Long-term services and supports (LTSS) manual

LTC change of circumstance

Revised Date: 
December 10, 2014

WAC 182-504-0105 Washington apple health -- Changes that must be reported.

Effective August 29, 2014.

  1. You must report changes in your household and family circumstances to us (the agency or its designee) timely according to WAC 182-504-0110.
  2. We tell you what you are required to report at the time you are approved for WAH coverage. We also will tell you if the reporting requirements change.
  3. You must report the following:
    1. Change in residential address;
    2. Change in mailing address;
    3. Change in marital status;
    4. When family members or dependents move in or out of the residence;
    5. Pregnancy;
    6. Incarceration;
    7. Change in institutional status;
    8. Change in health insurance coverage including medicare eligibility; and
    9. Change in immigration or citizenship status.
  4. If you are eligible for a WAH long-term care program described in chapter 182-513 or 182-515 WAC, you must also report changes to the following:
    1. Income;
    2. Resources;
    3. Medical expenses; and
    4. Spouse or dependent changes in income or shelter cost when expenses are allowed for either.
  5. If you get WAH parent or caretaker (as described in WAC 182-505-0240) or WAH modified adjusted gross income (MAGI)-based adult coverage (as described in WAC 182-505-0250), you must also report changes to the following:
    1. When total income increases or total deductions decrease by one hundred fifty dollars or more a month and the change will continue for at least two months;
    2. Your federal income tax filing status that you expect to use when you file your taxes for the current tax filing year (such as changing from "married filing separately" to "married filing jointly"); and
    3. The tax dependents you expect to claim when you file your federal income tax return for the current tax filing year.
  6. If you get WAH based on age, blindness, or disability (SSI-related medical), then you must also report changes to the following:
    1. Income; and
    2. Resources. 

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 182-504-0110 Washington apple health -- When to report changes.

Effective August 29, 2014.

  1. All changes you report to us (the agency or its designee), as required by WAC 182-504-0105, are used to decide if you can receive or keep receiving Washington apple health (WAH) coverage.
  2. You must report changes during your certification period within thirty days of when the change happened.
  3. You must report all changes during application, renewal, or redetermination of your WAH eligibility, regardless of when the change happened.
  4. For a change in income, the date a change happened is the first date you received income based on the change. For example, the date you receive your first paycheck for a new job or the date you got a paycheck with a wage increase is the date the change happened.
  5. If you do not report a change or you report a change late, we will decide if you can receive or keep receiving WAH coverage based on the date the change was required to be reported.
  6. If you do not report a change or you report a change late, and if it affects the amount you must pay toward your cost of care as described in WAC 182-513-1380 or chapter 182-515 WAC, you may become liable for overpayments we make on your behalf and you may need to pay more to your care provider.
  7. If you do not report a change or you report a change late, it may result in us overpaying you and you having to pay us back for the health care costs we overpaid. See chapter 182-520 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.

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

When to report changes

  • Changes must be reported by the 30th day after the change.
  • For a change in income or post eligibility deductions, the date a change happened is the first date income based on the change was received.

Example: The date a new pension amount is received is the date the change happened.

Example: The date the client is notified of their liability after a primary insurance has paid on a claim is the first date a medical expense is known.

Changes and how it affects post eligibility treatment of income

Method 1, 2 and 3 is described in WAC 182-504-0120 (11) for institutional and (12) for HCB Waivers :

  1. 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 (Method 1)
    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. (Method 2)
  2. 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. (Method 3)

For individuals residing in medical institutions federal rule requires clients to contribute to their cost of care, in the amount of:

  • Income received
  • Less allowable post eligibility deductions

Two methods are allowed to determine post eligibility participation for individuals residing in a medical institution

  1. Method 1 Total income received less allowable deductions in the month incurred.
  2. Method 2 Projecting income and deductions, not to exceed six (6) months. Income and deductions can be reconciled at the end of the six (6) months, earlier if a significant change occurs.
  • Method 1 is used for income and deductions that typically do not change much
  • Method 2 is used for clients that have frequent changes in income or post eligibility deductions. An example is an RHC DDA client with varying earned income.
  • Method 1 and 2 are used for institutional post eligibility, (residing in a medical institution).
  • Method 1 or Method 2 is the rule – there is no option for Method 3

Method 3 is used for HCB Waiver post eligibility.

  • When changes affect your HCB Waiver cost of care we calculate the 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.
  • Any change to an HCB Waiver client’s income or deductions that affect cost of care takes effect in the ongoing month in ACES.
    With the exception of loss of an income source or the lowering of income. The change takes effect the actual month of change. We will make these historical changes in ACES.
  • For HCB Waiver clients, Method 3 is the rule – there is no option to use Method 1 or Method 2
  • Medical expenses
  • Qualifying medical expenses incurred by the institutional client can be used to reduce participation (Institutional 182-513-1380)
  • Qualifying unpaid medical expenses can be used to reduce participation (182-515-1509 and 182-515-1514). For HCB Waiver clients, as long as a medical expense is still outstanding, a report of this expense will be timely, regardless of Chapter 182-504 WAC reporting requirements. The expense will be allowed (If requirements of 182-513-1350 are met.) This is because the client's expenses have not "changed" when an expense is unpaid.

For additional information on Method 1, Method 2 and Method 3, go to the financial SharePoint site. Financial training under the policy and program changes. HCB Waiver - Method 3

For additional information on allowable medical expenses and post eligibility treatment of income, see allowable medical expenses.