WAC 182-513-1315 General eligibility requirements for long-term care (LTC) programs.

Effective February 20, 2017

This section lists the sections in this chapter that describe how the agency determines a person's eligibility for long-term care services. These sections are:

1. WAC 182-513-1316 General eligibility requirements for long-term care (LTC) programs.
2. WAC 182-513-1317 Income and resource criteria for an institutionalized person.
3. WAC 182-513-1318 Income and resource criteria for home and community based (HCB) waiver programs and hospice.
4. WAC 182-513-1319 State-funded programs for noncitizens who are not eligible for a federally funded program.

WAC 182-513-1316 General eligibility requirements for long-term care (LTC) programs.

Effective February 20, 2017

1. To be eligible for long-term care (LTC) services, a person must:
   1. Meet the general eligibility requirements for medical programs under WAC 182-503-0505, except:
      1. An adult age nineteen or older must meet citizenship and immigration status requirements under WAC 182-503-0535 (2)(a) or (b);
      2. A person under age nineteen must meet citizenship and immigration status requirements under WAC 182-503-0535 (2)(a), (b), (c), or (d); and
      3. If a person does not meet the requirements in (a)(i) or (ii) of this subsection, the person is not eligible for medicaid and must have eligibility determined under WAC 182-513-1319.
   2. Attain institutional status under WAC 182-513-1320;
   3. Meet the functional eligibility under:
      1. Chapter 388-106 WAC for a home and community services (HCS) home and community based (HCB) waiver or nursing facility coverage; or
      2. Chapter 388-828 WAC for developmental disabilities administration (DDA) HCB waiver or institutional services; and
   4. Meet either:
      1. SSI-related criteria under WAC 182-512-0050; or
      2. MAGI-based criteria under WAC 182-503-0510(2), if residing in a medical institution. A person who is eligible for MAGI-based coverage is not subject to the provisions under subsection (2) of this section.
2. A supplemental security income (SSI) recipient or a person meeting SSI-related criteria who needs LTC services must also:
   1. Not have a penalty period of ineligibility due to the transfer of assets under WAC 182-513-1363;
   2. Not have equity interest in a primary residence greater than the home equity standard under WAC 182-513-1350; and
   3. Disclose to the agency or its designee any interest the applicant or spouse has in an annuity, which must meet annuity requirements under chapter 182-516 WAC.
3. A person who receives SSI must submit a signed health care coverage application form attesting to the provisions under subsection (2) of this section. A signed and completed eligibility review for LTC benefits can be accepted for people receiving SSI who are applying for long-term care services.
4. To be eligible for HCB waiver services, a person must also meet the program requirements under:
   1. WAC 182-515-1505 through 182-515-1509 for HCS HCB waivers; or
   2. WAC 182-515-1510 through 182-515-1514 for DDA HCB waivers.

WAC 182-513-1317 Income and resource criteria for an institutionalized person.

Effective February 20, 2017

1. This section provides an overview of the income and resource eligibility rules for a person who lives in an institutional setting.
2. To determine income eligibility for an SSI-related long-term care (LTC) applicant under the categorically needy (CN) program, the agency or its designee:
   1. Determines available income under WAC 182-513-1325 and 182-513-1330;
   2. Excludes income under WAC 182-513-1340; and
   3. Compares remaining available income to the special income level (SIL) defined under WAC 182-513-1100. A person's available income must be equal to or less than the SIL to be eligible for CN coverage.
3. To determine income eligibility for an SSI-related LTC client under the medically needy (MN) program, the agency or its designee follows the income standards and eligibility rules under WAC 182-513-1395.
4. To be resource eligible under the SSI-related LTC CN or MN program, the person must:
   1. Meet the resource eligibility requirements under WAC 182-513-1350;
   2. Not have a penalty period of ineligibility due to a transfer of assets under WAC 182-513-1363;
   3. Disclose to the state any interest the person or the person's spouse has in an annuity, which must meet the annuity requirements under chapter 182-516 WAC.
5. A resident of eastern or western state hospital is eligible for medicaid if the person:
   1. Has attained institutional status under WAC 182-513-1320; and
   2. Is under age twenty-one; or
   3. Applies for or receives inpatient psychiatric treatment in the month of the person's twenty-first birthday that will likely continue through the person's twenty-first birthday, and can receive coverage until:
      1. The facility discharges the person; or
      2. The end of the month in which the person turns age twenty-two, whichever occurs first; or(d) Is at least age sixty-five.
6. To determine long-term care CN or MN income eligibility for a person eligible under a MAGI-based program, the agency or its designee follows the rules under chapter 182-514 WAC.
7. There is no asset test for MAGI-based LTC programs under WAC 182-514-0245.
8. The agency or its designee determines a person's total responsibility to pay toward the cost of care for LTC services as follows:
   1. For an SSI-related person residing in a medical institution, see WAC 182-513-1380;
   2. For an SSI-related person on a home and community based waiver, see chapter 182-515 WAC.

WAC 182-513-1318 Income and resource criteria for home and community based (HCB) waiver programs and hospice.

Effective February 20, 2017

1. This section provides an overview of the income and resource eligibility rules for a person to be eligible for a categorically needy (CN) home and community based (HCB) waiver program under chapter 182-515 WAC or the hospice program under WAC 182-513-1240 and 182-513-1245.
2. To determine income eligibility for an SSI-related long-term care (LTC) HCB waiver, the agency or its designee:
   1. Determines income available under WAC 182-513-1325 and 182-513-1330;
   2. Excludes income under WAC 182-513-1340;
   3. Compares remaining gross nonexcluded income to:
      1. The special income level (SIL) defined under WAC 182-513-1100; or
      2. For HCB service programs authorized by the aging and long-term supports administration (ALTSA), a higher standard is determined following the rules under WAC 182-515-1508 if a client's income is above the SIL but net income is below the medically needy income level (MNIL).
3. A person who receives MAGI-based coverage is not eligible for HCB waiver services unless found eligible based on program rules in chapter 182-515 WAC.
4. To be resource eligible under the HCB waiver program, the person must:
   1. Meet the resource eligibility requirements and standards under WAC 182-513-1350;
   2. Not be in a period of ineligibility due to a transfer of asset penalty under WAC 182-513-1363;
   3. Disclose to the state any interest the person or that person's spouse has in an annuity and meet the annuity requirements under chapter 182-516 WAC.
5. The agency or its designee determines a person's responsibility to pay toward the cost of care for LTC services as follows:
   1. For people receiving HCS HCB waiver services, see WAC 182-515-1509;
   2. For people receiving DDA HCB waiver services, see WAC 182-515-1514.
6. To be eligible for the CN hospice program, see WAC 182-513-1240.
7. To be eligible for the MN hospice program in a medical institution, see WAC 182-513-1245.

WAC 182-513-1319 State-funded programs for noncitizens who are not eligible for a federally funded program.

Effective February 20, 2017

1. This section describes the state-funded programs available to a person who does not meet the citizenship and immigration status criteria under WAC 182-513-1316 for federally funded coverage.
2. If a person meets the eligibility and incapacity criteria of the medical care services (MCS) program under WAC 182-508-0005, the person may receive nursing facility care or state-funded residential services in an alternate living facility (ALF).
3. Noncitizens age nineteen or older may be eligible for the state-funded long-term care services program under WAC 182-507-0125. A person must be preapproved by the aging and long-term support administration (ALTSA) for this program due to enrollment limits.
4. Noncitizens under age nineteen who meet citizenship and immigration status under WAC 182-503-0535 (2)(e) are eligible for:
   1. Nursing facility services if the person meets nursing facility level of care; or
   2. State-funded personal care services if functionally eligible based on a department assessment under chapter 388-106 or 388-845 WAC.

WAC 182-512-0350 SSI-related medical -- Property and contracts excluded as resources.

Effective November 14, 2019.

