WAC 182-524-0100 General.

Effective June 17, 2019

1. Compact of Free Association (COFA) islander health care is a state-funded program administered by the health care authority (the agency) to pay the monthly premiums and out-of-pocket expenses for silver level qualified health plans for eligible COFA islanders.
2. For the purpose of this chapter, "our," "us," and "we" refer to the agency or the agency's designee and "you" refers to the applicant for, or recipient of, COFA islander health care.
3. You have the right to appeal any adverse agency action regarding COFA islander health care as described in chapter 182-526 WAC. For coordinated appeals with the Washington health benefit exchange, as described under WAC 182-526-0102, we treat appeals made to either the Washington health benefit exchange or us as filed on the same day. You will not have to submit any information that you have previously submitted to either the Washington health benefit exchange or us.

WAC 182-524-0200 Definitions.

Effective June 17, 2019

This section defines terms used in this chapter. See chapter 182-500 WAC for additional definitions.

"Advance premium tax credit (APTC)" - A tax credit taken in advance to lower a monthly health insurance payment (or premium).

"COFA islander" – A person who is a citizen of the Federated States of Micronesia, the Republic of the Marshall Islands, or the Republic of Palau.

"COFA islander health care" – An agency-administered program that pays the premium and out-of-pocket costs for a silver level qualified health plan for eligible COFA islanders.

"Compact of Free Association (COFA)" – A legal agreement between the government of the United States and the governments of the Federated States of Micronesia (U.S. Pub. L. 108-188); the Republic of the Marshall Islands (U.S. Pub. L. 108-188); and the Republic of Palau (U.S. Pub. L. 99-658).

"Cost-sharing funds" – Agency-provided funds for out-of-pocket costs.

"Out-of-pocket costs" – Copayments, coinsurance, deductibles, and other cost-sharing requirements imposed under a qualified health plan for services, pharmaceuticals, devices, and other health benefits covered by the plan and rendered as in-network. Excludes premiums, balance billing amounts for out-of-network providers, and spending for noncovered services.

"Premium cost" – A person's premium for a qualified health plan, minus the amount of the person's advanced premium tax credit.

"Silver level qualified health plan (QHP)" – Silver level indicates the category of a qualified health plan (QHP) offered by the Washington health benefit exchange (HBE). For a definition of QHP, see WAC 182-500-0090.

WAC 182-524-0250 How to apply.

Effective June 10, 2019

1. COFA islanders age nineteen and older may apply for a qualified health plan (QHP) by:
   1. Completing the application via the Washington Healthplanfinder web site at www.wahealthplanfinder.org;
   2. Calling the Washington health benefit exchange (HBE) customer support center and completing an application by telephone;
   3. Calling the COFA islander health care support line and completing an application by telephone; or
   4. Completing the application for health care coverage (HCA 18-001P), and mailing or faxing to the HBE.
2. When you submit an application for a QHP through HBE using any of the methods listed in subsection (1) of this section, you are automatically considered for COFA islander health care.

WAC 182-524-0300 Eligibility.

Effective June 17, 2019

In order to be eligible for state-funded COFA islander health care, you must enroll in a silver level qualified health plan (QHP) through the Washington health benefit exchange (HBE) during open enrollment or when you qualify for a special enrollment period as described in 45 C.F.R. 155.410 and 45 C.F.R. 155.420.

1. You are eligible for state-funded COFA islander health care administered by us no earlier than January 1, 2019, if you:
   1. Are a COFA islander;
   2. Meet the residency requirements as described under WAC 182-524-0400;
   3. Have household income, as defined under 26 C.F.R. 1.36B-1(e), under one hundred thirty-three percent of the federal poverty level (FPL);
   4. Do not qualify for another federal or state medical assistance programs under chapter 74.09 RCW, that provides minimum essential coverage;
   5. Qualify for, and accept, the maximum advance premium tax credit available under 45 C.F.R. 155.305(f); and
   6. Are enrolled in a silver level QHP.
2. Eligibility for COFA islander health care is subject to the availability of amounts appropriated for the program.
3. You will be terminated from COFA islander health care if you:
   1. Do not meet the eligibility criteria under subsection (1) of this section; or
   2. Request termination.
4. You may be terminated from COFA islander health care if you:
   1. Perform an act, practice, or omission that constitutes fraud, and an insurer rescinds your QHP policy; or
   2. Use your COFA islander health care cost-sharing funds to pay for anything other than out-of-pocket costs.
5. We will reinstate your COFA islander health care if you were:
   1. Terminated in error; or
   2. Successful in your appeal of a termination.
6. Your COFA islander health care begins the first day of the month your silver level QHP coverage begins and you meet the other eligibility requirements as described in subsection (1) of this section.
7. If you report a change that makes you eligible for COFA islander health care, your sponsorship begins either:
   1. The first day of the following month if the change was reported before the fifteenth of the month; or
   2. The first day of the second month if the change was reported after the fifteenth of the month.
8. Your COFA islander health care ends the day your enrollment in a silver level QHP ends or the last day of the month your COFA islander health care eligibility ends, whichever is earlier.

