WAC 182-503-0535 Washington apple health -- Citizenship and immigration status.

Effective June 11, 2025

1. Definitions.
   1. Nonqualified alien means someone who is lawfully present in the United States (U.S.) but who is not a qualified alien, a U.S. citizen, a U.S. national, or a qualifying American Indian born abroad.
   2. Qualified alien means someone who is lawfully present in the United States and who is one or more of the following:
      1. A person lawfully admitted for permanent residence (LPR).
      2. An abused spouse or child, a parent of an abused child, or a child of an abused spouse who no longer resides with the person who committed the abuse, and who has one of the following:
         1. A pending or approved I-130 petition or application to immigrate as an immediate relative of a U.S. citizen or as the spouse of an unmarried LPR younger than 21 years of age.
         2. Proof of a pending application for suspension of deportation or cancellation of removal under the Violence Against Women Act (VAWA).
         3. A notice of prima facie approval of a pending self-petition under VAWA. An abused spouse's petition covers his or her child if the child is younger than 21 years of age. In that case, the child retains qualified alien status even after he or she turns 21 years of age.
      3. A person who has been granted parole into the U.S. for one year or more, under the Immigration and Nationality Act (INA) Section 212 (d)(5), including public interest parolees.
      4. A member of a Hmong or Highland Laotian tribe that rendered military assistance to the U.S. between August 5, 1964, and May 7, 1975, including the spouse, unremarried widow or widower, and unmarried dependent child of the tribal member.
      5. A person who was admitted into the U.S. as a conditional entrant under INA Section 203 (a)(7) before April 1, 1980.
      6. A person admitted to the U.S. as a refugee under INA Section 207.
      7. A person who has been granted asylum under INA Section 208.
      8. A person granted withholding of deportation or removal under INA Section 243(h) or 241 (b)(3).
      9. A Cuban or Haitian national who was paroled into the U.S. or given other special status.
      10. An Amerasian child of a U.S. citizen under 8 C.F.R. Section 204.4(a).
      11. A person from Iraq or Afghanistan who has been granted one of the following:
          1. Special immigrant status under INA Section 101 (a) (27);
          2. Special immigrant conditional permanent resident; or
          3. Parole under Section 602 (b) (1) of the Afghan Allies Protection Act of 2009 or Section 1059(a) of the National Defense Authorization Act of 2006.
      12. An Afghan granted humanitarian parole between July 31, 2021, and September 30, 2023, their spouse or child, or a parent or guardian of an unaccompanied minor who is granted parole after September 30, 2022, under Section 2502 of the Extending Government Funding and Delivering Emergency Assistance Act of 2021.
      13. A citizen or national of Ukraine (or a person who last habitually resided in Ukraine) who, under section 401 of the Additional Ukrainian Supplemental Appropriations Act, 2022 (AUSAA) and the Ukraine Security Supplemental Appropriations Act, 2024 (USSAA), is evaluated as a qualified alien until the end of their parole term when:
          1. Granted parole into the United States between February 24, 2022, and September 30, 2024; or
          2. Granted parole into the United States after September 30, 2024, and is:
             1. The spouse or child of a person described in (b)(xiii)(A) of this subsection; or
             2. The parent or guardian of a person described in (b)(xiii)(A) of this subsection who is an unaccompanied minor.
      14. A person who has been certified or approved as a victim of trafficking by the federal office of refugee resettlement, or who is:
          1. The spouse or child of a trafficking victim of any age; or
          2. The parent or minor sibling of a trafficking victim who is younger than 21 years of age. 
      15. A person from the Federated States of Micronesia, the Republic of Palau, or the Republic of the Marshall Islands living in the United States in accordance with the Compacts of Free Association. 
   3. U.S. citizen means someone who is a United States citizen under federal law.
   4. U.S. national means someone who is a United States national under federal law.
   5. Undocumented person means someone who is not lawfully present in the U.S.
   6. Qualifying American Indian born abroad means someone who:
      1. Was born in Canada and has at least 50 percent American Indian blood, regardless of tribal membership; or
      2. Was born outside of the United States and is a member of a federally recognized tribe or an Alaska Native enrolled by the Secretary of the Interior under the Alaska Native Claims Settlement Act.
2. Eligibility.
   1. A U.S. citizen, U.S. national or qualifying American Indian born abroad may be eligible for:
      1. Apple health for adults;
      2. Apple health for kids;
      3. Apple health for pregnant women; or
      4. Classic medicaid.
   2. A qualified alien who meets or is exempt from the five-year bar may be eligible for:
      1. Apple health for adults;
      2. Apple health for kids;
      3. Apple health for pregnant women; or
      4. Classic medicaid.
   3. A qualified alien who neither meets nor is exempt from the five-year bar may be eligible for:
      1. Alien medical programs;
      2. Apple health for kids;
      3. Apple health for pregnant women; or
      4. Medical care services.
   4. A nonqualified alien may be eligible for:
      1. Alien medical programs;
      2. Apple health for kids;
      3. Apple health for pregnant women; or
      4. Medical care services.
   5. An undocumented person may be eligible for:
      1. Alien medical programs;
      2. State-only funded apple health for kids; 
      3. State-only funded apple health for pregnant women; or
      4. State-only funded apple health expansion.
3. The five-year bar.
   1. A qualified alien meets the five-year bar if he or she:
      1. Continuously resided in the U.S. for five years or more from the date he or she became a qualified alien; or
      2. Entered the U.S. before August 22, 1996, and:
         1. Became a qualified alien before August 22, 1996; or
         2. Became a qualified alien on or after August 22, 1996, and has continuously resided in the U.S. between the date of entry into the U.S. and the date he or she became a qualified alien.
   2. A qualified alien is exempt from the five-year bar if he or she is:
      1. A qualified alien as defined in subsections (1)(b)(vi) through (xv) of this section;
      2. An LPR, parolee, or abused person, who is also an armed services member or veteran, or a family member of an armed services member or veteran, as described below:
         1. An active-duty member of the U.S. military, other than active-duty for training;
         2. An honorably discharged U.S. veteran;
         3. A veteran of the military forces of the Philippines who served before July 1, 1946, as described in Title 38 U.S.C. Section 107; or
         4. The spouse, unremarried widow or widower, or unmarried dependent child of an honorably discharged U.S. veteran or active-duty member of the U.S. military.

