Apple Health for parents and caretakers

Revised date

WAC 182-505-0240 Parents and caretaker relatives.

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.

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

  1. Individuals who are over income for Apple Health for Parents/Caretakers (N01) may be eligible for Apple Health for Adults (N05) as described in WAC 182-505-0250.
  2. Individuals who are ineligible for Apple Health for Parents/Caretakers (N01) based on citizenship may be eligible for Alien Emergency Medical (N21) as described in WAC 182-507-0110.
  3. Individuals are eligible for Apple Health for Parents/Caretakers (N01) even if they are eligible for Medicare and/or age 65 or older.

Individuals may apply for MAGI health care coverage using the following options:

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Scope of care Early and Periodic Screening, Diagnosis and Treatment (EPSDT)

Revised date
Purpose statement

To describe Early and Periodic Screening, Diagnosis and Treatment (EPSDT) that is available to individuals under 21 years of age who are eligible for Apple Health CN or MN coverage.

WAC 182-534-0100 EPSDT

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.

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

This program provides preventive and enhanced service coverage for anyone under 21 years of age who is eligible for Apple Health CN or MN coverage. Parents who are under 21 years of age and who are on CN or MN coverage are also eligible for EPSDT services. "Under 21" means through the day before their 21st birthday.

The significance of this program is that medically necessary services identified by medical service providers are covered even if the services are not otherwise covered services under the standard scope of care.

If you are an Apple Health client and/or a parent/caregiver of a child enrolled in Apple Health, visit the well-child checkups webpage or review the EPSDT well-child checkups for your child or teen brochure (HCA 19-0056).

If you are a provider or biller, please see the EPSDT billing guide for guidance on billing for these services.

Program overview

Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) is a federally mandated, comprehensive, and preventive health care benefit. The purpose of this program is to ensure children and adolescents age 20 and younger receive appropriate preventive, dental, mental health, developmental, and specialty services. Medically necessary treatment identified in the EPSDT well-child checkup is covered under the EPSDT benefit.

The following are descriptions of the components of the program:

Early: Assessing and monitoring a child's health and ongoing development early in life can help prevent, identify, and intervene, so potential diseases and disabilities can be addressed before they become more complex and are in their preliminary stages, when they are most effectively treated. This means as early as possible in a child's life in the case of a family already receiving medical benefits or as soon as a child's eligibility has been established.

Periodic: As children and adolescents grow, visits with their health care providers should occur at regular intervals to ensure continued healthy development and to monitor current or emerging needs. Section 1905 of the Social Security Act requires periodicity schedules sufficient to ensure that at least a minimum number of health examinations occur at critical points in a child’s life, and that medically necessary screenings are provided.

Screening: Providers use preventive services, including comprehensive interviews, medical examinations, and standardized tools, to identify children who require further diagnostic assessment or intervention for health and developmental issues. The five categories of screenings covered under this program are medical, vision, hearing, dental, and developmental. Screening services must be available both at established times and on an as-needed basis. When a screening indicates the need for further diagnostic assessment, a child and their family should be referred for diagnosis without delay.

Diagnosis: When there is an indication that a child or adolescent may have a health problem, a follow-up diagnostic assessment and additional evaluations must be provided. This includes recommendations and any necessary referrals to needed services when a diagnosis is determined.

Treatment: In response to an identified need, health care services needed to correct, ameliorate, or lessen health problems, including care coordination for chronic conditions, are offered and provided. Services provided to the child or adolescent must be considered medically necessary (see WAC 182-500-0070).

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Renewals

Revised date
Purpose statement

This section describes the WAC and policy of the renewal process for long-term services and supports (LTSS) and SSI-related medical programs. Consult the Eligibility A-Z (EA-Z) manual for the eligibility review process for cash and recertification process for food benefits.

Washington Apple Health renewals

WAC 182-504-0035

What forms are used for Washington Apple Health LTSS renewals?

Renewals for LTSS medical can be completed:

  • Online through Washington Connections. Go to "renew by benefits"; or
  • By submitting DSHS 14-416 Eligibility Review for Long-Term Services and Supports (used just for SSI-related Medicaid) ; or
  • By submitting DSHS 14-078 Eligibility Review (used for cash, food and SSI-related Medicaid reviews); or
  • By phone. Contact the HCS Public Benefit Specialist (PBS) at the local Home and Community Service (HCS) office (link has HCS phone numbers by county).

Eligibility review forms for LTSS should be sent to:

Department of Social and Health Services 
Attn: HCS
PO Box 45826
Olympia WA 98504-5826

Or FAXED to:

Department of Social and Health Services
Attn: HCS
FAX: 1-855-635-8305

Any document mailed or faxed to DSHS should always include a complete name and the DSHS client ID so the document is assigned to the correct case record.

First annual review when there is a Community Spouse

A phone review can be completed at the first annual review when there is a community spouse, however, it is important that verification of all resources in excess of the $2,000 resource limit are out of the institutional spouse's name and into the community spouse's name. To confirm, request asset verification system (AVS) verifications for both spouses. 

Make sure the resources are document on the community spouse's screen in ACES.

Worker responsibilities

At the renewal process, review eligibility elements below for LTSS. Document in remarks where changes have occurred or new information is provided.

