WAC 182-519-0100 Eligibility for the medically needy program

1. An individual who meets the following conditions may be eligible for medically needy (MN) coverage under the special rules in chapters 388-513 WAC  and  388-515 WAC:
   1. Meets the institutional status requirements of WAC 388-513-1320;
   2. Resides in a medical institution as described in WAC 388-513-1395;
   3. Receives waiver services under a medically needy in-home waiver (MNIW) according to WAC 388-515-1550 or a medically needy residential waiver (MNRW) according to WAC 388-515-1540.
2. An SSI-related individual who lives in a department contracted alternate living facility may be eligible for MN coverage under the rules described in WAC 388-513-1305.
3. An individual may be eligible for MN coverage under this chapter when he or she is:
   1. Not covered under subsection (1) and (2) of this section;
   2. Eligible for categorically needy (CN) medical coverage in all other respects except that his or her CN countable income is above the CN income standard.
4.  MN coverage may be available if the individual is:
   1. A child;
   2. A pregnant woman;
   3. A refugee;
   4. An SSI-related individual including an aged, blind or disabled individual with countable income under the CN income standard, who is an ineligible spouse of an SSI recipient; or
   5. A hospice client with countable income which is above the special income level  (SIL).
5. An individual who is not eligible for CN medical and who is applying for MN coverage has the right to income deductions in addition to, or instead of,  those used to arrive at CN countable income. Deductions to income are applied to each month of the base period to determine MN countable income. The following deductions are used to calculate countable income for MN:
   1. The agency disregards the difference between the MNIL described in WAC 182-519-0050 and the federal benefit rate (FBR) established by the Social Security Administration each year.  The FBR is the one person Supplemental Security Income (SSI) payment standard;
   2. All health insurance premiums, with the exception of medicare Part A, Part B, Part C and Part D premiums expected to be paid by the individual or family member during the base period(s); 
   3. Any allocations to a spouse or to dependents for an SSI-related individual who is married or who has dependent children. Rules for allocating income are describe in WAC 182-512-0900 through WAC 182-512-0960;
   4. For an SSI-related individual who is married and lives in the same home as his or her spouse who receives home and community based waiver services under chapter 388-515 WAC, an income deduction equal to the medically needy income level (MNIL) minus the nonapplying spouse's income; and
   5. A child or pregnant woman who is applying for MN coverage is eligible for income deductions allowed under TANF/SFA rules and not under the rules for CN programs based on the federal poverty level.  See WAC 182-509-0001 (4)  for exceptions to the TANF/SFA rules which apply to medical programs and not to the cash assistance program.
6. The MNIL for individuals who qualify for MN coverage under subsection (1) of this section is based on rules in chapter 388-513 and 388-515 WAC.
7. The MNIL for all other individuals is described in WAC 182-519-0050. If an individual has countable income which is at or below the MNIL, he or she is certified as eligible for up to twelve months of MN medical coverage.
8. If an individual has countable income which is over the MNIL, the countable income that exceeds the agency's MNIL standards is called "excess income."
9. When individuals have "excess income" they are not eligible for MN coverage until they provide evidence to the agency or its designee of medical expenses incurred by themselves, their spouse or family members who live in the home for whom they are financially responsible.  See WAC 182-519-0110(8).  An expense has been incurred when:
   1. The individual has received the medical treatment or medical supplies, is financially liable for the medical expenses but has not yet paid the bill; or
   2. The individual has paid for the expenses with in the current or retroactive base period described in WAC 182-519-0110 .
10. Incurred medical expenses or obligations may be used to offset any portion of countable income that is over the MNIL.  This is the process of meeting "spenddown."
11. The agency or its designee calculates the amount of an individual's spenddown by multiplying the monthly excess income amount by the number of months in the certification period as described in WAC 182-519-0110.  The qualifying medical expenses must be greater than or equal to the total calculated spenddown amount.
12. An individual who is considered for MN coverage under this chapter may not spenddown excess resources to become eligible for the MN program.  Under this chapter individuals are ineligible for MN coverage if their resources exceed the program standard in WAC 182-519-0050.  An individual who is considered fro MN coverage under WAC 388-513-1395, 182-514-0250 or 182-514-0255 is allowed to spenddown excess resources.
13. There is no automatic redetermination process for MN coverage.  An individual must submit an application for each eligibility period under the MN program.
14. An individual who requests a timely administrative hearing under WAC 388-458-0040 is not eligible for continued benefits beyond the end of the original certification date under the MN program.