1. The agency excludes the following resources when determining eligibility for SSI-related medical assistance:
   1. A client's household goods and personal effects;
   2. One home (which can be any shelter), including the land on which the dwelling is located, and all contiguous property and related out-buildings in which the client has ownership interest for long-term care programs, see WAC 182-513-1350 for home equity limits, when:
      1. The client uses the home as a primary residence;
      2. The client's spouse lives in the home;
      3. The client does not currently live in the home, but the client or the client's representative has stated the client intends to return to the home; or
      4. A relative, who is financially or medically dependent on the client, lives in the home and either the dependency is documented or a written statement of dependency is provided by the client, the client's authorized representative, or by the client's dependent relative.
   3. The value of ownership interest in jointly owned real property is an excluded resource for as long as sale of the property would cause undue hardship to a co-owner due to loss of housing. Undue hardship would result if the co-owner:
      1. Uses the property as the client's principal place of residence;
      2. Would have to move if the property were sold; and
      3. Has no other readily available housing.
2. Proceeds from the sale of an interest described in subsection (1)(b) of this section, are excluded as a resource if the client uses the proceeds to purchase another home by the end of the third month after receiving the proceeds from the sale.
3. An installment contract from the sale of the home described in subsection (1)(b) above is not a resource as long as the client plans to use the entire down payment and the entire principal portion of a given installment payment to buy another excluded home, and does so within three months after the month of receiving such down payment or installment payment.
4. The value of sales contracts is excluded when the:
   1. Current market value of the contract is zero;
   2. Contract cannot be sold; or
   3. Current market value of the sales contract combined with other resources does not exceed the resource limits.
5. Sales contracts executed before December 1, 1993, are excluded resources as long as they are not transferred to someone other than a spouse.
6. A sales contract for the sale of the client's principal place of residence executed between December 1, 1993, and May 31, 2004, is an excluded resource unless it has been transferred to someone other than a spouse and it:
   1. Provides interest income within the prevailing interest rate at the time of the sale;
   2. Requires the repayment of a principal amount equal to the fair market value of the property; and
   3. The term of the contract does not exceed thirty years.
7. A sales contract executed on or after June 1, 2004, on a home that was the principal place of residence for the client at the time of institutionalization is an excluded resource as long as it is not transferred to someone other than a spouse and it:
   1. Provides interest income within the prevailing interest rate at the time of the sale;
   2. Requires the repayment of a principal amount equal to the fair market value of the property within the anticipated life expectancy of the client; and
   3. The term of the contract does not exceed thirty years.
8. Payments received on sales contracts of the home described in subsection (1)(b) of this section are treated as follows:
   1. The interest portion of the payment is treated as unearned income in the month of receipt of the payment;
   2. The principal portion of the payment is treated as an excluded resource if reinvested in the purchase of a new home within three months after the month of receipt;
   3. If the principal portion of the payment is not reinvested in the purchase of a new home within three months after the month of receipt, that portion of the payment is a liquid resource as of the date of receipt.
9. Payments received on sales contracts described in subsection (4) of this section are treated as follows:
   1. The principal portion of the payment on the contract is treated as a resource and counted toward the resource limit to the extent retained at the first moment of the month following the month of receipt of the payment; and
   2. The interest portion is treated as unearned income the month of receipt of the payment.
10. For sales contracts that meet the criteria in subsection (5), (6), or (7) of this section but do not meet the criteria in subsection (3) or (4) of this section, both the principal and interest portions of the payment are treated as unearned income in the month of receipt.
11. Property essential to self-support (PESS) is excluded as a resource within certain limits. There are three categories of PESS:
    1. Real and personal property used in a trade or business:
       1. That is a resource defined under WAC 182-512-0200;
       2. That is in current use as described under the Social Security Administration's Program Operations Manual System (POMS) SI 01130.504; and
       3. Where the trade or business is a sole proprietorship or simple partnership.
    2. Nonbusiness income-producing property (i.e., property not used in a trade or business), such as:
       1. Houses or apartments for rent; and
       2. Land, other than home property.
    3. Property used to produce goods or services essential to a client's daily activities, such as land used to produce vegetables or livestock, which is used only for personal consumption in the client's household. This includes personal property necessary to perform daily functions including vehicles such as boats for subsistence fishing and garden tractors for subsistence farming, but does not include other vehicles such as those that qualify as automobiles (e.g., cars, trucks).
12. The agency excludes a client's real and personal property used in a trade or business, described under subsection (11)(a) of this section, regardless of value as long as it is in current use (as described under POMS SI 01130.504) in the trade or business and remains used in the trade or business.
13. The agency excludes up to $6,000 of a client's equity in nonbusiness income-producing property, described under subsection (11)(b) of this section, if it produces a net annual income to the client of at least six percent of the excluded equity.
    1. If a client's equity in the property is over $6,000, only the amount over $6,000 is counted toward the resource limit, as long as the net annual income requirement of six percent is met on the excluded equity.
    2. If the six percent requirement is not met due to circumstances beyond the client's control (e.g., illness), and there is a reasonable expectation that the activities will again meet the six percent rule, the same exclusions as in subsection (13)(a) of this section apply.
    3. If a client has more than one piece of real property in this category, each is independently evaluated to see if it meets the six percent return, and the total equities of all those properties are added to see if the total is over $6,000. If the total is over the $6,000 limit, the amount exceeding the limit is counted toward the resource limit.
    4. The equity in each property that does not meet the six percent annual net income limit is counted toward the resource limit, with the exception of property that represents the authority granted by a governmental agency to engage in an income-producing activity if it is:
       1. Used in a trade or business or nonbusiness income-producing activity; or
       2. Not used due to circumstances beyond the client's control (e.g., illness), and there is a reasonable expectation that the use will resume.
14. Property used to produce goods or services essential to a client's daily activities is excluded if the client's equity in the property does not exceed $6,000.
15. Personal property used by a client as an employee for work is not counted toward the resource limit, regardless of value, while in current use (as described under POMS SI 01130.504), or if the required use for work is reasonably expected to resume.
16. Interests in trust or in restricted Indian land owned by a client who is of Indian descent from a federally recognized Indian tribe or held by the spouse or widow/er of that client, is not counted toward the resource limit if permission of the other people, the tribe, or an agency of the federal government must be received in order to dispose of the land.
17. Receipt of money by a member of a federally recognized tribe from exercising federally protected rights or extraction of excluded resources, such as fishing, shell-fishing, or selling timber from protected land, is considered conversion of an excluded resource during the month of receipt. Any amount remaining from the conversion of this excluded resource on the first of the month after the month of receipt will remain excluded if it is used to purchase another excluded resource. Any amount remaining in the form of a countable resource (such as in a checking or savings account) on the first of the month after receipt, will be added to other countable resources for eligibility determinations.

WAC 182-512-0400 SSI-related medical -- Vehicles excluded as resources.

Effective February 20, 2017.

1. For SSI-related medical programs, a vehicle is defined as anything used for transportation. In addition to cars and trucks, a vehicle can include boats, snowmobiles, and animal-drawn vehicles.
2. One vehicle is excluded regardless of its value, if it is used to provide transportation for the SSI-related person or a member of the person's household.
3. A vehicle used as the person's primary residence is excluded as the home, and does not count as the one excluded vehicle under subsection (2) of this section.

WAC 182-512-0450 SSI-related medical -- Life insurance excluded as a resource.

Effective April 14, 2014.

1. The agency excludes life insurance policies that do not have or cannot accrue a cash surrender value (CSV) in determining whether owned policies exceed the life insurance exclusion limits for resources and in determining burial fund exclusion limits.
2. Policies owned by each spouse are evaluated and counted separately.
3. If the total face value of all policies with a CSV potential that a person owns on the same insured is equal to or less than fifteen hundred dollars, the resource is excluded.
4. If the total face value of all policies with a CSV potential that a person owns on the same insured is more than fifteen hundred dollars, the total CSV of the policies is counted toward the resource limit, unless the person designates such policies as burial funds. If they are designated as burial funds, they must be evaluated under the burial fund exclusion described in WAC 182-512-0500.

WAC 182-512-0500 SSI-related medical -- Burial funds, contracts and spaces excluded as resources.

Effective June 11, 2023.

1. For the purposes of this section, burial funds are funds set aside and clearly designated solely for burial and related expenses, and kept separate from all other resources not intended for burial. These include:
   1. Revocable burial contracts;
   2. Revocable burial trusts; or
   3. Other revocable burial arrangements. The designation is effective the first day of the month in which the person intended the funds to be set aside for burial.
2. Burial funds in a revocable burial contract, burial trust, cash accounts, or other financial instruments with a definite cash value are excluded as resources for the person and their spouse, up to $1,500 each, when set aside solely for burial or cremation and related expenses.
3. Interest earned in burial funds and appreciation in the value of excluded burial arrangements in subsection (2) of this section are excluded from resources and are not counted as income if left to accumulate and become part of the separate burial fund.
4. An irrevocable burial account, burial trust, or other irrevocable burial arrangement, set aside solely for burial and related expenses, is not considered a resource. To be excluded, the amount set aside must be reasonably related to the anticipated death-related expenses.
5. The $1,500 exclusion for burial funds described in subsection (2) of this section is reduced by:
   1. The face value of life insurance with CSV excluded in WAC 182-512-0450; and
   2. Amounts that meet the requirements of subsection (4) of this section.
6. A person's burial funds are no longer excluded when they are mixed with other resources that are not related to burial.
7. When excluded burial funds are spent for other purposes, the spent amount is added to other countable resources and any amount exceeding the resource limit is considered available income on the first of the month it is used. The amount remaining in the burial fund remains excluded.
8. Burial space and accessories for the person and any member of the person's immediate family described in subsection (9) of this section are excluded. Burial space and accessories include:
   1. Conventional gravesites;
   2. Crypts, niches, and mausoleums;
   3. Urns, caskets and other repositories customarily used for the remains of deceased persons;
   4. Necessary and reasonable improvements to the burial space including, but not limited to:
      1. Vaults and burial containers;
      2. Headstones, markers and plaques;
      3. Arrangements for the opening and closing of the gravesite; and
      4. Contracts for care and maintenance of the gravesite.
   5. A burial space purchase agreement that is fully or partially paid, and any accrued interest.
9. Immediate family, for the purposes of subsection (8) of this section includes the person's:
   1. Spouse;
   2. Parents and adoptive parents;
   3. Minor and adult children, including adoptive and stepchildren;
   4. Siblings (brothers and sisters), including adoptive and stepsiblings;
   5. Spouses of any of the above.

