Description
Chapter 182-561 WAC is a new chapter to establish the Community Behavioral Support Services (CBHS) benefit.
The CBHS benefit assists eligible clients with obtaining the skills necessary to reside successfully in home and community-based
settings. The chapter includes the eligibility criteria for clients; Apple Health rules requiring medical necessity do not
apply to this benefit. The chapter also includes CBHS provider requirements, eligible diagnoses, covered services, and the
appeal process. Additionally, the agency is amending WAC 182-501-0065 to include CBHS as a service category.

Agency contacts

Rulemaking contact

Melinda Froud

Program contact

Rebecca Carrell

Rulemaking status history

Preproposal (CR101)

Proposal (CR102)

Withdrawal (CR102)

Proposal (CR102)

Permanent Adoption (CR103P)

Income (part 2)

Revised date

WAC 182-509-0340 MAGI income -- American Indian/Alaska Native excluded income.

WAC 182-509-0340 MAGI income -- American Indian/Alaska Native excluded income.

Effective January 18, 2014.

For the purposes of determining eligibility of American Indians/Alaska Natives for modified adjusted gross income (MAGI)-based Washington apple health (WAH) (see WAC 182-509-0300), the agency excludes from MAGI the following:

  1. Distributions from Alaska Native corporations and settlement trusts;
  2. Distributions from any property held in trust, subject to federal restrictions, located within the most recent boundaries of a prior federal reservation, or otherwise under the supervision of the Secretary of the Interior;
  3. Distributions and payments from rents, leases, rights of way, royalties, usage rights, or natural resource extraction and harvest from:
    1. Rights of ownership or possession in any lands described in (b) of this subsection; or
    2. Federally protected rights regarding off-reservation hunting, fishing, gathering, or usage of natural resources.
  4. Distributions resulting from real property ownership interests related to natural resources and improvements that are:
    1. Located on or near a reservation or within the most recent boundaries of a prior federal reservation; or
    2. Resulting from the exercise of federally protected rights relating to such real property ownership interests.
  5. Payments resulting from ownership interests in or usage rights to items that have unique religious, spiritual, traditional, or cultural significance or rights that support subsistence or a traditional lifestyle according to applicable tribal law or custom;
  6. Student financial assistance provided under the Bureau of Indian Affairs education programs; and
  7. Any other applicable income exclusion as provided by federal law, regulation, or rule, including the Internal Revenue Code, treasury regulations, and Internal Revenue Service revenue rulings, revenue procedures, notices, and other official tax guidance.

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

Taxable per capita distributions, such as per capita from tribal gaming is countable MAGI income.

For more information, see the Tribal Income Desk Aid.

WAC 182-509-0360 MAGI income -- How the income of a child age eighteen or younger or a tax dependent is counted.

WAC 182-509-0360 MAGI income -- How the income of a child age eighteen or younger or a tax dependent is counted.

Effective January 21, 2017

The medicaid agency determines what income is counted when determining eligibility for modified adjusted gross income (MAGI)-based Washington apple health under WAC 182-509-0300

  1. When determining countable income for persons described in subsections (2) through (4) of this section, the countable income of a child age eighteen or younger or of a tax dependent is included only when it meets the threshold required for tax filing under 26 U.S.C. Sec. 6012 (a) (1). For purposes of this section, countable income of a child or tax dependent does not include Social Security dependent benefits.
  2. Determining countable income of a tax filer. The countable income of a tax filer includes the countable income of each member in the tax filer's medical assistance unit (MAU) under WAC 182-506-0012 (1).
  3. Determining countable income of a tax dependent. The countable income of a tax dependent includes the countable income of each member in the tax dependent's MAU under WAC 182-506-0012 (2).
  4. Determining countable income of a nonfiler. The countable income of a nonfiler, including a person considered a nonfiler under WAC 182-506-0012 (2) (b) (ii), includes the countable income of each member in the nonfiler's MAU under WAC 182-506-0012 (3).

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

Income of a tax dependent or child aged 18 or younger is only countable for the assistance unit if it meets or exceeds the tax filing threshold, regardless of their intent to file taxes.

