WAC 182-519-0050 Monthly income and countable resource standards for medically needy (MN).

Effective February 10, 2023

1. Changes to the Medically Needy Income Level (MNIL) occur on January 1st of each calendar year when the Social Security Administration (SSA) issues a cost-of-living adjustment.
2. Medically Needy (MN) standards for people who meet institutional status requirements are in WAC 182-513-1395. The standard for a client who lives in an alternate living facility is in WAC 182-513-1205.
3. The resource standards for institutional programs are in WAC 182-513-1350. The institutional standard chart is found at Long Term Care Standards.
4. Countable resource standards for the noninstitutional MN program are:
   1. One person $2,000.
   2. A legally married couple $3,000.
   3. For each additional family member add $50.
5. People who do not meet institutional status requirements use the "effective" MNIL income standard to determine eligibility for the MN program. The "effective" MNIL is the one-person federal benefit rate (FBR) established by SSA each year, or the MNIL listed in the chart below, whichever amount is higher. The FBR is the supplemental security income (SSI) payment standard. For example, in 2023 the FBR is $914.

WAC 182-519-0100 Eligibility for the medically needy program

Effective January 27, 2019

1. A person who meets the following conditions may be eligible for medically needy (MN) coverage under the special rules in chapters 182-513 and 182-515 WAC:
   1. Meets the institutional status requirements of WAC 182-513-1320;
   2. Resides in a medical institution as described in WAC 182-513-1395.
2. A supplemental security income (SSI)-related person who lives in a medicaid agency-contracted alternate living facility may be eligible for MN coverage under WAC 182-513-1205.
3. A person may be eligible for MN coverage under this chapter when he or she is:
   1. Not covered under subsection (1) and (2) of this section; and
   2. Eligible for categorically needy (CN) medical coverage in all other respects, except that his or her CN countable income is above the CN income standard.
4. MN coverage may be available if the person is:
   1. A child;
   2. A pregnant woman;
   3. A refugee;
   4. An SSI-related person, including an aged, blind, or disabled person, with countable income under the CN income standard, who is an ineligible spouse of an SSI recipient; or
   5. A hospice client with countable income above the special income level (SIL).
5. A person who is not eligible for CN medical who applies for MN coverage has the right to income deductions in addition to, or instead of, those used to calculate CN countable income. These deductions to income are applied to each month of the base period to calculate MN countable income:
   1. The agency disregards the difference between the medically needy income level (MNIL) described in WAC 182-519-0050 and the federal benefit rate (FBR) established by the Social Security Administration each year. The FBR is the one-person SSI payment standard;
   2. All health insurance premiums, except for medicare Part A through Part D premiums, expected to be paid by the person or family member during the base period or periods;
   3. Any allocations to a spouse or to dependents for an SSI-related person who is married or who has dependent children. Rules for allocating income are described in WAC 182-512-0900 through 182-512-0960;
   4. For an SSI-related person who is married and lives in the same home as his or her spouse who receives home and community-based waiver services under chapter 182-515 WAC, an income deduction equal to the MNIL, minus the nonapplying spouse's income; and
   5. A child or pregnant woman applying for MN coverage is eligible for income deductions allowed under temporary assistance for needy families (TANF) and state family assistance (SFA) rules and not under the rules for CN programs based on the federal poverty level. See WAC 182-509-0001(4) for exceptions to the TANF and SFA rules that apply to medical programs and not to the cash assistance program.
6. The MNIL for a person who qualifies for MN coverage under subsection (1) of this section is based on rules in chapters 182-513 and 182-515 WAC.
7. The MNIL for all other people is described in WAC 182-519-0050. If a person has countable income at or below the MNIL, the person is certified as eligible for up to 12 months of MN medical coverage.
8. If a person has countable income over the MNIL, the countable income that exceeds the agency's MNIL standards is called "excess income."
9. A person with "excess income" is not eligible for MN coverage until the person gives the agency or its designee evidence of medical expenses incurred by that person, their spouse, or family members living in the home for whom they are financially responsible. See WAC 182-519-0110(8). An expense is incurred when:
   1. The person receives medical treatment or medical supplies, is financially liable for the medical expense, and has not paid the bill; or
   2. The person pays for the expense within the current or retroactive base period under WAC 182-519-0110.
10. Incurred medical expenses or obligations may be used to offset any portion of countable income that is over the MNIL. This is the process of meeting "spenddown."
11. The agency or its designee calculates the amount of a person's spenddown by multiplying the monthly excess income amount by the number of months in the certification period under WAC 182-519-0110. The qualifying medical expenses must be greater than or equal to the total calculated spenddown amount.
12. A person who is considered for MN coverage under this chapter may not spenddown excess resources to become eligible for the MN program. Under this chapter, a person is ineligible for MN coverage if the person's resources exceed the program standard in WAC 182-519-0050. A person who is considered for MN coverage under WAC 182-513-1395, 182-514-0250 or 182-514-0263 is allowed to spenddown excess resources.
13. There is no automatic redetermination process for MN coverage. A person must apply for each eligibility period under the MN program.
14. A person who requests a timely administrative hearing under WAC 182-518-0025 is not eligible for continued benefits beyond the end of the original certification date under the MN program.