  1. Resource eligibility.
    1. If the home or property is owned by the client, check to make sure the home or property is still in the client's name.
    2. Use the AVS process to verify resources for the recipient only (except at first annual review for a married couple).
    3. Verification of life insurance and burial plans are required at application, don't request verification at review unless a new policy is reported or if client has a whole life policy with countable cash surrender value that needs to be verified.
    4. Use prudent person to request verification of any questionable resources.
  2. Income eligibility
    1. Request verification of gross income at renewal only if a change is reported and there is no interface such as social security, veterans, or Washington State pension. Only request verification if the department does not have access to income verification.
  3. Post eligibility deductions
    1. Request verification of post eligibility deductions such as uncovered medically necessary expenses, guardianship fees, etc. if the client is reporting a change in the amount.
    2. Spousal and dependent deductions
      1. Request verification of spousal income and shelter costs only if the community spouse would receive a spousal allocation and changes are reported.
      2. Request verification of dependent income only if the dependent would receive an allocation and changes are reported. 
  4. If doing a phone renewal it's important to document all eligibility elements including who you conducted the phone interview with and their contact information. 

Worker Responsibilities - Processing Late Reviews

ALTSA gives all clients the extra time and consideration they need during the renewal process. We assure clients, representatives, case managers and facility staff all are made aware of the required eligibility review (ER) and that benefits will end if one isn't completed.

When an ER isn't initiated in ACES by mid-month, deadline alert 214 is generated. The day after alert 214 appears ACES sends a termination letter to the client and to all representatives coded in ACES to receive letters. The termination letter doesn't include another ER form and isn't sent to facilities on the institutional care facility page.

Please note: Refer to the ACES production calendar for exact dates the 214 alerts are generated. 

To ensure we meet equal access (EA) service requirements for all clients:

  1. Initiate Washington Apple Health Medical reviews only when the following has occurred:
    1. Review is physically received in office; or
    2. Contact is made with the client, authorized representative, or guardian and
      1. You completed a phone interview. Document the phone review including who you talked to.
  2. When 214 alerts are generated for Washington Apple Health Medical:
    1. Review your 214 alerts,
    2. Contact the client, authorized representative (AREP), or guardian by the last day of the certification period. If contact is made:
      1. Initiate a phone renewal,
      2. Review all eligibility factors subject to change during the renewal process, 
      3. Add remarks on the applicable screens, and 
      4. Complete an asset verification system (AVS) search on known accounts.
    3. Send a Request for Information (0023-01) for questionable information where verification is needed or there is conflicting information. Don't ask clients to provide verification of items we're able to obtain through interfaces.
  3. ACES will continue to mail renewal notices for Washington Apple Health medical 45 days prior to the client's certification ends date. Completing the phone renewal is applicable when:
    1. Client, AREP, or guardian makes contact with your anytime during the month of review, or
    2. Client, AREP or guardian hasn't returned the eligibility review form and you initiate phone contact to complete the review. Please note: You don't need to wait until a 214 alert is generated to begin the phone renewal process.
  4. If unable to contact the client, AREP or guardian, reprint the termination letter. For Washington Apple Health medical, send the letter and an ER form with a business reply envelope to:
    1. The client.
    2. All authorized representatives, or
    3. The nursing facility representative (if applicable). 
  5. If you're unable to reach the client by the 5th of the month following the certification end date for Apple Health, make a final contact with the client, AREP, or guardian by phone.
    1. If contact is made, reinstate, initiate the phone renewal process and send the reinstatement letter. 
    2. If no contact is made by phone, mail an additional ER request to the client, and authorized representative.
    3. If the phone renewal is completed, send the recertification letter (27-04), provided services were in place during the time period the case was closed.​ NOTE: Clients have 30 days from the termination date to submit a completed renewal per WAC 182-504-0035. 
  6. For cash and basic food.

The policy described above is for medical programs. Some recipients of LTSS are receiving cash and/or food benefits. Eligibility review requirements for cash assistance and recertification processes for food assistance are described in the EA-Z manual below.

  1. Eligibility review requirements for cash assistance are described in WAC 388-434-0005.
  2. Recertification process for food assistance is described in WAC 388-434-0010.

Follow Equal Access policies when doing renewals

Equal Access for LTSS

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Lump sum income

Revised date
Purpose statement

How are lump sums counted for aged, blind, disabled (SSI-related) and long term care medicaid.

Note: This policy applies to SSI related Medicaid programs only and not Modified Adjusted Gross Income (MAGI) programs authorized by the Health Benefit Exchange (HBE)

Lump Sums LTSS

Lump Sums are money received in the form of a nonrecurring payment including, but not limited to: lottery, bingo, or gambling winnings, inheritance, income tax refunds, rebates, retroactive payments, and insurance settlements.

For long term care, we must use the SSI related WACs to determine their effect on eligibility:

  • The SSI related WAC specifically excludes SSI and RSDI retroactive payments as income in the month of receipt and as a resource for 9 months following the month of receipt.
    WAC 182-512-0700 SSI related medical-Income eligibility 
    WAC 182-512-0550 SSI related medical-All other excluded resources 
  • Unspent portion of non recurring lump sum is counted as a resource on the first of the month following its receipt. (With the exception of any RSDI or SSI retroactive payment indicated above).

Note: What is RSDI? RSDI is Retirement and Survivors Disability Insurance payments under Title II of the Social Security Act.

  • All other lump sums must be looked at based on whether the agency could anticipate their receipt, and therefore anticipate their effect on eligibility, as well as reporting requirements and advance notice requirements for recipients. This includes retroactive VA payments.
  • For recipients, in most cases we will not be able to anticipate the lump sum and therefore the lump sum will not count as income.
  • Due to reporting requirements and the need to provide advance notice, a lump sum may not affect eligibility until the month following the change of circumstance report. See Change of Circumstance reporting requirement.

