600 Series reason codes

Revised date
Purpose statement

600 Series Reason Code Protocols

Go to the Reason Code Link chart to find information regarding other series reason codes. This chart will be for codes 100 through 500.

Reason Code HCA Reason For Closure Washington Healthplanfinder Letters Text Washington Healthplanfinder Screen Text WAC References Forced Closure Code Required?
600 Due to incarceration You are not eligible for Washington Apple Health because you reported you are currently incarcerated. Not eligible for Washington Apple Health due to reported incarceration. 182-505-0210
182-505-0240
182-503-0505
182-505-0250		 Yes
601 Due to residing in State hospital You are not eligible for Washington Apple Health because you are currently living in Eastern or Western State hospital and do not meet the age criteria for coverage. Not eligible for Washington Apple Health due to living in Eastern or Western State hospital and do not meet age criteria for coverage. 182-505-0210
182-505-0240
182-503-0505
182-505-0250		 Yes
602 Not living in the household You are not eligible for Washington Apple Health because you are no longer living in the home. Not eligible for Washington Apple Health due to no longer living in the home. 182-506-0010 Yes
604 Other health insurance - Medicare You are not eligible for Washington Apple Health for Adults coverage because you have other health coverage through Medicare. Not eligible for Washington Apple Health due to other health coverage through Medicare. 182-505-0250 Yes
605 You must submit your own application You must submit your own application for Washington Apple Health coverage. Must submit separate application for Washington Apple Health due to age requirement. 182-503-0010 No
606 Age 65 or older You are not eligible for Washington Apple Health adult coverage because you are age 65 or older. Not eligible for Washington Apple Health due to age 65 or older. 182-505-0250 No

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Authorized representatives

Revised date
Purpose statement

To explain what an authorized representative (AREP) is, how to designate someone as AREP, and what information the agency may disclose to AREPs.

WAC 182-503-0130 Authorized representative.

WAC 182-503-0130 Authorized representative.

Effective August 17, 2015

  1. ​Designating an authorized representative (AREP).
    1. A person may designate an AREP to act on his or her behalf in eligibility-related interactions with the medicaid agency by completing the agency's Authorized Representative Designation Form (DSHS 14-532), or through any of the methods described in 42 C.F.R. 435.907(a) and 42 C.F.R. 435.923. The Authorized Representative Designation Form is available online at https://www.dshs.wa.gov/fsa/forms.
    2. A court-appointed legal guardian with authority to make financial decisions on a person's behalf is that person's AREP.
    3. An agreement creating power of attorney (POA) that grants decision-making authority regarding the person's financial interactions with the agency establishes the POA as the AREP.
    4. If a person is unable to designate an AREP due to a medical condition, an individual may designate himself or herself as the AREP by signing the agency's Authorized Representative Designation Form (DSHS 14-532).
  2. Serving as an AREP. To serve as an AREP, an individual or organization must:
    1. Have a good-faith belief that the information he or she provides to the agency is correct.
    2. Report any change in circumstance required under WAC 182-504-0105 unless doing so would exceed the scope of authorized representation or violate state or federal law.
    3. A provider, staff member, or volunteer of an organization must also comply with 42 C.F.R. 435.923(d-e).
  3. Terminating authorized representation.
    1. The person or the AREP may terminate the authorized representation at any time for any reason by notifying the agency verbally or in writing.
    2. Authorized representation terminates automatically when the person dies.

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

What is an authorized representative (AREP)?

Defined in WAC 182-503-0130, an AREP is a person or organization who is authorized by an applicant or recipient to get only the information needed to determine the applicant's or recipient's eligibility for Apple Health programs and other information related to Apple Health coverage such as certification periods, renewals, etc. An AREP assists the applicant/recipient with the application, recertification, and general eligibility processes. Designating an AREP is never required.