None of the family members listed above, need to be dependent on or living with the person, to be considered immediate family members.

WAC 182-512-0550 SSI-related medical — All other excluded resources.

Effective June 4, 2021.

All resources described in this section are excluded resources for SSI-related medical programs. Unless otherwise stated, interest earned on the resource amount is counted as unearned income.

1. Resources necessary for a person who is blind or disabled to fulfill a self-sufficiency plan approved by the agency.
2. Retroactive payments from SSI or old age, survivors, and disability insurance (OASDI), including benefits a person receives under the interim assistance reimbursement agreement with the Social Security Administration, are excluded for nine months following the month of receipt. This exclusion applies to:
   1. Payments received by the person, the person's spouse, or any other person financially responsible for the person;
   2. SSI payments for benefits due for the month(s) before the month of continuing payment;
   3. OASDI payments for benefits due for a month that is two or more months before the month of continuing payment; and
   4. Proceeds from these payments as long as they are held as cash, or in a checking or savings account. The funds may be commingled with other funds, but must remain identifiable from the other funds for this exclusion to apply. This exclusion does not apply once the payments have been converted to any other type of resource.
3. All resources specifically excluded by federal law, such as those described in subsections (4) through (11) of this section as long as such funds are identifiable.
4. Payments made under Title II of the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970.
5. The excluded resources described in WAC 182-512-0770 and other resources of American Indians/Alaska Natives that are excluded by federal law.
6. Restitution payment and any interest earned from this payment to persons of Japanese or Aleut ancestry who were relocated and interned during war time under the Civil Liberties Act of 1988 and the Aleutian and Pribilof Islands Restitution Act.
7. Funds received from the Agent Orange Settlement Fund or any other funds established to settle Agent Orange liability claims.
8. Payments or interest accrued on payments received under the Radiation Exposure Compensation Act received by the injured person, the surviving spouse, children, grandchildren, or grandparents.
9. Payments or interest accrued on payments received under the Energy Employees Occupational Illness Compensation Act of 2000 (EEOICA) received by the injured person, the surviving spouse, children, grandchildren, or grandparents.
10. Payments from:
    1. The Dutch government under the Netherlands' Act on Benefits for Victims of Persecution (WUV).
    2. The Victims of Nazi Persecution Act of 1994 to survivors of the Holocaust.
    3. Susan Walker vs. Bayer Corporation, et al., 96-C-5024 (N.D. Ill.) (May 8, 1997) settlement funds.
    4. Ricky Ray Hemophilia Relief Fund Act of 1998 P.L. 105-369.
11. The unspent social insurance payments received due to wage credits granted under sections 500 through 506 of the Austrian General Social Insurance Act.
12. Tax refunds and earned income tax credit refunds and payments are excluded as resources for twelve months after the month of receipt.
13. Payments from a state administered victim's compensation program for a period of nine calendar months after the month of receipt.
14. Cash or in-kind items received as a settlement for the purpose of repairing or replacing a specific excluded resource are excluded:
    1. For nine months. This includes relocation assistance provided by state or local government.
    2. Up to a maximum of thirty months, when:
       1. The person intends to repair or replace the excluded resource; and
       2. Circumstances beyond the control of the settlement recipient prevented the repair or replacement of the excluded resource within the first or second nine months of receipt of the settlement.
    3. For an indefinite period, if the settlement is from federal relocation assistance.
    4. Permanently, if the settlement is assistance received under the Disaster Relief and Emergency Assistance Act or other assistance provided under a federal statute because of a catastrophe which is declared to be a major disaster by the President of the United States, or is comparable assistance received from a state or local government or from a disaster assistance organization. Interest earned on this assistance is also excluded from resources. Any cash or in-kind items received as a settlement and excluded under this subsection are available resources when not used within the allowable time periods.
15. Insurance proceeds or other assets recovered by a Holocaust survivor.
16. Pension funds owned by an ineligible spouse. Pension funds are defined as funds held in a(n):
    1. Individual retirement account (IRA) as described by the IRS code; or
    2. Work-related pension plan (including plans for self-employed persons, known as Keogh plans).
17. Cash payments received from a medical or social service agency to pay for medical or social services are excluded for one calendar month following the month of receipt.
18. SSA- or division of vocational rehabilitation (DVR)-approved plans for achieving self-support (PASS) accounts, allowing blind or disabled persons to set aside resources necessary for the achievement of the plan's goals, are excluded.
19. Food and nutrition programs with federal involvement. This includes Washington Basic Food, school reduced and free meals and milk programs and WIC.
20. Gifts to, or for the benefit of, a person under eighteen years old who has a life-threatening condition, from an organization described in section 501 (c)(3) of the Internal Revenue Code of 1986 which is exempt from taxation under section 501(a) of that code, as follows:
    1. In-kind gifts that are not converted to cash; or
    2. Cash gifts up to a total of two thousand dollars in a calendar year.
21. Veteran's payments made to, or on behalf of, natural children of Vietnam veterans regardless of their age or marital status, for any disability resulting from spina bifida suffered by these children.
22. The following are among assets that are not resources and as such are neither excluded nor counted:
    1. Home energy assistance/support and maintenance assistance;
    2. Retroactive in-home supportive services payments to ineligible spouses and parents; and
    3. Gifts of domestic travel tickets.
23. Resources accumulated in a separate account, designated by the client, that result from work activity during the client's enrollment in apple health for workers with disabilities (HWD) program under chapter 182-511 WAC.
24. Limited to clients who have been or continue to be subject to participation as defined in WAC 182-513-1100 during the public health emergency (PHE), resources accumulated due to not increasing participation in response to section 6008(b) of the Families First Coronavirus Response Act (FFCRA) are excluded for:
    1. The duration of the PHE; and
    2. A period of twelve months after the PHE ends.
25. Resources listed in the program operations manual system (POMS), not otherwise excluded under this section, are excluded (see SSA POMS Section SI 01130.050 https://secure.ssa.gov/apps10/poms.nsf/lnx/0501130050).

WAC 182-512-0770 SSI-related medical -- American Indian or Alaska Native excluded income and resources.

Effective April 16, 2015.

1. The agency excludes the following types of income from being considered when determining eligibility for Washington apple health (WAH) categorically needy (CN) and medically needy (MN) SSI-related programs for American Indians or Alaska Natives:
   1. Distributions from Alaska Native corporations and settlement trusts;
   2. Distributions from any property held in trust, subject to federal restrictions, located within the most recent boundaries of a prior federal reservation, or otherwise under the supervision of the Secretary of the Interior;
   3. Distributions and payments from rents, leases, rights of way, royalties, usage rights, or natural resource extraction and harvest from:
      1. Rights of ownership or possession in any lands described in (b) of this subsection; or
      2. Federally protected rights regarding off-reservation hunting, fishing, gathering, or usage of natural resources.
   4. Distributions resulting from real property ownership interests related to natural resources and improvements that are:
      1. Located on or near a reservation or within the most recent boundaries of a prior federal reservation; or
      2. Resulting from the exercise of federally protected rights related to such real property ownership interests.
   5. Payments resulting from:
      1. Ownership interests in or usage rights to items that have unique religious, spiritual, traditional, or cultural significance; or
      2. Rights that support subsistence or a traditional lifestyle according to applicable tribal law or custom.
   6. Student financial assistance provided under the Bureau of Indian Affairs education programs; and
   7. Any other applicable income exclusion as provided by federal law, regulation, or rule.
2. The agency excludes the following types of resources from being considered when determining eligibility for WAH-CN and WAH-MN SSI-related programs for American Indians or Alaska Natives:
   1. Property, including real property and improvements, that is:
      1. Held in trust, subject to federal restrictions, or otherwise under the supervision of the Secretary of the Interior; and
      2. Located on a reservation, including any federally recognized Indian tribe's reservation, pueblo, or colony, including:
         1. Former reservations in Oklahoma;
         2. Alaska Native regions established by the Alaska Native Claims Settlement Act; and
         3. Indian allotments on or near a reservation as designated and approved by the Bureau of Indian Affairs of the Department of the Interior.
   2. Property located within the most recent boundaries of a prior federal reservation for any federally recognized tribe not described in (a) of this subsection;
   3. Ownership interests in rents, leases, royalties, or usage rights related to natural resources (including, but not limited to, extraction of natural resources or harvesting of timber, other plants and plant products, animals, fish and shellfish) resulting from the exercise of federally protected rights; and
   4. Ownership interests in or usage rights to items not covered in (a), (b), or (c) of this subsection that have unique religious, spiritual, traditional, or cultural significance or rights that support subsistence or a traditional lifestyle according to applicable tribal law or custom.
3. When determining eligibility for WAH-CN and WAH-MN SSI-related programs for American Indians or Alaska Natives, the agency counts or excludes amounts received by tribal members from exercise of gaming revenues (per capita distributions) that are retained after the month of receipt based on the type of resource in which the money is retained.  If the amounts are retained in a countable resource (for example, cash, checking account, or savings account), the agency treats the amounts as a countable resource.  If the amounts are converted to an excluded resource (for example, personal property like a refrigerator), the agency treats the amounts as excluded resources.

