WAC 182-515-1510 Home and community based (HCB) waiver services authorized by the developmental disabilities administration (DDA).

Effective February 20, 2017

This chapter describes the general and financial eligibility requirements for categorically needy (CN) home and community based (HCB) waivers authorized by the developmental disabilities administration (DDA). The definitions in WAC 182-513-1100 and chapter 182-500 WAC apply throughout this chapter.

1. The DDA waiver programs are:
   1. Basic Plus;
   2. Core;
   3. Community protection;
   4. Children's intensive in-home behavioral support (CIIBS); and
   5. Individual and family services (IFS).
2. WAC 182-515-1511 describes the general eligibility requirements for HCB waiver services authorized by DDA.
3. WAC 182-515-1512 describes the financial requirements for eligibility for HCB waiver services authorized by DDA if a person is eligible for a noninstitutional SSI-related CN program.
4. WAC 182-515-1513 describes the financial eligibility requirements for HCB waiver services authorized by DDA when a person is not eligible for an SSI-related noninstitutional CN program under WAC 182-515-1512.
5. WAC 182-515-1514 describes the rules used to determine a person's responsibility in the cost of care and room and board for HCB waiver services authorized by DDA if the person is eligible under WAC 182-515-1512.

WAC 182-515-1511 Home and community based (HCB) waiver services authorized by the developmental disabilities administration (DDA) - General eligibility.

Effective February 25, 2023

1. To be eligible for home and community based (HCB) waiver services authorized by the developmental disabilities administration (DDA), a person must:
   1. Meet specific program requirements under chapter 388-845 WAC;
   2. Be an eligible client of the DDA;
   3. Meet the disability criteria for the supplemental security income (SSI) program under WAC 182-512-0050;
   4. Need the level of care provided in an intermediate care facility for the intellectually disabled (ICF/ID);
   5. Have attained institutional status under WAC 182-513-1320;
   6. Be able to reside in the community and choose to do so as an alternative to living in an ICF/ID;
   7. Be assessed for HCB waiver services, be approved for a plan of care, and receive HCB waiver services under (a) of this subsection, and:
      1. Be able to live at home with HCB waiver services; or
      2. Live in a department-contracted facility with HCB waiver services, such as:
         1. A group home;
         2. A group training home;
         3. A child foster home, group home, or staffed residential facility;
         4. An adult family home (AFH); or
         5. An adult residential care (ARC) facility.
      3. Live in the person's own home with supported living services from a certified residential provider; or
      4. Live in the home of a contracted companion home provider.
2. A person is not eligible for home and community based (HCB) waiver services if the person:
   1. Is subject to a penalty period of ineligibility for the transfer of an asset under WAC 182-513-1363; or
   2. Has a home with equity in excess of the requirements under WAC 182-513-1350.
3. See WAC 182-513-1315 for rules used to determine countable resources, income, and eligibility standards for long-term care (LTC) services.
4. Current income and resource standard charts are found at http://www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/program-standard-income-and-resources.

WAC 182-515-1512 Home and community based (HCB) waiver services authorized by the developmental disabilities administration (DDA)- Financial eligibility if a client is eligible for a noninstitutional SSI-related categorically needy (CN) program.

