Medical Assistance Programs - Family Medical Programs
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Medical Assistance Programs - Family Medical Programs


Revised May 2, 2014



WAC 182-505-0210Washington apple health -- Eligibility for children.
WAC 182-505-0215Washington apple health -- Premium-based children's program -- Purpose and scope.
WAC 182-505-0220REPEALED -- Definitions for premium-based healthcare coverage under programs included in apple health for kids.
WAC 182-505-0225Premium-based Washington apple health for kids -- Premium requirements.
WAC 182-505-0230REPEALED -- Waiting period for premium-based healthcare coverage under programs included in apple health for kids following employer coverage.
WAC 182-505-0237Premium-based Washington apple health for kids -- Other rules that apply.
WAC 182-505-0240Washington apple health -- Parents and caretaker relatives.

IMPORTANT NOTE

On October 1, 2013, the new MAGI methodology replaced the legacy Medicaid net income methodology for determining eligibility for the MAGI-based Family, Pregnant Women, and Child medical programs. MAGI methodology follows Internal Revenue Service (IRS) rules for counting income -- in other words, if it is included in adjusted gross income (AGI), it is countable income -- with certain exceptions.

In addition, on October 1, 2013, the new Adult medical program started to accept applications for coverage to begin on January 1, 2014, using the MAGI methodology.

Please see the ACA Transition Plan for more information.

If you have clients who wish to apply for the MAGI-based Family, Pregnant Women, Child, or Adult medical programs, they can apply in the following ways:

Washington Healthplanfinder
PO Box 946
Olympia, WA 98507

Clients who have questions regarding their eligibility for MAGI-based medical assistance should call the Medical Eligibility Determination Service at the Health Care Authority at 1-855-923-9357. Clients who have questions about applying online for MAGI-based medical assistance should call the Health Benefit Exchange at 1-855-923-4633.

While the WACs on this page have been updated (or noted as repealed where applicable) effective October 1, 2013, the Clarifying Information below applied to Family Medical programs prior to October 1, 2013 and is now out of date.

 



WAC 182-505-0210

WAC 182-505-0210

Effective October 1, 2013

WAC 182-505-0210 Washington apple health -- Eligibility for children.



(1) Unless otherwise stated in this section, a child is a person who is under nineteen years of age (including the month the person turns nineteen). To be eligible for one of the Washington apple health (WAH) for kids programs described below, a child must:

(a) Be a resident of Washington state, as described in WAC 182-503-0520 and 182-503-0525;

(b) Provide a Social Security number (SSN) as described in WAC 182-503-0515 unless exempt; and

(c) Meet any additional requirements listed for the specific program.

(2) Children under one year of age are eligible for WAH categorically needy (CN) coverage, without a new application, when they are born to a mother who is eligible for WAH:

(a) On the date of the newborn's birth, including a retroactive eligibility determination; or

(b) Based on meeting a medically needy (MN) spenddown liability with expenses incurred no later than the date of the newborn's birth.

(3) Children are eligible for WAH at no cost when they:

(a) Have countable family income that is no more than two hundred ten percent of the federal poverty level (FPL) as described in WAC 182-505-0100;

(b) Are currently eligible for supplemental security income (SSI); or

(c) Received SSI 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.

(4) Children are eligible for premium-based WAH as described in WAC 182-505-0215 when they:

(a) Have countable family income that is not more than three hundred twelve percent of FPL as described in WAC 182-505-0100;

(b) Do not have other creditable health insurance as described in WAC 182-505-0220; and

(c) Pay the required monthly premiums as described in WAC 182-505-0225.

(5) Children are eligible for WAH home and community based waiver programs as described in chapter 182-515 WAC when they:

(a) Meet citizenship or immigration status as described in WAC 182-503-0525;

(b) Meet SSI-related eligibility requirements as described in chapter 182-512 WAC; and

(c) Meet program specific age requirements.