WAC 182-503-0005 Washington apple health -- How to apply.

Effective June 4, 2023

1. You may apply for Washington apple health at any time.
2. For apple health programs for children, pregnant people, parents and caretaker relatives, and adults age 64 and under without medicare, (including people who have a disability or are blind), you may apply:
   1. Online via the Washington Healthplanfinder at www.wahealthplanfinder.org;
   2. By calling the Washington Healthplanfinder customer support center and completing an application by telephone;
   3. By completing the application for health care coverage (HCA 18-001P), and mailing or faxing to Washington Healthplanfinder; or 
   4. At a department of social and health services (DSHS) community services office (CSO).
3. ​If you seek apple health coverage and are age 65 or older, have a disability, are blind, need assistance with medicare costs, or seek coverage of long-term services and supports, you may apply:
   1. Online via Washington Connection at www.WashingtonConnection.org;
   2. By completing the application for aged, blind, disabled/long-term care coverage (HCA 18-005) and mailing or faxing it to DSHS;
   3. By calling the DSHS customer service contact center and completing an application by telephone;
   4. In person at a local DSHS CSO or home and community services (HCS) office; or
   5. As specified in subsection (2) of this section, if you are a child, pregnant, a parent or caretaker relative, or an adult age 64 and under without medicare.
4. You may receive help filing an application.
   1. For households containing people described in subsection (2) of this section:
      1. Call the Washington Healthplanfinder customer support center number listed on the application for health care coverage form (HCA 18-001P); or 
      2. Contact a navigator, health care authority volunteer assistor, or broker.
   2. For people described in subsection (3) of this section who are not applying with a household containing people described in subsection (2) of this section:
      1. Call or visit a local DSHS CSO or HCS office; or 
      2. Call the DSHS community services customer service contact center number listed on the medicaid application form. 
5. To apply for tailored supports for older adults (TSOA), see WAC 182-513-1625.
6. You must apply directly with the service provider for the following programs:
   1. The breast and cervical cancer treatment program under WAC 182-505-0120;
   2. The family planning only programs under chapter 182-532 WAC; and
   3. The kidney disease program under chapter 182-540 WAC.
7. For the confidential pregnant minor program under WAC 182-505-0117 and for minors living independently, you must complete a separate application directly with us (the medicaid agency). More information on how to give us an application may be found at the agency's web site:  www.hca.wa.gov/free-or-low-cost-health-care (search for "teen").
8. As the primary applicant or head of household, you may start an application for apple health by providing your:
   1. Full name;
   2. Date of birth; 
   3. Physical address, and mailing addresses (if different); and
   4. Signature.
9. To complete an application for apple health, you must also give us all of the other information requested on the application.
10. You may have an authorized representative apply on your behalf as described in WAC 182-503-0130.
11. We help you with your application or renewal for apple health in a manner that is accessible to you. We provide equal access (EA) services as described in WAC 182-503-0120 if you:
    1. ​Ask for EA services, you apply for or receive long-term services and supports, or we determine that you would benefit from EA services; or
    2. Have limited-English proficiency as described in WAC 182-503-0110. 

WAC 182-503-0010 Washington apple health -- Who may apply.

Effective January 16, 2020.

1. You may apply for Washington apple health for yourself.
2. You may apply for apple health for another person if you are:
   1. A legal guardian;
   2. An authorized representative (as described in WAC 182-503-0130);
   3. A parent or caretaker relative of a child age eighteen or younger;
   4. A tax filer applying for a tax dependent;
   5. A spouse; or
   6. A person applying for someone who is unable to apply on their own due to a medical condition and who is in need of long-term care services.
3. If you reside in an institution of mental diseases (as defined in WAC 182-500-0050(1)) or a public institution (as defined in WAC 182-500-0050(4)), including a Washington state department of corrections facility, city, tribal, or county jail, or secure community transition facility or total confinement facility (as defined in RCW 71.09.020), you, your representative, or the facility may apply for you to get the apple health coverage for which you are determined eligible.
4. You are automatically enrolled in apple health and do not need to submit an application if you are a:
   1. Supplemental security income (SSI) recipient;
   2. Person deemed to be an SSI recipient under 1619(b) of the SSA;
   3. Newborn as described in WAC 182-505-0210; or
   4. Child in foster care placement as described in WAC 182-505-0211.
5. You are the primary applicant on an application if you complete and sign the application on behalf of your household.
6. If you are an SSI recipient, then you, your authorized representative as defined in WAC 182-500-0010, or another person applying on your behalf as described in subsection (2) of this section, must turn in a signed application to apply for long-term care services as described in WAC 182-513-1315.

WAC 182-503-0040 Washington apple health -- Interview requirements.

Effective July 25, 2013

1. An individual applying for Washington apple health (WAH) (as defined in WAC 182-500-0120) is not required to have an in-person interview to determine eligibility.
2. The agency or its designee may contact an individual by phone or in writing to gather any additional information that is needed to make an eligibility determination.
3. A phone or in-person interview is required to determine initial financial eligibility for WAH long-term care services.
4. The interview requirement described in subsection (3) of this section may be waived if the applicant is unable to comply:
   1. Due to his or her medical condition; or
   2. Because the applicant does not have a family member or another individual that is able to conduct the interview on his or her behalf.

WAC 182-503-0060 Washington apple health -- Application processing times.

Effective August 8, 2021

1. We process applications for Washington apple health medicaid within forty-five calendar days, with the following exceptions:
   1. If you are pregnant, we process your application within fifteen calendar days;
   2. If you are applying for a program that requires a disability decision, we process your application within sixty calendar days; or
   3. The modified adjusted gross income (MAGI)-based apple health application process using Washington Healthplanfinder may provide faster or real-time determination of eligibility for medicaid.
2. For calculating time limits, "day one" is the day we get an application from you that includes at least the information described in WAC 182-503-0005(8). If you give us your paper application during business hours, "day one" is the day you give us your application. If you give us your paper application outside of business hours, "day one" is the next business day. If you experience technical difficulties while attempting to give us your application in Washington Healthplanfinder, "day one" is the day we are able to determine, based on the evidence available, that you first tried to submit an application that included at least the information described in WAC 182-503-0005(8).
3. We determine eligibility as quickly as possible and respond promptly to applications and information received. We do not delay a decision by using the time limits in this section as a waiting period.
4. If we need more information to decide if you can get apple health coverage, we will send you a letter within twenty calendar days of your initial application that:
   1. Follows the rules in chapter 182-518 WAC;
   2. States the additional information we need; and
   3. Allows at least ten calendar days to provide it. We will allow you more time if you ask for more time or need an accommodation due to disability or limited-English proficiency.
5. Good cause for a delay in processing the application exists when we acted as promptly as possible but:
   1. The delay was the result of an emergency beyond our control;
   2. The delay was the result of needing more information or documents that could not be readily obtained;
   3. You did not give us the information within the time frame specified in subsection (1) of this section.
6. Good cause for a delay in processing the application does NOT exist when:
   1. We caused the delay in processing by:
      1. Failing to ask you for information timely; or
      2. Failing to act promptly on requested information when you provided it timely; or
   2. We did not document the good cause reason before missing a time frame specified in subsection (1) of this section. 

WAC 182-503-0070 Washington apple health (WAH)-- When coverage begins.

Effective August 29, 2014.

1. Your Washington apple health (WAH) coverage starts on the first day of the month you applied for and we decided you are eligible to receive coverage, unless one of the exceptions in subsection (4) of this section applies to you.
2. Sometimes we can start your coverage up to three months before the month you applied (see WAC 182-504-0005).
3. If you are confined or incarcerated as described in WAC 182-503-0010, your coverage cannot start before the day you are discharged, except when:
   1. You are hospitalized during your confinement; and
   2. The hospital requires you to stay overnight.
4. Your WAH coverage may not begin on the first day of the month if:
   1. Subsection (3) of this section applies to you. In that case, your coverage would start on the first day of your hospital stay;
   2. You must meet a medically needy spenddown liability (see WAC 182-519-0110). In that case, your coverage would start on the day your spenddown is met; or
   3. You are eligible under the WAH alien emergency medical program (see WAC 182-507-0115). In that case, your coverage would start on the day your emergent hospital stay begins.
5. For long-term care, the date your services start is described in WAC 388-106-0045.

WAC 182-503-0080 Washington apple health -- Application denials and withdrawals.

Effective November 3, 2019. 

1. We follow the rules about notices and letters in chapter 182-518 WAC. We follow the rules about timelines in WAC 182-503-0060.
2. We deny your application for apple health coverage when:
   1. You tell us either orally or in writing to withdraw your request for coverage; or
   2. Based on all information we have received from you and other sources within the time frames stated in WAC 182-503-0060, including any extra time given at your request or to accommodate a disability or limited-English proficiency:
      1. We are unable to determine that you are eligible; or
      2. We determine that you are not eligible.
   3. You are subject to asset verification and do not provide authorization as described in WAC 182-503-0055.
3. We send you a written notice explaining why we denied your application (per chapter 182-518 WAC).
4. We reconsider our decision to deny your apple health coverage without a new application from you when:
   1. We receive the information that we need to decide if you are eligible within thirty days of the date on the denial notice;
   2. You give us authorization to verify your assets as described in WAC 182-503-0055 within thirty days of the date on the denial notice;
   3. You request a hearing within ninety days of the date on the denial letter and an administrative law judge (ALJ) or HCA review judge decides our denial was wrong (per chapter 182-526 WAC).
5. If you disagree with our decision, you can ask for a hearing. If we denied your application because we do not have enough information, the ALJ will consider the information we already have and any more information you give us. The ALJ does not consider the previous absence of information or failure to respond in determining if you are eligible. 