Effective February 25, 2023

1. A client is financially eligible for home and community based (HCB) waiver services authorized by the developmental disabilities administration (DDA) if:
   1. The client is receiving coverage under one of the following categorically needy (CN) medicaid programs:
      1. Supplemental security income (SSI) program under WAC 182-510-0001. This includes SSI clients under 1619(b) status; or
      2. Health care for workers with disabilities (HWD) under chapter 182-511 WAC; or
      3. SSI-related noninstitutional (CN) program under chapter 182-512 WAC; or
      4. The foster care program under WAC 182-505-0211 and the client meets disability requirements under WAC 182-512-0050.
   2. The client does not have a penalty period of ineligibility for the transfer of an asset as under WAC 182-513-1363; and
   3. The client does not own a home with equity in excess of the requirements under WAC 182-513-1350.
2. A client eligible under this section does not pay toward the cost of care, but must pay room and board if living in an alternate living facility (ALF) under WAC 182-513-1100.
3. A client eligible under this section who lives in a department-contracted ALF described under WAC 182-513-1100:
   1. Keeps a personal needs allowance (PNA) under WAC 182-513-1105; and
   2. Pays towards room and board up to the room and board standard under WAC 182-513-1105.
4. A client who is eligible under the HWD program must pay the HWD premium under WAC 182-511-1250, in addition to room and board if residing in an ALF.
5. Current resource, income, PNA and room and board standards are found 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 182-515-1513 Home and community based (HCB) waiver services authorized by the developmental disabilities administration (DDA)—Financial eligibility using SSI-related institutional rules.

Effective February 25, 2023

1. If a person is not eligible for a categorically needy (CN) program under WAC 182-515-1512, the agency determines eligibility for home and community based (HCB) waiver services authorized by the developmental disabilities administration (DDA) using institutional medicaid rules. This section explains how a person may qualify using institutional rules.
2. A person must meet:
   1. General eligibility requirements under WAC 182-513-1315 and 182-515-1511;
   2. Resource requirements under WAC 182-513-1350; and
   3. Have available income at or below the special income level (SIL) defined under WAC 182-513-1100.
3. The agency determines available income and income exclusions according to WAC 182-513-1325, 182-513-1330, and 182-513-1340.
4. A person eligible under this section is responsible to pay income toward the cost of care and room and board, as described under WAC 182-515-1514.
5. Current resource, income standards are found 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 182-515-1514 Home and community based (HCB) services authorized by the developmental disabilities administration (DDA)- Client financial responsibility

Effective March 1, 2025

1. A client eligible for home and community based (HCB) waiver services authorized by the developmental disabilities administration (DDA) under WAC 182-515-1513 must pay toward the cost of care and room and board under this section.
   1. Post-eligibility treatment of income, participation, and participate are all terms that refer to a client's responsibility towards cost of care.
   2. Room and board is a term that refers to a client's responsibility toward food and shelter in an alternate living facility (ALF).
2. The agency determines how much a client must pay toward the cost of care for home and community based (HCB) waiver services authorized by the DDA when the client is living at home, as follows:
   1. A single client who lives at home (as defined in WAC 388-106-0010) keeps a personal needs allowance (PNA) of up to the special income level (SIL) defined under WAC 182-513-1100.
   2. A single client who lives at home on the roads to community living program authorized by DDA keeps a PNA up to the SIL but must pay any remaining available income toward cost of care after allowable deductions described in subsection (4) of this section.
   3. A married client who lives with the client's spouse at home (as defined in WAC 388-106-0010) keeps a PNA of up to the SIL but must pay any remaining available income toward cost of care after allowable deductions under subsection (4) of this section.
   4. A married couple living at home where each client receives HCB waiver services, one authorized by DDA and the other authorized by home and community services (HCS) is allowed the following:
      1. The client authorized by DDA keeps a PNA of up to the SIL but must pay any remaining available income toward the client's cost of care after allowable deductions in subsection (4) of this section; and
      2. The client authorized by HCS pays toward the cost of care under WAC 182-515-1507 or 182-515-1509.
3. The agency determines how much a client must pay toward the cost of care for HCB wavier services authorized by DDA and room and board when the client is living in a department-contracted ALF defined under WAC 182-513-1100. A client:
   1. Keeps a PNA under WAC 182-513-1105;
   2. Pays room and board up to the room and board standard under WAC 182-513-1105; and
   3. Pays the remainder of available income toward the cost of care after allowable deductions under subsection (4) of this section.
4. If income remains after the PNA and room and board liability under subsection (2) or (3) of this section, the remaining available income must be paid toward the cost of care after it is reduced by allowable deductions in the following order:
   1. An earned income deduction of the first $65, plus one-half of the remaining earned income;
   2. Guardianship fees, conservatorship fees, and administrative costs including any attorney fees paid by the guardian or conservator only as allowed under chapter 388-79A WAC;
   3. Current or back child support garnished or withheld from the client's income according to a child support order in the month of the garnishment if it is for the current month. If the agency allows this as a deduction from income, the agency does not count it as the child's income when determining the family allocation amount in WAC 182-513-1385;
   4. A monthly maintenance-needs allowance for the community spouse under WAC 182-513-1385. If the community spouse is on long-term care services, the allocation is limited to an amount that brings the community spouse's income to the community spouse's PNA;
   5. A monthly maintenance-needs allowance for each dependent of the institutionalized client, or the client's spouse, as calculated under WAC 182-513-1385; and
   6. Incurred medical expenses which have not been used to reduce excess resources. Allowable medical expenses are under WAC 182-513-1350.
5. The total of the following deductions cannot exceed the SIL defined under WAC 182-513-1100:
   1. The PNA described in subsection (2) or (3) of this section, including room and board;
   2. The earned income deduction in subsection (4)(a) of this section; and
   3. The guardianship fees, conservatorship fees, and administrative costs in subsection (4)(b) of this section.
6. A client may have to pay third-party resources defined under WAC 182-513-1100 in addition to the room and board and participation.
7. A client must pay the client's provider the sum of the room and board amount, the cost of care after all allowable deductions, and any third-party resources defined under WAC 182-513-1100.
8. A client on HCB waiver services does not pay more than the state rate for cost of care.
9. When a client lives in multiple living arrangements in a month, the agency allows the highest PNA available based on all the living arrangements and services the client has received in a month.
10. Standards described in this section are found on www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/program-standard-income-and-resources.

