WAC 182-513-1610 Tailored supports for older adults (TSOA) — Overview.

Effective July 1, 2017

1. The tailored supports for older adults (TSOA) program is a federally funded program approved under section 1115 of the So­cial Security Act. It enables the medicaid agency and the agency's designees to deliver person-centered long-term services and supports (LTSS) to a person who:
   1. Meets nursing facility level of care described in WAC 388-106-0355; and
   2. Meets the functional requirements under WAC 388-106-1900 through 388-106-1990.
2. For the purposes of TSOA, the applicant is the person receiv­ing care even though services may be authorized to the person provid­ing care. TSOA does not provide Washington apple health coverage.

WAC 182-513-1615 Tailored Supports for Older Adults (TSOA) - General Eligibility

Effective June 3, 2025

1. The person receiving care must meet the financial eligibility criteria for tailored supports for older adults (TSOA).
2. To be eligible for the TSOA program, the person receiving care must:
   1. Be age 55 or older;
   2. Be assessed as meeting nursing facility level of care under WAC 388-106-0355;
   3. Meet residency requirements under WAC 182-503-0520;
   4. Live at home and not in a residential or institutional setting;
   5. Have an eligible unpaid caregiver under WAC 388-106-1905, or meet the criteria under WAC 388-106-1910 if the person does not have an eligible unpaid caregiver;
   6. Meet citizenship or immigration status requirements under WAC 182-503-0535. To be eligible for TSOA, a person must be a:
      1. U.S. citizen under WAC 182-503-0535 (1)(c);
      2. U.S. national under WAC 182-503-0535 (1)(d);
      3. Qualifying American Indian born abroad under WAC 182-503-0535 (1)(f); or
      4. Qualified alien under WAC 182-503-0535 (1)(b) and have either met or is exempt from the five-year bar requirement for medicaid.
   7. Provide a valid Social Security number under WAC 182-503-0515;
   8. Have countable resources within specific program limits under WAC 182-513-1640; and
   9. Meet income requirements under WAC 182-513-1635.
3. TSOA applicants who receive coverage under Washington apple health programs are not eligible for TSOA, unless they are enrolled in:
   1. Medically needy program under WAC 182-519-0100;
   2. Medicare savings programs under WAC 182-517-0300;
   3. Family planning program under WAC 182-505-0115;
   4. Family planning only programs under chapter 182-532 WAC; or
   5. The kidney disease program under chapter 182-540 WAC.
4. A person who receives apple health coverage under a categorically needy (CN) or alternative benefit plan (ABP) program is not eligible for TSOA but may qualify for:
   1. Caregiver supports under medicaid alternative care (MAC) under WAC 182-513-1605; or
   2. Other long-term services and supports under chapter 182-513 or 182-515 WAC.
5. The following rules do not apply to services provided under the TSOA benefit:
   1. Transfer of asset penalties under WAC 182-513-1363;
   2. Excess home equity under WAC 182-513-1350;
   3. Client financial responsibility under WAC 182-515-1509;
   4. Estate recovery under chapter 182-527 WAC;
   5. Disability requirements under WAC 182-512-0050;
   6. Assignment of rights and cooperation under WAC 182-503-0540

WAC 182-501-0135 Patient review and coordination (PRC).