As Income (WAC 182-513-1325, 182-513-1330, 182-512-0650):

  • Anticipated nonrecurring lump sum payments are treated as income in the month received. Any remainder is considered a resource in the following month. Retroactive SSI and RSDI payments are an exception. They are always excluded as income in the month of receipt. To be anticipated means that the client reported to us early that they were going to be receiving a lump sum or we learned about the upcoming payment from some other source. It also means that we learned about it early enough that it could affect eligibility.
  • For applicants, a lump sum is income in the month received if we knew about the lump sum at the time we were making our eligibility decision.
  • For recipients, a lump sum is income in the month received if we knew about it early enough we could allow for 10 days' advance notice if the lump sum would cause the benefits to be reduced or terminated. 
  • Income that has been anticipated in a different amount than was actually received is not an overpayment if the anticipated amount was reasonable. If the anticipated amount was based on false information or information known at the time to be incomplete, or if the agency made an error in calculation, there may be an overpayment.

Unanticipated nonrecurring lump sums can't be counted as income in the month received because SSI related and LTC medical programs must budget prospectively. We can only count income that can be anticipated. However, any amounts remaining the first of the month after the month of receipt will be a resource. Even though the remaining amounts become a resource, retroactive SSI and RSDI are excluded for up to 9 months following the month of receipt.

As Resources (WAC 182-513-1350; 182-512-0300)

  • For most lump sums, the amount the person still has (unspent portion) on the first of the month following receipt is a resource, unless specifically excluded as a resource.
  • For applicants, the amount remaining following the month of receipt would be counted for resource eligibility.
  • For recipients, use reporting requirements and advance notice when determining the effect of the remaining lump sum on resource eligibility.

Example #1 Anticipated Retroactive Social Security:

Bill receives a letter March 1 from Social Security that he has been approved for Social Security Disability insurance (SSDI, a type of RSDI) and will be sent $15,000 retroactive SSDI on April 4. Bill expects to receive it in April.

Although he has 30 days to report the receipt of the lump sum and knows he will not receive the money until April, he is so excited he calls his financial worker on March 1 to tell of his Social Security approval.

Since we know about the payment early enough to affect eligibility, the $15,000 is an anticipated lump sum and can't be counted as income in April because it is an excluded income type.

Further, beginning May 1, any unspent portion is excluded as a resource for 9 months, or from May 1 through January 31. 

Because it is an excluded resource, Bill can transfer the lump sum monies within the 9 month exclusion period without causing a transfer penalty.

If Bill is married and has a community spouse, he can transfer any resource to his spouse without penalty.

Example #2 Unanticipated Retroactive Veteran's Administration (VA):

Bill is active on COPES and receives $15,000 retroactive VA Benefits on April 4. He reports the receipt of the funds on May 1. This report is timely. The $15,000 is considered an unanticipated lump sum and can't be counted as income in April. Beginning May 1, any unspent portion is a countable resource. However, because he reported the change timely, it does not affect May's eligibility. The agency must give advance notice to close the case effective 5/31. There is no overpayment for May.

We will determine whether Bill is resource eligible June 1.

If he is married and has a community spouse, he can transfer the money to his community spouse before June 1 and it will not affect his resource eligibility nor cause a transfer penalty.

If he is not married and spends the money before June 1, he will need to disclose how the money was spent so we can determine whether he was compensated. We will need to determine if any of it was transferred without adequate consideration causing a transfer penalty.

Example #3 Anticipated Retroactive VA:

Bill is active on COPES and receives a letter March 1 from Veterans Affairs that he has been approved for Veterans Benefits and will be sent $15,000 retroactive VA on April 4. He expects to receive it in April.

Although he needs to report the payment within 30 days of receipt (he has until May 3), he is so excited he calls his financial worker on March 1 to tell of his Veteran Benefit approval.

Because we know about the payment early enough to affect eligibility and retroactive VA benefits are not excluded, the $15,000 is an anticipated lump sum and is countable income for the month of April.

Further, any unspent portion is a countable resource beginning May 1.

If he is married and has a community spouse, he can transfer the money to his community spouse before May 1 and it will not cause a transfer penalty.

Example #4 Unanticipated Inheritance:

Mary is a COPES client and her aunt died and left Mary $50,000 cash in her will. Mary learned of the inheritance on July 10 at the reading of the will and knew it would be sent to her in September. Mary received the cash on September 15. She reported it to us within thirty days on October 10.

The $50,000 is an unanticipated lump sum and can't be counted as income in September. It does not matter that Mary knew she was getting it before she received it. She was not required to report it until she received it and then had 30 days to report the receipt of the lump sum. Beginning November 1, any unspent portion is potentially a countable resource.

We will determine whether Mary is resource eligible November 1.

If she is married and has a community spouse, she can transfer the money to her community spouse before November 1 and it will not affect her resource eligibility nor cause a transfer penalty.

If she is not married and spends the money before November 1, she will need to disclose how the money was spent so we can determine whether she was compensated. We will need to determine if any of it was transferred without adequate consideration causing a transfer penalty.

Example #5 Anticipated Inheritance:

Mary is a COPES client and her aunt died and left Mary $50,000 cash in her will. Mary learned of the inheritance on July 10 at the reading of the will and knew it would be sent to her September 8.

Mary was concerned about how the cash would affect her COPES services and called her financial worker on August 1 to find out. During the call she disclosed the money would be sent to her by the attorney on September 8.

Mary knew when the money would be received and informed the agency early enough that we could prospectively budget it for September. Send advance notice because the $50,000 is an anticipated lump sum and must be counted as income in the month of September. COPES services would close effective August 31 because her income is too high. Inform the case manager of the termination effective August 31 and there may be a potential the client would need to be reassessed for eligibility by October 1.

Beginning October 1, any unspent portion is potentially a countable resource.

If she is married and has a community spouse, she can transfer the money to her community spouse before October 1 and it will not cause a transfer penalty. However, we would need to redetermine the resource eligibility as a couple since there has been a 30 day break in eligibility of institutional services.

If she is not married and spends the money before October 1, she will need to disclose how the money was spent so we can determine whether she was compensated. We will need to determine if any of it was transferred without adequate consideration causing a transfer penalty.