WAC 182-504-0105 Washington apple health -- Changes that must be reported.

Effective August 29, 2014.

1. You must report changes in your household and family circumstances to us (the agency or its designee) timely according to WAC 182-504-0110.
2. We tell you what you are required to report at the time you are approved for WAH coverage. We also will tell you if the reporting requirements change.
3. You must report the following:
   1. Change in residential address;
   2. Change in mailing address;
   3. Change in marital status;
   4. When family members or dependents move in or out of the residence;
   5. Pregnancy;
   6. Incarceration;
   7. Change in institutional status;
   8. Change in health insurance coverage including medicare eligibility; and
   9. Change in immigration or citizenship status.
4. If you are eligible for a WAH long-term care program described in chapter 182-513 or 182-515 WAC, you must also report changes to the following:
   1. Income;
   2. Resources;
   3. Medical expenses; and
   4. Spouse or dependent changes in income or shelter cost when expenses are allowed for either.
5. If you get WAH parent or caretaker (as described in WAC 182-505-0240) or WAH modified adjusted gross income (MAGI)-based adult coverage (as described in WAC 182-505-0250), you must also report changes to the following:
   1. When total income increases or total deductions decrease by one hundred fifty dollars or more a month and the change will continue for at least two months;
   2. Your federal income tax filing status that you expect to use when you file your taxes for the current tax filing year (such as changing from "married filing separately" to "married filing jointly"); and
   3. The tax dependents you expect to claim when you file your federal income tax return for the current tax filing year.
6. If you get WAH based on age, blindness, or disability (SSI-related medical), then you must also report changes to the following:
   1. Income; and
   2. Resources. 

WAC 182-504-0110 Washington apple health -- When to report changes.

Effective August 29, 2014.

