Overview

Revised date
Purpose statement

To explain the general eligibility requirements for SSI-related individuals seeking Categorically Needy (CN) or Medically Needy (MN) health care coverage.

The SSI-Related eligibility requirements may be found in the following WACs:

For related eligibility rules and other information:

WAC 182-512-0050 SSI-related medical -- General information.

WAC 182-512-0050 SSI-related medical -- General information.

Effective April 14, 2014.

  1. The agency (which includes its designee for purposes of this chapter) provides health care coverage under the Washington apple health (WAH) categorically needy (CN) and medically needy (MN) SSI-related programs for SSI-related people, meaning those who meet at least one of the federal SSI program criteria as being:
    1. Age sixty-five or older;
    2. Blind with:
      1. Central visual acuity of 20/200 or less in the better eye with the use of a correcting lens; or
      2. A field of vision limitation so the widest diameter of the visual field subtends an angle no greater than twenty degrees.
    3. Disabled:
      1. "Disabled" means unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment, which:
        1. Can be expected to result in death; or
        2. Has lasted or can be expected to last for a continuous period of not less than twelve months; or
        3. In the case of a child seventeen years of age or younger, if the child suffers from any medically determinable physical or mental impairment of comparable severity.
      2. Decisions on SSI-related disability are subject to the authority of:
        1. Federal statutes and regulations codified at 42 U.S.C. Section 1382c and 20 C.F.R., parts 404 and 416, as amended; and
        2. Controlling federal court decisions, which define the OASDI and SSI disability standard and determination process.
  2. A denial of Title II or Title XVI federal benefits by SSA solely due to failure to meet the blindness or disability criteria is binding on the agency unless the applicant's:
    1. Denial is under appeal in the reconsideration stage in SSA's administrative hearing process, or SSA's appeals council; or
    2. Medical condition has changed since the SSA denial was issued.
  3. The agency considers a person who meets the special requirements for SSI status under Sections 1619(a) or 1619(b) of the Social Security Act as an SSI recipient. Such a person is eligible for WAH CN health care coverage under WAC 182-510-0001.
  4. Persons referred to in subsection (1) must also meet appropriate eligibility criteria found in the following WAC and EA-Z Manual sections:
    1. For all programs:
      1. WAC 182-506-0015, Medical assistance units;
      2. WAC 182-504-0015, Categorically needy and WAC 182-504-0020, Medically needy certification periods;
      3. Program specific requirements in chapter 182-512 WAC;
      4. WAC 182-503-0050, Verification;
      5. WAC 182-503-0505, General eligibility requirements for medical programs;
      6. WAC 182-503-0540, Assignment of rights and cooperation;
      7. Chapter 182-516 WAC, Trusts, annuities and life estates.
    2. For LTC programs:
      1. Chapter 182-513 WAC, Long-term care services;
      2. Chapter 182-515 WAC, Waiver services.
    3. For WAH MN, chapter 182-519 WAC, Spenddown;
    4. For WAH HWD, program specific requirements in chapter 182-511 WAC.
  5. Aliens who qualify for medicaid coverage, but are determined ineligible because of alien status may be eligible for programs as specified in WAC 182-507-0110.
  6. The agency pays for a person's medical care outside of Washington according to WAC 182-501-0180.
  7. The agency follows income and resource methodologies of the supplemental security income (SSI) program defined in federal law when determining eligibility for SSI-related medical or medicare savings programs unless the agency adopts rules that are less restrictive than those of the SSI program.
  8. Refer to WAC 182-504-0125 for effects of changes on medical assistance for redetermination of eligibility.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

Clarifying information

SSI-related individuals may qualify for SSI-Related Apple Health, which offers both CN and MN health care coverage. CN coverage is the most comprehensive, covering more services than MN coverage. Eligibility for CN is determined first and eligibility for MN or other programs is determined only if the individual is not eligible for CN.

If an individual is under age 65 and doesn't have Medicare, review their eligibility for MAGI-based coverage before looking at SSI-related medical.

SSI-related individuals are those who meet the requirements of aged, blind or disabled, as defined by the federal SSI program rules, but cannot get or choose not to receive SSI cash benefits, such as:

  • Aged, blind, or disabled adults who are not receiving SSI cash benefits, including;
    • Working age adults with disabilities who are working and have income or resources that exceed other SSI-related program requirements; See Clarifying Information that follows WAC 182-511-1100 in the Health Care for Workers with Disabilities (HWD) section for more information and rules that apply to all individuals with gross monthly earnings at or above substantial gainful activity (SGA).
    • The SGA test described in WAC 182-512-0050 below applies to all SSI-related programs (other than non-grant medical assistance (NGMA), including HWD, and Apple Health coverage provided under sections 1619(a) and (b) of the Social Security Act), unless the individual continues to receive a Title II cash benefit, e.g. SSDI or DAC.

Note: Individuals receiving Title II cash benefits may test their ability to work for a number of months without losing their cash benefit under the SSA Trial Work Period (TWP). After the TWP is completed, earnings at the SGA level result in the loss of Title II cash after a three-month "cessation and grace" period. For more information about the TWP, see SSA work incentives.

  • Children who are blind or disabled and who are not receiving SSI cash benefits (See WAC 182-505-0210); and
  • Certain qualified aliens who meet the nonimmigration status criteria for SSI-related medical (See WAC 182-508-0001).

The Agency uses the Federal SSI cash assistance rules when determining eligibility for SSI-related medical, with a few exceptions that provide less restrictive rules. For more comprehensive definitions of blind and disabled, see SSA Program Operating Manual Systems (POMS) @ SI 00501.001 Eligibility Under the Supplemental Security Income Provisions.

  • An individual who receives cash assistance from SSI, SSA disability, or who is age 65 or older, has met the requirements to be SSI-related and no further categorical determination is necessary.
  • An SSI individual who begins working and is terminated from SSI cash benefits by the Social Security Administration, but who is being determined for eligibility under the Social Security Act Title 1619(a) or 1619(b), remains eligible as an SSI recipient under the S01 CN coverage group during the SSA determination and appeal process.