WAC 182-503-0540 Assignment of rights and cooperation.

Effective January 27, 2019.

1. When you become eligible for any of the agency's health care programs, you assign certain rights to the state of Washington. You assign all rights to any type of coverage or payment for health care that comes from:
   1. A court order;
   2. An administrative agency order; or
   3. Any third-party benefits or payment obligations for medical care which are the result of subrogation or contract (see WAC 182-501-0100).
2. When you sign the application you assign the rights described in subsection (1) of this section to the state for:
   1. Yourself; and
   2. Any eligible person for whom you can legally make such assignment.
3. You must cooperate with us in identifying, using or collecting third-party benefits. If you do not cooperate, your health care coverage may end unless you can show good reason not to cooperate with us. Examples of good reason include, but are not limited to:
   1. Your reasonable belief that cooperating with us would result in serious physical or emotional harm to you, a child in your care, or a child related to you; and
   2. Your being incapacitated without the ability to cooperate with us.
4. Your WAH coverage will not end due solely to the noncooperation of any third party.
5. You will have to pay for your health care services if you:
   1. Received and kept the third-party payment for those services; or
   2. Refused to give to the provider of care your legal signature on insurance forms.
6. The state is limited to the recovery of its own costs for health care costs paid on behalf of a recipient of health care coverage. The legal term which describes the method by which the state acquires the rights of a person for whom the state has paid costs is called subrogation.

WAC 182-532-500  Family Planning only program - Purpose.

Effective October 1, 2019

The purpose of the family planning only programs is to provide family planning services to:

1. Improve access to family planning and family planning-related services;
2. Reduce unintended pregnancies; and
3. Promote healthy intervals between pregnancies and births.

WAC 182-532-510 Family planning only program—Client eligibility

Effective October 6, 2025

For the purposes of this section, "full-scope coverage" means coverage under either the categorically needy (CN) program, the broadest, most comprehensive scope of health care services covered or the alternative benefits plan (ABP), the same scope of care as CN, applicable to the apple health for adults program.

1. To be eligible for family planning only services, as defined in WAC 182-532-001, a client must:
   1. Provide a valid Social Security number (SSN) or proof of application to receive an SSN, be exempt from the requirement to provide an SSN as provided in WAC 182-503-0515, or meet good cause criteria listed in WAC 182-503-0515(2);
   2. Be a Washington state resident, as described under WAC 182-503-0520;
   3. Have an income at or below two hundred sixty percent of the federal poverty level, as described under WAC 182-505-0100;
   4. Need family planning services; and
   5. Have been denied apple health coverage within the last 30 days, unless the applicant:
      1. Has made an informed choice to not apply for full-scope coverage as described in WAC 182-500-0035 and 182-501-0060, including family planning;
      2. Is age 26 or younger and seeking services in confidence;
      3. Is a domestic violence victim who is seeking services in confidence; or
      4. Has an income of 150 percent to 260 percent of the federal poverty level, as described in WAC 182-505-0100.
2. A client is not eligible for family planning only medical if the client is:
   1. Pregnant;
   2. Sterilized;
   3. Covered under another apple health program that includes family planning services; or
   4. Covered by concurrent creditable coverage, as defined in RCW 48.66.020, unless they meet criteria in (1) (e) (ii) or (iii) of this section.
3. The agency does not limit the number of times a client may reapply for coverage.

WAC 182-512-0700 SSI-related medical -- Income eligibility.