Effective November 23, 2024

1. Patient review and coordination (PRC) is a health and safety program that coordinates care and ensures clients enrolled in PRC use services appropriately and in accordance with agency rules and policies.
   1. PRC applies to medical assistance fee-for-service and managed care clients organization (MCO) enrollees.
   2. PRC is authorized under federal medicaid law by 42 U.S.C. 1396n (a)(2) and 42 CFR 431.54.
2. Definitions. Definitions found in chapter 182-500 WAC and WAC 182-526-0010 apply to this section. The following definitions apply to this section:
   "Appropriate use" - Use of healthcare services that are safe and effective for a client's healthcare needs.
   "Assigned provider" - An agency-enrolled healthcare provider or one participating with an agency-contracted managed care organization (MCO) who agrees to be assigned as a primary provider and coordinator of services for an FFS client or MCO enrollee in the PRC program. Assigned providers can include a primary care provider (PCP), a pharmacy, a prescriber of controlled substances, and a hospital for nonemergency services.
   "At-risk" - A term used to describe one or more of the following:
   1. A client with a medical history of:
      1. Seeking and obtaining healthcare services at a frequency or amount that is not medically necessary;
      2. Potential life-threatening events or life-threatening conditions that required or may require medical intervention.
   2. Behaviors or practices that could jeopardize a client's medical treatment or health including, but not limited to:
      1. Indications of forging or altering prescriptions;
      2. Referrals from medical personnel, social services personnel, or MCO personnel about inappropriate behaviors or practices that place the client at risk;
      3. Noncompliance with medical or drug and alcohol treatment;
      4. Paying cash for medical services that result in a controlled substance prescription or paying cash for controlled substances;
      5. Arrests for diverting controlled substance prescriptions;
      6. Positive urine drug screen for illicit street drugs or nonprescribed controlled substances;
      7. Negative urine drug screen for prescribed controlled substances; or
      8. Unauthorized use of a client's services card for an unauthorized purpose.
         "Care management"- Services provided to MCO enrollees with multiple health, behavioral, and social needs to improve care coordination, client education, and client self-management skills.
         "Client" - See WAC 182-500-0020.
         "Conflicting" - Drugs or health care services that are incompatible or unsuitable for use together because of undesirable chemical or physiological effects.
         "Contraindicated" - A medical treatment, procedure, or medication that is inadvisable or not recommended or warranted.
         "Duplicative" - Applies to the use of the same or similar drugs and health care services without due medical justification. Example: A client receives health care services from two or more providers for the same or similar condition(s) in an overlapping time frame, or the client receives two or more similarly acting drugs in an overlapping time frame, which could result in a harmful drug interaction or an adverse reaction.
         "Emergency department information exchange (EDIE)" - An internet-delivered service that enables health care providers to better identify and treat high users of the emergency department and special needs patients. When patients enter the emergency room, EDIE can proactively alert health care providers through different venues such as fax, phone, email, or integration with a facility's current electronic medical records.
         "Emergency medical condition" - See WAC 182-500-0030.
         "Emergency services" - See 42 C.F.R. 438.114.
         "Fee-for-service" or "FFS" - See WAC 182-500-0035.
         "Just cause" - A legitimate reason to justify the action taken including but not limited to, protecting the health and safety of the client.
      9. "Managed care organization (MCO) enrollee" - A medical assistance client enrolled in, and receiving health care services from, an agency-contracted managed care organization (MCO).
         "Prescriber of controlled substances" - Any of the following health care professionals who, within their scope of professional practice, are licensed to prescribe and administer controlled substances (see chapter 69.50 RCW, Uniform Controlled Substance Act) for a legitimate medical purpose:
         (a) A physician under chapter 18.71 RCW;
         (b) A physician assistant under chapter 18.71A RCW;
         (c) An osteopathic physician under chapter 18.57 RCW;
         (d) An advanced registered nurse practitioner under chapter 18.79 RCW.
         "Primary care provider" or "PCP" - A person licensed or certified under Title 18 RCW including, but not limited to, a physician, an advanced registered nurse practitioner (ARNP), or a physician assistant (PA) who supervises, coordinates, and provides health care services to a client, initiates referrals for specialty and ancillary care, and maintains the client's continuity of care.
