WAC 182-503-0050 Verification of eligibility factors.

Effective November 3, 2019

1. General rules.
   1. We may verify the information we use to determine, redetermine, or terminate your apple health eligibility.
   2. We verify the eligibility factors listed in WAC 182-503-0505(3).
   3. Before we ask you to provide records to verify an eligibility factor, we use information available from state databases, including data from the department of social and health services and the department of employment security, federal databases, or commercially available databases to verify the eligibility factor.
   4. We may require information from third parties, such as employers, landlords, and insurance companies, to verify an eligibility factor if the information we received:
      1. Cannot be verified through available data sources;
      2. Did not verify an eligibility factor; or
      3. Is contradictory, confusing, or outdated.
   5. We do not require you to submit a record unless it is necessary to determine or redetermine your eligibility.
   6. If you can obtain verification within three business days and we determine the verification is sufficient to confirm an eligibility factor, we base our initial eligibility decision upon that record.
   7. If we are unable to verify eligibility as described in (f) of this subsection, then we may consider third-party sources.
   8. If a fee is required to obtain a necessary record, we pay the fee directly to the holder of the record.
   9. We do not deny or delay your application if you failed to provide information to verify an eligibility factor in a particular type or form.
   10. Except for eligibility factors listed in WAC 182-503-0505 (3)(c) and (d), we accept alternative forms of verification. If you give us a reasonable explanation that confirms your eligibility, we may not require additional documentation.
   11. Once we verify an eligibility factor that will not change, we may not require additional verification. Examples include:
       1. U.S. citizenship;
       2. Family relationships by birth;
       3. Social Security numbers; and
       4. Dates of birth, death, marriage, dissolution of marriage, or legal separation.
   12. If we cannot verify your immigration status and you are otherwise eligible for Washington apple health, we approve coverage and give additional time as needed to verify your immigration status.
2. Submission timelines.
   1. We allow at least ten calendar days for you to submit requested information.
   2. If you request more time to provide information, we allow the time requested.
   3. If the tenth day falls on a weekend or a legal holiday as described in RCW 1.16.050, the due date is the next business day.
   4. We do not deny or terminate your eligibility when we give you more time to provide information.
   5. If we do not receive your information by the due date, we make a determination based on all the information available.
3. Notice requirements.
   1. When we need more information from you to determine your eligibility for apple health coverage, we send all notices according to the requirements of WAC 182-518-0015.
   2. If we cannot determine you are eligible, we send you a denial or termination notice including information on when we reconsider a denied application under WAC 182-503-0080.
4. Equal access and limited-English proficiency services. If you are eligible for equal access services under WAC 182-503-0120 or limited-English proficiency services under WAC 182-503-0110, we provide legally sufficient support services.
5. Eligibility factors for nonmodified adjusted gross income (MAGI)-based programs. If you apply for a non-MAGI program under WAC 182-503-0510(3), we verify the factors in WAC 182-503-0505(3). In addition, we verify:
   1. Household composition, if spousal or dependent deeming under chapter 182-512 WAC or spousal or dependent allowance under chapters 182-513 and 182-515 WAC applies;
   2. Income and income deductions;
   3. Resources, including:
      1. Trusts, annuities, life estates and promissory notes under chapter 182-516 WAC;
      2. Real property transactions; and
      3. Financial records, as defined in WAC 182-503-0055, held by financial institutions.
   4. Medical expenses required to meet any spenddown liability under WAC 182-519-0110;
   5. All post-eligibility deductions used to determine cost of care for clients eligible for long-term services and supports under chapters 182-513 and 182-515 WAC;
   6. Transfers of assets under chapter 182-513 WAC and WAC 182-503-0055 when the program is subject to transfer of assets limitations;
   7. Shelter costs for long-term care cases where spousal and dependent allowances apply;
   8. Blindness or disability, if you claim either; and
   9. Social Security number for a community spouse if needed when you apply for long-term care.
6. Verification for MAGI-based programs.
   1. After we approve your coverage based on your self-attestation, we may conduct a post-eligibility review to verify your self-attested information.
   2. When conducting a post-eligibility review, we attempt to verify eligibility factors using your self-attested information available to us through state, federal, and commercially available data sources, or other third parties, before requiring you to provide information.
   3. You may be required to provide additional information if:
      1. We cannot verify an eligibility factor through other data sources listed in subsection (b) of this section; or
      2. The information received from the data source is not reasonably compatible with your self-attestation.
7. Reapplication following post-eligibility review. If your eligibility for MAGI-based apple health terminates because of a post-eligibility review and you reapply, we may request verification of eligibility factors prior to determining eligibility.