Effective June 3, 2025

The agency does not count income until the person begins to receive it. Income is budgeted prospectively for all Washington apple health health care programs.

1. Anticipated nonrecurring lump sum payments other than retroactive SSI/SSDI payments are considered income in the month received, subject to reporting requirements in WAC 182-504-0110. Any unspent portion is considered a resource the first of the following month.
2. The agency follows income and resource methodologies of the supplemental security income (SSI) program defined in federal law when determining eligibility for apple health SSI-related medical or medicare savings programs unless the agency adopts rules that are less restrictive than those of the SSI program.
3. Exceptions to the SSI income methodology:
   1. Lump sum payments from a retroactive old age, survivors, and disability insurance (OASDI) benefit, when reduced by the amount of SSI received during the period covered by the payment, are not counted as income;
   2. Unspent retroactive lump sum money from SSI or OASDI is excluded as a resource for nine months following receipt of the lump sum; and
   3. Both the principal and interest portions of payments from a sales contract, that meet the definition in WAC 182-512-0350(10), are unearned income.
4. To be eligible for apple health categorically needy (CN) SSI-related health care coverage, a person's countable income cannot exceed the apple health CN program standard described in:
   1. WAC 182-512-0010 for noninstitutional apple health coverage unless living in an alternate living facility; or
   2. WAC 182-513-1205 for noninstitutional apple health CN coverage while living in an alternate living facility; or
   3. WAC 182-513-1315 for institutional and waiver services coverage.
5. To be eligible for SSI-related health care coverage provided under the WAH medically needy (MN) program, a person must:
   1. Have countable income at or below the effective apple health MN program standard as described in WAC 182-519-0050;
   2. Satisfy spenddown requirements described in WAC 182-519-0110;
   3. Meet the requirements for noninstitutional apple health MN coverage while living in an alternate living facility (ALF). See WAC 182-513-1205; or
   4. Meet eligibility for institutional apple health MN coverage described in WAC 182-513-1315.

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

Effective August 29, 2014.

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

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

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

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

Effective October 1, 2017.

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

WAC 182-512-0900 SSI-related medical -- Deeming and allocation of income.

Effective April 14, 2014.

The agency considers income of financially responsible persons to determine if a portion of that income must be regarded as available to other household members.

1. Deeming is the process of determining how much of another person's income is counted when determining Washington apple health (WAH) eligibility of an SSI-related applicant. When income is deemed to the SSI-related applicant from other household members, that income is considered the applicant's income. Income is deemed only:
   1. From a nonapplying spouse who lives with the SSI-related applicant; or
   2. From a parent(s) residing with an SSI-related applicant child.
2. An allocation is an amount deducted from income counted in the eligibility determination and considered to be set aside for the support of a person other than the SSI-related applicant. When income is allocated to other household members from the SSI-related applicant(s) or from the applicant's spouse, that income is not counted as income of the SSI-related applicant.
3. An SSI-related person applying for WAH categorically needy (CN) health care coverage must have countable income at or below the SSI categorically needy income level (CNIL) described in WAC 182-512-0010 unless the person is working and meets all requirements for the health care for workers with disabilities (HWD) program described in WAC 182-511-1000 through 182-511-1250.
4. For WAH institutional or home and community based waiver programs, use rules described in WAC 182-513-1315.
5. The agency follows rules described in WAC 182-512-0600 through 182-512-0880 to determine the countable income of an SSI-related applicant or SSI-related couple.
6. If countable income of the applicant exceeds the one-person SSI CNIL prior to considering the income of a nonapplying spouse or children, the applicant is not eligible for WAH CN health care coverage and the agency determines eligibility for the WAH medically needy (MN) program. If the countable income does not exceed the SSI CNIL, see WAC 182-512-0920 to determine if income is to be deemed to the applicant from the nonapplying spouse.
7. If countable income (after allowable deductions) of an SSI-related couple both applying for medical coverage exceeds the two-person SSI CNIL, the couple is not eligible for WAH CN health care coverage and the agency determines eligibility for the WAH medically needy (MN) program.
8. For WAH CN health care coverage, allocations to children are deducted from the nonapplying spouse's unearned income, then from their earned income before income is deemed to the SSI-related applicant. See WAC 182-512-0820.
9. For MN medical coverage, allocations to children are deducted from the income of the SSI-related applicant or SSI-related applicant couple. See subsection (10) of this section to determine the amount of the allocation.
10. An SSI-related person or couple applying for WAH MN health care coverage is allowed an allocation to a nonapplying spouse, their SSI recipient spouse or their dependent child(ren) to reduce countable income before comparing income to the effective medically needy income level (MNIL) described in WAC 182-519-0050. The agency allocates income:
    1. Up to the effective one-person MNIL to a nonapplying spouse or SSI recipient spouse minus the spouse's countable income; and
    2. Up to one-half of the federal benefit rate (FBR) to each dependent minus each dependent's countable income. See WAC 182-512-0820 for child exclusions.
11. A portion of a nonapplying spouse's income may be deemed to the SSI-related applicant:
    1. See WAC 182-512-0920(5) to determine how much income is deemed from a nonapplying spouse to the SSI-related applicant when determining WAH CN eligibility; and
    2. See WAC 182-512-0920(10) to determine how much income is deemed from a nonapplying spouse to the SSI-related applicant when determining WAH MN eligibility.
12. A portion of the income of an ineligible parent or parents is allocated to the needs of an SSI-related applicant child. See WAC 182-512-0940 (4) through (7) to determine how much income is allocated from ineligible parent(s).
13. When income must be deemed from the sponsor or sponsors of a noncitizen applicant or recipient, see WAC 182-512-0795 to determine the amount that must be counted as income of the noncitizen applicant or recipient.

