General eligibility requirements that apply to all Apple Health programs

Changes of circumstance effect on eligibility

Revised Date: 
July 25, 2014

Purpose: To explain how reported changes of circumstance affect a recipient's Apple Health coverage.

WAC 182-504-0120 Washington apple health -- Effective dates of changes.

Effective August 29, 2014.

  1. We (the agency or its designee) determine the date a change affects your Washington apple health (WAH) coverage based on:
    1. The date you report the change to us;
    2. The date you give us the requested verification; and
    3. The type of WAH you or your family is receiving.
  2. When you report a change after you submit your application, but before your application is processed, the change is considered when processing your application.
  3. If another person, agency, or data source reports a change in circumstances, the information may be used in determining your eligibility. We will not rely on information received from a person, agency, or data source to terminate your WAH coverage without requesting additional information from you.
  4. A change in income affects your ongoing eligibility only if it is expected to continue beyond the month when the change is reported, and only if it is expected to last more than two months.
  5. A change that results in termination of your WAH coverage takes effect the first of the month following the advance notice period.
  6. The advance notice period:
    1. Begins on the day we send the letter about the change to you; and
    2. Is determined according to the rules in WAC 182-518-0025.
  7. A change that results in a decreased scope of care takes effect on the first of the month following the advance notice period. Examples of a decreased scope of care are:
    1. Termination of WAH categorically needy (CN) medical and approval for other WAH coverage with a lesser scope of care such as WAH medically needy (MN) medical;
    2. WAH-MN recipient with a change that increases the spenddown liability amount;
    3. WAH-MN recipient with no spenddown liability with a change that results in WAH-MN with a spenddown liability.
  8. A change that results in an increased scope of care takes effect on the first of the month following the date the change was reported, when you provide the required verification:
    1. Within ten days of the date we requested the verification; or
    2. By the end of the month of your change report, whichever is later.

      If you are a WAH-MN applicant with a spenddown liability that has not yet been met and you report a change that results in your becoming eligible for WAH-CN medical or WAH for adults, your change report will be treated as a new application for purposes of retroactive WAH coverage as described in WAC 182-504-0005.

  9. If you do not provide the required verification timely under subsection (8) of this section, we make the change effective the first of the month following the month in which you provide the verification. We may terminate your WAH coverage if you do not provide the required verification.
  10. When a law or regulation requires a change in WAH, the date specified by the law or regulation is the effective date of the change.
  11. When a change in income or allowable expenses is reported timely (within thirty days) and changes the amount you pay towards the cost of your care for institutional programs (residing in a medical institution), we calculate your new participation amount based on:
    1. Either actual income received in a month or allowable deductions incurred in a month, or both; or
    2. An estimate of your monthly or allowable expenses in a prospective period of six months or less, based on both actual income received in a preceding period of six months or less and income expected to be received during the prospective period. At the end of the prospective period or when any significant change occurs, we reconcile this estimate for the period with income received during the same period.
  12. When a change in income, or allowable expenses, changes the amount you pay towards the cost of your care for a home and community-based waiver or service, we calculate your new participation amount effective the first of the month following the date the change was reported, except that the new participation amount will be effective the month the change occurs if the change is the loss of an income source that you report within thirty days of the change.
  13. We use the following rules to determine the effective date of change for the health care for workers with disabilities (HWD) program:
    1. HWD coverage begins the month after coverage in another medical program ends and the premium amount has been approved by the eligible person; and
    2. If a change in income increases or decreases the monthly premium, the change is effective the first of the month after the change is reported. For more information on premium requirements for this program, see WAC 182-511-1250.

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 182-504-0125 Washington apple health -- Effect of reported changes.

Effective October 1, 2017.

