General eligibility requirements that apply to all Apple Health programs

Redetermination overview

Revised Date: 
July 25, 2014

Purpose: To define medical redetermination, describe when a medical redetermination is required, and to provide step by step directions through the process.

Definition: When eligibility ends for a CN Apple Health program during the certification period, federal law requires the agency (or its designee) to look at eligibility for other Apple Health programs before terminating CN coverage. Redetermination is completed at the point the agency considers eligibility for other Apple Health programs and documents in ACES that the reconsideration has been completed.

Without documentation of the redetermination process, the case will be found in error even if the correct action has been taken.

Note: CN coverage may end at the point of redetermination, even while waiting on a final disability determination, for example if the individual's income causes the CN medical (S02) to trickle to medically needy (MN) medical (S95/S99).

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

A medical redetermination is required for individuals who lose CN or ABP coverage during their certification period, which can be under any of the following medical groups:

  • Classic Apple Health (redetermination done by agency staff)
    • SSI terminations (S01, L01 or L21)
    • SSI-Related Medicaid (S02, G03)
    • Breast and Cervical Cancer (S30)
    • Institutional Medicaid (L02, K01, I01)
    • Hospice and Home and Community Waiver programs (L22)
  • MAGI-based Apple Health (redetermination for other MAGI-based programs automatically done by Washington Healthplanfinder)
    • Apple Health for Families/Caretaker Relatives (N01)
    • Apple Health for Newborns (N10)
    • Apple Health for Kids, with or without premiums (N11, N13, N31, N33)
    • Apple Health for Pregnant Women (N03, N23)
    • Apple Health for Adults (N05)

Note: Medical redetermination does not apply to individuals who lose eligibility during their certification period under the Apple Health Medical Care Services program (MCS).

A medical redetermination is not required in the following situations. The individual:

  • Dies;
  • Moves out of state;
  • Cannot be found (whereabouts unknown);
  • Is not federally qualified to receive Medicaid due to citizenship or immigration status; or
  • Asks the department to close medical coverage.

To complete the redetermination, the agency is required to review the individual's record for any indication that the individual may be eligible for another CN program, such as pregnancy or disability. The agency refers to this as "ex parte review", which is a required part of the redetermination process.

Worker Responsibilities

Ex Parte Review and Redetermination

For every redetermination for individuals who lose coverage under a CN medical coverage group, review available records of each individual within a terminated AU by checking:

  1. The electronic case record for the last review form, application or other documents;
  2. The notes in ACES or EJAS (if applicable); and
  3. SOLQ for a current SSI application or social security disability.

Instructions for Common Ex Parte Review Scenarios

Below are instructions for handling common ex parte review findings.

No Indication of Disability or Pregnancy

  1. Terminate the individual's CN coverage, and
  2. Document in ACES the actions taken and that the redetermination process has been completed.

Individual May Be Pregnant

  1. Refer the individual to Washington Healthplanfinder to apply for Apple Health for Pregnant Women;
  2. Set a 10-day tickler for follow-up;
  3. Terminate the individual's prior CN coverage only after the individual has been given 10 days to apply for Apple Health for Pregnant Women; and
  4. Document in ACES the actions taken and that the redetermination process has been completed

Individual Claims to Be Disabled or There Is an Indication of Disability in the Record

  1. Screen in SSI-related medical (S02) coverage so that medical coverage can be continued while gathering the medical documentation needed to do a disability referral;
  2. Pend for verification of disability;
  3. Set a 20-day tickler for follow-up;
    1. If the individual does not respond within 20 days:
      1. Terminate the individual's prior CN coverage; and
      2. Send termination letter with Reason Code 552 and insert appropriate free-form text.
      3. Document in ACES the actions taken and that the redetermination process has been completed.
    2. If the individual responds within 20 days:
      1. Terminate the individual's prior CN coverage;
      2. Send termination letter with the appropriate Reason Code and insert appropriate free-form text;
      3. Finalize the pending S02 AU, including entering any new income;
        1. If there is income, the S02 may trickle to S99. If this happens, insert appropriate free-form text
      4. Set 4-month tickler for follow-up; and
      5. Add remarks behind the DEM2 screen explaining that the disability coding is a workaround to continue medical coverage under S02 while waiting for the NGMA determination due to redetermination.
      6. Document in ACES the actions taken and that the redetermination process has been completed.
      7. If the NGMA referral is returned indicating the individual is not disabled, remove the disability coding on the DEM2 screen to terminate the S02/S99 coverage.