WAC 182-513-1400 Long-term care (LTC) partnership program (index).

Effective February 20, 2017

Under the long-term care (LTC) partnership program, people who purchase qualified long-term care partnership insurance policies can apply for long-term care medicaid under special rules for determining financial eligibility. These special rules generally allow the person to protect assets up to the insurance benefits received from a partnership policy so that such assets will not be taken into account in determining financial eligibility for long-term care medicaid and will not subsequently be subject to estate recovery for medicaid and long-term care services paid. The Washington long term care partnership program is effective on December 1, 2011.

The following rules govern long-term care eligibility under the long-term care partnership program:

1. WAC 182-513-1405 Definitions
2. WAC 182-513-1410 LTC Partnership policy qualifications.
3. WAC 182-513-1415 Assets that can't be protected under the LTC partnership provisions.
4. WAC 182-513-1420 Eligibility for asset protection under a partnership policy.
5. WAC 182-513-1425 Not qualifying for LTC medicaid if an LTC partnership policy is in pay status.
6. WAC 182-513-1430 Change of circumstances that must be reported when there is an LTC partnership policy paying a portion of my care.
7. WAC 182-513-1435 When Washington recognizes an LTC partnership policy purchased in another state.
8. WAC 182-513-1440 Determining how many assets can be protected.
9. WAC 182-513-1445 Designating a protected asset and required proof.
10. WAC 182-513-1450 How the transfer of assets affects LTC partnership and medicaid eligibility.
11. WAC 182-513-1455 Protected assets under an LTC partnership policy after death.

WAC 182-513-1405 Definitions.

Effective February 20, 2017

For purposes of WAC 182-513-1400 through 182-513-1455, the following terms have the meanings stated. See chapter 182-500 WAC and WAC 182-513-1100 for additional definitions.

"Issuer" means any entity that delivers, issues for delivery, or provides coverage to, a resident of Washington, any policy that claims to provide asset protection under the Washington long-term care partnership act, chapter 48.85 RCW. As used in this chapter, issuer specifically includes insurance companies, fraternal benefit societies, health care service contractors, and health maintenance organizations.

"Long-term care (LTC) insurance" means a policy under chapter 284-83 WAC.

"Protected assets" means assets that are designated as excluded or not taken into account upon determination of long-term care medicaid eligibility under WAC 182-513-1315. The protected or excluded amount is up to the dollar amount of benefits that have been paid for long-term care services by the qualifying long-term care partnership policy on the medicaid applicant's or client's behalf. The assets are also protected or excluded for the purposes of estate recovery under chapter 182-527 WAC, up to the amount of benefits paid by the qualifying policy for medical and long-term care services.

"Qualified long-term care insurance partnership" means an agreement between the Centers for Medicare and Medicaid Services (CMS), and the health care authority (HCA) which allows for the disregard of any assets or resources in an amount equal to the insurance benefit payments that are made to or on behalf of a person who is a beneficiary under a long-term care insurance policy that has been determined by the Washington state insurance commission to meet the requirements of section 1917 (b)(1)(c)(iii) of the act. These policies are described in chapter 284-83 WAC.

