Receive a cash grant under the Temporary Assistance for Needy Families (TANF);
Be eligible for TANF but choose not to receive cash assistance, such as recipients of diversion cash assistance; or
Be determined ineligible for TANF cash assistance for a reason that does not apply to medical programs as described in WAC 388-505-0220.
Consider the family as described in Assistance Units - Medical programs, including the establishment of separate medical assistance units (MAUs), if necessary.
All family members may not be eligible for a medical program. Some members may enroll in Healthy Options and others may not.
For family members who are not eligible under this category, refer to the following categories:
SSI-related Medical for children and adults who may meet SSI disability criteria services and is ineligible for any other medical program;
Pregnancy for medical programs for pregnant women;
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;
Long Term Care for family members requiring nursing facility or home and community-based services;
Medical Extensions for a family who has an increase in earned income, spousal support, or child support;
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 April 17, 2009
WAC 388-505-0210 Children's healthcare programs.
Funding for children's healthcare coverage may come through Title XIX (medicaid), Title XXI SCHIP, or through state-funded programs. There are no resource limits for children's healthcare programs. Children's healthcare programs that fall under the apple health for kids umbrella are described in subsections (1) through (4) below.
1. Newborns are eligible for federally matched categorically needy (CN) coverage through their first birthday when:
a. The child's mother was eligible for and receiving medical assistance at the time of the child's birth.
b. The child remains with the mother and resides in the state.
2. Children under the age of nineteen who are U.S. citizens, U.S. nationals, or qualified aliens as described in WAC 388-424-0001 and WAC 388-424-0006 (1) and (4) are eligible for 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 eligible for SSI-related CN or MN coverage.
3. Non-citizen children under the age of nineteen, who do not meet qualified alien status as described in WAC 388-424-0006, are eligible for state funded CN 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 are eligible for premium-based 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. 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 premiums as described in WAC 388-505-0211.
5. Children under the age of nineteen 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);
b. Are ineligible for other federal medicaid programs; and
6. Children under the age of twenty-one who reside or expect to reside in a medical institution, intermediate care facility for the mentally retarded (ICF/MR), nursing home, or psychiatric facility, may be eligible for healthcare coverage. See WAC 388-505-0230 "Family related institutional medical" and WAC 388-513-1320 "Determining institutional status for long-term care".
7. Children who are in foster care under the legal responsibility of the state, or a federally recognized tribe located within the state, are eligible for federally matched CN medicaid coverage through the month of their:
a. Eighteenth birthday;
b. Twenty-first birthday if 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.
8. Children who receive subsidized adoption services are eligible for federally matched CN Medicaid coverage.
9. Children under the age of nineteen may also be eligible for:
10. Children who are ineligible for other programs included in apple health for kids may be eligible for the Alien Emergency Medical program (AEM) if they meet the following criteria:
a. They have a documented emergent medical condition as defined in WAC 388-500-0005; and
b. They meet the other AEM program requirements as described in WAC 388-438-0110; and
c. They have income that exceeds three hundred percent FPL; or
d. They are disqualified from receiving premium-based coverage as described in subsection (4) of this section because of creditable coverage or non-payment of premiums.
11. Except for a client described in subsection (6), an inmate of a public institution, as defined in WAC 388-500-0005, is not eligible for any children's healthcare program.
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 388-418-0025 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 call 1-800-204-6429.
Apple Health for Kids
Newborn Medical (F05): See WAC 388-505-0210 (1). Newborns are automatically entitled to receive CN Medicaid through their first birthday as long as:
They live with their mother,
Their mother was receiving Medicaid on the day of delivery,
For MN spenddown pending on the day of delivery, spenddown was met with the labor and delivery expenses, and
The mother maintains Washington State residency.
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 and Citizenship). 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 citizenship and 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. Birth certificate is pulled from DOH and ER is completed for identity, worker adds the newborn to the existing F04 AU. 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. In June review is received (with place of birth completed for identity for children) client has provided SSN and BC is pulled from DOH 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.
Children's 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.
Children's CN Coverage (F07): SeeWAC 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.
Children’s (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.
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:
30 days or longer in a medical institution; or
30 days or longer if they are admitted to an inpatient psychiatric treatment program and they are aged eithteen or older; or
90 days or longer if they are admitted to an inpatient psychiatric treatment program and they are age seventeen or younger.
Children's Alien Emergency Medical (AEM) coverage (F99): See WAC 388-505-0210 (10): These alien children are eligible for MN coverage for emergency medical services only.
Age
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).
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.
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 children’s medical programs
Children may live with parents, relatives, non-relatives, or on their own and receive children’s medical.
EXAMPLE
Client 17 years old is homeless and living with friends applies for medical assistance. Client eligibility is determined for children’s medical 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, call 1-800-204-6429
Medical Eligibility Determination Services (MEDS) staff determine the eligibility for:
Children for BH Plus (F06).
Non BH plus children (F06) with no associated cash, food or family medical.
Pregnant BH members (P02/P04).
Premium-based Apple Health for Kids program (F07).
Children's MN spenddown (F99).