1. All changes you report to us (the agency or its designee), as required by WAC 182-504-0105, are used to decide if you can receive or keep receiving Washington apple health (WAH) coverage.
2. You must report changes during your certification period within thirty days of when the change happened.
3. You must report all changes during application, renewal, or redetermination of your WAH eligibility, regardless of when the change happened.
4. For a change in income, the date a change happened is the first date you received income based on the change. For example, the date you receive your first paycheck for a new job or the date you got a paycheck with a wage increase is the date the change happened.
5. If you do not report a change or you report a change late, we will decide if you can receive or keep receiving WAH coverage based on the date the change was required to be reported.
6. If you do not report a change or you report a change late, and if it affects the amount you must pay toward your cost of care as described in WAC 182-513-1380 or chapter 182-515 WAC, you may become liable for overpayments we make on your behalf and you may need to pay more to your care provider.
7. If you do not report a change or you report a change late, it may result in us overpaying you and you having to pay us back for the health care costs we overpaid. See chapter 182-520 WAC.

WAC 182-504-0120 Washington apple health -- Effective dates of changes.

Effective August 29, 2014.

1. We (the agency or its designee) determine the date a change affects your Washington apple health (WAH) coverage based on:
   1. The date you report the change to us;
   2. The date you give us the requested verification; and
   3. The type of WAH you or your family is receiving.
2. When you report a change after you submit your application, but before your application is processed, the change is considered when processing your application.
3. If another person, agency, or data source reports a change in circumstances, the information may be used in determining your eligibility. We will not rely on information received from a person, agency, or data source to terminate your WAH coverage without requesting additional information from you.
4. A change in income affects your ongoing eligibility only if it is expected to continue beyond the month when the change is reported, and only if it is expected to last more than two months.
5. A change that results in termination of your WAH coverage takes effect the first of the month following the advance notice period.
6. The advance notice period:
   1. Begins on the day we send the letter about the change to you; and
   2. Is determined according to the rules in WAC 182-518-0025.
7. A change that results in a decreased scope of care takes effect on the first of the month following the advance notice period. Examples of a decreased scope of care are:
   1. Termination of WAH categorically needy (CN) medical and approval for other WAH coverage with a lesser scope of care such as WAH medically needy (MN) medical;
   2. WAH-MN recipient with a change that increases the spenddown liability amount;
   3. WAH-MN recipient with no spenddown liability with a change that results in WAH-MN with a spenddown liability.
8. A change that results in an increased scope of care takes effect on the first of the month following the date the change was reported, when you provide the required verification:
   1. Within ten days of the date we requested the verification; or
   2. By the end of the month of your change report, whichever is later.

      If you are a WAH-MN applicant with a spenddown liability that has not yet been met and you report a change that results in your becoming eligible for WAH-CN medical or WAH for adults, your change report will be treated as a new application for purposes of retroactive WAH coverage as described in WAC 182-504-0005.

9. If you do not provide the required verification timely under subsection (8) of this section, we make the change effective the first of the month following the month in which you provide the verification. We may terminate your WAH coverage if you do not provide the required verification.
10. When a law or regulation requires a change in WAH, the date specified by the law or regulation is the effective date of the change.
11. When a change in income or allowable expenses is reported timely (within thirty days) and changes the amount you pay towards the cost of your care for institutional programs (residing in a medical institution), we calculate your new participation amount based on:
    1. Either actual income received in a month or allowable deductions incurred in a month, or both; or
    2. An estimate of your monthly or allowable expenses in a prospective period of six months or less, based on both actual income received in a preceding period of six months or less and income expected to be received during the prospective period. At the end of the prospective period or when any significant change occurs, we reconcile this estimate for the period with income received during the same period.
12. When a change in income, or allowable expenses, changes the amount you pay towards the cost of your care for a home and community-based waiver or service, we calculate your new participation amount effective the first of the month following the date the change was reported, except that the new participation amount will be effective the month the change occurs if the change is the loss of an income source that you report within thirty days of the change.
13. We use the following rules to determine the effective date of change for the health care for workers with disabilities (HWD) program:
    1. HWD coverage begins the month after coverage in another medical program ends and the premium amount has been approved by the eligible person; and
    2. If a change in income increases or decreases the monthly premium, the change is effective the first of the month after the change is reported. For more information on premium requirements for this program, see WAC 182-511-1250.