WAC 182-519-0110 Spenddown of excess income for the medically needy program

Effective January 27, 2019

1. A person who applies for Washington apple health (WAH) and is eligible for medically needy (MN) coverage with a spenddown may choose a three-month or a six-month base period. A base period is a time period used to compute the spenddown liability amount. The months must be consecutive calendar months, unless a condition in subsection (4) of this section applies.
2. A base period begins on the first day of the month a person applies for WAH, unless a condition in subsection (4) of this section applies.
3. A person may request a separate base period to cover up to three calendar months immediately before the month of application. This is called a retroactive base period.
4. A base period may vary from the terms in subsections (1), (2), or (3) of this section if:
   1. A three-month base period would overlap a previous eligibility period;
   2. The person has countable resources over the applicable standard for any part of the required base period;
   3. The person is not or will not be able to meet the temporary assistance to needy families (TANF)-related or supplemental security income (SSI)-related requirement for the required base period;
   4. The person is eligible for categorically needy (CN) coverage for part of the required base period; or
   5. The person was not otherwise eligible for MN coverage for each month of the retroactive base period.
5. The medicaid agency or its designee calculates a person's spenddown liability. The MN countable income from each month of the base period is compared to the effective medically needy income level (MNIL) under WAC 182-519-0050. Income over the effective MNIL standard (based on the person's household size) in each month in the base period is added together to determine the total spenddown amount.
6. If household income varies and a person's MN countable income falls below the effective MNIL for one or more months, the difference offsets the excess income in other months of the base period. See WAC 182-519-0100(7) if a spenddown amount results in zero dollars and cents.
7. If a person's income decreases, the agency or its designee approves CN coverage for each month in the base period when the person's countable income and resources are equal to or below the applicable CN standards. Children age eighteen and younger and pregnant women who become CN eligible in any month of the base period are continuously eligible for CN coverage for the remainder of the certification, even if there is a subsequent increase in income.
8. Once a person's spenddown amount is determined, qualifying medical expenses are deducted. A qualifying medical expense must:
   1. Be an expense for which the person is financially liable;
   2. Not have been used to meet another spenddown;
   3. Not be the confirmed responsibility of a third party. The agency or its designee allows the entire expense if a third party has not confirmed its coverage of the expense within:
      1. Forty-five days of the date of service; or
      2. Thirty days after the base period ends.
   4. Be an incurred expense for the person:
      1. The person's spouse;
      2. A family member residing in the person's home for whom the person is financially responsible; or
      3. A relative residing in the person's home who is financially responsible for the person.
   5. Meet one of the following conditions:
      1. Be an unpaid liability at the beginning of the base period;
      2. Be for paid or unpaid medical services incurred during the base period;
      3. Be for medical services incurred and paid during the three-month retroactive base period if eligibility for WAH was not established in that base period. Paid expenses that meet this requirement may be applied towards the current base period; or
      4. Be for medical services incurred during a previous base period, either unpaid or paid, if it was necessary for the person to make a payment due to delays in the certification for that base period.
9. An exception to subsection (8) of this section exists for qualifying medical expenses paid on the person's behalf by a publicly administered program during the current or the retroactive base period. The agency or its designee uses the qualifying medical expenses to meet the spenddown liability. To qualify for this exception, the program must:
   1. Not be federally funded or make payments from federally matched funds;
   2. Not pay the expenses before the first day of the retroactive base period; and
   3. Provide proof of the expenses paid on the person's behalf.
10. Once the agency or its designee determines the expenses are a qualified medical expense under subsection (8) or (9) of this section, the expenses are subtracted from the spenddown liability to determine the date the person's eligibility for medical coverage begins. Qualifying medical expenses are deducted in the following order:
    1. First, medicare and other health insurance deductibles, coinsurance charges, enrollment fees, copayments, and premiums that are the person's responsibility under medicare Part A through Part D. (Health insurance premiums are income deductions under WAC 182-519-0100(5));
    2. Second, medical expenses incurred and paid by the person during the three-month retroactive base period if eligibility for WAH was not established in that base period;
    3. Third, current payments on, or unpaid balance of, medical expenses incurred before the current base period that were not used to establish eligibility for medical coverage in another base period. The agency or its designee sets no limit on the age of an unpaid expense; however, the expense must be a current liability and be unpaid at the beginning of the base period;
    4. Fourth, other medical expenses that are not covered by the agency's or its designee's medical programs, minus any third-party payments that apply to the charges. A licensed health care provider must provide or prescribe the items or services allowed as a medical expense;
    5. Fifth, other medical expenses incurred by the person during the base period that are potentially payable by the MN program (minus any confirmed third-party payments that apply to the charges). This deduction is allowed even if payment is denied for these services because they exceed the agency's or its designee's limits on amount, duration, or scope of care. Scope of care is described in WAC 182-501-0060 and 182-501-0065; and
    6. Sixth, other medical expenses incurred by the person during the base period that are potentially payable by the MN program (minus any confirmed third-party payments that apply to the charges) and that are within the agency's or its designee's limits on amount, duration, or scope of care.
11. If a person submits verification of qualifying medical expenses with his or her application that meet or exceed the spenddown liability, the person is eligible for MN medical coverage for the remainder of the base period unless their circumstances change. See WAC 182-504-0105 to determine which changes must be reported to the agency or its designee. The beginning of eligibility is determined under WAC 182-504-0020.
12. If a person cannot meet the spenddown amount when the application is submitted, the person is not eligible until he or she provides proof of additional qualifying expenses that meet the spenddown liability.
13. Each dollar of a qualifying medical expense may count once against a spenddown period that leads to eligibility for MN coverage. However, medical expenses may be used more than once if:
    1. The person did not meet his or her total spenddown liability and become eligible in a previous base period and the bill remains unpaid; or
    2. The medical expense was incurred and paid within three months of the current application, and the agency or its designee could not establish WAH eligibility for the person in the retroactive base period.
14. The person must provide the proof of qualifying medical expense information to the agency or its designee within thirty days after the base period ends, unless there is a good reason for delay.
15. Once a person meets the spenddown requirement and the certification begin date is established, newly identified expenses are not considered toward that spenddown unless:
    1. There is a good reason for the delay in submitting the expense; or
    2. The agency or its designee made an error when determining the correct begin date.
16. Good reasons for delay in providing medical expense information to the agency or its designee include, but are not limited to:
    1. The person did not receive a timely bill from his or her medical provider or insurance company;
    2. The person has medical issues that prevent him or her from submitting proof on time; or
    3. The person meets the criteria for needing equal access under chapter WAC 182-503-0120.
17. The agency or its designee does not pay for any expense or portion of an expense used to meet a person's spenddown liability.
18. If an expense is potentially payable under the MN program, and only a portion of the medical expense is assigned to meet spenddown, the medical provider must not:
    1. Bill the person for more than the amount assigned to the remaining spenddown liability; or
    2. Accept or retain any additional amount for the covered service from the person. Any additional amount may be billed to the agency or its designee. See WAC 182-502-0160, Billing a client.
19. The agency or its designee determines whether any payment is due to the medical provider on medical expenses partially assigned to meet a spenddown liability under WAC 182-502-0100.
20. If the medical expense assigned to spenddown was incurred outside of a period of MN eligibility, or if the expense is not covered by WAH, the agency or its designee does not pay any portion of the bill.