An AREP can be any adult (including anyone who is not a member of the household/medical assistance unit) or organization (including any department, division, or other subset of an organization) who is both:

  • Sufficiently aware of the applicant's or recipient's household circumstances, and
  • Authorized by the applicant or recipient to act on behalf of him or her for eligibility purposes.

If an AREP is an organization, other individuals of that organization may also act as AREPs. If an AREP is a division or another part of a larger organization, only individuals in that division or part may act as AREPs.

Note: For example, King County Public Health is a large organization. If the Access and Outreach department of King County Public Health is designated an AREP, only those individuals in that department may act as AREPs. Individuals from other departments in King County Public Health are not AREPs.

An AREP is not authorized to receive health information about individuals unless they have power of attorney or have been named on the completed and signed DSHS 14-012 consent form.

An AREP can share any information relevant to eligibility; however, the department can only share information with the AREP that is necessary for the purposes of determining financial eligibility.

An AREP can receive letters, including the income computation sheet, renewal forms, and ProviderOne services cards if the individual has authorized the sharing of such correspondence.

Forms

The table below describes the forms used by HCA and DSHS for the following purposes:

  • Designating an AREP
  • Authorizing consent to share information
  • Releasing agency records
Type of form and questions Authorized representative Consent to use and share confidential information Authorization to release agency records
HCA forms: 18-001
(14-430 for pregnant teens)		 * See note below 80-020
DSHS forms: 14-532 or 18-005 ** 14-012 17-063
When to use? To authorize the agency to exchange with the AREP only the information needed to determine eligibility for Apple Health programs. HIPAA restrictions prevent us from discussing the person's individual health information with an AREP unless a current signed DSHS 14-012 consent form is in the record. To give consent for the agency to exchange more information with health care providers or other agencies (as identified on the form) than the basic eligibility information that can be shared with an AREP. DSHS Form 14-012 is HIPAA-compliant. To authorize the agency to release agency records and other information (as identified on the form) to the person or organization (as identified on the form). DSHS Form 17-063 and HCA Form 80-020 are HIPAA-compliant.
Who processes the request?

If the individual designates an AREP in Healthplanfinder (which the individual can do anytime), Healthplanfinder accepts the request when submitted. Outside of Healthplanfinder, the AREP designation is received and entered into ACES or Healthplanfinder as follows:

 DSHS receives DSHS Form 14-012 and uploads it into the Electronic Case Record (ECR). Only the Public Disclosure Unit at HCA or DSHS can approve or deny requests to release agency records, whether on HCA Form 80-020 or DSHS Form 17-063 or by other correspondence.
How long is the designation effective?

An AREP designation on HCA Form 18-001 or HCA Form 18-005 or DSHS Form14-532 is effective until applicant/recipient revokes or AREP notifies they are no longer the AREP

An AREP designation is effective until revoked by the client or authorized representative unless otherwise designated by the applicant/recipient and automatically terminates when a person dies.

 The consent on DSHS Form 14-012 is effective for the period of time specified on the form. The authorization to release records on HCA Form 80-020 or DSHS Form 17-063 is effective for the period of time specified on the form.

* Note: The consent to Use and Share Confidential information form is not required for HCA to obtain information from a provider.

**Note: To designate an authorized representative complete DSHS forms 14-532 or designate your authorized representative on the completed Washington Apple Health Application for Aged, Blind, Disabled/Long-Term Services and Supports (18-005, page 16).

Note: Every signed consent form is unique, so it is critical that the authorized information, designated parties, and effective dates be carefully reviewed before releasing information.

Power of Attorney/Legal Guardianship

DSHS Form 14-532 and DSHS Form 14-012 are not required when the AREP has Power of Attorney or Legal Guardianship. Power of Attorney/Legal Guardianship must be verified. For medical assistance programs, legal guardianship is designated by coding the AREP screen Rep Type field in ACES with CG or GN and power of attorney is designated by coding the AREP screen Rep Type field in ACES with AD or NA.