Breast and Cervical Cancer Treatment program (S30).
Foster Care medical (D01/D02). To contact Foster Care call 1-800-547-3109
Take Charge Family Planning Waiver (P06). To contact Take Charge call 1-877-787-2119
MEDS will process and maintain stand alone applications/reviews for Apple Health for Kids (no associated cash, food or family medical) that are mailed by the client to their office or where they already have an associated children’s medical only AU active.
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
BH provides affordable health insurance to any Washington resident, and is administered by the Washington State Health Care Authority (HCA).
An application for BH is only considered a joint application for BH PlusMedicaid) when the family applying for BH coverage also requests BH plus for their child on the application.
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.
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.
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.
To request a transfer of a BH plus case contact MEDS at 1-800-204-6429.
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.
Before taking action on an open case:
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.
MEDS staff needs to examine the STAT screens to determine if the household is receiving other benefits in the CSO.
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.
If these messages do not appear send a DMS tickler to the MEDS worker.
Do not close a shared MEDS AU while the CSO AU is still pending.
If the CSO needs a shared case transferred call 1-800-204-6429 or send an email to CSO 076 MEDS (this email box is checked several times a day by MEDS staff).
For MEDS if the shared case is for any program other than F06, prior contact with the CSO is required before making any change.
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.
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: 1-800-204-6429
FAX: (866) 720-2892 or (360) 586-2042
TTY: 1-800-204-6430
Applications received in the CSO or MEDS with clients eligible for AEM are forwarded to the Centralized Medical Unit (CMU) in the Region 4 Customer Service Center (132) if AEM 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 132.
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 AEM.
How To Contact the CMU:
Mail: DSHS
PO Box 34350
Seattle, Washington 98124-9511
Phone: DSHS
General Information: 1-800-337-1835
Local (206) 341-7433
Fax (206) 298-4453
DMS: AEM Applications
forward in DMS to CSO 132 @AEM.
WAC 388-505-0211
WAC 388-505-0211
Effective April 17, 2009
WAC 388-505-0211 Premium requirements for premium-based healthcare coverage under programs included in apple health for kids.
For the purposes of this chapter, "premium" means an amount paid for coverage under programs included in apple health for kids.
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), unless the child is:
Pregnant; or
An American Indian or Alaska Native.
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.
The premium amount for the assistance unit is based on the net countable income as described in WAC 388-450-0210 and the number of children in the assistance unit. If the household includes more than one assistance unit, the premium amount billed for the assistance units may be different amounts.
The premium amount for each eligible child shall be:
Twenty dollars per month per child for households with income above two hundred percent FPL, but not above two hundred and fifty percent FPL;
Thirty dollars per month per child for households with income above two hundred and fifty percent FPL, but not above three hundred percent FPL; and
Limited to a monthly maximum of two premiums for households with two or more children.
All children in an assistance unit are ineligible for healthcare coverage when the head of household fails to pay required premium payments for three consecutive months.
When the department terminates the medical coverage of a child due to nonpayment of premiums, the child has a three-month period of ineligibility beginning the first of the following month. The three-month period of ineligibility is rescinded only when the:
Past due premiums are paid in full prior to the begin date of the period of ineligibility; or
The child becomes eligible for coverage under a nonpremium-based healthcare program. The department will not rescind the three-month period of ineligibility for reasons other than the criteria described in this subsection.
The department writes off past-due premiums after twelve months.
When the designated three-month period of ineligibility is over, all past due premiums that are an obligation of the head of household must be paid or written off before a child can become eligible for premium-based coverage under a program included in apple health for kids.
A family cannot designate partial payment of the billed premium amount as payment for a specific child in the assistance unit. The full premium amount is the obligation of the head of household of the assistance unit. A family can decide to request healthcare coverage only for certain children in the assistance unit, if they want to reduce premium obligation.
A change that affects the premium amount is effective the month after the change is reported and processed.
A sponsor or other third party may pay the premium on behalf of the child or children in the assistance unit. The premium payment requirement remains the obligation of head of household of the assistance unit. The failure of a sponsor or other third party to pay the premium does not eliminate the:
Establishment of the period of ineligibility described in subsection (7) of this section; or
Obligation of the head of household to pay past-due premiums.
A person is eligible for categorically needy (CN) medical assistance when they are:
Receiving temporary assistance for needy families (TANF) cash benefits;
Receiving Tribal TANF;
Receiving cash diversion assistance, except SFA relatable families described in WAC 388-400-0010 (2);
Eligible for TANF cash benefits but choose not to receive; or
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:
Is an unmarried minor parent who is not in a department-approved living situation;
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;
Is a fleeing felon or fleeing to avoid prosecution for a felony charge, or is a probation and parole violator;
Was convicted of a drug related felony;
Was convicted of receiving benefits unlawfully;
Was convicted of misrepresenting residence to obtain assistance in two or more states;
Has gross earnings exceeding the TANF gross income level; or
Is not cooperating with WorkFirst requirements.
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.
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.
A family may be eligible for one of the following programs:
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.
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.
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.
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.
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.
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.