The Division of Disability Determination Services (DDDS) processes referrals for blindness or disability determinations. See "Worker Responsibilities" in the NGMA overview.

Individuals who receive a cash grant under the Aged, Blind, Disabled cash program and meet SSI criteria for disability, income and resources, may receive health care coverage under the following programs while their SSI application is pending with the Social Security Administration (SSA):

Note: The following apply to individuals enrolled in Health Care for Workers with Disabilities (HWD):

  • An eligible individual may choose to enroll in HWD with gross monthly earnings above or below the substantial gainful activity (SGA) level. If an individual is working at SGA and never received a federal cash benefit based on disability, or no longer receives it because of earnings, then HWD is the only Medicaid option for coverage, unless Medicaid protections under Section 1619 of the Social Security Act apply.
  • An impairment-related work expense (IRWE) approved by SSA or the financial worker may be used to reduce gross earnings that are compared to SGA. For information about IRWEs, see WAC 182-512-0840 and SSA Red Book - Employment Supports.
  • Determinations made by SSA to establish IRWEs or a subsidy and special conditions exist in their "eWork" and Disability Control File (DCF) databases; such information is not provided in a Benefits Planning Query (BPQY) and is not available in any other SSA database. If current documentation is not available, SSA staff can help determine whether an individual with higher earnings is working at SGA.

Worker responsibility

  1. When SSA terminates an individual’s SSI cash payment, but is determining 1619(a) or 1619(b) eligibility for that individual, continue the individual on S01 medical until you receive additional information on the SDX referring the individual back to the State for a Medicaid determination (R on the medical eligibility field on SDX1).
    1. While the individual is in 1619(b) status, SSA sends notification to the State on the SDX interface using the 'C' code in the medical eligibility field on the SDX1.
    2. After the SSA sends the final decision on the SDX record, determine eligibility for any appropriate programs based on the SSA decision.
  2. When SSA terminates the individual’s SSI cash eligibility for reasons other than disability ending or improvement, a new referral to DDDS is needed to get the disability end date – the date a new disability determination will be needed. Set an alert at least 90 days prior to the disability end date to begin the process of getting the new disability determination from DDDS.
  3. To be an SSI-related individual, the individual must be age 65 or older or determined blind or disabled by either the federal SSI/SSA program or by DDDS. An individual who is only receiving disability benefits such as VA, L&I, Railroad Retirement Benefits (RRB), etc., is not necessarily an SSI-related individual. For a disability determination, initiate a Non-Grant Medical Assistance (NGMA) referral.

WAC 182-512-0010 Supplemental security income (SSI) standards, SSI-related categorically needy income level (CNIL), and countable resource standards.

WAC 182-512-0010 Supplemental security income (SSI) standards, SSI-related categorically needy income level (CNIL), and countable resource standards.

Effective January 27, 2019

  1. The SSI payment standards, also known as the federal benefit rate (FBR), change each January 1st.
  2. See WAC 388-478-0055 for the amount of the state supplemental payments (SSP) for SSI recipients.
  3. See WAC 182-513-1205 for standards of clients living in an alternate living facility.
  4. The SSI-related CNIL standards are the same as the SSI payment standards for single persons and couples. Those paying out shelter costs have a higher standard than people who have supplied shelter.
  5. The countable resource standards for SSI and SSI-related CN medical programs are:
    1. One person                          $2,000
    2. A legally married couple        $3,000

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

Clarifying information

  1. The Categorically Needy (CN) program provides a federal-funded Apple Health benefit for certain individuals with income below Categorically Needy (CN) standards. SSI-related CN standards are described in WAC 182-512-0010.
  2. An individual who is eligible for an SSI cash grant and chooses not to accept it is still eligible for CN medical as an SSI-related individual.
  3. Sometimes an SSI recipient stops receiving the SSI cash grant because he or she is working. He or she will still be eligible for CN medical under the S01 program under Section 1619(a) and/or (b) if there is a "C" Medical Eligibility Code on the SDX screen in ACES.
  4. The "ineligible spouse" of an SSI recipient (i.e., a spouse who does not receive SSI in his or her own right but who is included in the SSI recipient's benefits) is not considered an SSI recipient for purposes of SSI-related medical.
    1. The spouse must apply for health care coverage and have SSI-related eligibility determined separately.
    2. An SSI-ineligible spouse cannot receive noninstitutional CN coverage, but may qualify for medically needy (MN) coverage.
  5. Eligibility redeterminations must be completed on each individual in the AU for all possible health care programs, including MAGI coverage, before terminating CN coverage and before denying an application.

WAC 182-512-0150 SSI-related medical -- Medically needy (MN) medical eligibility.

WAC 182-512-0150 SSI-related medical -- Medically needy (MN) medical eligibility.

Effective June 26, 2022.

  1. Washington apple health (WAH) medically needy (MN) health care coverage is available for any of the following:
    1. A person who is SSI-related and not eligible for WAH categorically needy (CN) medical coverage because the person has countable income that is above the WAH CN income level (CNIL) (or for long-term care (LTC) recipients, above the special income limit (SIL)):
      1. The person's countable income is at or below WAH MN standards, leaving no spenddown requirement; or
      2. The person's countable income is above WAH MN standards requiring the person to spenddown their excess income (see subsection (4) of this section). See WAC 182-512-0500 through 182-512-0800 for rules on determining countable income, and WAC 182-519-0050 for program standards or chapter 182-513 WAC for institutional standards.
    2. An SSI-related ineligible spouse of an SSI recipient;
    3. A person who meets SSI program criteria but is not eligible for the SSI cash grant due to immigration status or sponsor deeming. See WAC 182-503-0535 for limits on eligibility for aliens;
    4. A person who meets the WAH MN LTC services requirements of chapter 182-513 WAC;
    5. A person who lives in an alternate living facility and meets the requirements of WAC 182-513-1205; or
    6. A person who meets resource requirements as described in chapter 182-512 WAC, elects and is certified for hospice services per chapter 182-551 WAC.
  2. A person whose countable resources are above the SSI resource standards is not eligible for WAH MN noninstitutional health care coverage. See WAC 182-512-0200 through 182-512-0550 to determine countable resources.
  3. A person who qualifies for services under WAH long-term care programs has different criteria and may spend down excess resources to become eligible for WAH LTC institutional or waiver health care coverage. Refer to WAC 182-513-1315 and 182-513-1395.
  4. A person with income over the effective WAH MN income limit (MNIL) described in WAC 182-519-0050 may become eligible for WAH MN coverage when the person has incurred medical expenses that are equal to the excess income. This is the process of meeting spenddown. Refer to chapter 182-519 WAC for spenddown information.
  5. A person may be eligible for health care coverage for any or all of the three months immediately prior to the month of application, if the person has:
    1. Met all eligibility requirements for the months being considered; and
    2. Received medical services covered by medicaid during that time.
  6. A person who is eligible for WAH MN without a spenddown is certified for up to 12 months. For a person who must meet a spenddown, refer to WAC 182-519-0110. For a person who is eligible for a WAH long-term care MN program, refer to WAC 182-513-1395 and 182-513-1315.
  7. A person must reapply for each certification period. There is no continuous eligibility for WAH MN.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