(6) Children are eligible for the WAH long-term care program when they meet the institutional program rules as described in chapter 182-513 or 182-514 WAC, and either:

(a) Reside or are expected to reside in a medical institution, intermediate care facility for the intellectually disabled (ICF/ID), hospice care center, or nursing home for thirty days or longer; or

(b) Reside or are expected to reside in an institution for mental diseases (IMD) or inpatient psychiatric facility:

(i) For ninety days or longer and are age seventeen or younger; or

(ii) For thirty days or longer and are age eighteen through twenty-one.

(7) Children are eligible for the WAH medically needy (MN) program as described in WAC 182-519-0100 when they:

(a) Meet citizenship or immigrant status as described in WAC 182-503-0535;

(b) Have countable family income that exceeds three hundred twelve percent of FPL as described in WAC 182-505-0100; or

(c) Have countable family income that is more than two hundred ten percent of FPL, but are not eligible for premium-based WAH as described in subsection (4) of this section because of creditable coverage; and

(d) Meet a spenddown liability as described in WAC 182-515-0110, if required.

(8) Children are eligible for WAH SSI-related programs as described in chapter 182-512 WAC when they:

(a) Meet citizenship or immigration status as described in WAC 182-503-0535;

(b) Meet SSI-related eligibility as described in chapter 182-512 WAC; and

(c) Meet an MN spenddown liability as described in WAC 182-519-0110, if required.

(9) Children who are not eligible for WAH under subsections (5) through (8) of this section because of their immigration status, are eligible for the WAH alien emergency medical program if they:

(a) Meet the eligibility requirements of WAC 182-507-0110;

(b) Have countable family income:

(i) That exceeds three hundred twelve percent of FPL as described in WAC 182-505-0100; or

(ii) That is more than two hundred ten percent of FPL, but they are not eligible for premium-based WAH as described in subsection (4) of this section because of creditable coverage; and

(c) Meet a spenddown liability as described in WAC 182-519-0110, if required.

(10) Children who are in foster care or receive subsidized adoption services are eligible for coverage under the WAH foster care program described in WAC 182-505-0211.

(11) Children who are incarcerated in a public institution (as defined in WAC 182-500-0050), or a city or county jail, are not eligible for any WAH program, with the following exceptions:

(a) Children who reside in an IMD as described in subsection (6) of this section; or

(b) Children who are released from a public institution or city or county jail to a hospital for inpatient treatment. Children who are released from an IMD to a hospital setting must be unconditionally discharged from the IMD to qualify for coverage under this provision.

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 182-505-0215
WAC 182-505-0215

Effective October 1, 2013

WAC 182-505-0215 Washington apple health -- Premium-based children's program -- Purpose and scope.



The medicaid agency administers the programs included in Washington apple health (WAH) for kids that provide premium-based coverage through a combination of state and federal funding sources as described below:

(1) Federally matched health care coverage as authorized by Title XXI of the Social Security Act state children's health insurance program (CHIP) and RCW 74.09.450 for citizen and federally qualified immigrant children whose family income is above two hundred ten percent of the federal poverty level (FPL) but is not above three hundred twelve percent FPL.

(2) State funded health care coverage for children with family income above two hundred ten percent FPL, but not above three hundred twelve percent FPL, who are ineligible for federally matched health care coverage due to immigration status.

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 182-505-0220
WAC 182-505-0220

Effective October 1, 2013

WAC 182-505-0220 REPEALED -- Definitions for premium-based healthcare coverage under programs included in apple health for kids.

  

REPEALED ON OCTOBER 1, 2013.

The following definitions, as well as those found in WAC 388-538-0050  and in 388-500-0005  Medical Definitions, apply to premium-based coverage under programs included in apple health for kids.

"Creditable coverage" means most types of public and private health coverage, except Indian Health Services, that provides access to physicians, hospitals, laboratory services, and radiology services.  This term applies to the coverage whether or not the coverage is equivalent to that offered under premium-based programs included in apple health for kids.  "Creditable coverage" is described in 42 U.S.C. Sec. 1397jj.

"Employer-sponsored dependent coverage" means creditable health coverage for dependents offered by a family member's employer or union, for which the employer or union may contribute in whole or part towards the premium.  Extensions of such coverage (e.g., COBRA extensions) also qualify as employer-sponsored dependent coverage as long as there remains a contribution toward the premiums by the employer or union.