Institutionalized children and designating facilities as AREPs

When a child aged 18 or younger is institutionalized and the facility is applying on their behalf, the DSHS 14-532 AREP form or the designation of the facility as an AREP on the application or eligibility review is not required when the individual is:

  • In a court ordered, out-of-home placement under chapter 13.34 RCW; or
  • Involuntarily committed to an inpatient treatment program by a court order under chapter 71.34 RCW.

Worker responsibilities

For information regarding AREP Screens for Long-Term Care cases.

  1. Depending on what an Apple Health recipient chooses, an AREP may:
    1. Receive letters/notices/forms/ProviderOne cards; or
    2. Have permission only to discuss the case; or
    3. Both.
  2. For Classic Medicaid:
    1. The worker records on the AREP screen in ACES the representative's name and address and the REP Type code, which determines what forms, letters, etc. they receive.
    2. If the individual is completing their review over the phone and they are designating a new AREP, the individual should complete a DSHS 14-532 AREP form. The worker should not add the new AREP until they receive the completed DSHS 14-532 AREP form or written confirmation from the individual. Completing the DSHS 14-532 AREP form is not required if the individual is confirming or making changes to their current AREP.
  3. For MAGI-based Medicaid, the applicant or worker clicks the box in Washington Healthplanfinder to choose whether the AREP will receive letters/notices/form/ProviderOne cards. This information is then transferred to ACES.
  4. Initial designation of an AREP by an individual should be made on the application, review or DSHS 14-532 AREP form. Changes to an existing AREP can be made verbally but must be well documented in the remarks behind the AREP screen in ACES.

ACES Procedures

Authorized Representative/Protective Payee

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Chart of requirements

Revised date

Verification Requirements Chart - Apple Health

What to verify Verification needed for MAGI-Based Apple Health for Adults, Pregnant Women, and Children? Verification needed for SSI Related Apple Health (Aged, Blind and Disabled)? Verification needed for Long-Term Supports and Services Apple Health?
Child Support obligation No - Deduction not allowed No - Deduction not allowed Yes - Only if income is garnished
Citizenship (1) Yes Yes Yes
Dependent care expenses No - Deduction not allowed No - Deduction not allowed No - Deduction not allowed
Disability Not applicable Yes Yes
Health insurance premiums other than Medicare No - Deduction not allowed Yes Yes
Household composition Only if questionable Only if questionable Yes - For spousal and deeming cases only
Immigration and lawful presence (1) Yes Yes Yes
Income Yes (2) Yes Yes
Medical expenses No - Deduction not allowed Yes - For spenddown only Yes
Pregnancy No - Self-attestation accepted No - Self-attestation accepted No - Self-attestation accepted
Residency Only if questionable Only if questionable Only if questionable
Resources Not applicable Yes - Except HWD (5) Yes
Shelter costs Not applicable Not applicable Yes - Spousal and dependent deeming cases only
Social Security number Yes (3)(4) Yes (4) Yes (4)
Tax filing status No Not applicable Not applicable
Tribal status No - Self-attestation accepted No - Self-attestation accepted No - Self-attestation accepted

1 - Citizenship, identity, and lawful presence is verified using the SSA citizenship data match, federal hub services, or SAVE. If citizenship or lawful presence is unverified, verification is requested.

2 - Income for MAGI-based health care coverage is verified in post-eligibility review when electronic verifications do not confirm attested income.

3 - A newborn born to a mom on Washington Apple Health (see WAC 182-505-0210 (2)) is eligible for Washington Apple Health without meeting the SSN requirement until his or her first birthday.

4 - A client needs to provide his or her SSN, or proof one has been applied for, unless claiming an exemption for religious or domestic violence reasons.

5 - No, if there are no resources listed on the application or review form.

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Equal Access services

Revised date
Purpose statement

To provide staff with basic information on the steps to identify individuals who need extra help (an accommodation) to access or maintain health care coverage resulting from any disability or learning or literacy issue.