Clarifying information

  1. The Medically Needy (MN) program provides a federal and state-funded Apple Health benefit for individuals with income above Categorically Needy (CN) standards. MN standards are described in WAC 182-519-0050. MN provides slightly less medical coverage than CN. See Scope of Care for which services are covered by CN and MN.
  2. For MN individuals with spenddown, the certification period starts either:
    1. The first of the certification period if the individual meets the spenddown with only Medicare cost sharing expenses, private insurance cost-sharing expenses, prior unpaid bills, or expenses of the type that are not covered under DSHS medical programs (or any combination of these); or
    2. The day spenddown is met if the expenses are hospital expenses, medical expenses of the type that are potentially payable by HCA/DSHS medical programs or prescription expenses (non-Medicare Part D expenses). See Certification Periods, chapter 182-504 WAC.
  3. There is no automatic redetermination process for MN at the end of a certification period. An individual must apply for each certification period.

Worker responsibilities

  1. Make sure a new application is mailed to the individual before the end of the base period, especially if the review has fallen out of the ACES review cycle or if the individual moved.
  2. The 3-month retroactive period of eligibility does not require a separate application.
  3. For reported changes that will alter the spenddown amount:
    1. If the individual has met spenddown, no change can be made for previous months. Recalculate spenddown for the remaining base period using the new information. If the change increases the spenddown, changes are effective the month after the month of change, following the rules of advance and adequate notice. If the change makes the individual eligible for CN coverage, make those changes for the appropriate months. Be sure to send an award letter explaining the changes.
    2. If the individual has not met spenddown, recalculate the spenddown using current information and notify the individual of the changes. See the Change of Circumstances of the Spenddown chapter of the manual.
  4. Allow an individual 30 days after the base period has expired to send in bills to meet spenddown. It may take this long for the individual to gather medical bills. If the individual requests more time to send bills in, allow it. If a fair hearing is filed, allow the individual to continue submitting bills incurred during the established base period until the fair hearing is resolved.

Referral process to Division of Disability Determination Services (DDDS):

In Washington State, DDDS makes the blindness and disability determinations for both:

  1. Social Security Administration (Social Security disability benefits and SSI cash grant); and
  2. SSI-related individuals who:
    1. Do not receive SSI or SSA disability;
    2. Need a reexamination for continuing eligibility;
    3. Were terminated from SSI due to no longer meeting disability criteria;
    4. Meet SSI-related income and resource standards; or
    5. Have gross monthly earnings at or above the current substantial gainful activity (SGA) level (See SSA "Substantial Gainful Activity - Amounts"). For more information about SGA, see the SSA Red Book.
  3. If an individual is currently receiving SSI or SSA disability, DDDS has already determined that the individual is blind or disabled.
  4. When a blindness or disability determination is needed, follow instructions described in the NGMA overview.

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Income (part 1)

Revised date

WAC 182-509-0300 Modified adjusted gross income (MAGI).

WAC 182-509-0300 Modified adjusted gross income (MAGI).

Effective September 18, 2020.

  1. The agency uses the modified adjusted gross income (MAGI) methodology to determine eligibility for MAGI-based Washington apple health programs described in WAC 182-509-0305.
  2. MAGI methodology is described in WAC 182-509-0300 through 182-509-0375. Generally, MAGI includes adjusted gross income (as determined by the Internal Revenue Code (IRC)) increased by:
    1. Any amount excluded from gross income under Section 911 of the IRC;
    2. Any amount of interest received or accrued by the taxpayer during the taxable year which is exempt from tax; and
    3. Any amount of Title II Social Security income or Tier 1 Railroad Retirement income which is excluded from gross income under Section 86 of the IRC.
  3. When calculating a person's eligibility for the programs listed in WAC 182-509-0305, the agency uses the person's MAGI income with the following exceptions:
    1. Scholarships or fellowship grants described in WAC 182-509-0335 used for education purposes are excluded from income;
    2. Income received by American Indian/Alaskan Native individuals described in WAC 182-509-0340 is excluded from income; and
    3. Any income received as a lump sum as described in WAC 182-509-0375 is counted as income only in the month in which it is received; and
    4. Income received by a child are eighteen or younger or a tax dependent as described in WAC 182-509-0360 is excluded from income.
  4. Countable MAGI income is reduced by an amount equal to five percentage points of the federal poverty level (FPL) based on household size to determine net income except that there is no such reduction of countable MAGI income for parents or caretaker relatives with an eligible dependent child whose net countable income is below fifty-four percent of the FPL (as described in WAC 182-509-0305(1)). Net income is compared to the applicable standard described in WAC 182-505-0100.
  5. When calculating a person's eligibility for MAGI-based programs listed in WAC 182-509-0305, the agency determines the medical assistance unit for each person according to WAC 182-506-0010.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

Clarifying information

Total MAGI income is equal to IRS adjusted gross income

Plus:

  • Interest income
  • Title 2 Social Security income/Tier 1 Railroad Retirement income
  • Foreign income (Section 911 IRC)

Subtract:

  • Educational benefits exempt from income.
  • American Indian/Alaskan Native exempt income.
  • One-time lump sums not received in the month of application.
  • Income of tax dependents or children aged 19 or younger that does not meet tax filing threshold requirements.