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

  1. The family may:
    1. Receive a cash grant under the Temporary Assistance for Needy Families (TANF);
    2. Be eligible for TANF but choose not to receive cash assistance, such as recipients of diversion cash assistance; or
    3. Be determined ineligible for TANF cash assistance for a reason that does not apply to medical programs as described in WAC 182-505-0240. Consider the family as described in Assistance Units - Medical programs, including the establishment of separate medical assistance units (MAUs), if necessary.
  2. All family members may not be eligible for a medical program.  Some members may enroll in Healthy Options and others may not.
  3. For family members who are not eligible under this category, refer to the following categories:
    1. SSI-related Medical for children and adults who may meet SSI disability criteria services and is ineligible for any other medical program;
    2. Pregnancy for medical programs for pregnant women;
    3. 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;
    4. Long Term Care for family members requiring nursing facility or home and community-based services;
    5. Medical Extensions for a family who has an increase in earned income, spousal support, or child support;
    6. 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.

CLARIFYING INFORMATION

Apple Health for Kids Programs

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 182-504-0125.) 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:

Before 2:00 pm call 1-800-562-3022, Ext 16136.

After 2:00 pm E-Mail  MEDSTRANSFER@HCA.WA.GOV.


Apple Health for Kids

  1. Newborn Medical (F05): See WAC 182-505-0210 (1). Newborns are automatically entitled to receive CN Medicaid through their first birthday as long as:
    •  Their mother was eligible for medical (medicaid or CHIP) on the day of delivery, including through a retroactive eligibility determination. 
    • For MN spenddown pending on the day of delivery, spenddown was met with the labor and delivery expenses, and
    • The newborn is a Washington State resident. 

It is important for the newborn to get its own client ID number as soon as possible after the day of delivery, to ensure there are no coverage problems.

  • If the mother is served fee-for-service on the date of the baby's birth, a newborn is covered by Medicaid fee-for-service under the mother's client ID through the month that includes the baby's 60th day of life.
  • Managed care organizations (MCOs, Healthy Options) only cover a newborn on the mother's client ID for the month(s) in which the first 21 days of life occur.  After that, a newborn must have its own client identification number, or the only medical coverage the newborn receives is fee-for-service, up through the month that includes its 60th day of life, or until the newborn is assigned its own client ID number, whichever is earlier.
  • Once the newborn has been issued its own client ID number, the newborn cannot use the mother's client ID number.

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).  If you open the newborn on F06 or F05 you must use the newborns date of birth as the application date.  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 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.  Worker adds the newborn to the existing F04 AU with January 10 date of birth as application date.  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.  Review received in June. Client provides SSN 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.


  1. Apple Health for Kids CN coverage (F06):  See WAC 182-505-0210 (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.


  1. Apple Health for Kids CN Coverage (F07): See WAC 182-505-0210 (4). These children receive federal or state funded CN medical, but are required to pay a premium see WAC 182-505-0225.Federally funded children are enrolled in managed care, while state funded children remain fee-for-service.
  2. Apple Health for Kids (MN) Medically Needy coverage (F99, S99, K99):  See WAC 182-505-0210 (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.
  3. Children's Institutional coverage (K01, K95, K99):  See WAC 182-514-0230 - 182-514-0265: These children are approved for medical assistance based on institutional rules once they reside, or are expected to reside:

    a.  30 days or longer in a medical institution; or

    b.  30 days or longer if they are admitted to an inpatient psychiatric treatment program and they are aged eighteen or older; or

    c.  90 days or longer if they are admitted to an inpatient psychiatric treatment program and they are age seventeen or younger.

    6.  Children's Alien Medical Program (AMP) coverage (F99):   See WAC 182-505-0210 (10): These alien children are eligible for MN coverage for emergency medical services only.

Age

  1. 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).
  2. 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.
  3. 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 Apple Health for Kids programs

Children may live with parents, relatives, non-relatives, or on their own and receive Apple Health for kids.