"Reciprocity Agreement" means an agreement between states approved under section 6021(b) of the Deficit Reduction Act of 2005, Public Law 109-171 (DRA) under which the states agree to provide the same asset protections for qualified partnership policies purchased by a person while residing in another state and that state has a reciprocity agreement with the state of Washington.

WAC 182-513-1410 LTC partnership policy qualifications.

Effective February 20, 2017

A LTC partnership policy is a LTC policy that has been approved by the office of insurance commissioner as a LTC partnership policy described in chapter 284-83 WAC.

WAC 182-513-1415 Assets that can't be protected under the LTC partnership provisions.

Effective February 20, 2017

The following assets cannot be protected under a LTC partnership policy.

1. Resources in a trust under WAC 182-516-0100 (6) and (7).
2. Annuity interests in which Washington must be named as a preferred remainder beneficiary as under WAC 182-516-0201.
3. Home equity in excess of the standard under WAC 182-513-1350. Individuals who have excess home equity interest are not eligible for long-term care medicaid services.
4. Any portion of the value of an asset that exceeds the dollar amount paid out by the LTC partnership policy.
5. The unprotected value of any partially protected asset is subject to estate recovery described in chapter 182-527 WAC.

WAC 182-513-1420 Eligibility for asset protection under a partnership policy.

Effective February 20, 2017

1. The LTC partnership policy must meet all the requirements in chapter 284-83 WAC. For existing LTC policies which are converted to a LTC partnership policy via an exchange or through the addition of a policy rider or endorsement, the conversion must take place on or after December 1, 2011 unless the policy is paying out benefits at the time the policy is exchanged.
2. You meet all applicable eligible requirements for LTC medicaid and:
   1. Your LTC partnership policy benefits have been exhausted and you are in need of LTC services.
   2. Your LTC partnership policy is not exhausted and is:
      1. Covering all costs in a medical institution and you are still in need for medicaid; or
      2. Covering a portion of the LTC costs under your LTC partnership policy but does not meet all of your LTC needs.
   3. At the time of your LTC partnership policy has paid out more benefits than you have designated as protected. In this situation your estate can designate additional assets to be excluded from the estate recovery process up to the dollar amount the LTC partnership policy has paid out.

WAC 182-513-1425 Not qualifying for LTC medicaid if an LTC partnership policy is in pay status.

Effective February 20, 2017

You are not eligible for long-term care (LTC) medicaid when the following applies:

1. The income you have available to pay toward your cost of care under WAC 182-513-1380, combined with the amount paid under the qualifying LTC partnership policy, exceeds the monthly private rate at the institution.
2. The income you have available to pay toward your cost of care on a home and community based (HCB) waiver under chapter 182-515 WAC, combined with the amount paid under the qualifying LTC partnership policy, exceeds the monthly private rate in a home or residential setting.
3. You fail to meet another applicable eligibility requirement for LTC medicaid.

WAC 182-513-1430 Change of circumstances that must be reported when there is an LTC partnership policy paying a portion of care.

Effective February 20, 2017

You must report changes described in WAC 182-504-0105 plus the following:

1. You must report and verify the value of the benefits that your issuer has paid on your behalf under the long-term care (LTC) partnership policy upon request by the agency, and at each annual eligibility review.
2. You must provide proof when you have exhausted the benefits under your LTC partnership policy.
3. You must provide proof if you have given away or transferred assets that you have previously designated as protected. Although, there is no penalty for the transfer of protected assets once you have been approved for LTC medicaid, the value of transferred assets reduces the total dollar amount that is designated as protected and must be verified.
4. You must provide proof if you have sold an asset or converted a protected asset into cash or another type of asset. You will need to make changes in the asset designation and verify the type of transaction and new value of the asset.

WAC 182-513-1435 When Washington recognizes an LTC partnership policy purchased in another state.