Social Security income alone of a tax dependent or child age 18 or younger is never countable as the tax filing threshold is never reachable when determining their eligibility.

WAC 182-509-0365 MAGI income -- Self-employment income.

WAC 182-509-0365  MAGI income -- Self-employment income.

Effective September 13, 2021.

For purposes of determining eligibility for modified adjusted gross income (MAGI)–based Washington apple health (WAH) (see WAC 182-509-0300):

  1. Self-employment income is income earned by a person from running a business, performing a service, selling items that are made, or reselling items with the intent to make a profit, after deducting allowable IRS self-employment expenses. This income can be earned if the person is carrying on a trade or business as a sole proprietor or an independent contractor; a member of a partnership that carries on a trade or business; or otherwise in business for themselves (including a part-time business). Examples of self-employment business structures include, but are not limited to:
    1. Sole proprietorship - An unincorporated business owned by one person.
    2. Partnership - A relationship between two or more people who conduct a trade or business.
    3. Corporation - An entity that conducts business, realizes net income or loss, pays taxes, and distributes profits to shareholders.
    4. S corporation - Similar to a corporation, but this structure passes corporate income, losses, deductions, and credits through to the shareholders for federal tax purposes.
    5. Limited liability company (LLC) - An entity formed by one or more people or entities through a special written agreement that details the organization of the LLC.
  2. Self-employment income is counted as earned income as described in WAC 182-509-0330, except when it is earned by a child or tax dependent and the income is below the filing threshold, as described in WAC 182-509-0360(1). 
  3. A person is considered to be self-employed if they earn income without having an employer/employee relationship with the individual who pays the income. Self-employed people do not work for a specific employer who pays them a consistent salary or wage. Factors to consider are whether:
    1. The person has primary control or has the right to control what they do and how they do their job;
    2. The business aspects of the person's job are controlled by the person and not the payer (this includes things like how the person is paid, whether expenses are reimbursed, or who provides tools/supplies);
    3. The person has a contract stating that they are an independent contractor; or
    4. The person reports their income using one or more IRS schedules or forms that include, but are not limited to:
      1. Schedule C;
      2. Schedule C-EZ;
      3. Schedule E;
      4. Schedule F;
      5. Schedule K-1;
      6. Schedule SE;
      7. Form 940;
      8. Form 941;
      9. Form 942;
      10. Form 943;
      11. Form 1065; or 
      12. Form 1120.
  4. A person is considered to have an employer/employee relationship when:
    1. The individual the person provides services for has primary control of how the work is done; or
    2. The person receives an IRS Form W-2 to report the income that is earned.
  5. Self-employment does not have to be a licensed business for a person's business or activity to qualify as self-employment. 
  6. A person must keep records of his or her self-employment income and deductions and provide this information to the agency upon request.

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 182-509-0370 MAGI income -- How self-employment income is counted.

WAC 182-509-0370 MAGI income -- How self-employment income is counted.

Effective September 13, 2021.

For purposes of determining eligibility for modified adjusted gross income (MAGI)–based Washington apple health, the medicaid agency counts self-employment income by:

  1. Adding together gross self-employment income and any profit made from selling business property or equipment over a period of time; and 
  2. Subtracting business expenses and income deductions allowed by the Internal Revenue Service that the person would be entitled to if they were filing a federal tax return and either:
    1. Averaging the income to come up with a monthly amount based on the period of time the business has been in operation within the last year; or
    2. Averaging the income over a representative period of time if the current income does not represent the person's projected income as shown by clear indications of future changes in income; or
    3. By averaging the self-employed income and deductions claimed on the previous year's tax return over a representative period of time.

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

Individuals are self-employed when they are in business for themselves. Countable self-employment income is gross income minus any allowable Internal Revenue Service allowable business expenses. Types of businesses can include sole proprietorships, rentals, farming, partnerships, and corporations. 

Most self-employed individuals can verify their income with their tax return unless they don’t file one or their most recent tax return is not a good reflection of their current income. These individuals can provide profit and loss statements for their business for the past three months.