EXAMPLE

Client 17 years old is homeless and living with friends applies for medical assistance.  Client eligibility is determined for Apple Health for Kids 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 before 2:00 pm, call 1-800-562-3022 x 16136.

For case transfers from MEDS after 2:00 pm, E-Mail MEDSTRANSFER@HCA.WA.GOV   Medical Eligibility Determination Services (MEDS) staff determine the eligibility for:

    1. Children for BH Plus (F06).
    2. Non BH plus children (F06) with no associated cash, food or family medical.
    3. Pregnant BH members (P02/P04).
    4. Premium-based Apple Health for Kids program (F07).
    5. Children's MN spenddown (F99).
    6. Breast and Cervical Cancer Treatment program (S30).
    7. Foster Care medical (D01/D02).
      To contact Foster Care call 1-800-562-3022 x 15480
    8. Take Charge Family Planning Waiver (P06). 
      To contact Take Charge call 1-800-562-3022 x 15481 
  1. MEDS will process and maintain stand alone applications/reviews for Apple Health for Kids (no associated cash, food or family medical) mailed by the client to the MEDS office or any associated with another active 076 case.

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

  1. BH provides affordable health insurance to any Washington resident, and is administered by the Washington State Health Care Authority (HCA).
  2. An application for BH is only considered a joint application for BH Plus Medicaid) when the family applying for BH coverage also requests BH plus for their child on the application.
  3. 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.
  4. 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.
  5. 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.
  6. To request a transfer of a BH plus case contact MEDS before 2:00 pm at 1-800-562-3022 x 16136 or after 2:00 pm E-mail MEDSTRANSFER@HCA.WA.GOV.

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. 


  1. Before taking action on an open case:

a.  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.

b.  MEDS staff needs to examine the STAT screens to determine if the household is receiving other benefits in the CSO.

2.  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.

  1. If these messages do not appear send a DMS tickler to the MEDS worker.
  2. Do not close a shared MEDS AU while the CSO AU is still pending.

3.  If the CSO needs a shared case transferred before 2:00 pm call 1-800-562-3022 Ext. 16136, or after 2 :00 pm e-mail MEDSTRANSFER@HCA.WA.GOV.

4.  For MEDS if the shared case is for any program other than F06, prior contact with the CSO is required before making any change.

5.  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.

6.  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: 1-800-562-3022 x 16136 before 2:00 pm daily.
FAX: (866) 720-2892 or (360) 586-2042

E-Mail:

Case transfers MEDSTRANSFER@HCA.WA.GOV  


Children’s Alien Medical Program (AMP)

Applications received in the CSO or MEDS with clients eligible for AMP are forwarded to the Specialized Medical Unit (SMU) in site 157 if AMP 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 157.


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 AMP.


How To Contact the SMU:

Mail:                                                                         
DSHS
CSD - Customer Service Center
PO Box 11699
Tacoma, Washington 98411-6699

 

Phone:
1-877-501-2233

DMS:
AMP Applications
forward in DMS to CSO 157@AEM.


WAC 182-505-0225

WAC 182-505-0225

Effective July 1, 2012

WAC 182-505-0225 Premium-based Washington apple health for kids -- Premium requirements.



(1) For the purposes of this chapter, "premium" means an amount paid for Washington apple health (WAH) coverage for kids as described in WAC 182-505-0210(4).

(2) Payment of a premium is required as a condition of eligibility for premium-based WAH coverage for kids, as described in WAC 182-505-0210(4), unless the child is:

(a) Pregnant; or

(b) An American Indian or Alaska native.

(3) The premium requirement begins the first of the month following the determination of eligibility. There is no premium requirement for WAH coverage received in a month or months before the determination of eligibility.

(4) The premium amount is limited to a monthly maximum of two premiums for families with two or more children.

(5) The premium amount is:

(a) Twenty dollars per month per child for families with countable income above two hundred ten percent FPL, but not above two hundred sixty percent FPL; or

(b) Thirty dollars per month per child for families with countable income above two hundred sixty percent FPL, but not above three hundred twelve percent FPL.