WAC 182-527-2730 Definitions

Effective March 16, 2016

The following definitions apply to this chapter:

"Contract health service delivery area (CHSDA)" means the geographic area within which contract health services will be made available by the Indian health service to members of an identified Indian community who reside in the area as identified in 42 C.F.R. Sec. 136.21(d) and 136.22.

"Estate" means all property and any other assets that pass upon the client's death under the client's will or by intestate succession under chapter 11.04 or 11.62 RCW. The value of the estate will be reduced by any valid liability against the client's property when the client died. An estate also includes:

1. For a client who died after June 30, 1995, and before July 27, 1997, nonprobate assets as defined by RCW 11.02.005, except property passing through a community property agreement; or
2. For a client who died after July 26, 1997, and before September 14, 2006, nonprobate assets as defined by RCW 11.02.005.
3. For a client who died on or after September 14, 2006, nonprobate assets as defined by RCW 11.02.005 and any life estate interest held by the client immediately before death.

"Heir" means a person entitled to inherit a deceased client's property under a valid will accepted by the court, or a person entitled to inherit under the Washington state intestacy statute, RCW 11.04.015. 

Life estate" means an ownership interest in a property only during the lifetime of the person owning the life estate. 

"Lis pendens" means a notice filed in public records warning that title to certain real property is in litigation and the outcome of the litigation may affect the title.

"Long-term care services (LTC)" means, for the purposes of this chapter only, the services administered directly or through contract by the department of social and health services (DSHS) for clients of the home and community services division of DSHS and the developmental disabilities administration of DSHS including, but not limited to, nursing facility care and home and community services.

"Property" means everything a person owns, whether in whole or in part.

1. "Personal property" means any movable or intangible thing a person owns, whether in whole or in part; 
2. "Real property" means land and anything growing on, attached to, or built on it, excluding anything that may be removed without injury to the land;
3. "Trust property" means any type of property held in trust for the benefit of another.

"Qualified long-term care insurance partnership" means an agreement between the Centers for Medicare and Medicaid services (CMS) and the Washington state insurance commission which allows for the disregard of any assets or resources in an amount equal to the insurance benefit payments that are made to or on behalf of a person who is a beneficiary under a long-term care insurance policy that has been determined by the Washington state insurance commission to meet the requirements of section 1917 (b)(1)(C)(iii) of the act.

"Recover" or "recovery" means the agency or the agency's designee's receipt of funds to satisfy the client's debt.

WAC 182-527-2734 Liens during a client's lifetime.

Effective July 1, 2017

For the pur­poses of this section, the term "agency" includes the agency's desig­nee.

1. When the agency may file.
   1. The agency may file a lien against the property of a Washing­ton apple health client during the client's lifetime if:
      1. The client resides in a skilled nursing facility, intermedi­ate care facility for individuals with an intellectual disability, or other medical institution under WAC 182-500-0050;
      2. The agency determines that a client cannot reasonably be expected to return home because:
         1. The agency receives a physician's verification that the client will not be able to return home; or
         2. The client has resided for six months or longer in an institution as defined in WAC 182-500-0050; and
      3. None of the following people lawfully reside in the client's home:
         1. The client's spouse or state-registered domestic partner;
         2. The client's child who is age twenty or younger, or is blind or permanently disabled as defined in WAC 182-512-0050; or
         3. A client's sibling who has an equity interest in the home and who has been residing in the home for at least one year immediately before the client's admission to the medical institution.
   2. If the client returns home from the medical institution, the agency releases the lien.
2. Amount of the lien.
   1. The agency may file a lien to recoup the cost of all non-MAGI-based and deemed eligible services under WAC 182-503-0510 it correctly purchased on the client's behalf, regardless of the client's age on the date of service.
   2. Services provided under the medicaid transformation project, defined in WAC 182-500-0070, are excluded when determining the amount of the lien.
3. Notice requirement.
   1. Before the agency may file a lien under this section, it sends notice via first class mail to:
      1. The client's last known address;
      2. The client's authorized representative, if any;
      3. The address of the property subject to the lien; and
      4. Any other person known to hold title to the property.
   2. The notice states:
      1. The client's name;
      2. The agency's intent to file a lien against the client's property;
      3. The county in which the property is located; and
      4. How to request an administrative hearing.
4. Interest assessed on past-due debt.
   1. Interest on a past-due debt accrues at a rate of one percent per month under RCW 43.17.240.
   2. A lien under this section becomes a past-due debt when the agency has recorded the lien in the county where the property is loca­ted and:
      1. Thirty days have passed since the property was transferred or
      2. Nine months have passed since the lien was filed.
   3. The agency may waive interest if reasonable efforts to sell the property have failed.
5. Administrative hearing. An administrative hearing under this section is governed by WAC 182-527-2753.

WAC 182-527-2738 Estate recovery—General right to recover.

Effective March 14, 2016

For the purposes of this section, the term "agency" includes the agency's designee.

1. When the agency may file. After a Washington apple health client has died, the medicaid agency may file liens to recover the cost of services subject to recovery that were correctly paid on the client's behalf.
2. Notice requirement.
   1. Before the agency may file a lien under this section, it sends notice via first class mail as follows:
      1. If the estate has a personal representative, the agency sends notification to:
         1. The personal representative; and
         2. Any known title holder.
      2. If the estate has known heirs but no personal representative, the agency sends notification to:
         1. Any known heir; and
         2. Any known title holder.
      3. If the estate has no personal representative and no known heirs, the agency sends notification to:
         1. The address listed on the title; and
         2. Any known title holder.
   2. The notice states:
      1. The agency's intent to file a lien against the deceased client's property;
      2. The amount the agency seeks to recover;
      3. The deceased client's name, identification number, date of birth, and date of death;
      4. The county in which the property is located; and
      5. How to request an administrative hearing.
3. The agency may not recover from the client's estate so long as there remains:
   1. A surviving spouse; or
   2. A surviving child who:
      1. Is age twenty or younger; or
      2. Is blind or disabled as defined in WAC 182-512-0050.
4. Interest assessed on past-due debt.
   1. Interest on a past-due debt accrues at a rate of one percent per month under RCW 43.17.240.
   2. A lien under this section becomes a past-due debt when the agency has recorded the lien in the county where the property is located and nine months have passed since the lien was recorded or a creditor's claim was filed, whichever is sooner.
   3. The agency may waive interest if reasonable efforts to sell the property have failed.
5. Administrative hearing. An administrative hearing under this section is governed by WAC 182-527-2753.

WAC 182-527-2740 Estate recovery - Age-related limitations.

Effective March 14, 2016

For the purposes of this section, the term "agency" includes the agency's designee.

1. Liability for medicaid services.
   1. Beginning July 26, 1987, a client's estate is liable for medicaid services subject to recovery that were provided on or after the client's sixty-fifth birthday.
   2. Beginning July 1, 1994, a client's estate is liable for medicaid services subject to recovery that were provided on or after the client's fifty-fifth birthday.
2. Liability for state-only-funded long-term care services.
   1. A client's estate is liable for all state-only-funded long-term care services provided by the home and community services division of the department of social and health services (DSHS) on or after July 1, 1995.
   2. A client's estate is liable for all state-only-funded long-term care services provided by the developmental disabilities administration of DSHS on or after June 1, 2004.

WAC 182-527-2742 Estate recovery-Service-related limitations.

Effective June 23, 2024

For the purposes of this section, the term "agency" includes the agency's designee.