  1. If you report a change required under WAC 182-504-0105 during a certification period, you continue to be eligible for Washington apple health coverage until we decide if you can keep getting apple health coverage under your current apple health program or a different apple health program.
  2. If your apple health categorically needy (CN) coverage ends due to a reported change and you meet all the eligibility requirements for a different apple health CN program, we will approve your coverage under the new apple health CN program. If you are not eligible for coverage under any apple health CN program but you meet the eligibility requirements for either apple health alternative benefits plan (ABP) coverage or apple health medically needy (MN) coverage, we will approve your coverage under the program you are eligible for. If you are not eligible for coverage under any apple health CN program but you meet the eligibility requirements for both apple health ABP coverage and apple health MN coverage, we will approve the apple health ABP coverage unless you notify us that you prefer  apple health MN coverage.
  3. If your apple health coverage ends and you are not eligible for a different apple health program, we stop your apple health coverage after giving you advance and adequate notice unless the exception in subsection (4) of this section applies to you.
  4. If you claim to have a disability and that is the only basis for you to be potentially eligible for apple health coverage, then we refer you to the division of disability determination services (within the department of social and health services) for a disability determination. Pending the outcome of the disability determination, we also determine if you are eligible for apple health coverage under the SSI-related medical program described in chapter 182-512 WAC. If you have countable income in excess of the SSI-related categorically needy income level (CNIL), then we look to see if you can get coverage under apple health MN with spenddown as described in chapter 182-519 WAC pending the final outcome of the disability determination.
  5. If you are eligible for and receive coverage under the apple health parent and caretaker relative program described in WAC 182-505-0240, you may be eligible for the apple health medical extension program described in WAC 182-523-0100, if your coverage ends as a result of an increase in your earned income.
  6. Changes in income during a certification period do not affect eligibility for the following programs:
    1. Apple health for pregnant women;
    2. Apple health for children, except as specified in subsection (7) of this section;
    3. Apple health for SSI recipients;
    4. Apple health refugee program; and
    5. Apple health medical extension program.
  7. We redetermine eligibility for children receiving apple health for kids premium-based coverage described in WAC 182-505-0210 when the:
    1. Household's countable income decreases to a percentage of the federal poverty level (FPL) that would result in either a change in premium for apple health for kids with premiums or the children becoming eligible for apple health for kids (without premiums);
    2. Child becomes pregnant;
    3. Family size changes; or
    4. Child receives SSI.
  8. If you get SSI-related apple health CN coverage and report a change in work or earned income which results in a determination by the division of disability determination services that you no longer meet the definition of a disabled person as described in WAC 182-512-0050 due to work or earnings at the level of substantial gainful activity (SGA), we redetermine your eligibility for coverage under the health care for workers with disabilities (HWD) program. The HWD program is a premium-based program that waives the SGA work or earnings test, and you must approve the premium amount before we can authorize coverage under this program. For HWD program rules, see chapter 182-511 WAC.

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 following shows how to report changes of circumstance and the effects of reported changes:

MAGI-Based Apple Health and Apple Health for Parents and Caretaker Relatives Classic Medicaid (Aged, Blind, Disabled (SSI-Related and Long-Term Care)

Individuals can report changes:

  1. Log into their Healthplanfinder account, under Quick Links, select "Report a Change in Income or Household," and follow the prompts to report the change.
  2. Call the Healthplanfinder Customer Support Center (HPF CSC) at 855-923-4633. The HPF CSC worker will go into the client's HPF account to enter the changes.
  3. Call the HCA Medical Eligibility Determination Services (MEDS) at 800-562-3022.
  4. By mail to P.O. Box 946, Olympia, WA 98507.
  5. By fax to 360-841-7620

Individuals can report changes:

  1. Report the change in Washington Connection, either by logging into their account or clicking on the "Report a Change" link and following the prompts.
  2. Call the Community Service Division Customer Service Center at 877-501-2233.
  3. By mail to DSHS, CSD-Customer Service Center, P.O. Box 11699, Tacoma, WA 98411-6699.
  4. By fax to 888-338-7410.

Taking action on changes:

  1. When information about someone's circumstances becomes known: determine the impact on the person's benefits. This may include contacting them, contacting other parties, or asking for proof of their circumstances.
  2. Individual Reports: Take action based on changes the person reports by entering the changes into the Healthplanfinder.
  3. Third Party Reports: If we receive information from a third party, follow-up to decide how the information affects the person's/household's health care coverage. This may include contacting the person, contacting other parties, or asking for proof of their circumstances under WAC 182-503-0050 Verification Requirements for Apple Health.