WAC 182-504-0125 Washington apple health -- Effect of reported changes.

Effective October 1, 2017.

1. If you report a change required under WAC 182-504-0105 during a certification period, you continue to be eligible for Washington apple health coverage until we decide if you can keep getting apple health coverage under your current apple health program or a different apple health program.
2. If your apple health categorically needy (CN) coverage ends due to a reported change and you meet all the eligibility requirements for a different apple health CN program, we will approve your coverage under the new apple health CN program. If you are not eligible for coverage under any apple health CN program but you meet the eligibility requirements for either apple health alternative benefits plan (ABP) coverage or apple health medically needy (MN) coverage, we will approve your coverage under the program you are eligible for. If you are not eligible for coverage under any apple health CN program but you meet the eligibility requirements for both apple health ABP coverage and apple health MN coverage, we will approve the apple health ABP coverage unless you notify us that you prefer  apple health MN coverage.
3. If your apple health coverage ends and you are not eligible for a different apple health program, we stop your apple health coverage after giving you advance and adequate notice unless the exception in subsection (4) of this section applies to you.
4. If you claim to have a disability and that is the only basis for you to be potentially eligible for apple health coverage, then we refer you to the division of disability determination services (within the department of social and health services) for a disability determination. Pending the outcome of the disability determination, we also determine if you are eligible for apple health coverage under the SSI-related medical program described in chapter 182-512 WAC. If you have countable income in excess of the SSI-related categorically needy income level (CNIL), then we look to see if you can get coverage under apple health MN with spenddown as described in chapter 182-519 WAC pending the final outcome of the disability determination.
5. If you are eligible for and receive coverage under the apple health parent and caretaker relative program described in WAC 182-505-0240, you may be eligible for the apple health medical extension program described in WAC 182-523-0100, if your coverage ends as a result of an increase in your earned income.
6. Changes in income during a certification period do not affect eligibility for the following programs:
   1. Apple health for pregnant women;
   2. Apple health for children, except as specified in subsection (7) of this section;
   3. Apple health for SSI recipients;
   4. Apple health refugee program; and
   5. Apple health medical extension program.
7. We redetermine eligibility for children receiving apple health for kids premium-based coverage described in WAC 182-505-0210 when the:
   1. Household's countable income decreases to a percentage of the federal poverty level (FPL) that would result in either a change in premium for apple health for kids with premiums or the children becoming eligible for apple health for kids (without premiums);
   2. Child becomes pregnant;
   3. Family size changes; or
   4. Child receives SSI.
8. If you get SSI-related apple health CN coverage and report a change in work or earned income which results in a determination by the division of disability determination services that you no longer meet the definition of a disabled person as described in WAC 182-512-0050 due to work or earnings at the level of substantial gainful activity (SGA), we redetermine your eligibility for coverage under the health care for workers with disabilities (HWD) program. The HWD program is a premium-based program that waives the SGA work or earnings test, and you must approve the premium amount before we can authorize coverage under this program. For HWD program rules, see chapter 182-511 WAC.

WAC 182-513-1635 Tailored Supports for Older Adults (TSOA) — Income Eligibility.

Effective October 6, 2023

1. To determine income eligibility for the tailored supports for older adults (TSOA) program, the medicaid agency or the agency's designee uses the following rules depending on whether the person is single or married.
2. If the TSOA applicant is single:
   1. Determine available income under WAC 182-513-1325;
   2. Exclude income under WAC 182-513-1340; and
   3. Compare remaining gross nonexcluded income to 400 percent of the federal benefit rate (FBR) for the supplemental security income (SSI) cash grant program. To be eligible, a person's gross income must be equal to or less than 400 percent of the FBR.
3. If the TSOA applicant is married, the agency or the agency's designee:
   1. Determines available income under WAC 182-513-1330 with the exception of subsections (5) and (6) of that section;
   2. Exclude income under WAC 182-513-1340;
   3. Compare the applicant's remaining gross nonexcluded income to 400 percent of the FBR. To be eligible, a person's gross income must be equal to or less than 400 percent of the FBR.
4. The FBR changes annually on January 1st.
5. The current TSOA income standard is found on the Washington apple health income and resource standards chart, institutional standards section; see www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/program-standard-income-and-resources.