Worker Responsibilities

When a lump sum affects resource eligibility, propose termination giving 10 day advance notice. On the termination notice indicate the following text:

Your resources are currently over the resource standard described in WAC 182-513-1350. If resources are at or below the resource standard by the first of the following month, provide verification of the value of resources as of the first. Provide this verification within 30 days. A reconsideration of the termination will be completed and if eligible your case will be reinstated. Keep in mind, transfer of asset rules described in WAC 182-513-1363 apply for long-term care services. If you are married a redetermination of the couple's resources are required when there is a break of at least 30 days of service per WAC 182-513-1350.

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Program options for the justice involved

Revised date

The Department of Corrections and city/county correctional agencies have a variety of confinement levels that the justice involved individual may be placed in. The following table is intended to help clarify how participation in a correctional program affects a person's eligibility for Medicaid.

Is the justice involved individual eligible for Medicaid?

Correctional type Medicaid eligibility -
Inpatient coverage only*		 Medicaid eligibility -
Full coverage
Electronic Home Monitoring (EHD/EHM)
The justice involved individual resides in their home and is monitored electronically. The justice involved individual does not occupy a jail or prison bed while in this program.		   X
Day jail / Day reporting
The justice involved individual reports at various assigned times throughout a 24-hour period OR are placed on supervised work or community betterment programs during regular work hours. In either situation, the justice involved individual does not occupy a jail or prison bed while in the program.		   X
Pretrial supervision / Probation
Pretrial supervision staff monitor the justice involved individual who is released from custody by the court pending the outcome of their trial and they do not occupy a jail or prison bed		   X
District Court probation
District Court probation officers monitor the justice involved individual who is convicted of or are pending trial for misdemeanor charges. The justice involved individual does not occupy a jail or prison bed.		   X
DOC community supervision
Community Corrections Officers monitor the justice involved individual who is convicted of felony charges. The justice involved individual does not occupy a jail or prison bed.		   X
Drug Court
A court-ordered program in which the justice involved individual with drug-related charges voluntarily chooses to participate in chemical dependency treatment. The individual may have their charges dismissed if they successfully complete the program. The individual does not occupy a jail or prison bed.		   X
Furloughs
Individuals are sometimes furloughed by a city/county jail for various reasons. When medically furloughed the individual is typically not reported out of the facility so the suspension coding does not change in ProviderOne. To be eligible for a Medicaid payment the individual must receive inpatient hospitalization services lasting 24 hours or more and not return to the jail in the same day. Same-day furloughs for services are typically the responsibility of the jail or a payer other than Medicaid.		 Depends  
**Work Release in city/county facilities
Justice involved individuals who are housed in a work release facility, jail, or corrections facility and are authorized to leave the facility for purposes of employment, education, court-ordered treatment or employment search. The justice involved individual does occupy a corrections bed while in this program. Most county work release programs operate under this model. For a complete list of approved city/county work release facilities, please refer to the list provided below this table. For DOC work release eligibility, please refer to Supervised Community Residential Facility/Halfway House / DOC Work Release.		 X  
Work crews / Community betterment
This program is offered to select justice involved individuals. The program includes working in the community on various public or nonprofit programs. The individual does occupy a corrections bed while in this program. There may be exceptions for those not occupying a corrections bed while in this program.		 X  

***Supervised Community Residential facility/Halfway House / DOC work release
The justice involved individual is housed in state or local corrections-related supervised community residential facility which allows for 'freedom of movement' to: 1) work outside the facility in employment opportunities available to individuals who are not under justice system supervision, 2) use community resources at will (libraries, grocery stores, recreation, etc.) and 3) seek health care treatment in the broader community to the same or similar extent as other Medicaid enrollees. The residential facility may be public or privately operated. These facilities may have “house rules” where for example residents may be required to report during certain times and sign in and out. Similarly, they may be restricted from traveling to or frequenting locations associated with criminal activity. The majority of state operated (DOC) work release programs use this model. Please refer to the list of approved work release facilities.

   X

Residential Reentry Centers (RCC) – Federal corrections facility
A justice involved individual housed in a RCC does not have freedom of movement and is only authorized to leave the RCC through sign-out procedures for approved activities, such as seeking employment, working, counseling, visiting, or recreational purposes. During the approved activity, the inmate's location and movements are constantly monitored and RCC staff may visit or call them at any time.

 No coverage - these are federal facilities and the cost of medical care is the responsibility of the Federal Government. No coverage - these are federal facilities and the cost of medical care is the responsibility of the Federal Government.

Voluntary and temporary residence in a public institution
This includes justice involved individuals who are residing in a public institution or detention center for a temporary period of time voluntarily after their case has been adjudicated and arrangements are being made for their transfer to a community residence. The justice involved individual must be free to leave and is voluntarily residing there pending other appropriate arrangements based on their needs.

   X

Residents in a Mental Health Facility or IMD
Individuals (justice involved and general public) who are between the ages of 22 and 64 and are a patient of an Institution for Mental Diseases (IMD) where there are over sixteen beds (e.g. Western State) for more than 15 days in a given month.

 X  

*Inpatient hospital events; must be admitted for 24 hours or more

**List of City/County Jail work release facilities that are approved living situations are Seattle/King County, Whatcom, and Thurston County.

***List of DOC work release facilities that are approved living situations are: Ahtanum View - Yakima County, Bellingham - Whatcom County, Bishop House - King County, Brownstone - Spokane County, Clark County - Clark County, Eleanor Chase House - Spokane County, Helen B Ratcliff - King County, Longview - Cowlitz County, Olympia - Thurston County, Peninsula - Kitsap County, Progress House - Pierce County, Reynolds - King County, Tri-Cities - Benton County. The only DOC facilities that are unapproved are: Lincoln and Rap Houses in Pierce County.