(6) All children in an assistance unit (AU) are ineligible for WAH coverage when the family fails to pay required premium payments for three consecutive months.

(7) When the agency or its designee terminates the WAH coverage due to nonpayment of premiums, the child's eligibility is restored when the:

(a) Past due premiums are paid in full prior to the end of the certification period; or

(b) The child becomes eligible for coverage under WAH without a premium.

(8) The agency or its designee writes off past-due premiums after twelve months.

(9) If all past due premiums are paid after the certification period is over:

(a) Eligibility for prior months is not restored; and

(b) Children are not eligible for premium-based WAH for kids until:

(i) The month the premiums are paid or the agency writes off the debt; and

(ii) The family reapplies and is found eligible.

(10) A family cannot designate partial payment of the billed premium amount as payment for a specific child in the AU. The full premium amount is the obligation of the head of household of the AU. A family can decide to request health care coverage only for certain children in the AU, if they want to reduce premium obligation.

(11) A change that affects the premium amount is effective the month after the change is reported and processed.

(12) A sponsor or other third party may pay the premium on behalf of the child or children in the AU. The premium payment requirement remains the obligation of head of household of the AU. The failure of a sponsor or other third party to pay the premium does not eliminate the obligation of the head of household to pay past due premiums.

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

When the household fails to pay the required premium for three months, all premium-based assistance units are closed through the end of the certification period.  If the household pays the entire 3 months’ delinquent premiums within the certification period, then the assistance unit is reinstated back to the month of termination. The household will not be charged a premium for the reinstated months and will enter the premium billing cycle with the ongoing month.

If the household pays the delinquent premium after the end of the certification period, the assistance unit remains closed.  The household will need to reapply in order to have eligibility for premium-based coverage redetermined.

If the household reapplies within twelve months of their case closing for failing to pay the required premium, they are ineligible for premium-based coverage until:

  1. They pay the delinquent premium, or
  2. Twelve months have elapsed and the department writes off the delinquent balance.

 


WORKER RESPONSIBILITIES

When the assistance unit is closed for failing to pay the required premium:

  1. Send the client a letter explaining that coverage may be reinstated if the delinquent premium is paid in full by the end of the certification period.
  2. Document the closure, that the letter was sent, and the date that the delinquent premium must be paid by in order for coverage to be reinstated.

If the household pays the delinquent premium in full prior to the end of the certification period:

  1. Reinstate eligibility for all months since the termination of the au for non-payment of the premium.
  2. Document the reinstatement, months reinstated, and send the client a reinstatement letter that includes the months reinstated, and the last month of the certification period.

If the household pays the delinquent premium in full after the end of the certification period:

  1. Note that the payment was received, but do not reinstate the assistance unit.
  2. Send the household a letter with an application and explain that they will need to reapply in order to have ongoing eligibility determined.

If the household reapplies for medical assistance within twelve months of termination for failing to pay the required premium:

  1. Review the household’s income eligibility for nonpremium-based Apple Health for Kids (e.g. F06).  If eligible for such a program, authorize that program. 
  2. If not eligible for a nonpremium-based program review the record to see if there is a delinquent balance on their premium account.

a.  If there is a delinquent balance, contact the client and explain they are not eligible for premium-based Apple Health for Kids until their delinquent account is paid in full, or the department writes of the delinquent balance.

b.  Give the household the amount of the delinquent premium and contact information for mailing the delinquent premium to FSA.  The household should:

i.   Make the check or money order payable to: DSHS

ii.   Include a statement that the payment is for their delinquent Apple Health premium.

iii.  Include their account number (HOH client ID number)

iv.  Mail the payment to:

DSHS
Office of Financial Recovery
PO Box 9501
Olympia, WA 98507-9726

 

  3.  If there are questions about the delinquent account; that a payment has been made, or  it appears the delinquency is over twelve months old, the worker should contact the FSA representative.  Do not refer clients to FSA.  