WAC 182-503-0120 Washington apple health -- Equal access services.

WAC 182-503-0120 Washington apple health -- Equal access services.

Effective December 3, 2025.

  1. When you have a mental, neurological, cognitive, physical or sensory impairment, or limitation that prevents you from receiving health care coverage, we provide services to help you apply for, maintain, and understand the health care coverage options available and eligibility decisions we make. These services are called equal access (EA) services.
  2. We provide EA services on an ongoing basis to ensure that you are able to maintain health care coverage and access to services we provide. EA services include, but are not limited to:
    1. Helping you to:
      1. Apply for or renew coverage;
      2. Complete and submit forms;
      3. Give us information to determine or continue your eligibility;
      4. Ask for continued coverage;
      5. Ask for reinstated (restarted) coverage after your coverage ends; and
      6. Ask for and participate in a hearing.
    2. Giving you additional time, when needed, for you to give us information before we reduce or end your health care coverage;
    3. Explaining our decision to change, reduce, end, or deny your health care coverage;
    4. Working with your authorized representative, if you have one, and giving that person copies of notices and letters we send you; and
    5. Providing you the services of a sign language interpreter/transliterator who is certified by the Registry of Interpreters for the Deaf at the appropriate level of certification.
      1. These services may include in-person sign language interpreter services, relay interpreter services, and video interpreter services, as well as other services; we decide which services to offer you based on your communication needs and preferences.
      2. We offer these services as a reasonable accommodation, free of charge, if you are deaf, hard-of-hearing, or a deaf-blind person who uses sign language to communicate.
    6. Not taking adverse action in your case, or automatically reinstating your coverage for up to three months after the adverse action was taken, if we determine that your impairment or limitation was the cause of your failure to follow through on something you need to do to get or keep your Washington apple health coverage, such as:
      1. Applying for or renewing coverage;
      2. Completing and submitting forms;
      3. Giving us information to determine or continue your eligibility;
      4. Asking for continued or reinstated coverage; or
      5. Asking for and participating in a hearing.
  3. We inform you of your right to EA services listed in subsection (2) of this section:
    1. On printed applications and notices, including the printed rights and responsibilities form;
    2. In the Washington healthplanfinder web site, including the electronic rights and responsibilities form; and
    3. During contact with us.
  4. We provide you the EA services listed in subsection (2) of this section if you ask for EA services, you are receiving services through the home and community living administration, or we determine that you would benefit from EA services. We determine you would benefit from EA services if you:
    1. Appear to have or claim to have any impairment or limitation described in subsection (1) of this section;
    2. Have a developmental disability;
    3. Are disabled by alcohol or drug addiction;
    4. Are unable to read or write in any language;
    5. Appear to have limitations in your ability to communicate, understand, remember, process information, exercise judgment and make decisions, perform routine tasks, or relate appropriately with others (whether or not you have a disability) that may prevent you from understanding the nature of EA services or affect your ability to access our programs; or
    6. Are a minor not residing with your parents.
  5. If we determine that you are eligible for EA services, we develop and document an EA plan appropriate to your needs. The plan may be updated or changed at any time based on your request or a change in your needs.
  6. You may at any time refuse the EA services offered to you.
  7. We reinstate your coverage when:
    1. We end coverage because we were unable to determine if you continue to qualify; and
    2. You provide proof that you are still qualified for coverage within 20 calendar days from when we ended your coverage. We restore your coverage retroactive to the first of the month so there is no break in your coverage.
  8. If you believe that we have discriminated against you on the basis of a disability or another protected status, the person may file a complaint with the U.S. Department of Health and Human Services at https://www.hhs.gov/civil-rights/filing-a-complaint/complaint-process/ or Region Manager, Office for Civil Rights, U.S. Department of Health and Human Services, 2201 Sixth Ave. – M/S: RX-11, Seattle, WA 98121-1831 (voice phone 800-368-1019, fax 206-615-2297, TDD 800-537-7697).