WAC 182-512-0920 SSI-related medical -- Deeming/allocation of income from nonapplying spouse.

Effective April 1, 2024.

The agency considers the income of financially responsible persons to determine if a portion of that income is available to other household members.

1. A portion of the income of a nonapplying spouse is considered available to meet the needs of a Washington apple health SSI-related applicant. A nonapplying spouse is defined as someone who is:
   1. Financially responsible for the SSI-related applicant as described in WAC 182-506-0015 and 182-512-0960. For apple health institutional and home and community based waiver programs, see WAC 182-513-1315;
   2. Living in the same household with the SSI-related applicant;
   3. Not receiving a needs based payment such as temporary assistance to needy families (TANF) or state-funded cash assistance (SFA); or
   4. Not related to SSI, or is not applying for apple health coverage including spouses receiving SSI.
2. An ineligible spouse is the spouse of an SSI cash recipient and is either not eligible for SSI for themselves or who has elected to not receive SSI cash so that their spouse may be eligible. An SSI-related applicant who is the ineligible spouse of an SSI cash recipient is not eligible for apple health categorically needy (CN) health care coverage and must be considered for health care coverage under the apple health medically needy (MN) program or for a modified adjusted gross income-based program if the person does not receive medicare.
3. When determining whether a nonapplying spouse's income is countable, the agency:
   1. Follows the income rules described in WAC 182-512-0600 through 182-512-0780;
   2. Excludes income described in WAC 182-512-0800 (2) through (10), and all income excluded under federal statute or state law as described in WAC 182-512-0860;
   3. Excludes work-related expenses described in WAC 182-512-0840, with the exception that the $65 plus one half earned income deduction described in WAC 182-512-0840(2) does not apply;
   4. Deducts any court ordered child support which the nonapplying spouse pays for a child outside of the home (current support or arrears); and
   5. Deducts any applicable child-related income exclusions described in WAC 182-512-0820.
4. The agency allocates income of the nonapplying spouse to nonapplying children who reside in the home as described in WAC 182-512-0820. Allocations to children are deducted first from the nonapplying spouse's unearned income, then from their earned income.
   1. For apple health CN medical determinations, allocations to children are not allowed out of the income of the SSI-related applicant, only from the income of the nonapplying spouse.
   2. For apple health MN medical determinations, allocations to children are allowed from the income of the SSI-related applicant if the applicant is unmarried.
5. For apple health SSI-related CN medical determinations, a portion of the countable income of a nonapplying spouse remaining after the deductions and allocations described in subsections (3) and (4) of this section may be deemed to the SSI-related applicant. If the nonapplying spouse's countable income is:
   1. Less than or equal to one-half of the federal benefit rate (FBR), no income is deemed to the applicant. Compare the applicant's countable income to the one-person SSI categorically needy income level (CNIL) described in WAC 182-512-0010.
   2. Greater than one-half of the FBR, then the entire nonapplying spouse's countable income is deemed to the applicant. Compare the applicant's income to the two-person SSI CNIL.
6. When income is not deemed to the SSI-related applicant from the nonapplying spouse per subsection (5)(a) of this section, allow all allowable income deductions and exclusions as described in chapter 182-512 WAC to the SSI-related applicant's income, and compare the net remaining income to the one-person SSI CNIL.
7. When income is deemed to the SSI-related applicant from the nonapplying spouse per subsection (5)(b) of this section:
   1. Combine the applicant's unearned income with any unearned income deemed from the nonapplying spouse and allow one $20 general income exclusion to the combined amount. If there is less than $20 of unearned income, the remainder of the twenty dollar general income exclusion is deducted from earned income.
   2. Combine the applicant's earned income with any earned income deemed from the nonapplying spouse and allow the $65 plus one half of the remainder earned income deduction (described in WAC 182-512-0840(2)) to the combined amount.