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Continued coverage pending an appeal

Revised date
Purpose statement

To explain how to receive continued when an administrative appeal is pending and how continued coverage works.

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

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.

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

  1. When Apple Health coverage is terminated, an individual can request an administrative appeal. This appeal must be requested by the end of the month their coverage is to be terminated in order to be considered timely and to receive continued coverage.
  2. When an individual requests an administrative hearing, the agency sends a notice that includes the approval or denial of continued coverage, the reason for denial of continued coverage (if applicable), and that the individual might be liable for up to two months of medical expenses (overpayments) if continued coverage is received and the agency’s termination is upheld.
  3. An individual is eligible for continued coverage if:
    1. An appeal is received by the agency, its designee (including the Health Benefits Exchange), or the Office of Administrative Hearings by 5:00PM on the last day of the month; or
    2. If the last day of the month falls on a weekend or holiday, the appeal is received by 5:00PM on the following business day; or
    3. An administrative law judge issues an order granting continued coverage.
  4. Continued coverage ends the last day of the month when:
    1. The individual fails to appear for his or her hearing.
    2. An administrative law judge issues an order upholding the agency’s decision;
    3. The individual withdraws their appeal.
    4. The individual declines continued coverage in writing; or
    5. An administrative law judge issues an order stopping continued coverage.
  5. If an individual fails to appear for the hearing or if an order is issued upholding the agency’s decision, the agency may seek reimbursement for the cost of the two months of continued coverage received. See WAC 182-520-0010 for more information.
  6. Continued coverage is not an option when a termination is caused by a change in rule. There is also not an option for continued coverage for medically needy coverage after the original certification period.

Worker responsibilities

Administrative hearing coordinator

  1. Review each hearing request to determine eligibility for continued benefits. An individual may have noted on the request that they do not want continued coverage.
  2. If an individual is eligible for continued coverage:
    • Reopen health care coverage.
    • Document in ACES why coverage was reopened;
    • Send a notice to the individual with the following text:

      You have requested an administrative hearing and will receive continued health care coverage unless you tell us you do not want it (WAC 182-504-0130).

      You may have to pay back the agency’s costs for the two months of continued coverage after you requested a hearing if the Administrative Law Judge (ALJ) agrees with our decision (WAC 182-520-0010).

      You will receive continued coverage through the end of the month an administrative hearing decision is sent to you unless:

      a) An ALJ or our presiding officer serves an order ending continued coverage; or

      b) You:

      1. Tell us in writing that you do not want continued health care coverage; or

      2. Withdraw your request for an administrative hearing in writing or during the hearing.

  3. If an individual is not eligible for continued coverage:
    1. Document in ACES why they are not eligible; and
    2. Send a notice to the individual with the following text:

      “You have requested an administrative hearing regarding your health care coverage. Your request has been sent to the Office of Administrative Hearings.

      You requested continued coverage pending the outcome of your appeal. You are not eligible because _______. See WAC 182-504-0130.

      If you disagree with the decision to deny continued coverage, you may contact the Office of Administrative Hearings at 360-407-2700 and request a prehearing conference. The prehearing conference will be with an Administrative Law Judge who will determine only if you are or are not eligible for continued coverage.”

  4. If the individual is on continued coverage for any long-term care, COPES or other services through ALTSA, notify the case manager of the reopening of coverage pending the appeal.

Example: Mohamed is on WAH for adults. He is terminated 6/30 for being over income. He submits a request for a hearing on 6/29. He is eligible for continued coverage.

Example: Gloria receives WAH for her children. Coverage ends 1/31. She submits a request for a hearing on 2/15. Deny continued coverage as the request was not timely.

Example: Giuseppe receives WAH for adults. Coverage ends Sunday, 12/31. He submits a request for a hearing on 1/2. He is eligible for continued coverage as the last day of the month falls on a weekend, the next day is a holiday, and the hearing request was received on the next business day.

Example: Jacques applies for WAH and is denied for not meeting the immigration criteria. He submits a timely appeal and wants continued coverage. He is not eligible because he was not a recipient of WAH at the time of the denial.

Example: Walter was on an active WAH MN spenddown for 9/14 to 11/30. He submits an appeal on 11/15 about having to meet a new spenddown as of 12/1. He asks for continued coverage. He is not eligible as continued coverage for MN programs does not extend past the certification period end date.

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Excluded income

Revised date

WAC 182-513-1345 Determining disregarded income for institutional or hospice services under the medically needy (MN) program.

WAC 182-513-1345 Determining disregarded income for institutional or hospice services under the medically needy (MN) program.

Effective February 20, 2017

This section describes income the agency or its designee disregards when determining a person's eligibility for institutional or hospice services under the medically needy (MN) program. Disregarded income is available when determining a person's participation in the cost of care.

  1. The agency or its designee disregards the following income amounts in the following order:
    1. Income that is not reasonably anticipated, or is received infrequently or irregularly, when such income does not exceed:
      1. Twenty dollars per month if unearned; or
      2. Ten dollars per month if earned.
    2. The first $20 per month of earned or unearned income, unless the sole source of income paid to a person is:
      1. Based on need; and
      2. Totally or partially funded by the federal government or a nongovernmental agency.
  2. For a person who is related to the supplemental security income (SSI) program under WAC 182-512-0050(1), the first $65 per month of earned income not excluded under WAC 182-513-1340, plus one-half of the remainder.
  3. Department of Veterans Affairs benefits designated for:
    1. The veteran's dependent when determining LTC eligibility for the veteran. The VA dependent allowance is considered countable income to the dependent unless it is paid due to unusual medical expenses (UME);
    2. Unusual medical expenses, aid and attendance allowance, special monthly compensation (SMC) and housebound allowance, with the exception under subsection (4) of this section.
  4. Benefits under subsection (3)(b) of this section for a person who receives long-term care services are excluded when determining eligibility, but are considered available as a third-party resource (TPR) defined under WAC 182-513-1100 when determining the amount the person contributes in the cost of care.

