WAC 182-511-1250 Health care for workers with disabilities (HWD) -- Premium payments.

WAC 182-511-1250 Apple health for workers with disabilities (HWD) -- Premium payments.

Effective June 3, 2025

This section describes how the Medicaid agency calculates the premium amount a person must pay for apple health for workers with disabilities (HWD) coverage. This section also describes program requirements regarding the billing and payment of HWD premiums.

1. When determining the HWD premium amount, the agency counts only the income of the person approved for the program. It does not count the income of another household member.
2. When determining countable income used to calculate the HWD premium, the agency applies the following rules:
   1. Income is considered available and owned when it is:
      1. Received; and
      2. Can be used to meet the person's needs for food, clothing, and shelter, except as described in WAC 182-512-0600(5) and 182-512-0650.
   2. Income is considered unavailable when it is:
      1. Described in 20 C.F.R. Sec. 416.1103.
      2. Used to pay the fee described in WAC 182-512-0800 (5).
3. The HWD premium amount equals the lesser of the two following amounts:
   1. A total of the following (rounded down to the nearest whole dollar):
      1. Fifty percent of unearned income above the medically needy income level (MNIL) described in WAC 182-519-0050; plus
      2. Five percent of total unearned income; plus
      3. Two and one-half percent of earned income after first deducting $65; or
   2. Seven and one-half percent of countable income described in subsection (2) of this section, including both earned and unearned income.
4. When determining the premium amount, the agency will use the currently verified income amount until a change in income is reported and processed, unless good cause for delay in verifying changes exists.
5. A change in the premium amount is effective the month after the change in income is reported and processed.
6. For current and ongoing coverage, the agency will bill for HWD premiums during the month following the benefit month.
7. For retroactive coverage, the agency will bill the HWD premiums during the month following the month in which coverage is requested and necessary information that establishes eligibility is received by the agency.
8. If initial coverage for the HWD program is approved in a month that follows the month of application, the first monthly premium includes the costs for both the month of application and any following months that have passed during determination of eligibility.
9. As described in WAC 182-511-1050 (3)(b), the agency will close HWD coverage if premiums are not paid in full for four consecutive months.
10. The person must pay the monthly premium in full to avoid losing HWD coverage. If a person makes a partial payment, the payment does not count as a full payment toward the premium.
11. Payments received are applied to premiums owed in the following order:
    1. If retroactive coverage is requested, the retroactive coverage month(s);
    2. Past due months, beginning with the most delinquent month;
    3. The current coverage month that has been invoiced; then
    4. Future coverage months.
12. A person must pay a premium for any month that HWD coverage is provided. This includes months when a redetermination of coverage is made, and months when continued coverage that is requested, pending the outcome of an administrative hearing.