3. Clients selected for PRC review. The agency or agency's designee selects a client for PRC review when either or both of the following occur:
   1. An agency or MCO claims utilization review report indicates the client has not used health care services appropriately; or
   2. Medical providers, social service agencies, or other concerned parties have provided direct referrals to the agency or MCO.
4. Clients not selected for PRC review. Clients are not reviewed or placed into the PRC program when they :
   1. Are in foster care;
   2. Are covered under state-only funded programs;
   3. Do not have medicaid as the primary payor; or
   4. Are covered under the alien emergency medical (AEM) program according to WAC 182-507-0115.
5. Prior authorization. When an FFS client is selected for PRC review the prior authorization process as defined in WAC 182-500-0085 may be required:
   1. Before or during a PRC review; or
   2. When the FFS client is currently in the PRC program.
6. Review for placement in the PRC program. When the agency or MCO selects a client for PRC review, the agency or MCO staff, with clinical oversight, reviews either the client's medical history or billing history, or both, to determine if the client has used health care services at a frequency or amount that is not medically necessary (42 CFR 431.54(e)).
7. Usage guidelines for PRC placement. Agency or MCO staff use the following usage guidelines to determine PRC placement. A client may be reviewed for placement in the PRC program when the review shows the usage is not medically necessary and either the client's medical history or billing history, or both, documents any of the following:
   1. Any two or more of the following conditions occurred in a period of 90 consecutive calendar days in the previous 12 months. The client:
      1. Received services from four or more different providers, including physicians, ARNPs, and PAs not located in the same clinic or practice;
      2. Had prescriptions filled by four or more different pharmacies;
      3. Received 10 or more prescriptions;
      4. Had prescriptions written by four or more different prescribers not located in the same clinic or practice;
      5. Received similar services in the same day not located in the same clinic or practice; or
      6. Had 10 or more office visits;
   2. Any one of the following occurred within a period of 90 consecutive calendar days in the previous 12 months. The client:
      1. Made two or more emergency department visits;
      2. Exhibits "at-risk" usage patterns;
      3. Made repeated and documented efforts to seek health care services that are not medically necessary; or
      4. Was counseled at least once by a health care provider, or an agency or MCO staff member with clinical oversight, about the appropriate use of health care services;
   3. The client received prescriptions for controlled substances from two or more different prescribers not located in the same clinic or practice in any one month within the 90-day review period; or .
   4. The client has either a medical history or billing history, or both, that demonstrates a pattern of the following at any time in the previous 12 months:
      1. Using health care services in a manner that is duplicative, excessive, or contraindicated;
      2. Seeking conflicting health care services, drugs, or supplies that are not within acceptable medical practice;
8. PRC review results. As a result of the PRC review, the agency or MCO staff may take any of the following steps:
   1. Determine that no action is needed and close the client's file;
   2. Send the client and, if applicable, the client's authorized representative a one-time only written notice of concern with information on specific findings and notice of potential placement in the PRC program; or
   3. Determine that the usage guidelines for PRC placement establish that the client has used health care services at an amount or frequency that is not medically necessary, in which case one or more of the following actions take place:
      1. The MCO:
         1. Refers the MCO enrollee:
            1. For education on appropriate use of health care services; or
            2. To other support services or agencies; or
         2. Places the MCO enrollee into the PRC program for an initial placement period of no less than 24 months. For MCO enrollees younger than 18 years of age, the MCO must get agency approval before placing the MCO enrollee into the PRC program; or
      2. The agency places the FFS client into the PRC program for an initial placement period of no less than 24 months.
9. Initial placement in the PRC program.
   1. When an FFS client is initially placed in the PRC program, the agency places the FFS client for no less than 24 months with a primary care provider (PCP) for care coordination and a pharmacy for all medication prescriptions and one or more of the following types of health care providers:
      1. Prescriber of all controlled substances if different than PCP;