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 that is counted

Income that remains after exclusions and disregards provided by specific program rules must be counted when determining eligibility and participation in the cost of care for long-term care (LTC) services. This is "countable" income.

Income described in WAC 182-513-1340 is excluded when determining both initial eligibility and post eligibility (participation) in the cost of care. These exclusions apply to both the categorically needy (CN) and medically needy (MN) programs. Specific federal statutes provide that each type of income listed be excluded when determining a client's countable income.

Income described in WAC 182-513-1345 is disregarded when determining eligibility for MN programs. Disregarded income must be counted when determining eligibility for CN programs and when determining a client's participation in the cost of care.

Refer to WAC 182-515-1510 for income post eligibility deductions provided under DDA HCB Waivers.

Refer to WAC 182-515-1505 for income deductions post eligibility deductions provided under HCS HCB Waivers.

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Income ownership and availability

Revised date
Purpose statement

This section includes rules and procedures for determining whether an individual owns income, if the income is available to the individual, and what an individual must do to make potential income available.

WAC 182-512-0650 SSI-related medical -- Available income.

WAC 182-512-0650 SSI-related medical -- Available income.

Effective June 3, 2025

  1. Income is considered available to a person at the earliest of when it is:
    1. Received; or
    2. Credited to a person's account; or
    3. Set aside for the person's use; or
    4. Used or can be used to meet the person's needs for shelter.
  2. Anticipated nonrecurring lump sum payments are treated as income in the month received, with the exception of those listed in WAC 182-512-0700(4), and any remainder is considered a resource in the following month.
  3. Reoccurring income is considered available in the month of normal receipt, even if the financial institution posts it before or after the month of normal receipt.
  4. In-kind income received from anyone other than a legally responsible relative is considered available income only if it is earned income.

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

  1. When recurring income is received in advance or electronically deposited in the individual's account, the income is considered available for the month it would normally be received.
    Example: A Social Security check normally received in February is electronically deposited on January 31st because February 1st is a Saturday. The income is still counted for February.
  2. Unanticipated nonrecurring lump sums cannot be counted as income in the month received because income must be budgeted prospectively. However, any amount remaining after the month of receipt is considered a resource.
  3. Income that has been anticipated in a different amount than was actually received is not an overpayment if the anticipated amount was reasonable. If the anticipated amount was based on false information or information known at the time to be incomplete, or if the department made an error in calculation, there may be an overpayment.

Worker Responsibilities

Determine if individuals have any potential income available.

Making a source of income available:

  1. If someone meets all other eligibility factors, do not delay benefits if they try to make a potential source of income available.
  2. If a person can't make a source of income available for reasons beyond their control, consider the income as unavailable to the individual.
  3. Request verification and ask for proof that the individual has tried to make potential income available. Examples of proof include:
    1. Financial Statements;
    2. Collateral Statements; and
    3. Letter from the person or company that has control of the income.
      See General Verification for information on how to ask for proof from individuals.
    4. Unemployment compensation.
      See WAC 388-406-0030 to decide how much time to allow individuals to provide the proof.

Individuals must take all needed steps to get any income (such as annuities, pensions, retirement, and disability benefits) they can receive.

  1. Individuals do not have to take steps to get the income if they can show a good reason for not doing so.
  2. Examples of benefits the individual must try to make available include:
    1. Veteran’s compensation and pensions;
    2. OASDI benefits;
    3. Railroad retirement benefits; and
  3. Refer individuals to the correct agency to apply for potential income and/or help individuals get potential income if they ask for assistance.

When the date income is available changes:

  • Budget the income for the date you expect the individual to receive the income.
  • Set an alert in ACES for the date we expect the individual to receive the income to check if the income is available.
  1. Community income:
    1. When a husband and wife live together, count the following as community income:
      1. Income in the name of the husband, wife, or both spouses;
      2. Income that the husband, wife, or both spouses have access to;
      3. Income the husband, wife, or both spouses received; and
      4. Earnings of the husband, wife, or both spouses.
  2. Separate income:
    1. Count income as separate income when the income:
      1. Was received by either spouse before marriage;
      2. Was received as a result of a gift or inheritance;
      3. Was received from separate property; or
      4. Are the earnings of the husband, wife, or both spouses when the spouses live separate and apart.
    2. Separate income becomes community income when someone puts the income into an account with community income.
  3. Jointly owned bank accounts:
    1. When an individual has a joint bank account or is holding funds for someone else, determine if the individual and the other person have a written or verbal agreement about the amount of the funds available to the individual.
    2. If the individual and the other person have an agreement, decide if the individual uses more than this amount to meet their current needs. Count the excess as available unearned income and budget it for the assistance unit.
    3. If the individual and the other person do not have an agreement, decide if the funds are available to meet the individual’s needs:
      1. Get a detailed record of the dates and amounts of money deposited into the account or given to the individual to hold for the other person.
      2. Get a detailed record of the types and amounts of payments for the other party.
      3. Consider any amount over the itemized payments for the other party as income available to the individual. Budget it as unearned income for the assistance unit.
    4. Review the individual’s circumstances at each eligibility review, reapplication, or when they report a change in the joint bank account or the source of funds.

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Hospice eligibility (with institutional Medicaid rules)

Revised date

Eligibility for the L32 Hospice program utilizing institutional rules

The L32 hospice program should be used for a client who receives hospice services and who resides in a medical institution (nursing facility, hospice care center). ACES will trickle to an L95 or L99 medically needy (MN) program if the gross income is over the medicaid special income level (SIL) when the client is in a medical institution.