Effective February 20, 2017

The Washington long term care partnership program provides reciprocity with respect to qualifying long-term care insurance policies covered under other state long-term care insurance partnerships. This allows you to purchase a partnership policy in one state and move to Washington without losing your asset protection. If your LTC policy is in pay status at the time you move to Washington and you are otherwise eligible for LTC medicaid, Washington will recognize the amount of protection you accumulated in the other state.

WAC 182-513-1440 Determining how many of my assets can be protected.

Effective February 20, 2017

You can protect assets based on the amount paid by your LTC partnership policy. Assets are protected in both LTC eligibility and estate recovery. If the partnership for long-term care program is discontinued, an individual who purchased an approved plan before the date the program is discontinued remains eligible to receive dollar-for-dollar asset disregard and asset protection under the long-term care (LTC) medicaid program.

WAC 182-513-1445 Designating a protected asset and required proof.

Effective February 20, 2017

1. Complete a department of social and health services (DSHS) 10-438 long-term care partnership (LTCP) asset designation form listing assets and the full fair market value that are earmarked as protected at the time of initial application for long-term services and supports under medicaid.
   1. The full fair market value (FMV) of real property or interests in real property will be based on the current assessed value for property tax purposes for real property. A professional appraisal by a licensed appraiser can establish the current value if the assessed value is disputed.
   2. The value of a life estate in real property is determined using the life estate tables found at https://www.hca.wa.gov/free-or-low-cost-health-care/program-administration/determining-value-life-estates.
   3. If you own an asset with others, you can designate the value of your pro rata equity share.
   4. If the dollar amount of the benefits paid under a LTCP policy is greater than the fair market value of all assets protected at the time of the application for long-term care medicaid, you may designate additional assets for protection under this section. The DSHS LTCP asset designation form must be submitted with the updated assets indicated along with proof of the current value of designated assets.
   5. The value of your assets protected for you under your LTC partnership policy do not carry over to your spouse should the spouse need medicaid LTC services during or after your lifetime. If your surviving spouse has an LTC partnership policy the spouse may designate assets based on the dollar amount paid under the spouse's own policy.
   6. Assets designated as protected under this subsection will not be subject to transfer penalties under WAC 182-513-1363.
2. Proof of the current fair market value of all protected assets is required at the initial application and each annual review.
3. Submit current verification from the issuer of the LTCP policy of the current dollar value paid toward LTC benefits. This verification is required at application and each annual eligibility review.
4. Any person or the personal representative of the person's estate who asserts that an asset is protected has the initial burden of:
   1. Documenting and proving by convincing evidence that the asset or source of funds for the asset in question was designated as protected;
   2. Demonstrating the value of the asset and the proceeds of the asset beginning from the time period the LTC partnership has paid out benefits to the present; and
   3. Documenting that the asset or proceeds of the asset remained protected at all times.

WAC 182-513-1450 How the transfer of assets affect LTC partnership and medicaid eligibility?

Effective February 20, 2017

1. If you transfer an asset within the sixty months prior to the medicaid application or after medicaid eligibility has been established, the agency will evaluate the transfer based on WAC 182-513-1363 and determine if a penalty period applies unless:
   1. You have already been receiving institutional services;
   2. Your LTC partnership policy has paid toward institutional services for you; and
   3. The value of the transferred assets has been protected under the LTC partnership policy.
2. The value of the transferred assets that exceed your LTC partnership protection will be evaluated for a transfer penalty.
3. If you transfer assets ((whose)) with values that are protected, you lose that value as future protection unless all the transferred assets are returned.
4. The value of your protected assets less the value of transferred assets equals the adjusted value of the assets you are able to protect.

WAC 182-513-1455 What happens to protected assets under a LTC partnership policy after death.

