WAC 388-523-0120 Medical extensions - Premium requirements.

1. "Countable income" means, for the purposes of determining the premium amount described in this chapter, all earned income of the adult family members, minus the amount of employment-related child care paid for by the family. The earned income of an adult, living in the household, who is financially responsible for other members of the assistance unit is included, whether or not the person is an eligible member of the assistance unit. 

2. The department requires the family pay to premiums for medical coverage provided during the second six-month medical extension period. The premium amount is one percent of the family's average countable income rounded down to the nearest whole dollar.  This whole dollar amount is billed per adult per month.  See subsection (3).

3. The premiums for:

   1. Months seven, eight, and nine are based solely on the average countable income received in months one, two and three of the medical extension period; and

   2. Months ten, eleven, and twelve are based solely on the average countable income received in months four, five, and six of the medical extension period.

4. A subsequent change in income does not effect the premium amount described in subsection (2) and (3) of this section.

5. When a family's premium is one month in arrears, the family is ineligible for the balance of the medical extension period unless good cause exists. Reasons for good cause include, but are not limited to:

   1. Illness, mental impairment, injury, trauma, or stress;

   2. Lack of understanding the premium payment requirement due to a language barrier;

   3. Transportation problems;

   4. Non-payment of thepremium because the client expected to be able to meet the family medical needs, but could not; or

   5. Receipt ofincorrect information or non-receipt of advance and adequate notice about the premium payment requirements. Refer to WAC 388-422-0020(4) and (5).

6. The department exempts individual family members from the premium requirements, as follows:

   1. Children;

   2. Pregnant women;

   3. American Indians and Alaska Natives; and

   4. Caretaker adults in a family whose countable income is equal to or less than one hundred percent of the Federal Poverty Level based on family size as described in WAC 388-478-0075(2).

7. When determining the exemption described in (6)(b), the premium exemption is effective the first of the month following the client’s report of the pregnancy to the department.

8. When determining the exemption described in (6)(d), the department shall include in the household size an unborn child and a person who is financially responsible for other members of the assistance unit, whether or not the person is an eligible member of the assistance unit. A person receiving SSI cash assistance is not included when determining the household size.

9. The department determines a family's exemption from the premium requirement as described in subsection (6)(d) for:

   1. Months seven, eight and nine based solely on information available to the department at the time the premium for these months is calculated; and

   2. Months ten, eleven, and twelve based solely on information available to the department at the time the premium for these months is calculated.

10. Any change resulting in an individual meeting the exemption criteria in subsection (6)(d) after the establishment of the premium amount for months seven, eight and nine is used to calculate the premium amount for months ten, eleven, and twelve.  Any change resulting in an individual meeting the exemption criteria in  subsection (6)(d) after the establishment of the premium amount for months ten, eleven, and twelve is not used to recalculate the premium amount for months ten, eleven, and twelve.