For some clients who do not reside in medical institutions, it could be to their benefit to follow institutional rules when determining eligibility for hospice services. Institutional rules allow the spend-down of excess resources towards the cost of care, a higher resource standard for married couples, a higher income allocation amount for a spouse and a higher income standard for a single person. Clients need to meet aged, blind, or disabled criteria to be eligible for the L32 hospice program. Examples of cases that should be considered for L32 coverage are listed below:

L32 is a categorically needy (CN) program and has advantages over a MN program.

  1. SSI related medically needy. A client should always be considered for a L32 program before authorizing benefits or services under MN for the following reasons:
    • Clients will not have to meet a spend-down amount prior to becoming eligible. They may have to pay toward the cost of care each month; participation is paid directly to the hospice provider).
    • Once the client is found eligible, medicaid is backdated to the first of the month and CN scope of care.
    • The CN income limit is the SIL which is higher than the CN income limit for noninstitutional medical.
    • For a single client at home, the personal needs allowance standard is higher (100% FPL), as opposed to the Medically Needy Income Limit (MNIL) used for noninstitutional medical.
    • A community spouse’s income is not counted when determining hospice participation. The personal needs allowance (PNA) is the MNIL when there is a community spouse.
    • A dependent’s income is not counted when determining hospice participation.
    • Higher income allocation to a community spouse and dependents when living with a community spouse.

  2. A single Apple Health for Workers with Disability (HWD) client with income below 100% of the FPL. They would not have to pay a premium for medical coverage and would have no participation.

  3. A minor child with a disability who is not eligible for a children’s health care program due to the income of their parents.

For clients receiving waiver services through Aging and Long-term Supports Administration (ALTSA), see additional instructions under Worker Responsibilities - ALTSA HCB Waiver Programs.

HCB Waiver rules for Home and Community Services (HCS) clients are described in WAC 182-515-1505.

HCB Waiver rules for Development Disabilities Administration (DDA) clients are described in WAC 182-515-1510.

A client can be on an HCB waiver program (L21, L22) with HCS or DDA and receive hospice services, if functionally and financially eligible. Both waiver and hospice services are coded on the Institutional Care screen under Services. The Waiver program is the priority program over Hospice. All participation is applied to the waiver program.

For a hospice client in a medical institution with income over the SIL, see WAC 182-513-1395 Determining eligibility for institutional services for people living in a medical institution under the SSI-related medically needy program. 

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Social Security number

Revised date
Purpose statement

To explain the Social Security number (SSN) requirements and instructions for obtaining SSNs for applicants and recipients for Apple Health.

WAC 182-503-0515 Washington apple health -- Social Security number requirements.

WAC 182-503-0515 Washington apple health -- Social Security number requirements.

Effective June 11, 2025

  1. To be eligible for Washington apple health (medicaid), or tailored supports for older adults (TSOA) described in WAC 182-513-1610, you (the applicant or recipient) must provide your valid Social Security number (SSN) or proof of application for an SSN to the medicaid agency or the agency's designee, except as provided in subsections (2) and (6) of this section.
  2. An SSN is not required if you are:
    1. Not eligible to receive an SSN or may only be issued or may only be issued an SSN for a valid nonwork reason described in 20 C.F.R. 422.104;
    2. A household member who is not applying for apple health coverage, unless verification of that household member's resources is required to determine the eligibility of the client;
    3. Refusing to obtain an SSN for well-established religious objections as defined in 42 C.F.R. 435.910 (h) (3); or
    4. Not able to obtain or provide an SSN because you are a victim of domestic violence.
  3. If you are receiving coverage because you meet an exception under either subsection (2) (c) or (d) of this section, we (the agency) will confirm with you at your apple health renewal, consistent with WAC 182-503-0050, that you still meet the exception.
  4. If we ask for confirmation that you continue to meet an exception in subsection (2) of this section and you do not respond in accordance with subsection (3) of this section, or if you no longer meet an exception and do not provide your SSN, we will terminate your apple health coverage according to WAC 182-518-0025.
  5. If you are not able to provide your SSN, either because you do not know it or it has not been issued, you must provide:
    1. Proof from the Social Security Administration (SSA) that you turned in an application for an SSN; and
    2. The SSN when you receive it.
      1. Your apple health coverage will not be delayed, denied, or terminated while waiting for SSA to send you your SSN. If you need help applying for an SSN, assistance will be provided to you.
      2. We will ask you every ninety days if your SSN has been issued.
  6. An SSN is not required for the following apple health programs:
    1. Refugee medical assistance program described in WAC 182-507-0120, and 182-507-0125;
    2. Alien medical programs described in WAC 182-507-0115, 182-507-0120, and 182-507-0125;
    3. Newborn medical program described in WAC 182-505-0210 (2)(a);
    4. Foster care program for a child age eighteen and younger as described in WAC 182-505-0211(1); or
    5. Medical programs for children and pregnant women who do not meet citizenship or immigration status described in WAC 182-503-0535 (2)(e)(ii) and (iii); or
    6. Family planning only program described in WAC 182-532-510 if you do not meet citizenship or immigration status for Washington apple health or you have made an informed choice to apply for family planning services only; or
    7. Washington apple health expansion program described in chapter 182-525 WAC.
  7. If you are required to provide an SSN under this section, and you do not meet an exception under subsection (2) of this section, failure to provide an SSN may result in:
    1. Denial of your application or termination of your coverage because we cannot determine your household's eligibility; or
    2. Inability to apply the community spouse resource allocation (CSRA) or monthly maintenance needs allowance (MMNA) for a client of long-term services and supports (LTSS).