   3. Add together the net unearned and net earned income amounts and compare the total to the two-person SSI CNIL described in WAC 182-512-0010. If the income is equal to or below the applicable two-person standard, the applicant is eligible for apple health CN health care coverage.
8. An SSI-related applicant who is working, whose level of work activity and earnings is determined not to be "substantial gainful activity" in accordance with all applicable Social Security disability determination rules and standards, but who is not eligible for apple health CN coverage under the regular apple health SSI-related program, may be considered for eligibility under the HWD program. For HWD program rules, see chapter 182-511 WAC.
9. If the SSI-related applicant's countable income is above the applicable SSI CNIL standard, the agency or its authorized representative considers eligibility under the apple health MN program or under the HWD program if the person is under the age of sixty-five and working. An SSI-related applicant who meets the following criteria is not eligible for apple health MN coverage and eligibility must be determined under HWD or under a MAGI-based apple health program:
   1. The applicant is blind or disabled and, for a MAGI-based apple health program, under the age of 65;
   2. The applicant's level of work activity and earnings is determined to be "substantial gainful activity" in accordance with all applicable Social Security disability determination rules and standards; and
   3. The applicant is not receiving a title II Social Security cash benefit based on blindness or disability.
10. For SSI-related apple health MN medical determinations, a portion of the countable income of a nonapplying spouse remaining after the deductions and allocations described in subsections (3) and (4) of this section may be deemed to the SSI-related applicant. If the nonapplying spouse's countable income is:
    1. Less than or equal to the effective one-person MNIL described in WAC 182-519-0050, no income is deemed to the applicant and a portion of the applicant's countable income is allocated to the nonapplying spouse's income to raise it to the effective MNIL standard.
    2. Greater than the effective MNIL, then the amount in excess of the effective one-person MNIL is deemed to the applicant. Compare the applicant's income to the effective one-person MNIL.
11. When income is not deemed to the SSI-related applicant from the nonapplying spouse per subsection (10)(a) of this section:
    1. Allocate income from the applicant to bring the income of the nonapplying spouse up to the effective one-person MNIL standard;
    2. Allow all allowable income deductions and exclusions as described in chapter 182-512 WAC to the SSI-related applicant's remaining income;
    3. Allow a deduction for medical insurance premium expenses (if applicable); and
    4. Compare the net countable income to the effective one-person MNIL.
12. When income is deemed to the SSI-related applicant from the nonapplying spouse per subsection (10)(b) of this section:
    1. Combine the applicant's unearned income with any unearned income deemed from the nonapplying spouse and allow one $20 general income exclusion to the combined amount (if there is less than $20 of unearned income, the remainder of the twenty dollar general income exclusion is deducted from earned income);
    2. Combine the applicant's earned income with any earned income deemed from the nonapplying spouse and allow the $65 plus one half of the remainder earned income deduction (described in WAC 182-512-0840(2)) to the combined amount;
    3. Add together the net unearned and net earned income amounts;
    4. Allow a deduction for medical insurance premium expenses (if applicable) per WAC 182-519-0100(5); and
    5. Compare the net countable income to the effective one-person MNIL described in WAC 182-519-0050. If the income is:
       1. Equal to or below the effective one-person MNIL, the applicant is eligible for apple health MN health care coverage with no spenddown.
       2. Greater than the effective MNIL, the applicant is only eligible for apple health MN health care coverage after meeting a spenddown liability as described in WAC 182-519-0110.
13. The ineligible spouse of an SSI-cash recipient applying for apple health MN coverage is eligible to receive the deductions and allocations described in subsection (10)(a) of this section.