Minus allowable IRS deductions 

Minus 5% FPL income disregard

  • Recipients of Parent/Caretakers Medical (N01) do not receive the 5% FPL income disregard unless they are receiving Medicare.

AmeriCorps living allowance

The Domestic Volunteer Service Act of 1973 specifically excludes payments made to certain volunteers from being used in determining eligibility for government assistance. Because of this exclusion, an AmeriCorps member’s living allowance is not counted for MAGI-based Washington Apple Health programs, even though it is taxable under IRS rules.

Income received from PFML

The Health Care Authority is waiting for official guidance from the IRS regarding the treatment of Washington State’s Paid Family and Medical Leave (PFML). Until this guidance is received, income received from PFML is not countable for MAGI-based Washington Apple Health programs.

WAC 182-509-0305 MAGI income -- Persons subject to the modified adjusted gross income (MAGI) methodology.

WAC 182-509-0305 MAGI income -- Persons subject to the modified adjusted gross income (MAGI) methodology.

Effective November 1, 2024.

  1. Eligibility for Washington apple health for the following people is determined using the modified adjusted gross income (MAGI) methodology described in WAC 182-509-0300:
    1. Parents or caretaker relatives with an eligible dependent child (described in WAC 182-503-0565) whose net countable income is below 54 percent of the federal poverty level (FPL) as described in WAC 182-505-0240.
    2. Parents or caretaker relatives with an eligible dependent child whose net countable income exceeds the standard described in (a) of this subsection but is at or below 133 percent FPL as described in WAC 182-505-0250 and 182-507-0110.
    3. Adults with no eligible dependent child with net countable income at or below 133 percent FPL as described in WAC 182-505-0250 and 182-507-0110.
    4. Pregnant people whose net countable income, based on a household size that includes any unborn children, is equal to or below 210 percent FPL at the time of application, as described in WAC 182-505-0115.
    5. People within the 12-month postpartum period beginning the month after the pregnancy ends whose net countable income is equal to or below 210 percent FPL at the time of application, as described in WAC 182-505-0115.
    6. Children age 18 or younger in households with net countable income which is equal to or below 210 percent FPL as described in WAC 182-505-0210.
    7. Children age 18 or younger in households with net countable income that is greater than 210 percent but equal to or below 312 percent FPL, as described in WAC 182-505-0215. Children who are eligible under this section are subject to premiums as described in WAC 182-505-0225.
  2. Household size for a person who is subject to MAGI income methodologies is determined according to WAC 182-506-0010.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

WAC 182-509-0310 MAGI income -- Timing of income.

WAC 182-509-0310 MAGI income -- Timing of income.

Effective January 9, 2014.

For purposes of determining eligibility for modified adjusted gross income (MAGI)–based Washington apple health (WAH) (see WAC 182-509-0300):

  1. The agency uses a point-in-time estimate to determine a person's countable income.
  2. Point-in-time means that the income is received, or is likely to be received, in the month in which the person submits an application or renewal for WAH, or the month in which the agency completes a redetermination of coverage, with the following provisions:
    1. When a person is paid less frequently than on a monthly basis, (for example, they are self-employed), the agency uses an average to calculate the monthly amount. The average is calculated by:
      1. Adding the total income for representative period of time;
      2. Dividing by the number of months in the time frame; and
      3. Using the result as a monthly average.
    2. When a person is paid more frequently than on a monthly basis, the agency uses the following budgeting method to calculate a monthly amount:
      1. If the person is paid weekly, the agency multiplies weekly expected income by 4.3;
      2. If the person is paid every other week, the agency multiplies expected income by 2.15.
    3. If the person's current income does not represent his or her projected income as evidenced by clear indications of future changes in income, the agency permits the person to estimate a monthly amount by averaging income over a representative period of time.
  3. If the person normally gets the income:
    1. On a specific day, the agency counts it as available on that date.
    2. Monthly or twice monthly and pay dates change due to a reason beyond the person's control, such as a weekend or holiday, it is counted in the month it would normally be received.
    3. Weekly or every other week and pay dates change due to a reason beyond the person's control, it is counted in the month it would normally be received.
  4. For information about how income is verified, see WAC 182-503-0050.
  5. If the person reports a change in income as required under WAC 182-504-0105 and the change is expected to last for two months or longer, the agency updates the estimate of income based on this change, unless the person receives categorically needy WAH coverage as a pregnant woman or child.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

WAC 182-509-0315 MAGI income -- Ownership of income.

WAC 182-509-0315 MAGI income -- Ownership of income.

Effective January 9, 2014.

  1. For purposes of determining eligibility for modified adjusted gross income (MAGI)–based Washington apple health (WAH) (see WAC 182-509-0300) income is considered available to a person if:
    1. An individual in the person's medical assistance unit receives or can reasonably predict that he or she will receive the income.
    2. The income must be counted based on rules under chapter 182-509 WAC.
    3. The person has control over the income, which means the income is available to them. If the person has a representative payee, protective payee, or other individual who manages the income on the person's behalf, it is considered as if the person has control over this income.
    4. The person can use the income to meet current needs.
  2. Income that is included in the person's taxable gross income which is required to be reported to the Internal Revenue Service (IRS) is considered as available even if it is paid to someone else or withheld to pay a garnishment, lien or other obligation. (For example, a person manages a block of apartments and lives in one of the apartments. The employer withholds a portion of the person's monthly wages as rent due for the apartment in which he resides. The income that is counted is the gross amount prior to the deduction for rent.)
  3. The agency may conduct post-eligibility reviews of health care applications as described in WAC 182-503-0050. Upon request by the agency, a person must provide proof about a type of income, including submitting clarification on:
    1. Who owns the income;
    2. Who has legal control of the income;
    3. The amount of the income; or
    4. If the income is available.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

Clarifying information

Individuals have the option to report their income that is most representative of their current circumstances.