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

Worker responsibilities

If you know that a particular individual needs assistance, it is your ethical and legal responsibility to help the individual identify if they need Equal Access (EA) services and what services are needed (and to confirm if they still need EA services and what those EA services are).

  • When department staff work with individuals identified as needing EA services, it is critical that the EA Plan be readily available and used to ensure the individual is able to fully access services and maintain eligibility.
  • Continually be alert to cues that might indicate an individual is in need of EA services.
  • Conduct an EA assessment and develop an EA Plan if one has not been done.
  • Provide accommodations whenever appropriate.

Note: Most accommodations are easily provided when the need for accommodation is understood. Other service providers, such as DVR may be able to assist in providing accommodations when the individual is eligible for DVR services. In some cases, DVR may have adaptive devices that can be shared, such as access to a TRS for communication with persons with hearing impairments.

Screening

Apple Health Classic Medicaid programs

  • Upon application, all applicants for, and recipients of, Washington Apple Health are assessed for their need for EA services.
  • Individuals are screened using the ACES Online EA Screens to determine the need for accommodations and the plan for delivery of services.
  • Most EA screenings and plan development are done by reception, financial or WorkFirst Program Specialists.
  • Social Service Specialists are called upon for their expertise in screening and plan development when necessary.

MAGI-Based Apple Health programs

MEDS/Community-Based Assistants document the need for an EA Plan and what accommodations are needed for the EA Plan as follows:

  1. With applicant on the phone or in-person, ask if they would like help to complete the application or renewal. If the applicant/recipient says “Yes”, then do the following:
    1. Navigate to the Client Summary in ACES Online
    2. Select Equal Access under the Details tab
      1. Click Update on the right side of the page
      2. Select Yes and a list of questions will appear
    3. Read questions and record client answers (all questions must be answered to continue)
      1. Click Next to save
    4. The Equal Access indicator under the client’s name should show as "Yes"

If the individual is currently on a DSHS program, the EA screening and EA Plan development will likely have been done by reception, a DSHS financial worker or a WorkFirst Program Specialist. However, the worker needs to ask at every contact if the individual or applicant would like help completing the application or renewal.

When an individual applies for or receives Apple Health they are entitled to EA services whether they self-identify or agency staff identify the need. Staff should make EA determinations and take appropriate action on a case-by-case basis until the process can be automated in Healthplanfinder.

For policies on equal access for clients receiving LTSS see Equal Access - Necessary Supplemental Accommodation (NSA) and long-term services and supports.

If you have any questions, please contact HCA regional representative.

Aces Procedures

Equal Access (Accommodation) Resources:

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Exception to Rule (ETR) process due to inability to provide citizenship and/or verification of identity

Revised date
Purpose statement

This section is additional information for Home and Community Services (HCS) cases if the applicant or recipient cannot provide evidence of U.S. citizenship or identity. An exception to rule can be requested in limited circumstances.

HCS ETR process regarding citizenship or identity verification requirements

This section gives additional information on processes as the information indicated in the citizenship and identity requirements for Medicaid.

If the applicant or recipient cannot provide evidence of U.S. citizenship or identity, an exception to rule (ETR) can be requested in limited circumstances. These are individuals that attest to being a U.S. citizen but have been unable to provide verification.

Examples for an ETR include but are not limited to:

  • Amnesia or coma victim
  • Individual with a dire medical condition whose life will be in jeopardy without medical care.
  • An individual needing services provided by Home and Community Services (HCS).

New applications are denied if citizenship or identity documents cannot be provided. Pend the application if an ETR is appropriate.

For recipients where, requested verification for citizenship or ID have not been provided, keep the case open and request an ETR if appropriate.

HCS ETRs

Health Care Authority (HCA) has requested that All ETR requests from HCS go through Lori Rolley at HCS Headquarters. HCS field staff need to email Lori Rolley with the following information:

  • Subject line: "ETR citizenship/ID requirements".
  • Include the client's name and client id in the text of the email.
  • Indicate whether the individual is at living at home, in residential or in a nursing home.