The agency's payment for the following services is subject to recovery:

1. State-only funded services, except:
   1. Adult protective services;
   2. Offender reentry community safety program services;
   3. Supplemental security payments (SSP) authorized by the developmental disabilities administration (DDA);
   4. Volunteer chore services; and
   5. Guardianship and conservatorship assistance program services.
2. For dates of service on or after January 1, 2014:
   1. Basic Plus waiver services;
   2. Community first choice (CFC) services;
   3. Community option program entry system (COPES) services;
   4. Community protection waiver services;
   5. Core waiver services;
   6. Hospice services;
   7. Intermediate care facility for individuals with intellectual disabilities services provided in either a private community setting or in a rural health clinic;
   8. Individual and family services;
   9. Medicaid personal care services;
   10. New Freedom consumer directed services;
   11. Nursing facility services;
   12. Personal care services funded under Title XIX or XXI;
   13. Private duty nursing administered by aging and long-term support administration (ALTSA) or the DDA;
   14. Residential habilitation center services;
   15. Residential support waiver services;
   16. Roads to community living demonstration project services;
   17. The portion of the managed care premium used to pay for ALTSA-authorized long-term care services under the program of all-inclusive care for the elderly (PACE); and
   18. The hospital and prescription drug services provided to a client while the client was receiving services listed in this subsection.
3. For dates of service beginning January 1, 2010, through December 31, 2013:
   1. Medicaid services;
   2. Premium payments to managed care organizations (MCOs); and
   3. The client's proportional share of the state's monthly contribution to the Centers for Medicare and Medicaid Services to defray the costs for outpatient prescription drug coverage provided to a person who is eligible for medicare Part D and medicaid.
4. For dates of service beginning June 1, 2004, through December 31, 2009:
   1. Medicaid services;
   2. Medicare premiums for individuals also receiving medicaid;
   3. Medicare savings programs (MSPs) services for people also receiving medicaid; and
   4. Premium payments to MCOs.
5. For dates of service beginning July 1, 1995, through May 31, 2004:
   1. Adult day health services;
   2. Home and community-based services;
   3. Medicaid personal care services;
   4. Nursing facility services;
   5. Private duty nursing services; and
   6. The hospital and prescription drug services provided to a client while the client was receiving services listed in this subsection.
6. For dates of service beginning July 1, 1994, through June 30, 1995:
   1. Home and community-based services;
   2. Nursing facility services; and
   3. Hospital and prescription drug services provided to a client while the client was receiving services listed in this subsection.
7. For dates of service beginning July 26, 1987, through June 30, 1994: Medicaid services.
8. For dates of service through December 31, 2009. If a client was eligible for the MSP, but not otherwise medicaid eligible, the client's estate is liable only for any sum paid to cover medicare premiums and cost-sharing benefits.
9. For dates of service beginning January 1, 2010. If a client was eligible for medicaid and the MSP, the client's estate is not liable for any sum paid to cover medical assistance cost-sharing benefits.
10. For dates of service beginning July 1, 2017, long-term services and supports authorized under the medicaid transformation project are exempt from estate recovery. Exempted services include those provided under:
    1. Medicaid alternative care under WAC 182-513-1600;
    2. Tailored supports for older adults under WAC 182-513-1610;
    3. Supportive housing under WAC 388-106-1700 through 388-106-1765; or
    4. Supported employment under WAC 388-106-1800 through 388-106-1865.

WAC 182-527-2746 Estate recovery—Asset-related limitations.

Effective March 14, 2016

For the purposes of this section, the term "agency" includes the agency's designee.

1. Before July 25, 1993. For services received before July 25, 1993, that are subject to recovery, the agency may exempt:
   1. The first fifty thousand dollars of the estate's value at the time of the client's death; and
   2. Sixty-five percent of the remaining value of the estate.
2. July 24, 1993, through June 30, 1994. For services that are subject to recovery that were received on or after July 25, 1993, through June 30, 1994, the agency exempts two thousand dollars' worth of personal property.
3. Life estate.
   1. The agency may file a lien against a client's life estate interest in real property.
   2. The agency's lien against the property may not exceed the value of the client's life estate. Under this subsection, value means the fair market value of the property multiplied by the life estate factor that corresponds to the client's age on the client's last birthday. For a list of life estate factors, see the life estate and remainder interest tables maintained by the Social Security Administration.
   3. The agency may not enforce a lien under this subsection against any property right that vested before July 1, 2005.
4. Joint tenancy.
   1. The agency may file a lien against property in which a client was a joint tenant when the client died.
   2. The agency's lien against the property may not exceed the value of the client's interest in the property. Under this subsection, value means the fair market value of the property divided by the number of joint tenants on the day the client died.
   3. The agency may not enforce a lien under this subsection against any property right that vested before July 1, 2005.
5. Qualified long-term care partnership.
   1. Assets designated as protected by a qualified long-term care partnership (QLTCP) policy issued after November 30, 2011, may be disregarded for estate recovery purposes if:
      1. The insured person's estate is the recipient of the estate recovery exemption; or
      2. The insured person holds title to property which is potentially subject to a predeath lien and that person asserts the property is protected under the QLTCP policy.
   2. A person must provide clear and convincing evidence to the office of financial recovery that the asset in question was designated as protected, including:
      1. Proof of a valid QLTCP policy;
      2. Verification from the LTC insurance company of the dollar amount paid out by the policy; and
      3. A current department of social and health services QLTCP asset designation form when the QLTCP policy paid out more than was previously designated.
   3. The insured person's estate must provide clear and convincing evidence proving an asset is protected before the final recovery settlement.
6. Rules specific to American Indians and Alaska natives.
   1. Certain properties belonging to American Indians/Alaska natives (AI/AN) are exempt from estate recovery if at the time of death:
      1. The deceased client was enrolled in a federally recognized tribe; and
      2. The estate or heir documents the deceased client's ownership interest in trust or nontrust real property and improvements located on a reservation, near a reservation as designated and approved by the Bureau of Indian Affairs of the U.S. Department of the Interior, or located:
         1. Within the most recent boundaries of a prior federal reservation; or
         2. Within the contract health service delivery area boundary for social services provided by the deceased client's tribe to its enrolled members.
   2. Protection of trust and nontrust property under subsection (4) of this section is limited to circumstances when the real property and improvements pass from an Indian (as defined in 25 U.S.C. Chapter 17, Sec. 1452(b)) to one or more relatives (by blood, adoption, or marriage), including Indians not enrolled as members of a tribe and non-Indians, such as spouses and stepchildren, that their tribe would nonetheless recognize as family members, to a tribe or tribal organization and/or to one or more Indians.
   3. Certain AI/AN income and resources (such as interests in and income derived from tribal land and other resources currently held in trust status and judgment funds from the Indian Claims Commission and the U.S. Claims Court) are exempt from estate recovery by other laws and regulations.
   4. Ownership interests in or usage rights to items that have unique religious, spiritual, traditional, and/or cultural significance or rights that support subsistence or a traditional life style according to applicable tribal law or custom.
   5. Government reparation payments specifically excluded by federal law in determining eligibility are exempt from estate recovery as long as such funds have been kept segregated and not commingled with other countable resources and remain identifiable.

WAC 182-527-2750 Estate recovery - Delay of recovery for undue hardship.

Effective March 14, 2016

For the purposes of this section, the term "agency" includes the agency's designee.

1. If an undue hardship exists at the time of the client's death, an heir may ask the agency to delay recovery.
   1. Undue hardship exists only when:
      1. The property subject to recovery is the sole income-producing asset of an heir;
      2. Recovery would deprive an heir of shelter and the heir cannot afford alternative shelter; or
      3. The client is survived by a state-registered domestic partner.
   2. Undue hardship does not exist if the client or the heir created circumstances to avoid estate recovery.
2. If the agency determines recovery would cause an undue hardship for an heir, the agency may delay recovery until the hardship no longer exists.
3. If the agency denies an heir's request to delay recovery, the agency notifies the heir in writing.  The notice includes instructions on how to request a hearing.
4. If the agency grants a delay of recovery under this section, the heir must:
   1. Timely comply with any agency request for information or records;
   2. Not sell, transfer, or encumber the property;
   3. Reside on the property;on the property;
   4. Timely pay property taxes and utilities;
   5. Ensure the property for its fair market  value;
   6. Name the state of Washington as the primary payee on the property insurance policy;
   7. Provide the agency with a copy of the property insurance policy upon request;
   8. Continue to satisfy the requirements in subsection (1) of this section.
5. If the heir dies, or violates any provision of subsection (4) of this section, the agency may begin recovery.
6. If the agency denies the request, the heir may request an administrative hearing under WAC 182-527-2753. 

WAC 182-527-2753 Hearings.

Effective March 14, 2016

For the purposes of this section, the term "agency" includes the agency's designee.

1. An administrative hearing to contest action under this chapter determines only:
   1. In the case of a lien filed during the client's lifetime under WAC 182-527-2734:
      1. Whether the client can reasonably be expected to return home from the medical institution;
      2. Whether the client, or the client's estate, holds legal title to the identified property; and
      3. Whether the client received services subject to recovery.
   2. In the case of a lien filed after the client's death:
      1. The cost the agency correctly paid for services subject to recovery;
      2. Whether the client, or the client's estate, holds legal title to the identified property; and
      3. Whether the agency's denial of an heir's request for a delay of recovery for undue hardship under WAC 182-527-2750 was correct.
2. A request for an administrative hearing must:
   1. Be in writing;
   2. State the basis for contesting the agency's proposed action;
   3. Be signed by the requestor and include the client's name, the requestor's address and telephone number; and
   4. Within twenty-eight days of the date on the agency's notice, be filed with the office of financial recovery either:
      1. In person at the Office of Financial Recovery, 712 Pear St. S.E., Olympia, WA 98504-0001; or
      2. By certified mail, return receipt requested, to Office of Financial Recovery, P.O. Box 9501, Olympia, WA 98507-9501.
3. Upon receiving a request for an administrative hearing, the office of administrative hearings notifies any known titleholder of the time and place of the administrative hearing.
4. An administrative hearing under this subsection is governed by chapters 34.05 RCW and 182-526 WAC and this section. If a provision in this section conflicts with a provision in chapter 182-526 WAC, the provision in this section governs.
5. Disputed assets must not be distributed while in litigation.
6. Absent an administrative or court order to the contrary, the agency may file a lien twenty-eight calendar days after the date the agency mailed notice of its intent to file a lien.