 

FSA CONTACTS

E-mail address

Melody Green

ofrpremium@dshs.wa.gov

WAC 182-505-0230

WAC 182-505-0230

Effective October 1, 2013

WAC 182-505-0230 REPEALED -- Waiting period for premium-based healthcare coverage under programs included in apple health for kids following employer coverage.



REPEALED ON OCTOBER 1, 2013.

1.  The department requires applicants to serve a waiting period of four full consecutive months before  

     receiving premium-based coverage under programs included in apple health for kids if the client or family:

 

            a.  Chooses to end employer sponsored dependent coverage.   The waiting period begins the day

                 after the employment-based coverage ends; or

            b.   Fails to exercise an optional coverage extension (e.g., COBRA) that meets the following

                 conditions.   The waiting period begins on the day there is a documented refusal of the  

                 coverage extension when the extended coverage is:

                        i.  Subsidized in part or in whole by the employer or union;

                        ii. Available and accessible to the applicant or family; and

                        iii.At a monthly cost to the family meeting the limitation of

                           subsection (2)(b)(iv).

 

2.  The department does not require a waiting period prior to premium-based coverage under a program included in apple health for kids when:

 

            a.   The client or family member has a medical condition that, without

                 treatment, would be life-threatening or cause serious disability or loss of function; or

            b.  The loss of employer-sponsored dependent coverage is due to any of the                        

                 following:

                        i.  Loss of employment with no post-employment subsidized coverage as described in

                            subsection (1)(b);

                        ii. Death of the employee;

                        iii.The employer discontinues employer-sponsored dependent coverage;

                        iv. The family's total out-of-pocket maximum cost for employer-sponsored                        

                            dependent coverage is two and one-half percent or more of the family's countable

                            monthly income;

                        v.  The plan terminates employer-sponsored dependent coverage for  the client because

                             the client reached the maximum lifetime coverage amount;

                        vi. Coverage under a COBRA extension period expired;

                        vii.Employer-sponsored dependent coverage is not reasonably available (e.g., client

                            would have to travel to another city or state to access care); or

                        viii.Domestic violence caused the loss of coverage for the victim.

 

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 182-505-0237
WAC 182-505-0237

Effective October 1, 2013

WAC 182-505-0237 Premium-based Washington apple health for kids -- Other rules that apply.



In addition to the rules of this chapter, children receiving premium-based Washington apple health (WAH) for kids are subject to the following rules:

(1) Chapter 182-538 WAC, Managed care (except WAC 182-538-061, 182-538-063, and 182-538-065) if the child is covered under federally matched CN coverage;

(2) WAC 182-504-0015, Certification periods for categorically needy (CN) scope of care medical assistance programs; and

(3) WAC 182-504-0125, Effect of changes on medical program eligibility.

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 182-505-0240

WAC 182-505-0240

Effective October 1, 2013

WAC 182-505-0240 Washington apple health -- Parents and caretaker relatives.



(1) A person is eligible for Washington apple health (WAH) categorically needy (CN) coverage when he or she:

(a) Is a parent or caretaker relative of a dependent child who meets the criteria described in WAC 182-503-0565(2);

(b) Meets citizenship and immigration status requirements described in WAC 182-503-0535;

(c) Meets general eligibility requirements described in WAC 182-503-0535; and

(d) Has countable income below fifty-four percent of the federal poverty level (FPL).

(2) To be eligible for WAH coverage as a caretaker relative, a person must be related to a dependent child who meets the criteria described in WAC 182-503-0565(2).

(3) A person must cooperate with the state of Washington in the identification, use and collection of medical support from responsible third parties as described in WAC 182-503-0540.

(4) A person who does not cooperate with the requirements in subsection (3) of this section is not eligible for WAH coverage.

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

Family Medical Programs

A family may be eligible for one of the following programs:

  1. 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.


  1. Family medical (F04): Families who do not want cash assistance or who are ineligible due to the reasons described in WAC 182-505-0240  (2) may be eligible for family medical.

    1. 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.


  1. 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.
  2. 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.

  1. 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. 

ACES PROCEDURES

See Medical

Modification Date: May 2, 2014