WAC 182-512-0940 SSI-related medical -- Deeming income from an ineligible parent(s) to a child applying for SSI-related medical.

Effective April 14, 2014.

The agency considers income of financially responsible persons to determine if a portion of that income must be regarded as available to other household members.

1. A portion of the income of a parent(s) is considered available to the SSI-related applicant child when the child is age seventeen or younger and the parent(s) is:
   1. Financially responsible for the SSI-related child as described in WAC 182-506-0015;
   2. The natural, adoptive, or step-parent of the child;
   3. Living in the same household with the child;
   4. Not receiving a needs-based payment such as TANF, SFA or SSI; and
   5. Not related to SSI or not applying for medical assistance.
2. If an SSI-related applicant between the ages of eighteen to twenty-one lives with their parents, only consider the parent's income available to the applicant if it is actually contributed to the applicant. If income is not contributed, count only the applicant's own separate income.
3. Income that is deemed to the child is considered as that child's income.
4. When determining whether a parent's income is countable, the agency:
   1. Follows the income rules described in WAC 182-512-0600 through 182-512-0780; and
   2. Excludes income described in WAC 182-512-0800 and 182-512-0840, and all income excluded under a federal statute or state law as described in WAC 182-512-0860.
5. When determining the amount of income to be deemed from a parent(s) to an SSI-related minor child for Washington apple health (WAH) categorically needy (CN) and medically needy (MN) coverage, the agency reduces the parent(s) countable income in the following order:
   1. Court ordered child support paid out for a child not in the home;
   2. An amount equal to one half of the federal benefit rate (FBR) for each SSI-eligible sibling living in the household, minus any countable income of that child. See WAC 182-512-0010 for FBR amount;
   3. A twenty dollar general income exclusion;
   4. A deduction equal to sixty-five dollars plus one-half of the remainder from any remaining earned income of the parent(s);
   5. An amount equal to the one-person SSI CNIL for a single parent or the two-person SSI CNIL for a two parent household;
   6. Any income remaining after these deductions is considered countable income to the SSI-related child and is added to the child's own income. If there is more than one child applying for SSI-related health care coverage, the deemed parental income is divided equally between the applicant children; and
   7. The deductions described in this section are deducted first from unearned income then from earned income unless they are specific to earned income.
6. The SSI-related applicant child is also allowed all applicable income exclusions and disregards described in chapter 182-512 WAC from their own income. After determining the child's nonexcluded income, the agency:
   1. Allows the twenty dollar general income exclusion from any unearned income;
   2. Deducts sixty-five dollars plus one half of the remainder from any earned income which has not already been excluded under the student earned income exclusion (see WAC 182-512-0820); and
   3. Adds the child's countable income to the amount deemed from their parent(s). If the combination of the child's countable income plus deemed parental income is equal to or less than the SSI CNIL, the child is eligible for SSI-related WAH CN health care coverage.
7. If the combination of the child's countable income plus deemed parental income is greater than the SSI CNIL, the agency considers the child for SSI-related WAH medically needy (MN) coverage. Any amount exceeding the effective medically needy income level (MNIL) is used to calculate the amount of the child's spenddown liability as described in WAC 182-519-0110. See WAC 182-519-0050 for the current MNIL standards.

WAC 182-512-0960 SSI-related medical -- Allocating income -- Determining eligibility for a spouse when the other spouse receives long-term services and supports.

Effective February 20, 2017.

1. General Information.
   1. This section describes how the agency determines household income and resources when the household contains both institutional and noninstitutional household members.
   2. A separate medical assistance unit is always established for persons who meet institutional status under WAC 182-513-1320. See WAC 182-506-0015 for rules on how to determine medical assistance units for households that include people related to the supplemental security income (SSI) program.
   3. Throughout this section, "home" means "own home" as defined in WAC 388-106-0010.
   4. The income and resources of each spouse are available to the other through the end of the month in which the spouses stopped living together, unless subsection (3) of this section applies.
   5. The agency determines income and resources separately starting the first day of the month following the month of separation if spouses stop living together in the same home.
   6. When one, or both members of a couple live in an alternative living facility (ALF), the agency considers the couple to be living:
      1. Apart when:
         1. Only one spouse enters the ALF;
         2. Both spouses enter the same ALF but have separate rooms; or
         3. Both spouses enter separate ALFs.
      2. Together when both spouses share a room in an ALF.
2. The agency counts income and resources under this chapter when both members of a couple live in the same house and the community spouse or spousal impoverishment protections community (SIPC) spouse applies for coverage and his or her spouse receives:
   1. Home and community-based (HCB) waiver;
   2. Program for all inclusive care to the elderly (PACE);
   3. Roads to community living (RCL);
   4. Hospice; or
   5. Community first choice (CFC).
3. When one member of a couple lives apart from their spouse and the community spouse or SIPC spouse applies for coverage, and the spouse who receives long-term services and supports lives:
   1. In an institution:
      1. The agency counts income under this chapter, plus any allocation the institutionalized spouse has made available to the community spouse; and
      2. The agency counts resources under this chapter, plus any resources allocated to the community spouse when eligibility for the institutionalized spouse was determined, that remain in the name of the institutionalized spouse and are available to the community spouse under WAC 182-512-0250.
   2. In an ALF and receives HCB waiver, PACE, RCL, or hospice:
      1. The agency counts income under this chapter, plus any allocation the institutionalized spouse has made available to the community spouse; and
      2. The agency counts resources under this chapter, plus any resources allocated to the community spouse when eligibility for the institutionalized spouse was determined, that remain in the name of the institutionalized spouse, and are available to the community spouse under WAC 182-512-0250; and
   3. In an ALF and receives CFC:
      1. The agency counts income under this chapter; and
      2. The agency counts resources under this chapter, plus any resources allocated to the SIPC spouse when eligibility for the spousal impoverishment protections institutionalized (SIPI) spouse was determined, that remain in the name of the SIPI spouse and are available to the community spouse under WAC 182-512-0250.
4. Determining household income when the spouse of an HCB waiver recipient is not eligible for categorically needy (CN) coverage.
   1. When the community spouse is not eligible for categorically needy (CN) coverage under subsection (2) of this section, the agency determines eligibility under the medically needy program;
   2. The agency counts income and resources as described under subsection (2) of this section;
   3. The agency allocates income to the institutionalized spouse before comparing the community spouse's income to the medically needy income level (MNIL) if:
      1. The community spouse lives in the same household as the institutionalized spouse;
      2. The institutionalized spouse is receiving home and community-based waiver services under WAC 182-515-1505 or institutional hospice services under WAC 182-513-1240; and
      3. The institutionalized spouse has gross income under the MNIL.
   4. The allocation in (c) of this subsection cannot exceed the one-person effective MNIL minus the institutionalized spouse's income.