WAC 182-524-0400 Residency requirements.

Revised June 17, 2019

1. This section applies only to residency requirement for COFA islander health care.
2. A resident is a person who currently lives in Washington and:
   1. Intends to reside here, including people without a fixed address; or
   2. Entered the state looking for a job; or
   3. Entered the state with a job commitment.
3. You do not need to live in the state for a specific period of time to meet the requirements in subsection (2) of this section.
4. You can be temporarily out-of-state and remain on COFA islander health care if you:
   1. Intend to return once the purpose of your absence concludes; and
   2. Meet the eligibility requirements as described under WAC 182-524-0300.

WAC 182-524-0500 Notice requirements.

Revised June 17, 2019

1. The provisions in chapter 182-518 WAC apply to COFA islander health care, where applicable. This section applies only to notices and letters that we send regarding COFA islander health care.
2. We send you written notices (letters) when we:
   1. Approve you for COFA islander health care;
   2. Deny you for COFA islander health care;
   3. Change or terminate your eligibility from COFA islander health care;
   4. Ask you for more information; and
   5. Reimburse you for premium costs, as determined by WAC 182-524-0600.
3. All written notices we send to you include:
   1. The date of the notice;
   2. Specific contact information for you to use if you have questions or need help with the notice;
   3. The nature of the action;
   4. The effective date of the action;
   5. The facts and reasons for the action;
   6. The specific regulation on which the action is based;
   7. Your appeal rights, if an appeal is available; and
   8. Other information required by the state.
4. If we request information from you, we allow at least ten calendar days for you to submit requested information. If you ask, we may allow you more time to get us the information.
   1. If the due date falls on a weekend or a legal holiday as described in RCW 1.16.050, the due date is the next business day.
   2. We do not deny or terminate your eligibility when we ask you to provide information.
   3. If we do not receive your information by the due date, we make a determination based on all the information available.
5. We send a written notice to you at least ten days before taking any adverse action. The ten-day notice period starts on the day we send the notice.
6. We may send a notice fewer than ten days before the date of the adverse action if:
   1. You request the action;
   2. You request termination;
   3. A change in statute, federal regulation, or administrative rule is the sole cause of the action;
   4. You are incarcerated and expect to remain incarcerated at least thirty days;
   5. Mail sent to you is returned without a forwarding address and we do not have a more current address for you;
   6. You move out-of-state;
   7. Your plan ends because you move to a county where your current silver level qualified health plan (QHP) is not available and you fail to select a new plan;
   8. You die;
   9. You begin receiving other state or federal medical assistance that provides minimum essential coverage; or
   10. Your silver level QHP is closed and you do not enroll in another silver level QHP.

WAC 182-524-0600 Payments.

Revised June 17, 2019

1. We pay your silver level qualified health plan (QHP) premium costs directly to the QHP carrier unless we determine good cause exists to reimburse you for the premium costs.
2. We pay your mandatory out-of-pocket costs separate from your premium costs through cost-sharing funds.
3. Cost-sharing funds are only for your out-of-pocket costs.
4. We will not pay for, or reimburse you for, costs not considered as out-of-pocket costs or expenses incurred by people not covered under COFA islander health care.
5. You are responsible for ensuring the services you receive are covered under your QHP and rendered as in-network.
6. We may stop payments of your silver level QHP premium costs and your cost-sharing funds when you:
   1. Fail to provide verification of payments through us or an agency-contracted vendor;
   2. Fail to respond to a request for information from us or an agency-contracted vendor;
   3. Misuse your cost-sharing funds by:
      1. Purchasing anything not considered an out-of-pocket cost; or
      2. Allowing another person access to your cost-sharing funds.
   4. Are no longer eligible for COFA islander health care as de-scribed under WAC 182-524-0300.
7. You must follow the requirements of any agency-contracted vendor that provides services enabling you to access your cost-sharing funds.
8. We monitor payments and cost-sharing transactions under COFA islander health care.

WAC 182-514-0230 Purpose.

Effective February 25, 2023.

1. This chapter describes eligibility requirements for the Washington apple health (WAH) modified adjusted gross income (MAGI)-based long-term care program (LTC) for children and adults who have been admitted to an institution as defined in WAC 182-500-0050 for at least 30 days. The rules are stated in the following sections:
   1. WAC 182-514-0240 General eligibility;
   2. WAC 182-514-0245 Resource eligibility;
   3. WAC 182-514-0250 Program for adults age 19 and older;
   4. WAC 182-514-0260 Program for children under age nineteen;
   5. WAC 182-514-0263 Non-SSI-related institutional medically needy coverage for pregnant women and people age 20 and younger.
   6. WAC 182-514-0270 Involuntary commitment to Eastern or Western State Hospital.
2. A noninstitutional WAH program recipient does not need to submit a new application for LTC coverage if admitted to an institution under this section. Admission to an institution constitutes a change of circumstances. Eligibility is based on institutional status under WAC 182-513-1320.
3. In this chapter, "medicaid agency" or "agency" means the Washington state health care authority and includes the agency's designee. See chapter 182-500 WAC for additional definitions.
4. Income standards used in this chapter are listed at www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/program-standard-income-and-resources.