Example 1

A fisherman works seasonally during the summer months and his family lives off his income the rest of the year. In his case, it is in his best interest to average his income over the course of the year to determine eligibility.

Example 2

An individual was employed and lost her job. She is now receiving unemployment compensation and actively looking for work. Because her income has changed and she cannot anticipate her future earnings, it is in her best interest to report her current unemployment benefits.

Example 3

An individual receives infrequent disbursements from an IRA as his sole source of income. Because this income is received infrequently but will continue, it is in his best interest to average this income over a period of time or take a yearly average.

WAC 182-509-0320 MAGI income -- Noncountable income.

WAC 182-509-0320 MAGI income -- Noncountable income.

Effective September 18, 2020.

For purposes of determining eligibility for modified adjusted gross income (MAGI)–based Washington apple health (see WAC 182-509-0300):

  1. Some types of income are not counted when determining eligibility for MAGI-based apple health. Under the MAGI income methodology described in WAC 182-509-0300, income is not counted if the Internal Revenue Service (IRS) permits it to be excluded or deducted for purposes of determining the tax liability of a person. (See 26 U.S.C. Sections 62(a) and 101-140.)
  2. Examples of income that are not counted include, but are not limited to:
    1. Bona fide loans, except certain student loans as specified under WAC 182-509-0335;
    2. Federal income tax refunds and earned income tax credit payments for up to 12 months from the date received;
    3. Child support payments received by any person included in household size under WAC 182-506-0010;
    4. Nontaxable time loss benefits or other compensation received for sickness or injury, such as benefits from the department of labor and industries (L&I) or a private insurance company;
    5. Title IV-E and state foster care and adoption support maintenance payments;
    6. Veteran's benefits including, but not limited to, disability compensation and pension payments for disabilities paid to the veteran or family members; education, training and subsistence; benefits under a dependent-care assistance program for veterans, housebound allowance and aid and attendance benefits;
    7. Money withheld from a benefit to repay an overpayment from the same income source;
    8. One-time payments issued under the Department of State or Department of Justice reception and replacement programs, such as Voluntary Agency (VOLAG) payments;
    9. Nontaxable income from employment and training programs;
    10. Any portion of income used to repay the cost of obtaining that income source;
    11. Insurance proceeds or other income received as a result of being a Holocaust survivor;
    12. Federal economic stimulus payments that are excluded for federal and federally assisted state programs;
    13. Income from a sponsor given to a sponsored immigrant;
    14. Fringe benefits provided on a pretax basis by an employer, such as transportation benefits or moving expenses;
    15. Employer contributions to certain pretax benefits funded by an employee's elective salary reduction, such as amounts for a flexible spending account;
    16. Distribution of pension payments paid by the employee (such as premiums or contributions) that were previously subject to tax;
    17. Gifts as described in IRS Publication 559; Survivors, Executors, and Administrators;
    18. Cash or noncash inheritances, except that the agency counts income produced by an inheritance;
    19. Death benefits from life insurance and certain benefits paid for deaths that occur in the line of duty;
    20. Working families' tax credit payments under RCW 82.08.0206; and
    21. Other payments that are excluded from income under state or federal law.
  3. Income received from other agencies or organizations as needs-based assistance is not countable income under this section.
    1. "Needs-based" means eligibility for the program is based on having limited income, or resources, or both. Examples of needs-based assistance are:
      1. Clothing;
      2. Food;
      3. Household supplies;
      4. Medical supplies (nonprescriptions);
      5. Personal care items;
      6. Shelter;
      7. Transportation; and
      8. Utilities (e.g. lights, cooking fuel, the cost of heating or heating fuel).
    2. Needs-based cash programs include, but are not limited to, the following apple health programs:
      1. Diversion cash assistance (DCA);
      2. Temporary assistance for needy families (TANF);
      3. State family assistance (SFA);
      4. Pregnant women's assistance (PWA);
      5. Refugee cash assistance (RCA);
      6. Aged, blind, disabled cash assistance (ABD); and
      7. Supplemental security income (SSI).

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

Clarifying information

Noncountable income is income that is not taxable under the Internal Revenue Code and noncountable for MAGI-based eligibility. Additionally needs-based income is also excluded such as payments from: 

  • Lived Experience (or Community) Compensation. This program allows low-income and community members with relevant lived experience to be compensated for their task force work, including a stipend of up to $200 per day and reimbursement of travel, childcare and lodging costs. Payments come from Washington state agencies.

WAC 182-509-0325 MAGI income -- Unearned income.

WAC 182-509-0325 MAGI income -- Unearned income.

Effective January 9, 2014.

For purposes of determining eligibility for modified adjusted gross income (MAGI)–based Washington apple health (WAH) (see WAC 182-509-0300):

  1. Unearned income is income received from a source other than employment or self-employment. Examples of unearned income include, but are not limited to:
    1. Tier 1 Railroad Retirement;
    2. Unemployment compensation, except as described in WAC 182-509-0320;
    3. Title II Social Security benefits (including retirement benefits, disability benefits, and benefits for survivors);
    4. Rental income;
    5. Pensions, IRAs, military retirement and annuity payments, except as described in WAC 182-509-0320;
    6. Dividend payments from stocks or shares held in companies; and
    7. Per capita distributions from gaming made by a tribe (see WAC 182-509-0340).
  2. When the unearned income must be counted, the agency counts the gross amount before any taxes or premiums are taken out.
  3. See WAC 182-509-0320 for examples of unearned income that are not counted.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

WAC 182-509-0330 MAGI income -- Earned income.

WAC 182-509-0330 MAGI income -- Earned income.

Effective January 9, 2014.