Lori will forward all ETR requests from HCS to the HCA policy representatives. A response from HCA will be forwarded back to the originator of the request.

Worker responsibilities

At each review, make sure the correct citizenship and ID coding is updated in ACES.

For individuals that are receiving Medicare, SSI (or past SSI) or SSA disability based on their own disability:

  • If there is no T1 or T2 document in the case record, indicate the citizenship coding as T4.

The following are acceptable identity documents:

  • A current state driver license with the individual's picture.
  • A state identity card with individual's picture.
  • A US American Indian/Alaska Native tribal document.
  • Military identification card with individual's picture.

For disabled individuals in residential care facilities the facility administrator or director may submit affidavits attesting to the individual's identity.

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Iraqi and Afghan immigrants

Revised date
Purpose statement

To explain the rules applicable to Iragi and Afghan Special Immigrants.

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

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

Effective October 3, 2025

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

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

Clarifying Information

Special Immigrants from Iraq and Afghanistan are "Qualified Aliens" (see WAC 182-503-0535 (5)(f)) and are eligible for federally-funded Apple Health
to the same extent and for the same time period as refugees. Their eligibility period starts from their date of entry into the United States or, if after the U.S. entry, the date the Special Immigrant status was granted as indicated on the I-551 (green card).

Documentation of Identity, Citizenship, and Immigration Status:

Iraqi or Afghan immigrants who were granted Special Immigrant status before entry into the U.S. (Primary Applicant, Spouse, and/or Unmarried Children under 21) have the following USCIS documentation:

  • Iraqi or Afghan passport stamped with one of the following Immigrant Visa (IV) codes: SI1, SI2, SI3, SQ1, SQ2, SQ3 and,
  • Department of Homeland Security (DHS) stamp or notification on passport or I-94 showing date of entry.

Iraqi or Afghan immigrants who were granted Special Immigrant status after entry into the U.S. (Primary Applicant, Spouse, and/or Unmarried Children under 21) have the following USCIS documentation.

  • Iraqi or Afghan passport stamped with one of the following Immigrant Visa (IV) codes: SI6, SI7, SI8, SQ6, SQ7, SQ8 or,
  • DHS Form I-551 ("green card") showing Iraqi or Afghan nationality.

Questions

If you have any questions regarding eligibility or how to process a case, please email hcawahrmaapps@hca.wa.gov or call 1-855-682-0798.

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300 Series reason codes

Revised date
Purpose statement

300 Series Reason Code Protocols

Go to the Reason Code Link chart to link directly to a specific reason code or scroll through the list below. For ACES Procedures go to ACES Letters in the ACES User Manual.

On this page: 300-307 | 320-327 | 330-339 | 340-388

300-307

Reason code Reason code description WAC references - Classic Apple Health Free form text - Classic Apple Health WAC references - MAGI-Based Apple Health Free form text - MAGI-Based Apple Health

300

Nonpayment of Premium

According to our records, you have not paid all required premiums. See WAC rule (Washington Administrative Code):

  

None required

    

301

Exceeds Income Standard

Your income is over the limit that is allowed for this program. See WAC rule (Washington Administrative Code):

388-478-0060

388-478-0055

388-450-0165

388-450-0162

388-450-0015

388-478-0090

The limit for your household size is $ __.

182-519-0050

182-505-0100

182-512-0010

182-517-0100

182-509-0001

  

306

Change In Unearned Income

The amount of unearned income you get has changed. See WAC rule (Washington Administrative Code):

388-418-0020

388-450-0025

388-450-0162

182-512-0010

388-492-0020

388-492-0030

Your income from (source) has changed from $ __ to $ __.