      2. Hospital for nonemergency services unless referred by the assigned PCP or a specialist. An FFS client may receive covered emergency services from any hospital; or
      3. Another qualified provider type, as determined by agency program staff on a case-by-case basis; or
      4. Additional pharmacies on a case-by-case basis.
   2. Based on a medical necessity determination, the agency may make an exception to PRC rules when in the best interest of the client. See WAC 182-501-0165 and 182-501-0160.
   3. When an MCO enrollee is initially placed in the PRC program, the MCO restricts the MCO enrollee for no less than 24 months with a primary care provider (PCP) for care coordination and a primary pharmacy for all medication prescriptions and one or more of the following types of health care providers:
      1. Prescriber of controlled substances if different than PCP;
      2. Hospital for nonemergency services unless referred by the assigned PCP or a specialist. An MCO enrollee may receive covered emergency services from any hospital;
      3. Another qualified provider type, as determined by MCO program staff on a case-by-case basis; or
      4. Additional pharmacies on a case-by-case basis.
10. MCO enrollees changing MCOs. MCO enrollees:
    1. Remain in the same MCO for no less than 12 months for initial placement and whenever the enrollee changes MCOs, unless:
       1. The MCO enrollee moves to a residence outside the MCO's service area and the MCO is not available in the new location;
       2. The MCO enrollee's assigned PCP no longer participates with the MCO and is available in another MCO, and the MCO enrollee wishes to remain with the current provider;
       3. The MCO enrollee is in a voluntary enrollment program or a voluntary enrollment county.
       4. The MCO enrollee is in the address confidentiality program (ACP), indicated by P.O. Box 257, Olympia, WA 98507; or
       5. The MCO enrollee is an American Indian/Alaska native.
    2. Placed in the PRC program must remain in the PRC program for no less than 24 months regardless of whether the MCO enrollee changes MCOs or becomes an FFS client.
11. Notifying the client about placement in the PRC program. When the client is initially placed in the PRC program, the agency or the MCO sends the client and, if applicable, the client's authorized representative, a written notice that:
    1. Informs the client of the reason for the PRC program placement;
    2. Informs the client of the providers the client has been assigned to;
    3. Directs the client to respond to the agency or MCO to take the following actions if applicable:
       1. Change assigned providers, subject to agency or MCO approval;
       2. Submit additional health care information, justifying the client's use of health care services; or
       3. Request assistance, if needed, from agency or MCO program staff; and
    4. Informs the client of administrative hearing or appeal rights (see subsection (16) of this section).
12. Selection and role of assigned provider. A client has a limited choice of providers.
    1. The following providers are not available:
       1. A provider who is being reviewed by the agency or licensing authority regarding quality of care;
       2. A provider who has been suspended or disqualified from participating as an agency-enrolled or MCO-contracted provider; or
       3. A provider whose business license is suspended or revoked by the licensing authority.
    2. For a client placed in the PRC program, the assigned:
       1. Provider(s) must be located in the client's local geographic area, in the client's selected MCO, and be reasonably accessible to the client.
          1. PCP supervises and coordinates health care services for the client, including continuity of care and referrals to specialists when necessary.
             (A) The PCP:
             (I) Provides the plan of care for clients that have documented use of the emergency department for a reason that is not deemed to be an emergency medical condition;
             (II) Files the plan of care with each emergency department that the client is using or with the emergency department information exchange;
             (III)Makes referrals to behavioral health treatment for clients who are using the emergency department for behavioral health treatment issues.
          2. (B) The assigned PCP must be one of the following:
             (I) A physician;
             (II) An advanced registered nurse practitioner (ARNP); or
             (III) A licensed physician assistant (PA)
             (iii) Prescriber of controlled substances prescribes all controlled substances for the client;
             (iv) Pharmacy fills all prescriptions for the client; and
             (v) Hospital provides all hospital nonemergency services.
    3. A client placed in the PRC program must remain with the assigned provider for 12 months after the assignments are made, unless:
       1. The client moves to a residence outside the provider's geographic area;
       2. The provider moves out of the client's local geographic area and is no longer reasonably accessible to the client;
       3. The provider refuses to continue to serve the client;