For purposes of determining eligibility for modified adjusted gross income (MAGI)–based Washington apple health (WAH) (see WAC 182-509-0300):

  1. Earned income is income received from working. This includes, but is not limited to:
    1. Wages;
    2. Salaries;
    3. Tips;
    4. Commissions;
    5. Profits from self-employment activities as described in WAC 182-509-0365; and
    6. One-time payments for work done over a period of time, if the income is received in the month of application.
  2. When earned income must be counted, the agency computes the countable amount based on deductions from income allowed by the Internal Revenue Service when determining a person's tax liability.
  3. See WAC 182-509-0370 for information on how self-employment income is counted.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

WAC 182-509-0335 MAGI income -- Educational benefits.

WAC 182-509-0335 MAGI income -- Educational benefits.

Effective September 18, 2020.

For purposes of determining eligibility for modified adjusted gross income (MAGI)–based Washington apple health (see WAC 182-509-0300), the agency or its designee does not count educational benefits as income when they are used for education expenses, unless the educational benefits are used for living expenses. Examples include, but are not limited to:

  1. Educational assistance in the form of grants or loans issued under Title IV of the Higher Education Amendments (Title IV - HEA) or through a program administered by the Department of Education (DOE), such as:
    1. Pell grants (Title IV);
    2. Stafford loans (Title IV);
    3. Perkins loan program (Title IV);
    4. State need grant program (Title IV); and
    5. Training programs administered by the Department of Education (DOE).
  2. Payments received for education, training, or subsistence under any law administered by the department of Veteran's Affairs (VA).
  3. Student financial assistance provided under the Bureau of Indian Affairs education programs.
  4. Educational assistance in the form of grants or loans under the Carl D. Perkins Vocational and Applied Technology Education Act, P.L. 101-392.
  5. Work study income including:
    1. Federal or state work study income; and
    2. WorkFirst work study income.
  6. Payments to service academy cadets at a military academy.
  7. Payments for the purposes of tuition made on behalf of the individual to an educational organization for the education or training of such individual.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

Clarifying information 

Educational benefits are not countable when they are used for educational expenses and not for living expenses. Work study can be taxable income, but it is not countable if it is used for educational expenses.

For more information on income, please see Income (part 2).

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Health Insurance Premium program

Revised date
Purpose statement

Provide information about the Premium Payment program that may reimburse premiums for private health insurance coverage for those receiving Apple Health (Medicaid), WAC 182-558.

Clarifying Information

Payment of Private Health Insurance Premiums

HCA has a Premium Payment program to help pay for Washington Apple Health (Medicaid) individuals' private health insurance premiums. For those that have access to private health insurance, the agency may pay premiums for the entire family as long as someone has Apple Health (either MAGI-based or Classic Medicaid). Insurance policies covered include:

  • Private health insurance (plans purchased through the Washington Health Benefit Exchange or the Washington Healthplanfinder receiving Premium Tax Credits are not eligible for reimbursement).
  • Employer sponsored insurance made available through your employment
  • COBRA continuing your job's health insurance if you become unemployed

The program does not apply to Medicare-eligible individuals.

How to Apply

  1. Individuals or workers can call the toll-free line at 800-562-3022 Ext 15473
  2. Or visit and download the application at the HCA website.
  3. Any applicant who declares ‘other medical coverage’ on the Medicaid application must complete the DSHS 14-194 Medical Coverage Information form.

Making a Referral for a Premium

Download and complete an application for the Premium Payment program, HCA 13-705.

Mail: Send all mail requests to Premium Payment program, P.O. Box 45518 Olympia WA 98504-5518

Fax: Application may be faxed toll free to: 877-893-3810

The COB premium specialist reviews for type of program, type of insurance, medical need, and cost effectiveness of paying the individual's premium. Premium payments are prospective and cannot be retroactive for any months they were approved for Medicaid. Allow 30 days for processing. The individual will be notified by mail with a copy to the CSO.

Contact the Premium Payment program:

Melissa Bruce melissa.bruce@hca.wa.gov 800-562-3022 Ext. 15473

Early Intervention Program for HIV-AIDS clients

If an applicant who has been diagnosed with HIV or AIDS is not eligible for an Apple Health program, there is another resource available. The Department of Health HIV Client Services Program funds a contract to assist persons who have HIV and/or AIDS with ongoing private health insurance premiums, or to acquire insurance. For more information about this program contact the Early Intervention Program (EIP) at DOH at 877-376-9216, or go to HIV Client Services Program or Evergreen Health Insurance Program.

Worker Responsibilities

Premium Payment program and spenddown

Health insurance premiums being paid on an individual's behalf by the Premium Payment program at HCA are still considered an income deduction for the Medically Needy program. Indicate the amount of the health insurance premium on the MEDX screen in ACES. Medicare premiums and related coinsurance expenses are not indicated on the MEDX screen in ACES but may be applied toward spenddown as the expenses are incurred.

All Medicare premium expenses under Part A, Part B, Part C, and Part D are entered as a spenddown expense in ACES online as the expenses are incurred. For initial applications, allow the first 2 months of premiums as a deduction if the individual has incurred the expense and they do not have coverage under a Medicare Savings program that is paying the expense on their behalf.

After April 2009, Medicare Part C premiums were no longer allowed as a health insurance deduction on the MEDX screen.

Some public programs use non-federal dollars to purchase private health insurance on behalf of individuals. When a public program verifies payment of a health insurance premium on behalf of a Spenddown individual, the worker needs to redetermine eligibility under the MN program using the expense as an income deduction and not a spenddown expense. In some cases, individuals will become eligible for Medically Needy (MN) with no spenddown liability and should be approved for a 12 month certification. In other cases, the spenddown liability will be reduced by the health insurance premium amount. Make sure a new letter is generated to indicate this change.

Department of Health (DOH) HIV/AIDS early intervention program and the Evergreen Health Insurance program are considered public programs for spenddown. DOH will verify expenses incurred or paid by these programs on behalf of spenddown individuals. These expenses are to be used toward meeting the individual's spenddown liability.