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

  1. A valid Social Security number (SSN) or proof that an individual has submitted an application for a SSN is required for all Apple Health programs except for the programs listed in subsection 6 of WAC 182-503-0515.
  2. If an individual is otherwise eligible for Apple Health, coverage is approved and time allowed to provide their SSN, proof an SSN was applied for, or proof they meet a good cause exception.
  3. Household members who are not applying for coverage are not required to provide their SSN. However, for long-term services and supports, a community spouse needs to provide an SSN for DSHS to use the community spouse resource allocation (CSRA) or monthly maintenance needs allowance (MMNA).
  4. An individual who refuses to apply for or provide an SSN due to religious beliefs must provide verification from a church elder or other officiant showing the individual is a member and that providing or applying for an SSN is against the church doctrine. Personal, cultural, or political beliefs do not qualify as a religious objection to providing or applying for an SSN.
  5. If a current and valid SSN is not available and the individual needs to pay an agency for a copy of his or her birth certificate, the agency must help the individual obtain the birth certificate and pay for any applicable fees. The individual receives Apple Health during this time if otherwise eligible.
  6. ACES and Healthplanfinder automatically submit every SSN to the SSA for validation.
  7. Individuals who are required to provide an SSN, but refuse to do so without good cause are not eligible for Apple Health.
  8. Some clients come from cultures where they only have one name. Their Social Security card may show only one name or may have “NFN” or “NLN” to signify no first/last name. Often the only way to get ACES and Healthplanfinder to verify the SSN is to update the first or last name to NFN or NLN.

Worker responsibilities

  1. Document all actions taken to comply with SSN requirements for Apple Health programs.
  2. For applications in ACES, see the SSN chapter in the ACES manual.
    1. Verification
      1. If SOLQ shows that the SSN does not belong to the individual or otherwise does not validate, send a request for verification of the SSN.
      2. If the individual sends verification, update the SSN and try to revalidate through SOLQ. If SOLQ does not validate the SSN, deny or close coverage.
      3. If the individual does not send verification or otherwise refuses to cooperate, close coverage.
    2. If the applicant does not provide an SSN that is required, but is otherwise eligible for Apple Health:
      1. Approve the application and send ACES Letter 023-08 (SSN Referral) to refer the applicant to Social Security Administration District Office (SSADO) for:
        1. Application for a SSN;
        2. Application for a replacement card; or
        3. Determination of a previously issued number.
      2. If the individual sends verification, update the SSN and try to validate through SOLQ. If SOLQ does not validate the SSN, check that the name in ACES matches the name on the Social Security card.
        1. If the name matches and still does not validate, request an explanation from the client. Close coverage if the client does not respond.
      3. If the individual does not send verification or otherwise refuses to cooperate, close coverage.
  3. For applications in Healthplanfinder (note Healthplanfinder automatically tries to validate every SSN):
    1. Verification
      1. If Healthplanfinder has not validated the SSN:
        1. Manually access SOLQ;
        2. Recheck and reverify the SSN; and
        3. Do a name/DOB search to see if the client already exists in ACES.
      2. If SOLQ shows that the SSN does not belong to the individual or otherwise does not validate:
        1. Update  the application with "SSN good cause" and approve coverage.
        2. If an Additional Verification letter did not already go out for verification of SSN from Healthplanfinder, send one.
        3. Set a follow-up tickle.
      3. If the individual sends verification, revalidate the SSN through SOLQ.
        1. If SOLQ does not validate the SSN, close coverage.
        2. If the individual does not send verification or otherwise refuses to cooperate, close coverage.
  4. If an individual requests assistance in obtaining an SSN: 
    1. Confirm they are required to provide an SSN based on WAC 182-503-0515(2)
    2. Provide resources to individuals required to provide an SSN:
      1. SSA website
      2. SSA office locator
      3. Individuals in urgent situations can receive assistance from Regional Public Affairs Office:
        1. Phone: 303-844-1888
        2. Email: den.sea.public@affairs.ssa.gov  
  5. Good cause.
    1. An individual can be granted good cause for not providing or applying for an SSN for certain reasons and periods of time. These are the reasons for good cause:
      1. Survivors of domestic violence who fear providing SSNs for themselves and/or their children will put them in danger. Good cause is granted for the certification period and rechecked yearly to see if the survivors feel safe enough to provide an SSN.
      2. Individuals claiming well-established religious objections. The individual must verify they are a member of a recognized religious sect or division of the sect and adheres to the tenets or teachings of the sect or division of the sect and for that reason is conscientiously opposed to applying for or using a national identification number. Good cause is granted for the certification period and rechecked yearly to see if the individual still claims the religious objection.
      3. Exception to rule on a case by case basis.
      4. SSN application pending with SSA. The individual receives coverage when the SSN app is pending with SSA. The agency checks with the individual every 90 days to obtain the issued SSN or check the status of the application. The individual must make substantial and reasonable efforts to supply SSA with the necessary information. The agency will assist the individual with applying for the SSN if the individual requests assistance.
      5. Good cause doesn't include delays due to illness, lack of transportation, temporary absence, or failure to respond to the SSN request.
      6. Every action of the good cause process must be documented in the ACES narrative.
  6. Adoption Cases:
    1. Domestic adoption
      1. When a child is being adopted or given adoption support through Children’s Administration, the child’s SSN is not always entered into ACES for confidentiality reasons. It is verified as valid by the Foster Care unit through FamLink and SOLQ. Actions are documented in the case narrative and in Remarks behind DEM1 screen and the child’s SSA/SSN Referral field is coded with “E” (Exception to Policy).
      2. Do not request an SSN until adoption is finalized.
    2. International adoption
      1. Effective February 27, 2001 adopted children born outside of the U.S. are granted automatic citizenship upon their arrival. Refer to the above procedures to obtain and verify SSN.

ACES procedures

For ACES processing details, visit the ACES Information Center in ACES online.

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