       4. The client did not select the provider. The client may request to change an assigned provider once within 30 calendar days of the assignment;
       5. The MCO enrollee's assigned PCP no longer participates with the MCO. In this case, the MCO enrollee may select a new provider from the list of available providers in the MCO network or follow the assigned provider to the new MCO; or
       6. The client is in the address confidentiality program (ACP), indicated by P.O. Box 257, Olympia, WA 98507.
    4. When an assigned prescribing provider no longer contracts with the agency or the MCO:
       1. All prescriptions from the provider are invalid 30 calendar days following the date the contract ends;
       2. The client must choose or be assigned another provider according to the requirements in this section.
13. PRC placement.
    1. The initial PRC placement is no less than 24 consecutive months.
    2. The second period of PRC placement is no less than an additional 36 consecutive months.
    3. Each subsequent PRC placement is no less than 72 consecutive months.
14. Agency or MCO review of a PRC placement period. The agency or MCO reviews a client's use of health care services before the end of each PRC placement period described in subsection (13) of this section using the guidelines in subsection (7) of this section.
    1. The agency or MCO assigns the next PRC placement if the usage guidelines for PRC placement in subsection (7) of this section apply to the client.
    2. When the agency or MCO assigns a subsequent PRC placement, the agency or MCO sends the client and, if applicable, the client's authorized representative, a written notice informing the client:
       1. Of the reason for the subsequent PRC program placement;
       2. Of the length of the subsequent PRC placement;
       3. That the current providers assigned to the client continue to be assigned to the client during the subsequent PRC placement;
       4. That all PRC program rules continue to apply;
       5. Of administrative hearing or appeal rights (see subsection (16) of this section); and
       6. Of the rules that support the decision.
    3. The agency or MCO may remove a client from PRC placement if the client:
       1. Successfully completes a treatment program that is provided by a substance use disorder (SUD) service provider certified by the agency under chapter 182-538D WAC;
       2. Submits documentation of completion of the approved treatment program to the agency; and
       3. Maintains appropriate use of health care services within the usage guidelines described in subsection (7) of this section for six consecutive months after the date the treatment ends; or
       4. Successfully stabilizes due to the usage of treatment medications including, but not limited to, Buprenorphine.
    4. The agency or MCO determines the appropriate placement for a client who has been placed back into the program.
    5. A client remains placed in the PRC program regardless of change in eligibility program type or change in address.
15. Client financial responsibility. A client placed in the PRC program may be billed by a provider and held financially responsible for nonemergency health care services obtained from a nonpharmacy provider when the provider is not an assigned or appropriately referred provider as described in subsection (12) of this section. See WAC 182-502-0160.
16. Right to administrative hearing or appeal.
    1. An FFS client who disagrees with an agency decision regarding placement or continued placement in the PRC program has the right to an administrative hearing regarding placement. An FFS client must request an administrative hearing from the agency within 90 days of the written notice of placement or continued placement to exercise this right.
    2. An MCO enrollee who disagrees with an MCO decision regarding placement or continued placement in the PRC program has a right to appeal this decision in the same manner as an adverse benefit determination under chapter 182-538 WAC.
    3. The agency conducts an administrative hearing according to chapter 182-526 WAC.
    4. A client who requests an administrative hearing or appeal within 10 calendar days from the date of the written notice of an initial PRC placement will not be placed in the PRC program until ordered by an administrative law judge (ALJ) or review judge.
    5. A client who requests an administrative hearing or appeal more than 10 calendar days from the date of the written notice of initial PRC placement will remain placed in the PRC program until a final administrative order is entered that orders the client's removal from the program.
    6. A client who requests an administrative hearing or appeal in all other cases and who has already been assigned providers will remain placed in the PRC program unless a final administrative order is entered that orders the client's removal from the program.
    7. An ALJ may rule the client be placed in the PRC program prior to the date the record is closed and before the date the initial order is issued based on a showing of just cause.