Related Link

Premium payment program

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Stella Ng

WAC 182-531-0425 Collaborative Care

WAC 182-531-0425 Collaborative Care

Effective November 23, 2024

  1. Under the authority of RCW 74.09.497, and subject to available funds, the medicaid agency covers collaborative care provided in clinical care settings.
  2. For the purposes of this section:
    1. Collaborative care means a specific type of integrated care where medical providers and behavioral health providers work together to address behavioral health conditions, including mental health conditions and substance use disorders.
    2. Collaborative care model is a model of behavior health integration that enhances usual primary care by adding two key services:
      1. Care management support for patients receiving behavioral health treatment; and 
      2. Regular psychiatric consultation with the primary care team, particularly clients whose conditions are not improving.
    3. Collaborative care team means a team of licensed behavioral health professionals operating within their scope of practice who participate on the clinical care team along with the collaborative care billing provider to provide collaborative care to eligible clients. The team must include a collaborative care billing provider, a behavioral health care manager, and a psychiatric consultant. Professionals making up this team include, but are not limited to:
      1. Advanced registered nurses;
      2. Substance use disorder professionals (SUDP);
      3. Substance use disorder professional trainees (SUDPT) under the supervision of a certified SUDP;
      4. Marriage and family therapists;
      5. Marriage and family therapist associates under the supervision of a licensed marriage and family therapist or equally qualified mental health practitioner;
      6. Mental health counselors;
      7. Mental health counselor associates under the supervision of a licensed mental health counselor, psychiatrist, or physician;
      8. Physicians;
      9. Physician assistants;
      10. Psychiatrists;
      11. Psychiatric advanced registered nurses;
      12. Psychologists;
      13. Registered nurses;
      14. Social workers;
      15. Social worker associate-independent clinical, under the supervision of a licensed independent clinical social worker or equally qualified mental health practitioner; and 
      16. Social worker associate-advanced, under the supervision of a licensed independent clinical social worker, advanced social worker, or equally qualified mental health practitioner;
  3. The behavioral health care manager is a designated licensed professional with formal education or specialized training in behavioral health (including social work, nursing, or psychology), working under the oversight and direction of the treating medical provider.
  4. The collaborative care billing provider must meet all of the following: 
    1. Be enrolled with the agency as one of the following:
      1. A physician licensed under Titles 18 RCW and 246 WAC;
      2. An advanced registered nurse practitioner licensed under Titles 18 RCW and 246 WAC;
      3. A federally qualified health center (FQHC);
      4. A rural health clinic (RHC); or
      5. A clinic that is not an FQHC or RHC that meets the requirements of Titles 70 RCW and 247 WAC.
    2. Complete, sign, and return the Attestation for Collaborative Care Model, form HCA 13-0017, to the agency; and
    3. Agree to follow the agency's guidelines for practicing a collaborative care model.
  5. Providers of collaborative care must:
    1. Use a registry to track the client's clinical outcomes;
    2. Use at least one validated clinical rating scale;
    3. Ensure the registry is used in conjunction with the practice's electronic health records (EHR);
    4. Include a plan of care; and
    5. Identify outcome goals of the treatments.
  6. If a provider no longer meets the agreed upon requirements in the agency's Attestation for Collaborative Care Model, form HCA 13-0017, the provider must immediately notify the agency. The agency does not pay for collaborative care if a provider does not meet the agreed upon requirements.
  7. Providers are subject to post pay review by the agency. The agency may recoup payment if the provider is found to have not met the requirements for providing collaborative care as agreed to in the agency's Attestation for Collaborative Care Model, form HCA 13-0017.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

WAC 182-546-4600 Ambulance transportation - Involuntary substance use disorder treatment - Ricky Garcia Act

WAC 182-546-4600 Ambulance transportation—Involuntary substance use disorder treatment—Ricky Garcia Act.

Effective November 8, 2018

  1. Definitions. For the purposes of this section, the following definitions and those found in chapter 182-500 WAC apply:
    1. "Behavioral health organization (BHO)" - See WAC 182-500-0015.
    2. "Chemical dependency professional" means a person certified as a chemical dependency professional by the department of health (DOH) under chapter 18.205 RCW.
    3. "Designated crisis responder (DCR)" means a mental health professional appointed by the behavioral health organization (BHO) to perform the duties described in chapter 71.05 RCW.
    4. "Detention" or "detain" means the lawful confinement of a person, under chapter 71.05 RCW.
    5. "Gravely disabled" means a condition in which a person, as a result of a mental disorder, or as the result of the use of alcohol or other psychoactive chemicals:
      1. Is in danger of serious physical harm as a result of being unable to provide for personal health or safety; or
      2. Shows repeated and escalating loss of cognitive control over personal actions and is not receiving care essential for personal health or safety.
    6. "Less restrictive alternative treatment" means a program of individualized treatment in a less restrictive setting than inpatient treatment and that includes the services described in RCW 71.05.585.
    7. "Nearest and most appropriate destination" means the nearest facility able and willing to accept the involuntarily detained person for treatment, not the closest facility based solely on driving dis­tance.​
    8. "Secure detoxification facility" means a facility operated by either a public or private agency that:
      1. Provides for intoxicated people:
        1. Evaluation and assessment by certified chemical dependency professionals;
        2. Acute or subacute detoxification services;
        3. Discharge assistance by certified chemical dependency profes­sionals, including assistance with transitions to appropriate volunta­ry or involuntary inpatient services, or to less-restrictive alterna­tives appropriate for the client;
      2. Includes security measures sufficient to protect the pa­tients, staff, and community; and
      3. Is certified as a secure withdrawal management and stabili­zation facility by the department of health (DOH).
  2. For a client involuntarily detained for substance use disor­der (SUD) treatment, the agency covers transportation services under the ITA when the client has been assessed by a DCR and found to be one of the following:
    1. A danger to self;
    2. A danger to others;
    3. At substantial risk of inflicting physical harm upon the property of others; or
    4. Gravely disabled as a result of SUD.
  3. The agency pays for transportation under this section only when the transportation is:
    1. From one of the following locations:
      1. The site of the initial detention;
      2. A local emergency room department;
      3. A court hearing; or
      4. A secure detoxification facility or crisis response center.
    2. To one of the following locations:
      1. A less restrictive alternative setting, except when ambulance transportation to a client's home is not covered;
      2. A local emergency room department;
      3. A court hearing; or
      4. A secure detoxification facility or crisis response center.
    3. Provided by an ambulance transportation provider or law en­forcement. The ambulance transportation provider must have an active core provider agreement (CPA) with the agency.
    4. To the nearest and most appropriate destination. The reason for a diversion to a more distant facility must be clearly documented in the client's file.
  4. The DCR authorizes the treatment destination based on the client's legal status.
  5. A copy of the agency's authorization of ambulance/secure transportation services under the Involuntary Treatment Act (ITA) form (HCA 42-0003) must be completed and signed by the DCR and kept in the client's file.
  6. The agency establishes payment for SUD-related transportation services when the transportation provider complies with the agency's requirements for drivers, driver training, vehicle and equipment standards and maintenance. Providers must clearly identify ITA trans­portation on the claim when billing the agency.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

WAC 182-516-0400 Promissory notes and loans.