Effective February 20, 2017

Assets designated as protected prior to death are not subject to estate recovery for medical or long-term care (LTC) services paid on your behalf under chapter 182-527 WAC as long as the following requirements are met:

1. A personal representative who asserts an asset is protected under this section has the initial burden of providing proof under chapter 182-527 WAC.
2. A personal representative must provide verification from the LTC insurance company of the dollar amount paid out by the LTC partnership policy.
3. If the LTC partnership policy paid out more than was previously designated, the personal representative has the right to assert that additional assets should be protected based on the increased protection. The personal representative must use the DSHS LTCP asset designation form and send it to the office of financial recovery.
4. The amount of protection available to you at death through the estate recovery process is decreased by the FMV of any protected assets that were transferred prior to death.

WAC 182-518-0005 Washington apple health -- Notice requirements -- General.

Effective August 29, 2014.

1. For the purposes of this chapter, "we" refers to the agency or its designee and "you" refers to the applicant for, or recipient of, health care coverage.
2. This section applies only to notices and letters that we send about eligibility for Washington apple health (WAH) programs. WAC 182-501-0165 applies to notices and letters regarding prior authorization or other action on requests to cover specific fee-for-service health care services.
3. We send you written notices (letters) when we:
   1. Approve you for health care coverage for any program;
   2. Reconsider your application for other types of health care coverage based on new information;
   3. Deny you health care coverage (including because you withdrew your application) for any program (according to rules in WAC 182-503-0080);
   4. Ask you for more information to decide if you can start or renew health care coverage;
   5. Renew your health care coverage; or
   6. Change or terminate your health care coverage, even if we approve you for another kind of coverage.
4. We send notices to you in your primary language if you ask us to and in English according to the rules in WAC 182-503-0110. If you need help to apply for or access your health care coverage due to a disability, we follow the equal access rules in WAC 182-503-0120.
5. All WAH notices we send you include the following information:
   1. The date of the notice;
   2. Specific contact information for you if you have questions or need help with the notice;
   3. Your appeal rights, if an appeal is available, and the availability of potentially free legal assistance; and
   4. Other information required by state or federal law.

WAC 182-518-0010 Washington apple health -- Notice requirements approval and denial notices.

Effective August 29, 2014.

1. We send written notice when we approve, reopen, reinstate, or deny coverage for any Washington apple health (WAH) program. The notice includes the information described in WAC 182-518-0005(4) and all of the following:
   1. The WAH coverage for each person approved, reopened or reinstated;
   2. The date that each person's coverage begins (the effective date); and
   3. The dates for which we approved each person's coverage (certification period).
2. Denial and withdrawal notices include:
   1. The date of denial;
   2. Specific facts and reason(s) supporting the decision;
   3. Specific rules or statutes that support or require the decision; and
   4. Information to get help applying for nonmodified adjusted gross income (MAGI)-based WAH.
3. If we deny your request for health care coverage or consider it withdrawn because you failed to give us requested information, the denial notice also includes:
   1. A list of the information you did not give us;
   2. The date we asked you for the information and the date it was due;
   3. Notice that we will reconsider your eligibility if we receive any information related to determining your eligibility, including any changes to information we have, within thirty days of the date of the notice;
   4. Information described in subsection (1) of this section; and
   5. Notice of administrative hearing rights.

WAC 182-518-0015 Washington apple health -- Notice requirements verification requests

Effective August 29, 2014.

1. We send you written notice when we need more information as described in WAC 182-503-0050 to decide if you are eligible to receive or continue receiving Washington apple health (WAH) coverage. The notice includes:
   1. A description or list of the information that we need;
   2. When we must have the information (see WAC 182-503-0060 for applications and WAC 182-504-0035 for renewals);
   3. What action we will take and on what date, if we do not receive the information; and
   4. Information required in WAC 182-518-0005(4).
2. If we have received conflicting information about facts we need to determine your coverage, the notice will also include:
   1. The information we received that does not match what you gave us and the source; and
   2. A request that you send us a statement explaining the difference(s) between the information from you and the information from the other source.
3. We allow you at least ten days to return the information. If you ask, we may allow you more time to get us the information. If the tenth day falls on a weekend or holiday, the due date is the next business day.
4. If the information we ask for costs money, we will pay for it or help you get the information in another way.