WAC 182-513-1200 Long-term services and supports authorized under Washington Apple Health programs

Effective February 20, 2017

1. Long-term services and supports (LTSS) programs available to people eligible for noninstitutional Washington apple health coverage who meet the functional requirements.
   1. Noninstitutional apple health coverage in an alternate living facility (ALF) under WAC 182-513-1205.
   2. Community first choice (CFC) under WAC 182-513-1210.
   3. Medicaid personal care (MPC) under WAC 182-513-1225.
   4. For people who do not meet institutional status under WAC 182-513-1320, skilled nursing or rehabilitation is available under the CN, medically needy (MN) or alternative benefits plan (ABP) scope of care if enrolled into a managed care plan.
2. Non-HCB waiver LTSS programs that use institutional rules under WAC 182-513-1315 and 182-513-1380 or HCB waiver rules under chapter 182-515 WAC, depending on the person's living arrangement:
   1. Program of all-inclusive care for the elderly (PACE) under WAC 182-513-1230.
   2. Roads to community living (RCL) under WAC 182-513-1235.
   3. Hospice under WAC 182-513-1240.

WAC 182-513-1230 Program of all-inclusive care for the elderly (PACE).

Effective February 20, 2017

1. The program of all-inclusive care for the elderly (PACE) provides long-term services and supports (LTSS), medical, mental health, and chemical dependency treatment through a department-contracted managed care plan using a personalized plan of care for each enrollee.
2. Program rules governing functional eligibility for PACE are listed under WAC 388-106-0700, 388-106-0705, 388-106-0710, and 388-106-0715.
3. A person is financially eligible for PACE if the person:
   1. Is age:
      1. Fifty-five or older and disabled under WAC 182-512-0050; or
      2. Sixty-five or older;
   2. Meets nursing facility level of care under WAC 388-106-0355;
   3. Lives in a designated PACE service area;
   4. Meets financial eligibility requirements under this section; and
   5. Agrees to receive services exclusively through the PACE provider and the PACE provider's network of contracted providers.
4. Although PACE is not a home and community based (HCB) waiver program, financial eligibility is determined using the HCB waiver rules under WAC 182-515-1505 when a person is living at home or in an alternate living facility (ALF), with the following exceptions:
   1. PACE enrollees are not subject to the transfer of asset rules under WAC 182-513-1363; and
   2. PACE enrollees may reside in a medical institution thirty days or longer and still remain eligible for PACE services. The eligibility rules for institutional coverage are under WAC 182-513-1315 and 182-513-1380.
5. A person may have to pay third-party resources as defined under WAC 182-513-1100 in addition to the room and board and participation.

WAC 182-513-1380 Determining a client's financial participation in the cost of care for long-term care in a medical institution

Effective June 6, 2025

This rule describes how the agency or the agency's designee allocates income and excess resources when determining participation in the cost of care in a medical institution.

1. The agency or the agency's designee defines which income and resources must be used in this process under WAC 182-513-1315.
2. The agency or the agency's designee allocates nonexcluded income in the following order, and the combined total of (a), (b), (c), and (d) of this subsection cannot exceed the effective one-person medically needy income level (MNIL):
   1. A personal needs allowance (PNA) under WAC 182-513-1105.
   2. Mandatory federal, state, or local income taxes owed by the client.
   3. Wages for a client who:
      1. Is related to the supplemental security income (SSI) program under WAC 182-512-0050(1); and
      2. Receives the wages as part of an agency-approved or department-approved training or rehabilitative program designed to prepare the client for a less restrictive placement. When determining this deduction, employment expenses are not deducted.
   4. Guardianship fees, conservatorship fees, and administrative costs, including any attorney fees paid by the guardian or conservator, as allowed under chapter 388-79A WAC.
3. The agency or the agency's designee allocates nonexcluded income after deducting amounts under subsection (2) of this section in the following order:
   1. Current or back child support garnished or withheld from income according to a child support order in the month of the garnishment if it is:
      1. For the current month;
      2. For the time period covered by the PNA; and
      3. Not counted as the dependent member's income when determining the dependent allocation amount under WAC 182-513-1385.
   2. A monthly maintenance needs allowance for the community spouse as determined using the calculation under WAC 182-513-1385. If the community spouse is also receiving long-term care services, the allocation is limited to an amount that brings the community spouse's income up to the PNA.
   3. A dependent allowance for each dependent of the institutionalized client or the client's spouse, as determined using the calculation under WAC 182-513-1385.
   4. Medical expenses incurred by the institutionalized individual and not used to reduce excess resources. Allowable medical expenses and reducing excess resources are described in WAC 182-513-1350.
   5. Maintenance of the home of a single institutionalized client, an institutionalized couple, or a married institutionalized client not sharing the same residence as the community spouse:
      1. Up to 100 percent of the one-person federal poverty level per month;
      2. Limited to a six-month period;
      3. When a physician has certified that the client or couple is likely to return to the home within the six-month period; and
      4. When social services staff documents the need for the income deduction.
4. A client may have to pay third-party resources as defined under WAC 182-513-1100 in addition to the participation.
5. A client is responsible to pay only up to the state rate for the cost of care. If long-term care insurance pays a portion of the state rate cost of care, a client pays only the difference up to the state rate cost of care.
6. 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 in a month.
7. Standards under this section for long-term care are found at www.hca.wa.gov/health-care-services-supports/program-standard-income-and-resources.