WAC 182-517-0100 Federal medicare savings programs.

Effective April 1, 2024

1. Available programs. The medicaid agency offers eligible clients the following medicare savings programs (MSPs):
   1. The qualified medicare beneficiary (QMB) program;
   2. The specified low-income medicare beneficiary (SLMB) program;
   3. The qualified individual (QI-1) program; and
   4. The qualified disabled and working individuals (QDWI) program.
2. Eligibility requirements.
   1. To be eligible for an MSP, a client must:
      1. Be entitled to medicare Part A; and
      2. Meet the general eligibility requirements under WAC 182-503-0505.
   2. To be eligible for QDWI, a client must be under age 65.
   3. Income limits.
      1. Income limits for all MSPs are found at www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/program-standard-income-and-resources.
      2. If a client's countable income is less than or equal to 110 percent of the federal poverty level (FPL), the client is income eligible for the QMB program.
      3. If a client's countable income is over 110 percent of the FPL, but does not exceed 120 percent of the FPL, the client is income eligible for the SLMB program.
      4. If a client's countable income is over 120 percent of the FPL, but does not exceed 138 percent of the FPL, the client is income eligible for the QI-1 program.
      5. If a client's countable income is over 138 percent of the FPL, but does not exceed 200 percent of the FPL, the client is income eligible for the QDWI program if the client is employed and meets disability requirements described in WAC 182-512-0050.
   4. The federal MSPs do not require a resource test.
3. MSP income eligibility determinations.
   1. The agency has two methods for determining if a client is eligible for an MSP:
      1. The agency first determines if the client is eligible based on SSI-rated methodologies under chapter 182-512 WAC. Under this method, the agency calculates the household's net countable income and compares the result to the one-person standard. However, if the spouse's income is deemed to the client, or if both spouses are applying, the household's net countable income is compared to the two-person standard.
      2. If the client is not eligible under the methodology described in (a)(i) of this subsection, the agency compares the same countable income, as determined under (a)(i) of this subsection, to the appropriate FPL standard based on family size. The number of individuals that count for family size include:
         1. The client;
         2. The client's spouse who lives with the client;
         3. The client's dependents who live with the client;
         4. The spouse's dependents who live with the spouse, if the spouse lives with the client; and
         5. Any unborn children of the client, or of the spouse if the spouse lives with the client.
   2. Under both eligibility determinations, the agency follows the rules for SSI-related people under chapter 182-512 WAC for determining
      1. Countable income;
      2. Availability of income;
      3. Allowable income deductions and exclusions; and
      4. Deemed income from and allocated income to a nonapplying spouse and dependents.
   3. The agency uses the eligibility determination that provides the client with the highest level of coverage.
      1. If the MSP applicant is eligible for QMB coverage under (a)(i) of this subsection, the agency approves the coverage.
      2. If the MSP applicant is not eligible for QMB coverage, the agency determines if the applicant is eligible under (a)(ii) of this subsection.
      3. If neither eligibility determination results in QMB coverage, the agency uses the same process to determine if the client is eligible under any other MSP.
   4. When calculating income under this section:
      1. The agency subtracts client participation from a long-term care client's countable income under WAC 182-513-1380, 182-515-1509, or 182-515-1514.
      2. The agency counts the annual Social Security cost-of-living increase beginning April 1st each year.
4. Covered costs.
   1. The QMB program pays:
      1. Medicare Part A and Part B premiums using the start date in WAC 182-504-0025; and
      2. Medicare coinsurance, copayments, and deductibles for Part A, Part B, and Part C, subject to the limitations in WAC 182-502-0110.
   2. If the client is eligible for both SLMB and another medicaid program:
      1. The SLMB program pays the Part B premiums using the start date in WAC 182-504-0025; and
      2. The medicaid program pays medicare coinsurance, copayments, and deductibles for Part A, Part B, and Part C subject to the limitations in WAC 182-502-0110.
   3. If the client is only eligible for SLMB, the SLMB program covers medicare Part B premiums using the start date in WAC 182-504-0025.
   4. The QI-1 program pays medicare Part B premiums using the start date in WAC 182-504-0025 until the agency's federal funding allotment is spent. The agency resumes QI-1 benefit payments the beginning of the next calendar year.
   5. The QDWI program covers medicare Part A premiums using the start date in WAC 182-504-0025.
5. MSP eligibility. Medicaid eligibility may affect MSP eligibility:
   1. QMB and SLMB clients may receive medicaid and still be eligible to receive QMB or SLMB benefits.
   2. QI-1 and QDWI clients who begin receiving medicaid are no longer eligible for QI-1 or QDWI benefits, but may be eligible for the state-funded medicare buy-in program under WAC 182-517-0300.
6. Right to request administrative hearing. A person who disagrees with agency action under this section may request an administrative hearing under chapter 182-526 WAC.

WAC 182-517-0300 State-funded medicare buy-in programs.

Effective July 23, 2016

1. A person is eligible for the state-funded medicare buy-in program if the person:
   1. Is entitled to or receiving medicare;
   2. Is not eligible for a federal medicare savings program under WAC 182-517-0100; and
   3. Is eligible for coverage under:
      1. The categorically needy (CN) program; or
      2. The medically needy (MN) program;
2. The SBIP begins the second month after the month a person meets eligibility requirements.
3. The SBIP pays only medicare Part B premiums.
4. The agency pays medicare deductibles and coinsurance under WAC 182-502-0110.
5. A person who disagrees with agency action under this section may request an administrative hearing under chapter 182-526 WAC.

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

Effective April 14, 2014.

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

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

Effective January 27, 2019

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

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

Effective June 26, 2022.

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

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

Effective September 18, 2020.

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

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

Effective November 1, 2024.

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

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

Effective January 9, 2014.

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

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

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

Effective January 9, 2014.

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

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

Effective September 18, 2020.

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

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

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

Effective January 9, 2014.

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

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

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

Effective January 9, 2014.

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

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

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

Effective September 18, 2020.

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

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