WAC 182-503-0520 Washington apple health -- Residency requirements -- Persons who are not residing in an institution.

Effective August 29, 2014.

1. A resident is a person (including an emancipated person under age eighteen and a married person under age eighteen who is capable of indicating intent) who currently lives in Washington and:
   1. Intends to reside here, including persons without a fixed address; or
   2. Entered the state looking for a job; or
   3. Entered the state with a job commitment.
2. A person does not need to live in the state for a specific period of time prior to meeting the requirements in subsection (1) of this section before being considered a resident.
3. A child under age eighteen who is not covered by subsection (1) of this section, is a resident if:
   1. The child lives in the state, with or without a fixed address, including with a custodial parent or caretaker; or
   2. The child's parent or caretaker is a resident as defined in subsection (1) of this section.
4. A resident applying for or receiving health care coverage can temporarily be out of the state for more than one month without their health care coverage being denied or terminated, if the person:
   1. Intends to return to the state once the purpose of his or her absence has been accomplished and provides adequate information of this intent after a request by the agency or its designee; and
   2. Has not been determined eligible for medicaid or state-funded health care coverage in another state (other than coverage in another state for incidental or emergency health care).
5. A person who enters Washington state only for health care is not a resident and is not eligible for any medical program. The only exception is for a person who moves from another state directly into an institution in Washington state. Residency rules for institutionalized persons are described in WAC 182-503-0525.
6. A person of any age who receives a state supplemental payment (SSP) is considered a resident of the state that is making the payment.
7. A person who receives federal payments for foster or adoption assistance is considered a resident of the state where the person physically resides even if:
   1. The person does not live in the state that is making the foster or adoption assistance payment; or
   2. The person does not live in the state where the adoption agreement was entered.
8. In a dispute between states, the state of residence is the state in which the person is physically located.

WAC 182-503-0525 Washington apple health -- Residency requirements for an institutionalized person.

Effective August 29, 2014.

1. An institutionalized person is a person who resides in an institution as defined in WAC 182-500-0050. The term "person" used in this section means an "institutionalized person" unless otherwise indicated. It does not include persons who receive services under a home and community-based waiver program. When a state is making a placement for a person in another state, the term institution also includes foster care homes, licensed as described in 45 C.F.R. 1355.20.
2. The agency must determine whether a person is capable of indicating their intent to reside in Washington state when deciding whether that person is a resident of the state. The agency determines that persons who meet the following criteria are deemed incapable of indicating intent to reside in the state:
   1. The person is judged legally incompetent by a court of law;
   2. A physician, psychologist or licensed medical professional in the field of intellectual disabilities has determined that the person is incapable of indicating intent; or
   3. The person is incapable of declaring intent due to a documented medical condition.
3. When a person is placed in an out-of-state institution by the agency, its designee or by a department of social and health services-contracted agency, the state arranging the placement is considered the person's state of residence, unless the person is capable of expressing intent and:
   1. Indicates a desire to change his or her state of residence; or
   2. Asks the current state of residence for help in relocating. This may include assistance in locating an institutional placement in the new state of residence.
4. If another state has not authorized the placement in the institution, as described in subsection (3) of this section, the agency or its designee uses one of the following criteria to determine the state of residence for a person who is age twenty or younger:
   1. The state of residence is the state where the parent or legal guardian is a resident at the time of the placement in the institution. To determine a parent's or legal guardian's place of residence, follow rules described in WAC 182-503-0520 for a noninstitutionalized person.
   2. The state of residence is the state where the parent or legal guardian currently is a resident if the person resides in an institution in that state.
   3. If the parents of the person are separated and live in different states, the state of residence is that of the parent filing the application.
   4. If the parental rights are terminated and the person has a legal guardian, the state of residence is where the legal guardian is a resident.
   5. If the person has both a guardian of the estate and a guardian of the person, the state of residence is where the guardian of the person is a resident, unless the state has laws which delegate guardianship to a state official or agency for persons who are admitted to state institutions. In that case, the state of residence for the person is the state where the institution is located (unless another state has authorized the placement).
   6. If the person has been abandoned by the parents or legal guardian, and an application is filed on their behalf by another party, the state of residence is the state where the person is institutionalized. The term abandoned also includes situations where the parents or legal guardian are deceased.
5. A person age twenty-one or older that is capable of indicating intent is considered a resident of the state where he or she is living and intends to reside.
6. A person age twenty-one or older who became incapable of indicating intent at age twenty-one or older is considered a resident of the state where the person is physically residing, unless the person has been placed in the institution by another state.
7. A person age twenty-one or older who became incapable of indicating intent before the age of twenty-one is considered a resident of the state where the parents or legal guardian were residents at the time of the placement in the institution.
8. If a noninstitutionalized person moves directly from another state to an institution in Washington state, it is not necessary for the person to establish residency in Washington state prior to entering the facility. The person is considered a resident if he or she intends to reside in the state unless the placement was made by the other state.
9. A person of any age who receives a state supplemental payment (SSP) is considered a resident of the state that is making the payment.
10. In a dispute between states, the state of residence is the state in which the person is physically located. 

WAC 182-505-0250 Washington apple health -- MAGI-based adult medical.

Effective August 29, 2014.

1. Effective on or after January 1, 2014, a person is eligible for Washington apple health (WAH) modified adjusted gross income (MAGI)-based adult coverage when he or she meets the following requirements:
   1. Is age nineteen or older and under the age of sixty-five;
   2. Is not entitled to, or enrolled in, medicare benefits under Part A or B of Title XVIII of the Social Security Act;
   3. Is not otherwise eligible for and enrolled in mandatory coverage under one of the following programs:
      1. WAH SSI-related categorically needy (CN);
      2. WAH foster care program; or
      3. WAH adoption support program;
   4. Meets citizenship and immigration status requirements described in WAC 182-503-0535;
   5. Meets general eligibility requirements described in WAC 182-503-0505; and
   6. Has net countable income that is at or below one hundred thirty-three percent of the federal poverty level for a household of the applicable size.
2. Parents or caretaker relatives of an eligible dependent child as described in WAC 182-503-0565 are first considered for WAH for families as described in WAC 182-505-0240. A person whose countable income exceeds the standard to qualify for family coverage is considered for coverage under this section.
3. Persons who are eligible under this section are eligible for WAH alternative benefit plan as defined in WAC 182-500-0010 coverage. A person described in this section is not eligible for medically needy WAH.
4. Other coverage options for adults not eligible under this section are described in WAC 182-508-0001.

WAC 182-505-0115 Washington apple health -- Eligibility for pregnancy and after-pregnancy coverage.

Effective June 24, 2022.

1. A pregnant person is eligible for Washington apple health pregnancy coverage if the person:
   1. Meets citizenship or immigration status under WAC 182-503-0535;
   2. Meets Social Security number requirements under WAC 182-503-0115;
   3. Meets Washington state residency requirements under WAC 182-503-0520 and 182-503-0525; and
   4. Has countable income at or below the limit described in:
      1. WAC 182-505-0100 to be eligible for categorically needy (CN) coverage; or
      2. WAC 182-505-0100 to be eligible for medically needy (MN) coverage. MN coverage begins when the pregnant person meets any required spenddown liability as described in WAC 182-519-0110.
2. A noncitizen pregnant person who does not meet the requirements in subsection (1)(a) or (b) of this section is eligible for apple health pregnancy coverage if they meet countable income standards for CN or MN coverage as described in subsection (1)(d) of this section.
3. The assignment of medical support rights as described in WAC 182-503-0540 does not apply to pregnant people.
4. A person who was eligible for and covered under any CN or MN scope of coverage apple health program on the last day of pregnancy remains continuously eligible for after-pregnancy coverage for 12 months, beginning the month after their pregnancy ends. This includes people who meet an MN spenddown liability with expenses incurred no later than the date the pregnancy ends.
5. Pregnancy coverage has CN scope of care for all people except those enrolled through the MN program who have MN scope of care. A person's after-pregnancy coverage has the same scope of coverage as their pregnancy coverage.
6. A person who does not meet the requirements in subsection (4) of this section may qualify for after-pregnancy coverage if they:
   1. Apply for and meet all requirements of the apple health pregnancy coverage program other than pregnancy; and
   2. Apply any time during their 12-month postpartum period to receive ongoing medical coverage until the end of the 12th month after their pregnancy ends.

WAC 182-505-0117 Washington apple health -- Eligibility for pregnant minors.

Effective June 24, 2022.

1. For the purposes of this rule, "minor" means a person under the age of 19.
2. A pregnant minor who meets Washington state residency requirements under WAC 182-503-0520 and 182-503-0525 is eligible for the Washington apple health for kids program.
3. The medical assistance unit (MAU) of a pregnant minor is the pregnant minor.
4. There are no income standards and no resource tests for a pregnant minor to be eligible for apple health for kids.
5. To ensure reimbursement from the U.S. Department of Health and Human Services, every pregnant minor applicant for apple health for kids must provide their Social Security number, unless they are exempt under WAC 182-503-0515, and must provide their citizenship or immigration status. The immigration status of a pregnant minor who is an undocumented alien (see WAC 182-503-0530) will not be disclosed to any third party.
6. The assignment of rights as described in WAC 182-503-0540 does not apply to pregnant minors.
7. A pregnant minor covered by the apple health for kids program has a one-year certification period. If a minor has their 19th birthday during their pregnancy, they are automatically enrolled in apple health for pregnancy coverage through the end of the month their pregnancy ends. They are eligible for after-pregnancy coverage for 12 months, beginning the first day of the month after their pregnancy ends.