Individual Has Pending SSI Application

Follow instructions above for "Individual Claims to Be Disabled or There Is an Indication of Disability in the Record" except:

  1. Do not do a NGMA referral; and
  2. Notify the Division of Disability Determination Services (DDDS) that the agency has continued the individual's medical coverage and ask them to notify you when a decision is made on the individual's SSI application.

Individual May Be Eligible for Apple Health for Workers with Disabilities (HWD)

If the individual is under age 65 and working and is not otherwise eligible for S02 coverage (and meets disability requirements) send a referral to the specialized medical unit to consider eligibility for the Health Care for Workers with Disabilities (HWD) program. Allow the termination under the original program to proceed (allowing advance and adequate notice).

Note: If an individual is working and has monthly gross earnings at or above the Substantial Gainful Activity (SGA) level and does not receive Title 2 (SSDI, DAC, DWB), then HWD is the only Medicaid program that may provide coverage for them. An individual who is working at SGA is not eligible for S02/S95/S99 coverage, unless their Title 2 cash benefit continues. If their Title 2 has not ended, then HWD staff will explain their options to either enroll in HWD for CN coverage or meet their spenddown for MN coverage.

Set a barcode tickler to the HWD unit in DMS for @HWD in CSO 157 to contact the individual and determine if they wish to pursue HWD. Since HWD is a premium based program, CN coverage should not be authorized under this program until the individual has approved the premium requirement and amount.

For HCS individuals, set a barcode tickler to the HCS Regional HWD specialist to contact the individual and determine if they wish to pursue HWD.

Note: A working individual who is eligible under a Home and Community Based CN waiver program (L22 in ACES) whose income goes over the Special Income Limit (SIL) or who accumulates excess resources should always be referred to the HWD unit prior to terminating CN medical coverage. Both Home and Community Services (HCS) and the Division of Developmental Disabilities (DDD) have included the HWD program as an available coverage group in the CN waivers. An ADSA individual may transition from the L22 program to the S08 program and remain eligible for long-term care funding for waiver services.

System-Generated Alerts

The ACES system helps with the medical redetermination process by sending alerts when CN coverage ends for an individual or for all members in an assistance unit (AU), however staff should not rely solely on system generated alerts to determine when a medical redetermination is required.

The following alerts require the department to follow up, make a redetermination decision and document that decision in the narrative.

  • Alert 416 - Case closed in batch
  • Alert 322 - New MAU created for certain members of the closed AU
  • Alert 248 - SSI terminated, redetermine medical eligibility

When Signed Applications or Review Forms Are Not Required

Signed application or eligibility review forms are NOT needed for:

  • Redeterminations of CN medical coverage for the same program (including MSP programs) with the same individuals in the assistance unit, either prior to the end of the certification period or within 30 days after the case closed. Reviews may be completed by phone or paper and documented in ACES.
  • Changing to a medical program which has a more stringent eligibility requirement (such as changing from HWD, with no resource test to CN SSI-related, which does have a resource test). However, we do need to document in ACES that we asked the necessary questions for the more stringent requirements and what the answers to those questions were. Again, phone or paper redeterminations are acceptable.

Continuous Eligibility

Redetermination does not apply to individuals who receive continuous eligibility, since their coverage continues through the end of their certification period. The following two programs provide continuous eligibility:

  1. Children terminated from any CN medical program are eligible through the end of their original 12-month certification period.
    1. Children whose coverage was approved under the family institutional medical program are eligible to receive one full year of coverage. When a child discharges from a medical facility and is no longer eligible for K01 coverage, open F06 for the balance of the certification period without requiring an application or review from the parents.
  2. Pregnant women terminated from any CN medical program are eligible for CN medical to continue through the end of the post partum period.

Note: A pregnant woman who applies for retroactive medical coverage and is found eligible for CN medical in any month of the retroactive period also remains continuously eligible for CN through the end of the post partum period.

SSI Redetermination

When an individual loses eligibility for Supplemental Security Income (SSI) cash assistance, the department must redetermine their eligibility for Medicaid. The State Data Exchange (SDX) interfaces with ACES and provides us with information regarding the termination or suspension of SSI cash assistance. (The ACES automated redetermination process does not apply to any individual where the SDX medical eligibility code shows as A, C, G, N, Q or Y on the SDX1 screen. These individuals are considered SSI cash recipients and remain eligible under the S01 medical coverage group).

