General eligibility requirements that apply to all Apple Health programs

Program standard for income and resources

Revised Date: 
July 25, 2015

Below are the WACs for the income and resource standards, which are summarized in the Medical Income and Resource Standards Chart (pdf).

WAC 182-505-0100 Medical programs-- Monthly income standards based on the federal poverty level (FPL).

WAC 182-512-0010 Supplemental Security Income (SSI) standards; SSI-related categorically needy income level (CNIL); and countable resource standards.

WAC 182-517-0100 Medicare savings programs--Monthly income standards.

WAC 182-519-0050 Monthly income and countable resource standards for medically needy (MN).

WAC 182-519-0050 Monthly income and countable resource standards for medically needy (MN).

Effective September 7, 2015

  1. Changes to the Medically Needy Income Level (MNIL) occur on January 1st of each calendar year when the Social Security Administration (SSA) issues a cost-of-living adjustment.
  2. Medically Needy (MN) standards for people who meet institutional status requirements are in WAC 182-513-1395. The standard for a client who lives in an alternate living facility is in WAC 182-513-1305.
  3. The resource standards for institutional programs are in WAC 182-513-1350. The institutional standard chart is found at Long Term Care Standards.
  4. Countable resource standards for the noninstitutional MN program are:
    1. One person $2,000.
    2. A legally married couple $3,000.
    3. For each additional family member add $50.
  5. People who do not meet institutional status requirements use the "effective" MNIL income standard to determine eligibility for the MN program. The "effective" MNIL is the one-person federal benefit rate (FBR) established by SSA each year, or the MNIL listed below, whichever amount is higher. The FBR is the supplemental security income (SSI) payment standard. For example, in 2012 the FBR is six hundred ninety-eight dollars.
1 2 3 4 5 6 7 8 9 10
467 592 667 742 858 975 1125 1242 1358 1483

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 182-505-0100 Monthly income standards for MAGI -based programs.

Effective July 1, 2017.

  1. Each year, the federal government publishes new federal poverty level (FPL) income standards in the Federal Register found at https://aspe.hhs.gov/poverty-guidelines.
    1. The income standards for the following Washington apple health programs change on the first day of April every year based on the new FPL, except for subsections (2) and (3) of this section.
    2. The agency determines income eligibility by comparing countable income as determined of the person's medical assistance unit (MAU), as determined under WAC 182-506-0010 and 182-506-0012, to the applicable income standard. Rules for determining countable income are in chapter 182-509 WAC.
  2. Parents and caretaker relatives under WAC 182-505-0240 must have countable income equal to or below the following standards:
    Medical Assistance Unit Size 1 2 3 4 5 6 7 8 9 10 11+
    Medical Assistance Unit Size $511 $658 $820 $972 $1,127 $1,284 $1,471 $1,631 $1,792 $1,951 $1,951
  3. Parents and caretaker relatives with earned income above the limits in subsection (2) of this section are the only people who may be eligible for the transitional medical program described in WAC 182-523-0100.
  4. Adults described in WAC 182-505-0250 who are not eligible under subsection (2) or (3) of this section must have countable income equal to or below one hundred thirty-three percent of the FPL.
  5. Pregnant people described in WAC 182-505-0115 must have countable income equal to or below one hundred ninety-three percent of the FPL. 
  6. Children with countable income:
    1. Equal to or below two hundred ten percent of the FPL as described in WAC 182-505-0210 (3)(a)(i) receive coverage at no cost.
    2. Greater than two hundred ten percent but equal to or less than three hundred twelve percent as described in WAC 182-505-0210 (3)(a)(ii) receive premium-based coverage. Premium amounts are described
      in WAC 182-505-0225.

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 182-512-0010 Supplemental security income (SSI) standards, SSI-related categorically needy income level (CNIL), and countable resource standards.

Effective January 27, 2019

  1. The SSI payment standards, also known as the federal benefit rate (FBR), change each January 1st.
  2. See WAC 388-478-0055 for the amount of the state supplemental payments (SSP) for SSI recipients.
  3. See WAC 182-513-1205 for standards of clients living in an alternate living facility.
  4. The SSI-related CNIL standards are the same as the SSI payment standards for single persons and couples. Those paying out shelter costs have a higher standard than people who have supplied shelter.
  5. The countable resource standards for SSI and SSI-related CN medical programs are:
    1. One person                          $2,000
    2. A legally married couple        $3,000

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 182-517-0100 Federal medicare savings programs.