WAC 182-516-0400 Promissory notes and loans.

Effective March 2, 2018

  1. General.
    1. In this section, note includes promissory note, loan or other obligation to pay.
    2. The medicaid agency or the agency's designee determines the value of outstanding principal and interest payments using amortization schedules, unless otherwise stated in this section.
  2. A note as a resource.
    1. A note is a resource. The value of the note is the fair market value (FMV).
    2. The FMV of a note is the outstanding principal of the note, unless convincing evidence to the contrary is provided to the agency or the agency's designee.
    3. If the note owner provides convincing evidence to the agency or the agency's designee of a legal bar to the sale of the note, the note's FMV is zero.
  3. A note as income.
    1. Interest on a note is unearned income.
    2. If the FMV of the note under subsection (2)(c) of this section is zero, the principal portion of recurring payments is unearned income.
    3. The agency or the agency's designee may budget the unearned income in equal monthly amounts at the request of the note owner, or at the agency's or the agency's designee's discretion. The budgeting period will be the note owner's certification period under chapter 182-504 WAC.
  4. A note as an asset transfer under WAC 182-513-1363.
    1. Subject to (b) of this subsection:
      1. The agency or the agency's designee evaluates the purchase of a note as an asset transfer if the purchase price of the note exceeds the FMV of the note;
      2. The value of the asset transfer is the difference between the purchase price of the note and the FMV of the note at the time of purchase; and
      3. The agency or the agency's designee determines the FMV of the note at the time of purchase using subsection (2) of this section, but can also determine the FMV of the note at a time after purchase if the agency or the agency's designee determines FMV of the note has changed since the time it was purchased.
    2. The assets used to purchase a note are an uncompensated asset transfer under WAC 182-513-1363, unless the note:
      1. Prohibits the cancellation of the balance of the note upon death of the note owner; and
      2. Is paid out, in equal periodic amounts with no deferral and no balloon payments, over a term not greater than the actuarial life expectancy of that note owner.
    3. The value of the uncompensated asset transfer under (b) of this subsection is the outstanding balance of the note due as of the date of the client's application for medical assistance for institutional or home and community-based waiver services.
    4. If the purchase of a note results in a period of ineligibili­ty under both (a) and (b) of this subsection, then the period of in­ eligibility under WAC 182-513-1363 will be the period that is longer.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

WAC 182-516-0145 Irrevocable trusts containing both assets of the beneficiary and third-party assets.

WAC 182-516-0145 Irrevocable trusts containing both assets of the beneficiary and third-party assets.

Effective January 27, 2019

  1. For irrevocable trusts that contain both assets of the beneficiary and third-party assets, the medicaid agency or the agency's designee treats the assets of the beneficiary under the self-settled trust rule in effect as of the date of the trust's establishment:
    1. After August 11, 1993:
      1. For irrevocable self-settled trusts for a disabled client under age sixty-five, see WAC 182-516-0120;
      2. For irrevocable pooled self-settled trusts for a disabled client, see WAC 182-516-0125; and
      3. For all other trusts, see WAC 182-516-0130.
    2. Before August 11, 1993, see WAC 182-516-0135.
  2. For irrevocable trusts that contain both assets of the beneficiary and third-party assets, the agency or the agency's designee treats third-party assets under the third-party trust rules under WAC 182-516-0140.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

WAC 182-516-0140 Third-party trusts

WAC 182-516-0140 Third-party trusts.

Effective March 2, 2018

  1. This section governs third-party trust as defined under WAC 182-516-0001.
  2. A trust containing the assets of a beneficiary's spouse may be a self-settled trust based on the date it was established. For specific rules regarding this, see WAC 182-516-0130.
  3. A testamentary trust is a third-party trust created by a will where the trust is in the will and the estate is the grantor.
  4. There is no requirement for a state to be named as a remainder beneficiary in third-party trusts.
  5. If the beneficiary has the power to acquire the assets from the third-party trust, the trust is an available resource.
  6. If the beneficiary has no power to access or control trust assets or distributions, as described under WAC 182-516-0105(4), a third-party trust is not an available resource.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

WAC 182-516-0135 Self-settled trusts established before August 11, 1993.

WAC 182-516-0135 Self-settled trusts established before August 11, 1993.

Effective March 2, 2018

  1. A revocable or irrevocable self-settled trust established before August 11, 1993, under this section is one:
    1. Established other than by will by a beneficiary or that bene­ficiary's spouse;
    2. Under which that beneficiary may be the beneficiary of all or part of the payments from the trust; and
    3. Under which the distribution of those payments is determined by one or more trustees who are permitted to exercise any discretion with respect to the distribution to the beneficiary.
  2. For trusts established under subsection (1) of this section, the maximum value the trustee may distribute, under any circumstances, to the beneficiary is unearned income.
  3. If a trust does not meet subsection (1)(c) of this section:
    1. The trust is an available resource to the extent that trust assets can be used for the beneficiary; and
    2. Any asset that cannot be used for the beneficiary is an un­ compensated asset transfer.
  4. This section does not apply to any trust or initial trust de­cree established before April 7, 1986, for the sole benefit of an intellectually disabled client who resides in an intermediate care fa­cility for the intellectually disabled.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

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