Information needed

Revised July 25, 2014

Purpose: To explain the rules and procedures when an individual applies for health care coverage and the agency needs other information to determine eligibility.

WAC 182-503-0050 Verification of eligibility factors.

Effective March 20, 2017.

For the purposes of this section, "we" refers to the medicaid agency or its designee and "you" refers to the applicant for, or recipient of, health care coverage. 

  1. General rules.
    1. We may verify the information we use to determine, redetermine, or terminate your Washington apple health eligibility.
    2. We verify the eligibility factors listed in WAC 182-503-0505(3).
    3. Before we ask you to provide records to verify an eligibility factor, we use information available from state data bases, including data from the department of social and health services and the department of employment security, federal data bases, or commercially available data bases to verify the eligibility factor.
    4. We may require information from third parties, such as employers, landlords, and insurance companies, to verify an eligibility factor if the information we received:
      1. Cannot be verified through available data sources;
      2. Did not verify an eligibility factor; or
      3. Is contradictory, confusing, or outdated.
    5. We do not require you to submit a record unless it is necessary to determine or redetermine your eligibility.
    6. If you can obtain verification within three business days and we determine the verification is sufficient to confirm an eligibility factor, we base our initial eligibility decision upon that record.
    7. If we are unable to verify eligibility as described in (f) of this subsection, then we may consider third-party sources.
    8. If a fee is required to obtain a necessary record, we pay the fee directly to the holder of the record.
    9. We do not deny or delay your application if you failed to provide information to verify an eligibility factor in a particular type or form.
    10. Except for eligibility factors listed in WAC 182-503-0505 (3)(c) and (d), we accept alternative forms of verification. If you give us a reasonable explanation that confirms your eligibility, we may not require additional documentation.
    11. Once we verify an eligibility factor that will not change, we may not require additional verification. Examples include:
      1. U.S. citizenship;
      2. Family relationships by birth;
      3. Social Security numbers; and
      4. Dates of birth, death, marriage, dissolution of marriage, or legal separation.
    12. If we cannot verify your immigration status and you are otherwise eligible for Washington apple health, we approve coverage and give additional time as needed to verify your immigration status.
  2. Submission timelines.
    1. We allow at least ten calendar days for you to submit requested information.
    2. If you request more time to provide information, we allow the time requested.
    3. If the tenth day falls on a weekend or a legal holiday as described in RCW 1.16.050, the due date is the next business day.
    4. We do not deny or terminate your eligibility when we give you more time to provide information.
    5. If we do not receive your information by the due date, we make a determination based on all the information available.
  3. Notice requirements.
    1. When we need more information from you to determine your eligibility for Washington apple health coverage, we send all notices according to the requirements of WAC 182-518-0015.
    2. If we cannot determine you are eligible, we send you a denial or termination notice including information on when we reconsider a denied application under WAC 182-503-0080.
  4. Equal access and limited-English proficiency services. If you are eligible for equal access services under WAC 182-503-0120 or limited-English proficiency services under WAC 182-503-0110, we provide legally sufficient support services.
  5. Eligibility factors for nonmodified adjusted gross income (MAGI)-based programs. If you apply for a non-MAGI program under WAC 182-503-0510(3), we verify the factors in WAC 182-503-0505(3). In addition, we verify:
    1. Household composition, if spousal or dependent deeming under chapter 182-512 WAC or spousal or dependent allowance under chapters 182-513 and 182-515 WAC applies;
    2. Income and income deductions;
    3. Resources, including trusts, annuities, and life estates under chapters 182-512, 182-513, and 182-516 WAC;
    4. Medical expenses required to meet any spenddown liability under WAC 182-519-0110;
    5. All post-eligibility deductions used to determine cost of care for clients eligible for long-term services and supports under chapters 182-513 and 182-515 WAC;
    6. Transfers of assets under chapter 182-513 WAC when the program is subject to transfer of assets limitations;
    7. Shelter costs for long-term care cases where spousal and dependent allowances apply;
    8. Blindness or disability, if you claim either; and
    9. Social Security number for a community spouse if needed when you apply for long-term care.
  6. Verification for MAGI-based programs.
    1. After we approve your coverage based on your self-attestation, we may conduct a post-eligibility review to verify your self-attested information.
    2. When conducting a post-eligibility review, we attempt to verify eligibility factors using your self-attested information available to us through state, federal, and commercially available data sources, or other third parties, before requiring you to provide information.
    3. You may be required to provide additional information if:
      1. We cannot verify an eligibility factor through other data sources listed in subsection (b) of this section; or
      2. The information received from the data source is not reasonably compatible with your self-attestation.
  7. Reapplication following post-eligibility review. If your eligibility for MAGI-based Washington apple health terminates because of a post-eligibility review and you reapply, we may request verification of eligibility factors prior to determining 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.

Clarifying Information

The agency requires only the information that is both needed to determine eligibility and readily available. "Readily available" means that the individual can get the information within three business days. If the verification costs money, the agency must pay for it or get the information in another way.

For more information on what information is needed to determine eligibility, see Verification.

Worker Responsibilities

  1. Whenever possible, obtain verification by cross-matches and interfaces.
  2. Do not request a specific form or type of document for verification. Instead, ask for what is needed to determine eligibility. Give or send the individual any departmental or approved local-office forms that would help give us the information we need to determine eligibility.

For example, do not request a Stop Work form; request verification of the date the individual received her last pay check and the amount of her last pay check. We may offer the Stop Work form for the individual's convenience.

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