WAC 182-514-0240 General eligibility.

Effective February 29, 2016.

1. To be eligible for modified adjusted gross income (MAGI) - based long-term care (LTC) coverage under this section, a person must:
   1. Meet institutional status under WAC 182-513-1320;
   2. Meet the general eligibility requirements under WAC 182-503-0505, unless the applicant is a noncitizen, in which case WAC 182-503-0505 (3) (c) and (d) do not apply;
   3. Have countable income below the applicable standard described in WAC 182-514-0250 (2) or 182-514-0260 (3), unless the applicant is eligible as medically needy;
   4. Satisfy the program requirements in WAC 182-514-0250 and 182-514-0260; and
   5. Meet the nursing facility level of care under WAC 388-106-0355 if admitted to a nursing facility for nonhospice care. Hospice patients are exempt from this requirement.
2. A person age nineteen or older who does not meet the citizenship or immigration requirements under WAC 182-503-0535 to qualify for medicaid must meet the criteria in subsection (1) of this section and:
   1. Have a qualifying emergency condition and meet the requirements under WAC 182-507-0115 and 182-507-0120; or
   2. Meet the requirements under WAC 182-507-0125 if the person needs LTC coverage in a nursing facility.
3. If a person meets institutional status, the medicaid agency counts only income received by the person or on behalf of the person when determining eligibility.
4. A person who meets the federal aged, blind, or disabled criteria may qualify for coverage under chapter 182-513 WAC.
5. A person who receives supplemental security income (SSI) is not eligible for the MAGI-based LTC program.
6. If a person does not meet institutional status, the agency determines the person's eligibility for a noninstitutional medical program.
7. A person eligible for categorically needy or medically needy coverage under a noninstitutional program who is admitted to a nursing facility for fewer than thirty days is only approved for coverage for the nursing facility room and board costs if the person meets the nursing facility level of care as described under WAC 388-106-0355.
8. A MAGI-based LTC recipient is not required to pay toward the cost of care.

WAC 182-514-0245 Resource eligibility.

Effective February 29, 2016.

Applicants for and recipients of the modified adjusted gross income (MAGI)-based long-term care program are exempt from the transfer-of-asset evaluation under WAC 182-513-1363, and there is no resource test. 

WAC 182-514-0260 Institutional program for children under age nineteen.

Effective July 1, 2017

1. To qualify for the modified adjusted gross income (MAGI)-based long-term care (LTC) program under this section, you (a child under age nineteen) must meet:
   1. The general eligibility requirements in WAC 182-514-0240; and
   2. Program requirements under WAC 182-505-0210 or 182-505-0117.
2. If you are eligible for the premium-based children's program under WAC 182-505-0215, we redetermine your eligibility under this section so that your family is not required to pay the premium.
3. The categorically needy (CN) income level for LTC coverage under this section is two hundred ten percent of the federal poverty level after the standard five percentage point income disregard.
4. To determine countable income for CN coverage under this section, we apply the MAGI methodology under chapter 182-509 WAC.
5. We approve CN coverage under this section for twelve calendar months (certification period). If you are discharged from the facility before the end of the certification period, the child remains continuously eligible for CN coverage through the certification period, unless you age out of the program, move out-of-state, or die.
6. If you are not eligible for CN coverage under this section, we determine your eligibility for coverage under the institutional medically needy program described in WAC 182-514-0263.
7. The institution where you reside may submit an application on your behalf and may act as your authorized representative if you are:
   1. In a court-ordered, out-of-home placement under chapter 13.34 RCW; or
   2. Involuntarily committed to an inpatient treatment program by a court order under chapter 71.34 RCW.

WAC 182-514-0270 Involuntary commitment to Eastern or Western State Hospital.

Effective February 29, 2016.

1. A person who is involuntarily committed to Eastern or Western State Hospital under chapter 71.34 RCW is eligible for categorically needy (CN) coverage if the person:
   1. Is under age twenty-one;
   2. Meets institutional status under WAC 182-513-1320; and
   3. Has countable income below:
      1. Two hundred ten percent of the federal poverty level if under age nineteen; or
      2. One hundred thirty-three percent of the federal poverty level if age nineteen or twenty.
2. A person who is involuntarily committed or receives MAGI-based long-term care coverage at Eastern or Western State Hospital in the month of the person's twenty-first birthday and receives active inpatient psychiatric treatment that will likely continue through the person's twenty-first birthday, is eligible for CN coverage until:
   1. The facility discharges the person; or
   2. The end of the month in which the person turns twenty-two, whichever occurs first.