WAC 182-513-1640 Tailored supports for older adults (TSOA) — Resource eligibility.

Effective October 9, 2023

1. The resource standard for a single applicant for tailored supports for older adults (TSOA) is six times the Washington state average monthly private nursing facility rate, as determined by the department of social and health services under chapter 74.46 RCW.
2. The resource standard for a married couple is six times the Washington state average monthly private nursing facility rate, as determined by the department of social and health services under chapter 74.46 RCW, for the TSOA applicant plus the state spousal resource standard for the spousal impoverishment protections community (SIPC) spouse. The state spousal resource standard may change annually on July 1st.
3. The medicaid agency or the agency's designee uses rules in WAC 182-513-1350 (1), (3) and (4) to determine general eligibility relating to resources, availability of resources, and which resources count.
4. The TSOA recipient has one year from the date of initial eligibility of TSOA to transfer resources in excess of the TSOA standard to the SIPC spouse.
5. The resource standard for TSOA changes annually on January 1st based on the current average private nursing facility rate, as determined by the department of social and health services under chapter 74.46 RCW.
6. The current TSOA standards and the current average private nursing facility rate are found on the Washington apple health income and resource standards chart, institutional standards section; see www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/program-standard-income-and-resources.

WAC 182-505-0240 Parents and caretaker relatives.

Effective July 1, 2017.

1. A person is eligible for Washington apple health categorically needy (CN) coverage when the person:
   1. Is a parent or caretaker relative of a dependent child who meets the criteria described in WAC 182-503-0565(2);
   2. Meets citizenship and immigration status requirements described in WAC 182-503-0535;
   3. Meets general eligibility requirements described in WAC 182-503-0505; and
   4. Has countable income below the standard in WAC 182-505-0100 (2).
2. To be eligible for coverage as a caretaker relative, a person must be related to a dependent child who meets the criteria described in WAC 182-503-0565(2).
3. A person must cooperate with the state of Washington in the identification, use and collection of medical support from responsible third parties as described in WAC 182-503-0540.
4. A person who does not cooperate with the requirements in subsection (3) of this section is not eligible for coverage.

WAC 182-534-0100  EPSDT

Effective August 24, 2014

1. Persons who are eligible for medicaid are eligible for coverage through the early and periodic screening, diagnosis, and treatment (EPSDT) program up through the day before their twenty-first birthday.
2. Access and services for EPSDT are governed by federal rules at 42 C.F.R., Part 441, Subpart B which were in effect as of January 1, 1998.
   1. The standard for coverage for EPSDT is that the services, treatment or other measures are:
      1. Medically necessary;
      2. Safe and effective; and
      3. Not experimental.
   2. EPSDT services are exempt from specific coverage or service limitations which are imposed on the rest of the CN and MN program. Examples of service limits which do not apply to the EPSDT program are the specific numerical limits in WAC 182-545-200.
   3. Services not otherwise covered under the medicaid program are available to children under EPSDT. The services, treatments and other measures which are available include but are not limited to:
      1. Nutritional counseling;
      2. Chiropractic care;
      3. Orthodontics; and
      4. Occupational therapy (not otherwise covered under the MN program).
   4. Prior authorization and referral requirements are imposed on medical service providers under EPSDT. Such requirements are designed as tools for determining that a service, treatment or other measure meets the standards in subsection (2)(a) of this section.
3. Transportation requirements of 42 C.F.R. 441, Subpart B are met through a contract with transportation brokers throughout the state.