WAC 182-505-0120 Washington apple health breast and cervical cancer treatment program for women--Client eligibility.

Effective September 14, 2015

1. Effective April 1, 2014, a woman is eligible for categorically needy (CN) coverage under the Washington apple health (WAH) breast and cervical cancer treatment program (BCCTP) only when she:
   1. Has been screened for breast or cervical cancer under the department of health's breast, cervical, and colon health program (BCCHP);
   2. Requires treatment for breast cancer, cervical cancer, or a related precancerous condition;
   3. Is under sixty-five years of age;
   4. Is not eligible for other WAH-CN coverage, including coverage under the MAGI-based adult group;
   5. Is uninsured or does not otherwise have creditable coverage;
   6. Meets residency requirements under WAC 182-503-0520;
   7. Meets Social Security number requirements under WAC 182-503-0515;
   8. Is a U.S. citizen, U.S. national, qualifying American Indian born abroad, or qualified alien under WAC 182-503-0535; and
   9. Meets the income standard set by the BCCHP in DOH form 342-031.
2. The certification period for breast and cervical cancer treatment covered under this section is twelve months, as provided in WAC 182-504-0015. To remain continuously enrolled, the client must renew her eligibility before the certification period ends. Eligibility for BCCTP coverage under subsection (1)(b) of this section continues throughout the course of treatment as certified by the BCCHP. Retroactive coverage may be available under WAC 182-504-0005.

WAC 182-505-0210 Eligibility for children.

Effective June 9, 2025

1. General eligibility. For purposes of this section, a child must:
   1. Be a Washington state resident under WAC 182-503-0520 and 182-503-0525;
   2. Provide a Social Security number under WAC 182-503-0515, unless exempt; and
   3. Meet program-specific requirements.
2. Deemed eligibility groups. A child is automatically eligible for coverage without an application if the child meets the program-specific requirements in (a) through (c) of this subsection.
   1. Newborn coverage. A child younger than age one is eligible for categorically needy (CN) coverage if the birth parent was eligible for Washington apple health on the date of delivery:
      1. Including a retroactive eligibility determination; or
      2. By meeting a medically needy (MN) spenddown liability with expenses incurred by the date of the newborn's birth:
   2. Washington apple health for supplemental security income (SSI) recipients. A child who is eligible for SSI is automatically eligible for CN coverage under WAC 182-510-0001.
   3. Foster care coverage. A child age 20 and younger is eligible for CN coverage under WAC 182-505-0211 when the child is in foster care or receives subsidized adoption services. For children who age out of the foster care program, see WAC 182-505-0211(3).
3. Continuous eligibility for children under age six. A child is eligible for Washington apple health continuous eligibility for children under age six when they:
   1. Have household income at or below 210 percent of the federal poverty level at the time of application; or
   2. On or after January 8, 2025, have household income greater than 210 percent but equal to or less than 312 percent of the federal poverty level at the time of application; or
   3. Received coverage under subsection (5) of this section and are no longer eligible for deemed coverage under subsection (5) (b) or (c) of this section.
4. MAGI-based eligibility groups. A child age 18 or younger is eligible for CN coverage based on modified adjusted gross income (MAGI):
   1. At no cost when the child's countable income does not exceed the standard in WAC 182-505-0100 (6)(a);
   2. With payment of a premium when the child's countable income does not exceed the standard in WAC 182-505-0100 (6)(b), and the child meets additional eligibility criteria in WAC 182-505-0215;
   3. Under chapter 182-514 WAC, if the child needs long-term care services because the child resides or is expected to reside in an institution, as defined in WAC 182-500-0050, for 30 days or longer. An institutionalized child is eligible for coverage under the medically needy (MN) program if income exceeds the CN income standard for a person in an institution (special income level);
   4. Under WAC 182-505-0117, if a child is pregnant;
   5. When the child has household income at or below 215 percent of the federal poverty level at the time of application and is eligible for Washington apple health continuous eligibility for children under age six.
5. Non-MAGI-based children's programs. The agency determines eligibility for the:
   1. MN program according to WAC 182-519-0100. A child age 18 or younger is eligible if the child:
      1. Is not eligible for MAGI-based coverage under subsection (3) of this section;
      2. Meets citizenship or immigration requirements under WAC 182-503-0535 (2)(a), (b), (c), or (d); and
      3. Meets any spenddown liability required under WAC 182-519-0110.
   2. SSI-related program. A child age 18 or younger is eligible for CN or MN SSI-related coverage if the child meets:
      1. SSI-related eligibility under chapter 182-512 WAC;
      2. Citizenship or immigration requirements under WAC 182-503-0535 (2)(a), (b), (c), or (d); and
      3. Any MN spenddown liability under WAC 182-519-0110.
   3. SSI-related long-term care program.
      1. A child age 18 or younger is eligible for home and community based (HCB) waiver programs under chapter 182-515 WAC if the child meets:
         1. SSI-related eligibility under chapter 182-512 WAC;
         2. Citizenship or immigration requirements under WAC 182-503-0535 (2)(a), (b), (c), or (d); and
         3. Program-specific age and functional requirements under chapters 388-106 and 388-845 WAC.
      2. A child age 18 or younger who resides or is expected to reside in a medical institution as defined in WAC 182-500-0050 is eligible for institutional medical under chapter 182-513 WAC if the child meets:
         1. Citizenship or immigration requirements under WAC 182-503-0535 (2)(a), (b), (c), or (d);
         2. Blindness or disability criteria under WAC 182-512-0050; and
         3. Nursing facility level of care under chapter 388-106 WAC.
6. Alien emergency medical program. A child age 20 or younger who does not meet the eligibility requirements for a program described under subsections (2) through (5) of this section is eligible for the alien emergency medical (AEM) program if the child meets:
   1. The eligibility requirements of WAC 182-507-0110; and
   2. MN spenddown liability, if any, under WAC 182-519-0110.
7. Other provisions.
   1. A child residing in an institution for mental disease (IMD) as defined in WAC 182-500-0050 is not eligible for inpatient hospital services, unless the child is unconditionally discharged from the IMD before receiving the services.
   2. A child incarcerated in a public institution as defined in WAC 182-500-0050 is only eligible for inpatient hospital services.

WAC 182-505-0215 Children's Washington apple health with premiums.

Effective January 23, 2021.

1. A child is eligible for Washington apple health with premiums if the child:
   1. Meets the requirements in WAC 182-505-0210(1);
   2. Has countable income below the standard in WAC 182-505-0100 (6)(b); and
   3. Pays the required premium under WAC 182-505-0225, unless the child is exempt under WAC 182-505-0225 (2)(c).
2. A child is not eligible for Washington apple health with premiums if the child:
   1. Is eligible for no-cost Washington apple health;
   2. Has creditable health insurance coverage as defined in WAC 182-500-0020.
3. A child with creditable health insurance coverage may be eligible for Washington apple health with premiums if the child is eligible for either:
   1. Public employees benefits board (PEBB) health insurance coverage based on a family member's employment with a Washington state agency, or a Washington state university, community college, or technical college; or
   2. School employees benefits board (SEBB) health insurance coverage based on a family member's employment with a Washington school district, charter school, or educational service district; and
   3. Meets the requirements in WAC 182-505-0210 (1).

WAC 182-505-0225 Children's Washington apple health with premiums - Calculation and determination of premium amount.

Effective October 25, 2024.

1. For the purposes of this chapter, "premium" means an amount paid for health care coverage under WAC 182-505-0215.
2. Premium requirement. The Washington apple health premium-based program under WAC 182-505-0215 requires payment of a monthly premium.
   1. The first monthly premium is due in the month following the determination of eligibility.
   2. There is no premium requirement for health care coverage received in the month eligibility is determined or in any prior month.
   3. A child who is American Indian or Alaska native is exempt from the monthly premium requirement.
3. Monthly premium amount.
   1. The premium amount for the medical assistance unit (MAU) is based on countable income under chapter 182-509 WAC and the number of people in the MAU under chapter 182-506 WAC.
   2. The premium amount is as follows:
      1. If the MAU's countable income exceeds 210 percent of the federal poverty level (FPL) but does not exceed 260 percent of the FPL, the monthly premium for each child is $20.
      2. If the MAU's countable income exceeds 260 percent of the FPL but does not exceed 312 percent of the FPL, the monthly premium for each child is $30.
      3. The medicaid agency charges a monthly premium for no more than two children per household.
      4. Payment of the full premium is required. Partial payments cannot be designated for a specific child or month.
      5. Any third party may pay the premium on behalf of the household. Failure of a third party to pay the premium does not eliminate the obligation of the household to pay past due premiums.
   3. A change that affects the premium amount takes effect the month after the change is reported.
4. Nonpayment of premiums.
   1. The agency writes off past-due premiums after 12 months.