Individuals who are shareholders in an S-corporation must provide proof of the wages the corporation pays them plus any ordinary business income received from the corporation.

WAC 182-509-0375 MAGI income -- Lump sums

WAC 182-509-0375 MAGI income -- Lump sums.

Effective September 13, 2021.

For purposes of determining eligibility for modified adjusted gross income (MAGI)–based Washington apple health (see WAC 182-509-0300):

  1. A lump sum payment is money that a person receives but does not expect to receive on a continuing basis, such as an insurance settlement.
  2. A lump sum payment is only counted as income if it is received in the month of application, and it otherwise qualifies as countable income under another rule.

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

To be considered a lump sum, it has to be:

  1. Anticipated to be received one-time; and
  2. A countable source of income

Example 1: Betty receives an inheritance from her mother who passed away during the month she applied for Washington Apple Health. She does not report this income because it is not a countable source of income.

Example 2: Johnny receives a distribution from stocks he holds in investments during the month of application. He reports this income, but this is not a lump sum. This is anticipated to be ongoing income. Johnny averages this income over a period of time.

Example 3: Jesse wins the lottery and receives a lump sum during his certification period. He reports this change, however, because the lump sum was not received during the month of application, it is not countable income. Only the interest income from the lottery winnings is countable income.

For more information on income, please see Income (part 1).

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What is dual enrollment across the SEBB and PEBB Programs, and why isn't it allowed?

View the answer to this question and other related information in the Dual Enrollment FAQ.

Liberty Mutual Auto & Home insurance

Liberty Mutual Auto & Home insurance

Liberty Mutual Auto & Home insurance

00349: 3M Inpatient Grouper Issue
Discovery log number
00349
Discovery description

Due to a system issue involving the inpatient grouping software that is still being tracked, some inpatient claims received by HCA may either improperly fail to group to a DRG, causing a denial, or in a smaller number of cases, group to an incorrect DRG, which may cause some denials or pricing changes. The issue will be resolved as quickly as possible.

In most cases involving this issue, providers will see inpatient claims deny for failure to group to a DRG. In a minority of cases, there may be some claims which group to an incorrect DRG.

Date reported
ETA
Provider impact
Phase 1
Workaround
Follow established processes for checking into claims denials through customer service phone or email. Alternatively, the user may attempt to adjust claims themselves as most claims group correctly on the second attempt.

Value-based purchasing (VBP)

The Health Care Authority (HCA) is the largest health care purchaser in the state. We purchase health care for almost 3 million Washington residents through our Apple Health (Medicaid), Public Employees Benefits Board (PEBB), and School Employees Benefits Board (SEBB) programs.

HCA is leading the effort to transform health care, helping ensure Washington residents have access to better health and better care at a lower cost. Our goal is to achieve a healthier Washington by containing costs while improving outcomes, patient and provider experience, and equity through innovative VBP strategies.

We call this effort “paying for health and value.” One way we achieve this is through value-based purchasing (VBP).

What's VBP?

VBP is a range of strategies intended to contain costs while improving outcomes by tying health care payment to care quality. VBP rewards providers for health care quality, incentivizing them to focus on primary and preventive care. It also holds plans and providers accountable for providing high-quality, high-value care and a satisfying patient experience.

What's fee-for-service?

Traditional health care payment is called fee-for-service (FFS) payment. In FFS contracts, providers are paid for each patient they see and each service they provide. This means that providers receive the same pay whether or not the patient improves and regardless of the appropriateness of care. FFS payment also incentivizes seeing a high volume of patients and providing more expensive specialty services.

VBP strategies take the place of traditional FFS payment. VBP comes in many forms, and HCA uses a variety of tools and approaches to promote VBP.

Goals

We achieve a healthier Washington by:

  • Aligning Apple Health, PEBB, SEBB, and other programs to a VBP philosophy.
  • Holding health care plan partners and delivery system networks accountable for providing quality and value.
  • Exercising significant oversight and quality assurance over contracting partners and implementing corrective action, if necessary.

News and updates

Visit our news page to view announcements. 

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