When the medical eligibility code is 'R' (Referred to State), the ACES system takes the following steps, depending on whether the SSI is in nonpay status or is in suspended status.

Suspended Status

ACES checks the SDX to determine the individual's payment status code. If the code is a payment suspense code (S01, S04, S05, S06, S07, S08, S09 or S10) ACES waits and does not generate the 22-05 Redetermination letter and Alert 248 - SSI Terminated, Redetermine Medical Eligibility for 60 days. Social Security uses the suspense codes when updating an individual's address, changing a payee or budgeting fluctuating income and in many cases the SSI cash starts again within a short period of time.

If the individual's status changes again from suspended status to nonpay status at any time during the 60 day wait period, the 22-05 Redetermination letter is generated, along with the 248 Alert.

If the individual's status changes from suspended back to a pay status, then all tracking is stopped and no 22-05 Redetermination letter is sent. ACES automatically removes the SSI closure information from the bottom of the UNER screen when this happens.

After 60 days, if the status on the SDX has not changed, ACES generates the 248 Alert and 22-05 Redetermination letter to the individual.

Nonpay Status

When the SSI closes for an individual who is not in a suspended status with Social Security Administration, ACES populates the bottom of the UNER screen with the SSI closure date and generates the 22-05 Redetermination letter and Alert 248.

Both suspended and terminated individuals have 60 days from the review is sent to return the form. At the end of 60 days, if the S01 AU is still active, ACES will check for 'Y' (Yes) in the ELIG RVW RCVD field on the MISC screen to indicate the review has been received. A barcode to ACES interface automatically populates this field if an eligibility review form is received in the Document Management System (DMS).

If there is a 'Y' on the MISC screen, Alert 251-SSI TERM'D 60 DAYS AGO, COMPLETE MED REDETERMINATION generates and the AU remains active until the review is initiated in the system.

If there is not a 'Y' on the MISC screen, the S01, L01 or L21 AU's will automatically close with reason code 235 - Review Not Complete and ACES generates the correct termination letter allowing advance notice. At this point, the redetermination process is complete. The ACES tracking process automatically stops if an SDX record is sent indicating the individual has started receiving SSI again.

Note: When SSI closes, a redetermination of the individual's disability status is also required, in addition to reviewing income and resource criteria. If SSI closed because the individual began receiving Title II Social Security Disability benefits, a new disability determination is not required. However, a referral needs to be made to DDDS to determine the disability review date if the individual is under the age of 65.

Disability Review Date

If SSI closed for some other reason, a new referral to DDDS for a disability determination may need to be made, unless you are able to contact the local SSA field office for the disability review date, or 'diary' date which is the term used by SSA. DDDS does not keep information about the disability review date once it sends the disability decision to the SSA field office, but SSA staff do have access to the information. Unfortunately, the diary date information is not available through any of the department interfaces with SSA, so if you are unable to obtain the diary date, or if it is time for the individual's disability status to be reviewed, a new DDDS referral for NGMA needs to be initiated. Follow directions under the Ex-Parte review process by screening in an S02. Then set the end date 4 months out to allow time for the disability decision to come back. Set a barcode tickler to review the case again at that time if no disability decision was received within that time frame.

Note: When approving the S02 (or S95/S99) coverage group, remember to change the Approval Source code on the DEM2 screen from "SI" to "SA" if the individual starts receiving Title II benefits.

If the individual receives long-term care services under a Home and Community Waiver (HCBS) program (COPES or DDD waiver), it is important to coordinate closely with the social worker or case manager during this process to ensure Apple Health coverage is not closed for these vulnerable individuals. If the individual has an Equal Access representative, guardian or designated authorized representative, ensure copies of all letters are sent to them so they can respond on behalf of the individual. See WAC 182-503-0120 for more information on Equal Access Services.

If the individual receives services through HCS or DDD, attach a copy of the latest individual CARE assessment to the NGMA referral packet (or ensure DDDS receives a copy if an electronic NGMA referral is initiated through barcode).

SSI-Related Special Income Disregards discusses the ACES redetermination process for individuals who lose eligibility under the SSI program but who remain eligible for CN Medicaid due to the SSI-related special income disregards: Pickle, Disabled Adult Child or the Disabled Widow(er) provisions.

Redetermination for Individuals Who Might Be Eligible for Apple Health.