WAC 182-505-0210 Eligibility for children.

Effective June 9, 2025

1. General eligibility. For purposes of this section, a child must:
   1. Be a Washington state resident under WAC 182-503-0520 and 182-503-0525;
   2. Provide a Social Security number under WAC 182-503-0515, unless exempt; and
   3. Meet program-specific requirements.
2. Deemed eligibility groups. A child is automatically eligible for coverage without an application if the child meets the program-specific requirements in (a) through (c) of this subsection.
   1. Newborn coverage. A child younger than age one is eligible for categorically needy (CN) coverage if the birth parent was eligible for Washington apple health on the date of delivery:
      1. Including a retroactive eligibility determination; or
      2. By meeting a medically needy (MN) spenddown liability with expenses incurred by the date of the newborn's birth:
   2. Washington apple health for supplemental security income (SSI) recipients. A child who is eligible for SSI is automatically eligible for CN coverage under WAC 182-510-0001.
   3. Foster care coverage. A child age 20 and younger is eligible for CN coverage under WAC 182-505-0211 when the child is in foster care or receives subsidized adoption services. For children who age out of the foster care program, see WAC 182-505-0211(3).
3. Continuous eligibility for children under age six. A child is eligible for Washington apple health continuous eligibility for children under age six when they:
   1. Have household income at or below 210 percent of the federal poverty level at the time of application; or
   2. On or after January 8, 2025, have household income greater than 210 percent but equal to or less than 312 percent of the federal poverty level at the time of application; or
   3. Received coverage under subsection (5) of this section and are no longer eligible for deemed coverage under subsection (5) (b) or (c) of this section.
4. MAGI-based eligibility groups. A child age 18 or younger is eligible for CN coverage based on modified adjusted gross income (MAGI):
   1. At no cost when the child's countable income does not exceed the standard in WAC 182-505-0100 (6)(a);
   2. With payment of a premium when the child's countable income does not exceed the standard in WAC 182-505-0100 (6)(b), and the child meets additional eligibility criteria in WAC 182-505-0215;
   3. Under chapter 182-514 WAC, if the child needs long-term care services because the child resides or is expected to reside in an institution, as defined in WAC 182-500-0050, for 30 days or longer. An institutionalized child is eligible for coverage under the medically needy (MN) program if income exceeds the CN income standard for a person in an institution (special income level);
   4. Under WAC 182-505-0117, if a child is pregnant;
   5. When the child has household income at or below 215 percent of the federal poverty level at the time of application and is eligible for Washington apple health continuous eligibility for children under age six.
5. Non-MAGI-based children's programs. The agency determines eligibility for the:
   1. MN program according to WAC 182-519-0100. A child age 18 or younger is eligible if the child:
      1. Is not eligible for MAGI-based coverage under subsection (3) of this section;
      2. Meets citizenship or immigration requirements under WAC 182-503-0535 (2)(a), (b), (c), or (d); and
      3. Meets any spenddown liability required under WAC 182-519-0110.
   2. SSI-related program. A child age 18 or younger is eligible for CN or MN SSI-related coverage if the child meets:
      1. SSI-related eligibility under chapter 182-512 WAC;
      2. Citizenship or immigration requirements under WAC 182-503-0535 (2)(a), (b), (c), or (d); and
      3. Any MN spenddown liability under WAC 182-519-0110.
   3. SSI-related long-term care program.
      1. A child age 18 or younger is eligible for home and community based (HCB) waiver programs under chapter 182-515 WAC if the child meets:
         1. SSI-related eligibility under chapter 182-512 WAC;
         2. Citizenship or immigration requirements under WAC 182-503-0535 (2)(a), (b), (c), or (d); and
         3. Program-specific age and functional requirements under chapters 388-106 and 388-845 WAC.
      2. A child age 18 or younger who resides or is expected to reside in a medical institution as defined in WAC 182-500-0050 is eligible for institutional medical under chapter 182-513 WAC if the child meets:
         1. Citizenship or immigration requirements under WAC 182-503-0535 (2)(a), (b), (c), or (d);
         2. Blindness or disability criteria under WAC 182-512-0050; and
         3. Nursing facility level of care under chapter 388-106 WAC.
6. Alien emergency medical program. A child age 20 or younger who does not meet the eligibility requirements for a program described under subsections (2) through (5) of this section is eligible for the alien emergency medical (AEM) program if the child meets:
   1. The eligibility requirements of WAC 182-507-0110; and
   2. MN spenddown liability, if any, under WAC 182-519-0110.
7. Other provisions.
   1. A child residing in an institution for mental disease (IMD) as defined in WAC 182-500-0050 is not eligible for inpatient hospital services, unless the child is unconditionally discharged from the IMD before receiving the services.
   2. A child incarcerated in a public institution as defined in WAC 182-500-0050 is only eligible for inpatient hospital services.

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 182-505-0215 Children's Washington apple health with premiums.

Effective January 23, 2021.

1. A child is eligible for Washington apple health with premiums if the child:
   1. Meets the requirements in WAC 182-505-0210(1);
   2. Has countable income below the standard in WAC 182-505-0100 (6)(b); and
   3. Pays the required premium under WAC 182-505-0225, unless the child is exempt under WAC 182-505-0225 (2)(c).
2. A child is not eligible for Washington apple health with premiums if the child:
   1. Is eligible for no-cost Washington apple health;
   2. Has creditable health insurance coverage as defined in WAC 182-500-0020.
3. A child with creditable health insurance coverage may be eligible for Washington apple health with premiums if the child is eligible for either:
   1. Public employees benefits board (PEBB) health insurance coverage based on a family member's employment with a Washington state agency, or a Washington state university, community college, or technical college; or
   2. School employees benefits board (SEBB) health insurance coverage based on a family member's employment with a Washington school district, charter school, or educational service district; and
   3. Meets the requirements in WAC 182-505-0210 (1).

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.