WAC 182-518-0025 Washington apple health -- Notice requirements -- Actions to terminate, suspend, or reduce eligibility or authorization for a covered service.

Effective December 1, 2016.

1. General rule.
   1. We send written notice to you at least ten days before taking adverse action to terminate, suspend, or reduce your:
      1. Medicaid eligibility; or
      2. Authorization for a covered service.
   2. The ten-day notice period starts on the day we sent the notice.
2. Exceptions to ten-day notice period. We may send a notice fewer than ten days before the date of the action in the following circumstances.
   1. We send written notice to you at least five days before taking action to terminate, suspend, or reduce your medicaid eligibility or authorization for a covered service if:
      1. We have facts indicating fraud by you or on your behalf; and
      2. We have verified the facts, if possible, through secondary sources.
   2. We send written notice to you no later than the date we took action to terminate, suspend, or reduce your medicaid eligibility or authorization for a covered service if:
      1. You requested the action;
      2. A change in statute, federal regulation or administrative rule is the sole cause of the action;
      3. You are incarcerated and expected to remain incarcerated at least thirty days;
      4. Mail sent to you has been returned without a forwarding address, and we do not have a more current address for you; or
      5. We are terminating your eligibility because you:
         1. Died; or
         2. Began receiving medicaid from a jurisdiction other than Washington
            state.
3. Notice contents. Written notice under this section states:
   1. The nature of the action;
   2. The effective date of the action;
   3. The facts and reason(s) for the action;
   4. The specific regulation on which the action is based;
   5. Your appeal rights, if any;
   6. Your right to continued coverage, if any; and
   7. Information found in WAC 182-518-0005(4).
4. Reinstated coverage.
   1. If we do not meet the advance notice requirements under this
      section, we reinstate your coverage back to the date of the action. We
      may still take action once we meet notice requirements under this section.
   2. If you are receiving medically needy coverage, you cannot receive
      reinstated coverage past the end of the certification period described
      in WAC 182-504-0020.
   3. We may end your coverage if a notice we mailed to you is returned
      with no forwarding address. We reinstate your coverage if we
      learn your new address and you meet eligibility requirements.
5. Hearing rights. If you do not agree with agency action under
   this section, you may request an administrative hearing under chapter
   182-526 WAC, and you may be entitled to continued coverage under WAC
   182-504-0130.

WAC 182-504-0130 Washington apple health -- Continued coverage pending an appeal.

Effective December 1, 2016

1. Continued coverage is when you continue to receive Washington apple health benefits while appealing a medicaid agency adverse action to terminate, suspend, or reduce your:
   1. Medicaid eligibility; or
   2. Authorization for a covered service.
2. To qualify for continued coverage, you must request a hearing on the adverse action no later than:
   1. The tenth day after we (the medicaid agency or its designee) sent a notice of the action to you; or
   2. The last day of the month before the action takes effect.
3. If your last day to request a hearing and still qualify for continued coverage falls on a Saturday, Sunday, or a designated holiday under WAC 357-31-005, you have until 5:00 p.m. on the next business day to request the hearing.
4. Continued coverage ends when:
   1. You state in writing you no longer wish to receive continued coverage;
   2. You withdraw the appeal;
   3. You default and an order of dismissal is entered;
   4. An administrative law judge or a review judge issues an adverse ruling or written decision:
      1. Terminating your continued coverage; or
      2. Ruling you do not qualify for benefits.
5. You cannot receive continued coverage if the adverse action was solely to a change in statute, federal regulation, or administrative rule, unless there is a question about whether you are in the class of people affected by the change.
6. If you are receiving medically needy coverage, you cannot receive continued coverage past the end of the certification period described in WAC 182-504-0020.
7. If you are receiving coverage under an alien medical program, you cannot receive continued coverage past the end of the certification period described in chapter 182-507 WAC.