WAC 182-512-0790 SSI-related medical -- Exemption from sponsor deeming.

Effective April 14, 2014.

1. A person who meets any of the following conditions is permanently exempt from deeming and the agency does not count the sponsor's income or resources when determining eligibility for Washington apple health (WAH) SSI-related coverage:
   1. The Immigration and Nationality Act (INA) does not require the person to have a sponsor. Immigrants who are not required to have a sponsor include those with the following status with U.S. Citizenship and Immigration Services (USCIS):
      1. Refugee;
      2. Parolee admitted under Section 212(d)(5) of the Immigration and Nationality Act (INA);
      3. Asylee;
      4. Cuban/Haitian entrant under Section 202 of the Immigration Reform and Control Act of 1986 (IRCA);
      5. Amerasians admitted with an I-551 admission code of AM1, AM2, AM3, AM6, AM7, or AM8; and
      6. Special immigrant from Iraq or Afghanistan.
   2. The person meets the blindness or disability requirements described in WAC 182-512-0050(1);
   3. The person was sponsored by an organization or group as opposed to another person;
   4. The person is a nonqualified or undocumented alien as defined in WAC 182-503-0530 (3) and (4);
   5. The person has worked or can get credit for forty qualifying quarters of work under Title II of the Social Security Act. The agency does not count a quarter of work toward this requirement if the person working received TANF, Basic Food, SSI, CHIP, or nonemergency medicaid coverage. A quarter of work earned by the following people is counted toward the forty qualifying quarters:
      1. The person;
      2. The person's parents for the time they worked before the person turned eighteen years old (including the time they worked before the person's birth); and
      3. The person's spouse if still married or if the spouse is deceased.
   6. The person has become a United States (U.S.) citizen;
   7. The sponsor is dead; or
   8. If USCIS or a court decides that the person, their child, or their parent was a victim of domestic violence from the person's sponsor and:
      1. The person no longer lives with the sponsor; and
      2. Leaving the sponsor caused the need for coverage.
2. A person is exempt from the deeming process while in the same assistance unit (AU) as the sponsor.
3. If the person, their child, or their parent was a victim of domestic violence, the person is exempt from the deeming process for twelve months if:
   1. They no longer live with the person who committed the violence; and
   2. Leaving this person caused the need for health coverage.
4. If the person's medical assistance unit (MAU) has income at or below one hundred thirty percent of the federal poverty level (FPL), the person is exempt from the deeming process for twelve months. This is called the "indigence exemption." A person may choose to use this exemption or not to use this exemption in full knowledge of the possible risks involved. See risks in subsection (5) of this section. For this rule, the agency counts the following as income:
   1. Earned and unearned income received by any member of the MAU from any source; and
   2. The value of any noncash items of value such as free rent, commodities, goods, or services received from another person or organization.
5. A person who chooses not to use the indigence exemption must provide verification of the sponsor's income and resources and will be subject to the deeming rules described in WAC 182-512-0795.
6. For federally funded programs, if the person uses the indigence exemption, the agency is required by law to give the U.S. Attorney General the following information:
   1. The names of the sponsored people in the person's AU;
   2. That the person is exempt from deeming due to income;
   3. The sponsor's name; and
   4. The effective date that the twelve-month exemption began.

WAC 182-512-0795 SSI-related medical -- Budgeting a sponsor's income.

Effective January 2, 2015.

1. The agency counts some of the income of a person's sponsor as unearned income to the medical assistance unit (MAU) if:
   1. The sponsor signed the U.S. Citizenship and Immigration Services (USCIS) Affidavit of Support form I-864 or I-864A; and
   2. The person is not exempt from the deeming process in WAC 182-512-0790.
2. The agency determines the amount of income that must be deemed from the sponsor by taking the following steps:
   1. Add together all of the sponsor's earned and unearned income that is not excluded under WAC 182-512-0860;
   2. Add all of the spouse's earned and unearned income that is not excluded under WAC 182-512-0860;
   3. Subtract an allocation for the sponsor equal to the one-person federal benefit rate (FBR);
   4. Subtract an allocation for the sponsor's spouse as follows:
      1. If the spouse is also a cosponsor of the noncitizen, allow an allocation equal to the one-person FBR; or
      2. If the spouse is not a cosponsor but lived in the same household as the sponsor, allow an allocation equal to one-half of the FBR.
   5. Subtract an allocation equal to one-half FBR for each dependent of the sponsor. The dependent's income is not subtracted from the sponsor's dependent's allocation; and
   6. The income remaining is deemed as unearned income to the noncitizen and is added to the noncitizen's own income.
3. If the sponsor has sponsored other noncitizens, all of the sponsor's income is deemed to each person that they sponsored and is not divided between them.

