible relative caring for an eligible dependent child;
  • Are not automatically related to a medical coverage group and more information is needed in order to establish whether the client may qualify for medicaid under a different program.

WORKER RESPONSIBILITIES - 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 that ACES uses to generate reviews and notices to the client and to the agency or its designee.

WORKER RESPONSIBILITIES - 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 the Disabled Widow(er) provisions. More information can be found in Clarifying Information under WAC 182-512-0880.  

Modification Date: December 31, 2013