WAC 182-508-0005 Washington apple health medical care services - eligibility and scope of coverage.

Effective February 12, 2023

1. A person is eligible for state-funded Washington apple health medical care services (MCS) coverage to the extent of available funds if the person is:
   1. Determined by the department of social and health services to be eligible for benefits under:
      1. The aged, blind, or disabled program as described in WAC 388-400-0060;
      2. The housing and essential needs referral program as described in WAC 388-400-0070; or
      3. The survivors of certain crimes (SCC) program, as described in WAC 388-424-0035, which includes victims of human trafficking as described in RCW 74.04.005;
   2. Not eligible for another federally funded categorically needy (CN) (as defined in WAC 182-500-0020) or alternative benefits plan (ABP) (as defined in WAC 182-500-0010) Washington apple health program and
   3. Not residing in a public institution as defined in WAC 182-500-0050.
2. If an enrollment cap exists under WAC 182-508-0150, a waiting list of people may be established.
3. A person's period of eligibility for MCS is the same as the person's period of eligibility for:
   1. The aged, blind, or disabled program as described in WAC 388-449-0150;
   2. The person's incapacity authorization period for the housing and essential needs referral program as described in WAC 388-447-0110;
   3. The person's period of eligibility for the SCC program as described in WAC 388-424-0035.
4. The MCS program covers only the medically necessary services defined in WAC 182-501-0060.
5. The MCS program does not cover medical services received outside the state of Washington unless the medical services are provided in a border city listed in WAC 182-501-0175.

WAC 182-503-0505 Washington apple health -- General eligibility requirements.

Effective April 27, 2019.

1. When you apply for Washington apple health programs established under chapter 74.09 RCW, you must meet the eligibility criteria in chapters 182-500 through 182-527 WAC.
2. When you apply for apple health, we first consider you for federally funded or federally matched programs. We consider you for state-funded programs after we have determined that you are ineligible for federally funded and federally matched programs.
3. Unless otherwise specified in a program specific WAC, the eligibility criteria for each program are as follows:
   1. Age (WAC 182-503-0050);
   2. Residence in Washington state (WAC 182-503-0520 and 182-503-0525);
   3. Citizenship or immigration status in the United States (WAC 182-503-0535);
   4. Possession of a valid Social Security account number (WAC 182-503-0515);
   5. Assignment of medical support rights to the state of Washington (WAC 182-503-0540);
   6. Application for medicare and enrollment into medicare's prescription drug program if:
      1. You are likely entitled to medicare; and
      2. We have authority to pay medicare cost sharing as described in chapter 182-517 WAC.
   7. If your eligibility is not based on modified adjusted gross income (MAGI) methodology, your countable resources must be within specific program limits (chapters 182-512, 182-513, 182-515, 182-517, and 182-519 WAC); and
   8. Countable income within program limits:
      1. For MAGI-based programs, see WAC 182-505-0100;
      2. For the refugee program, see WAC 182-507-0130;
      3. For the medical care services program, see WAC 182-508-0005;
      4. For the health care for workers with disabilities (HWD) program, see WAC 182-511-1000;
      5. For the SSI-related program, see WAC 182-512-0010;
      6. For long-term care programs, see chapters 182-513 and 182-515 WAC;
      7. For medicare savings programs, see WAC 182-517-0100; and
      8. For the medically needy program, see WAC 182-519-0050.
4. In addition to the general eligibility requirements in subsection (3) of this section, each program has specific eligibility requirements as described in applicable WAC.
5. If you are in a public institution, including a correctional facility, you are not eligible for full scope apple health coverage, except in the following situations:
   1. If you are age twenty-one or younger or age sixty-five or older and are a patient in an institution for mental disease (see WAC 182-513-1317(5)); or
   2. You receive inpatient hospital services outside of the public institution or correctional facility.
6. We limit coverage for people who become residents in a public institution, under subsection (5) of this section, until they are released.
7. If you are terminated from SSI or lose eligibility for categorically needy (CN) or alternative benefits plan (ABP) coverage, you receive coverage under the apple health program with the highest scope of care for which you may be eligible while we determine your eligibility for other health care programs. See WAC 182-504-0125.