Effective July 15, 2019

  1. Available programs.  The medicaid agency offers eligible clients the following medicare savings programs (MSPs):
    1. The qualified Medicare beneficiary (QMB) program;
    2. The specified low-income medicare beneficiary (SLMB) program;
    3. The qualified individual (QI-1) program; and
    4. The qualified disabled and working individuals (QDWI) program.
  2. Eligibility requirements.
    1. To be eligible for an MSP, a client must:
      1. Be entitled to medicare Part A; and
      2. Meet the general eligibility requirements under WAC 182-503-0505.
    2. To be eligible for QDWI, a client must be under age sixty-five.
    3. Income and resource limits.
      1. Income limits for all MSPs are found https://www.hca.wa.gov/health-care-services-supports/program-standard-income-and-resources.
      2. If a client's countable income is less than or equal to one hundred percent the federal poverty level (FPL), the client is income eligible for the QMB pro­gram.
      3. If a client's countable income is over one hundred percent of the FPL, but does not exceed one hundred twenty percent of the FPL, the client is income eligible for the SLMB program.
      4. If a client's countable income is over one hundred twenty percent of the FPL, but does not exceed one hundred thirty-five percent of the FPL, the client is income eligible for the QI-1 program.
      5. If a client's countable income is over one hundred thirty-five percent of the FPL, but does not exceed two hundred percent of the FPL, the client is income eligible for the QDWI program if the client is employed and meets disability requirements described in WAC 182-512-0050.
      6. Resource limits.
        1. The resource limit for the QMB, SLMB, and QI-1 programs are found at https://www.hca.wa.gov/health-care-services-supports/program-standard-income-and-resources.
        2. The resource limit for the QDWI program is $4,000 for a sin­gle person and $6,000 for a married couple.
  3. MSP income eligibility determinations.
    1. The agency has two methods for determining if a client is eligible for an MSP:
      1. The agency first determines if the client is eligible based on SSI-rated methodologies under chapter 182-512 WAC. Under this method, the agency calculates the household's net countable income and compares the result to the one-person standard. However, if the spouse's income is deemed to the client, or if both spouses are applying, the household's net countable income is compared to the two-person standard.
      2. If the client is not eligible under the methodology described in (a)(i) of this subsection, the agency compares the same countable income, as determined under (a)(i) of this subsection, to the appropriate FPL standard based on family size. The number of individuals that count for family size include:
        1. The client;
        2. The client's spouse who lives with the client;
        3. The client's dependents who live with the client;
        4. The spouse's dependents who live with the spouse, if the spouse lives with the client; and
        5. Any unborn children of the client, or of the spouse if the spouse lives with the client.
    2. Under both eligibility determinations, the agency follows the rules for SSI-related people under chapter 182-512 WAC for determining:
      1. Countable income and resources;
      2. Availability of income and resources;
      3. Allowable income deductions and exclusions; and
      4. Deemed income from and allocated income to a nonapplying spouse and dependents.
    3. The agency uses the eligibility determination that provides the client with the highest level of coverage.
      1. If the MSP applicant is eligible for QMB coverage under (a)(i) of this subsection, the agency approves the coverage.
      2. If the MSP applicant is not eligible for QMB coverage, the agency determines if the applicant is eligible under (a)(ii) of this subsection.
      3. If neither eligibility determination results in QMB coverage, the agency uses the same process to determine if the client is eligible under any other MSP.
    4. When calculating income under this section:
      1. The agency subtracts client participation from a long-term care client's countable income under WAC 182-513-1380, 182-515-1509, or 182-515-1514.
      2. The agency counts the annual Social Security cost-of-living increase beginning April 1st each year.
  4. ​Covered costs
    1. The QMB program pays:
      1. Medicare Part A and Part B premiums using the start date in WAC 182-504-0025; and
      2. Medicare coinsurance, copayments, and deductibles for Part A, Part B, and Part C, subject to the limitations in WAC 182-502-0110.
    2. If the client is eligible for both SLMB and another medicaid program:
      1. The SLMB program pays the Part B premiums using the start date in WAC 182-504-0025; and
      2. The medicaid program pays medicare coinsurance, copayments, and deductibles for Part A, Part B, and Part C subject to the limitations in WAC 182-502-0110.
    3. If the client is only eligible for SLMB, the SLMB program covers medicare Part B premiums using the start date in WAC 182-504-0025.
    4. The QI-1 program pays medicare Part B premiums using the start date in WAC 182-504-0025 until the agency's federal funding allotment is spent. The agency resumes QI-1 benefit payments the beginning of the next calendar year.
    5. The QDWI program covers medicare Part A premiums using the start date in WAC 182-504-0025.
  5. MSP eligibility. Medicaid eligibility may affect MSP eligibility:
    1. QMB and SLMB clients may receive medicaid and still be eligible to receive QMB or SLMB benefits.
    2. QI-1 and QDWI clients who begin receiving medicaid are no longer eligible for QI-1 or QDWI benefits, but may be eligible for the state-funded medicare buy-in program under WAC 182-517-0300.
  6. Right to request administrative hearing. A person who disagrees with agency action under this section may request an administrative hearing under chapter 182-526 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.