WAC 182-504-0015 Washington apple health -- Certification periods for categorically needy programs.

Effective September 6, 2025

1. A certification period is the period of time we determine that you are eligible for a categorically needy (CN) Washington apple health program. Unless otherwise stated in this section, the certification period begins on the first day of the month of application and continues through the end of the last month of the certification period.
2. Newborn coverage begins on the child's date of birth and continues through the end of the month of the child's first birthday.
3. If you are eligible for apple health based on pregnancy, the certification period continues through the last day of the month the pregnancy ends. After-pregnancy coverage begins the first day of the month, following the ends of the pregnancy, and ends the last day of the 12th month from the time after-pregnancy coverage began.
4. If you are newly eligible for apple health coverage and had a pregnancy end within the last 12 months, your certification period for after-pregnancy coverage:
   1. Begins the first day of the month you are eligible; and
   2. Ends the last day of the 12th month following the end of your pregnancy.
5. If you are eligible for the refugee program, the certification period ends at the end of the fourth month following your date of entry to the United States.
6. If you are a child under age six receiving apple health for kids without a premium or apple health for kids with premiums, your certification period ends the month of your sixth birthday.
7. If you are eligible for newborn coverage, your coverage continues through the last day of the month of your first birthday. Apple health for kids coverage begins the first day of the month after your newborn coverage ends and the certification period ends the last day of the month of your sixth birthday.
8. For all other CN coverage, the certification period is 12 months.
9. If you are a child, eligibility is continuous throughout the certification period regardless of a change in circumstances, unless you:
   1. Turn age 19;
   2. Move out-of-state; or
   3. Die.
10. When you turn 19, the certification period ends after the redetermination process described in WAC 182-504-0125 is completed, even if the 12-month period is not over, unless:
    1. You are receiving inpatient  services (described in WAC 182-514-0230) on the last day of the month you turn 19;
    2. The inpatient stay continues into the following month or months; and
    3. You remain eligible except for turning age 19.
11. A retroactive certification period is described in WAC 182-504-0005.
12. Coverage under premium-based programs included in apple health for kids as described in chapter 182-505 WAC begins no sooner than the month after creditable coverage ends.

WAC 182-504-0020 Certification periods for the noninstitutional medically needy program.

Effective July 11, 2015

1. The certification period for the noninstitutional medically needy (MN) program for clients with countable income equal to or below the medically needy income level (MNIL):
   1. Begins on the first day of the month in which eligibility is established; and
   2. Is approved for twelve calendar months.
2. The certification period for the noninstitutional MN program for clients with countable income above the MNIL:
   1. Begins on the day that spenddown is met; and
   2. Continues through the last day of the final month of the base period as described in WAC 182-519-0110.
3. A retroactive MN certification period may be established for up to three months preceding the month of application.
4. Expenses used to meet the spenddown liability for the current or the retroactive certification periods are the responsibility of the client. The agency is not responsible for paying any expense or portion of an expense which has been used to meet the spenddown liability. See WAC 182-519-0110.
5. A new application must be submitted for each subsequent certification period for which medically needy coverage is requested.

WAC 182-504-0025 Medicare savings program certification periods.

Effective December 1, 2011

Certification periods for the different kinds of Medicare Savings Programs are not all the same. The chart below explains the differences.

WAC 182-504-0005 Washington apple health -- Retroactive certification period.

Effective November 14, 2022.

1. The medicaid agency approves a retroactive Washington apple health (WAH) certification period for the three months immediately before the month of application when an individual:
   1. Requests retroactive WAH on the application, within the certification period following the retroactive period, or before the determination of benefits and any appeal process is final;
   2. Would have been eligible for WAH for any or all of the three months if the individual had applied during the retroactive period; and
   3. The individual received covered medical services as described in WAC 182-501-0060 and 182-501-0065.
2. When an individual is eligible only during the three-month retroactive certification period, that period is the only period of certification, except when:
   1. A pregnant individual is eligible in one of the three months immediately before the month of application, but no earlier than the month of conception. Eligibility continues as described in WAC 182-504-0015 (3) and (4).
   2. An individual who is applying within 12 months of their last pregnancy end date is eligible for after pregnancy coverage in any of the three months immediately before the month of application. Continuous eligibility begins from the earliest month the individual is found eligible as described in WAC 182-504-0015 (3) and (4).
   3. A child is eligible for categorically needy (CN) WAH as described in WAC 182-505-0210 (1) through (5) and (7) in at least one of the three months immediately before the month of application. Eligibility after the retroactive period continues as described in WAC 182-504-0015 (9).
3. An individual applying for the medically needy (MN) spenddown program may be eligible for a retroactive certification period as described in WAC 182-504-0020.
4. An individual applying for a medicare savings program may be eligible for a retroactive certification period as described in WAC 182-504-0025.

WAC 182-503-0050 Verification of eligibility factors.

Effective November 3, 2019

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