General eligibility requirements that apply to all Apple Health programs

Certification periods

Revised Date: 
July 25, 2014

Purpose: To explain certification periods for Apple Health programs, including categorically needy (CN) programs, medically needy (MN) noninstitutionalized programs, Medicare Savings Programs and Medical Care Services (MCS).

WAC 182-504-0015 Washington apple health -- Certification periods for categorically needy programs.

Effective July 1, 2017

  1. A certification period is the period of time we determine that you are eligible for a categorically needy (CN) Washington apple health program. Unless otherwise stated in this section, the certification period begins on the first day of the month of application and continues through the end of the last month of the certification period.
  2. For a newborn eligible for apple health, the certification period begins on the child's date of birth and continues through the end of the month of the child's first birthday.
  3. If you are a person eligible for apple health based on pregnancy, the certification period ends the last day of the month that includes the sixtieth day from the day the pregnancy ends.
  4. If you are eligible for the refugee program, the certification period ends at the end of the eighth month following your date of entry to the United States.
  5. For all other CN coverage, the certification period is twelve months.
  6. If you are a child, eligibility is continuous throughout the certification period regardless of a change in circumstances, unless a required premium (described in WAC 182-505-0225) is not paid for three consecutive months or you:
    1. Turn age nineteen;
    2. Move out-of-state; or
    3. Die.
  7. When you turn nineteen, the certification period ends after the redetermination process described in WAC 182-504-0125 is completed, even if the twelve-month period is not over, unless:
    1. You are receiving inpatient  services (described in WAC 182-514-0230) on the last day of the month you turn nineteen;
    2. The inpatient stay continues into the following month or months; and
    3. You remain eligible except for turning age nineteen.
  8. A retroactive certification period is described in WAC 182-504-0005.
  9. Coverage under premium-based programs included in apple health for kids as described in chapter 182-505 WAC begins no sooner than the month after creditable coverage ends.

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

Eligibility must be determined separately for any retroactive CN certification period (see Retroactive Certification Periods below). It is possible for an individual to be ineligible in the month of application, but eligible for one or more of the previous three months.

WAC 182-504-0020 Certification periods for the noninstitutional medically needy program.

Effective July 11, 2015

  1. The certification period for the noninstitutional medically needy (MN) program for clients with countable income equal to or below the medically needy income level (MNIL):
    1. Begins on the first day of the month in which eligibility is established; and
    2. Is approved for twelve calendar months. 
  2. The certification period for the noninstitutional MN program for clients with countable income above the MNIL:
    1. Begins on the day that spenddown is met; and
    2. Continues through the last day of the final month of the base period as described in WAC 182-519-0110.
  3. A retroactive MN certification period may be established for up to three months preceding the month of application.
  4. Expenses used to meet the spenddown liability for the current or the retroactive certification periods are the responsibility of the client.  The agency is not responsible for paying any expense or portion of an expense which has been used to meet the spenddown liability.  See WAC 182-519-0110.
  5. A new application must be submitted for each subsequent certification period for which medically needy coverage is requested.

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 base period begins with the month of application and is usually three or six months, depending upon the individual's choice. See Spenddown.

WAC 182-504-0025 Medicare savings program certification periods.

Effective December 1, 2011

Certification periods for the different kinds of Medicare Savings Programs are not all the same. The chart below explains the differences.

Medicare Savings Program Certification Period Start Date

QMB (Qualified Medicare Beneficiary)

S03

12 months On the first day of the month following QMB eligibility determination

SLMB (Special low income Medicare beneficiary)

S05

12 months

Up to three months prior to the certification period if on the first day of the first month of certification, the person:

  • Is or has been enrolled in Medicare Part B; and
  • Meets SLMB eligibility requirements.

QDWI (Qualified disabled working individual)

S04

12 months

Up to three months prior to the certification period if on the first day of the first month of certification, the person:

  • Is or has been enrolled in Medicare Part A; and
  • Meets QDWI eligibility requirements.

QI-1 (Qualified individual)

S06

Thru the end of the calendar year following QI-1 eligibility determination

Up to three months prior to the certification period if on the first day of the first month of certification, the person:

  • Is or has been enrolled in Medicare Part B; and
  • Meets QI-1 eligibility requirements.

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 182-504-0005 Washington apple health -- Retroactive certification period.

Effective April 14, 2015.

  1. The medicaid agency approves a retroactive Washington apple health (WAH) certification period for the three months immediately before the month of application when an individual:
    1. Requests retroactive WAH on the application, within the certification period following the retroactive period, or before the determination of benefits and any appeal process is final;
    2. Would have been eligible for WAH for any or all of the three months if the individual had applied during the retroactive period; and
    3. The individual received covered medical services as described in WAC 182-501-0060 and 182-501-0065.
  2. When an individual is eligible only during the three-month retroactive certification period, that period is the only period of certification, except when:
    1. A pregnant woman is eligible in one of the three months immediately before the month of application, but no earlier than the month of conception. Eligibility continues as described in WAC 182-504-0015(3).
    2. A child is eligible for categorically needy (CN) WAH as described in WAC 182-505-0210(1) through (5) and (7) in at least one of the three months immediately before the month of application. Eligibility after the retroactive period continues as described in WAC 182-504-0015(9).
  3. An individual applying for the medically needy (MN) spenddown program may be eligible for a retroactive certification period as described in WAC 182-504-0020.
  4. An individual applying for a medicare savings program may be eligible for a retroactive certification period as described in WAC 182-504-0025.

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. For retroactive certification periods for the Apple Health for Pregnant Women and Apple Health for Kids programs:
    1. If eligible in one of the three months prior to the application (the retroactive months), children will receive coverage for 12 months from the month of eligibility and pregnant women will receive coverage from the month of eligibility through the 60 days postpartum period.

Example: Pregnant woman applies in March, but her countable income exceeds the standard. She also requests retroactive coverage. Her countable income in January was below the standard. Since she was also pregnant in January, one of the previous three months, she is eligible from January 1 through the entire pregnancy and the postpartum extension. The certification period is for that entire period.