Taking action on changes:

  1. When information about someone's circumstances becomes known: determine the impact on the person's benefits. This may include contacting them, contacting other parties, or asking for proof of their circumstances.
  2. Individual Reports: Take action based on changes the person reports by entering the changes into the Healthplanfinder.
  3. Third Party Reports: If we receive information from a third party, follow-up to decide how the information affects the person's/household's health care coverage. This may include contacting the person, contacting other parties, or asking for proof of their circumstances under WAC 182-503-0050 Verification Requirements for Apple Health.

When a change happens:

  1. The date of the change is normally the date a change occurs, such as when someone gets married, a newborn comes home from the hospital, someone moves to a new home.
  2. However, the date of a change in income is the date someone receives the newly reported income, such as a first paycheck that reflects a wage increase or a first paycheck for a new job.

When a change happens:

  1. The date of the change is normally the date a change occurs, such as when someone gets married, a newborn comes home from the hospital, someone moves to a new home.
  2. However, the date of a change in income is the date someone receives the newly reported income, such as a first paycheck that reflects a wage increase or a first paycheck for a new job.

Effect of a reported change:

  1. If a reported change results in a change in coverage, the change takes place on the first of the month following the month in which the change is reported, after advance and adequate notice has been given.
  2. Unlike in ACES, Healthplanfinder does not have the functionality to enter a change into a specific month. If an individual reports a change early, the worker should keep in mind that the change should not be entered into Healthplanfinder before the month in which the change takes place.

Effect of a reported change:

  1. If a reported change results in a change in coverage, the change takes place on the first of the month following the month in which the change is reported, after advance and adequate notice has been given.
  2. In ACES, the worker can enter a change in the month that the change is reported to take place, including a future month.

Changes reported via Apple Health medical application, renewal or redetermination:

  1. The worker can use an application or renewal at any time to update the certification period.
 

AU member moves out of Washington State:

  1. Individuals must be residents of the state in order to be eligible for health care coverage under any Apple Health programs.
  2. If one or more members of the household (but not the entire household) leave the state, they may still be eligible for Apple Health. Refer to WAC 182-503-0520 Residency Requirements, to determine eligibility for the people who left the state.
 

Example: Sandy is hired for a new job on May 31st, begins work on June 10th, and receives her first paycheck on July 5th. As this is an income change, the date of Sandy's first paycheck, July 5th, is the date of the change. Sandy must report this change by August 5th based on WAC 182-504-0105 Reporting Requirements. If Sandy reports this change earlier (other than her reporting the change in Healthplanfinder), the worker should make sure the effective date of the change is when her first check is expected.

  1. Pregnant women and children found eligible for a CN medical program are continuously eligible through the end of their certification period. The only exceptions are aging out of the program, moving out of state, failing to pay a required premium, incarceration, or death. See WAC 182-504-0015.

    Note: Newborns approved SSI receive continuous CN for 12 months from the date of the SSI medical opening even if they are no longer eligible under the SSI program.

  2. If mail is returned, see if a forwarding address is provided.
    • If one is provided, update the address. No further action is necessary.
    • If one is not provided, terminate the assistance for loss of contact/whereabouts unknown. Advance notice is not necessary.
    • If the individual provides an updated Washington address at any time during the original certification period, the assistance unit is reinstated from the month of termination through the end of the original certification period. A new application is not necessary.
  3. When a pregnancy ends, regardless of the reason, medical coverage continues through the end of the month containing the sixtieth day from the day pregnancy ends.

    Note: If the pregnant woman is pending spenddown when the baby is born and meets spenddown with the birth of the baby, she is eligible for 60 days postpartum MN extension.
     

  4. See Medical Extensions for:
    1. Medical Extension Report; or
    2. A change resulting in eligibility for a medical extension.
  5. If changes in income increase the spenddown liability, the change is effective the first of the month after the change. An increase in resources may affect MN eligibility.

Worker Responsibilities

If the individual has not met the increased spenddown liability, terminate MN, giving advance and adequate notice. See Spenddown.

Aces Procedures

Add a Person

Add a Program

Update Assistance Unit / Client Data

Close Assistance Unit / Client

Deny an Assistance Unit / Client

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