    

307

Change In Gross Earned Income

The amount of money that you earn has changed. See WAC rule (Washington Administrative Code):

388-450-0030

182-512-0010

388-418-0020

Your gross earned income has changed from $ __ to $ __.

    

320-327

Reason code Reason code

description

 WAC references -

Classic Apple Health

 Free form text - Classic

Apple Health

 WAC

references - MAGI-Based Apple Health

 Free form text

- MAGI-Based Apple Health

320

Exceeds Gross Income Limit

Your income is higher than the income limit for this program. See WAC rule (Washington Administrative Code):

388-450-0015

388-450-0165

388-478-0060

388-478-0090

The limit for your
household size is $ __.

    

321

Change In Net Deemed Income

The amount of income we consider available to you from an outside source has changed. See WAC rule (Washington Administrative Code):

388-450-0100

388-450-0105

388-450-0115

388-450-0120

388-450-0135

388-450-0155

388-450-0130

388-450-0150

388-450-0140

388-450-0160

388-450-0125

We are counting
$ __ of (Name)'s income.

    

323

Change In Home Maintenance Exemption

The income amount that you are allowed to keep to pay for home expenses is called a home maintenance allowance. Yours is changing because:

  • You have been getting it for 6 months;
  • Your doctor says you have to stay longer; or
  • The amount of your home expense has changed.

See WAC rule (Washington Administrative Code):

388-513-1380

Your home maintenance amount has changed because __.
(add specific details, e.g. "Your rent has changed from $ __ to $ __. "
Or "On __ (date) __ Dr. __ told us you can't return home before __ .")

    

327

Change In Recoupment

We are taking a different amount from your benefits to repay an overpayment. See WAC rule (Washington Administrative Code):

388-410-0005

388-410-0010

388-410-0015

388-410-0030

None Required

    

330-339 

Reason code Reason code description WAC references - Classic Apple Health Free form text - Apple Health WAC references - MAGI-Based Apple Health Free form text - MAGI-Based Apple Health

330

Lump Sum

Your resources are over the limit for this month because of your lump sum payment. See WAC rule (Washington Administrative Code):

388-450-0245

388-470-0005

You got $ __ from __ on 00/00/00. Your countable resources are now $ __. Your resources cannot be more than $ __ (specify resource limit for household size).

If the grant is suspended:

We will be subtracting $ __ from next month's grant. This reduction is for one month only.

If the grant is terminated:

Your lump sum payment is more than the need standard for two months. You can reapply for a cash grant in (month).

    

332

Change In CPI Allowance

Your Personal Needs Allowance (PNA) changed. See WAC rule (Washington Administrative Code):

388-513-1380

      

334

Your earned income is over the limit for this program

388-478-0035

The limit for your household size is $ __.

    

335

Change In Uncovered Medical Expense Allocation

The amount you can use to pay medical expenses has changed. See WAC rule (Washington Administrative Code):

388-513-1380

The amount you can use to pay for the following medical expenses has changed: (Type of expense) from $ __ to $ __.

    

336

Change In CSMA / FMMA Allocation

The amount we can allow for the maintenance of your family members at home has changed. See WAC rule (Washington Administrative Code):

388-513-1380

Your allocation changed from $ __ to $ __ because __.

    

339

Medical Extension Ends

Your medical extension expired and we did not get your review form. If we get it before the end of the month, we will reconsider our decision. If you have already sent it, let me know. If your medical benefits stop and you decide that you still want them, you need to reapply. See WAC rule (Washington Administrative Code):

388-400-0035

182-523-0100

182-505-0115

 

    

340-388

Reason code Reason code

description

 WAC references -

Classic Apple Health

 Free form text - Classic

Apple Health

 WAC

references - MAGI-Based Apple Health

 Free form text

- MAGI-Based Apple Health

340

QMB Ineligible - Client Is Not Institutional Related

You are no longer eligible for assistance that pays for all or part of your Medicare costs and premiums. The department must count your income differently when you are no longer eligible for Long-Term Care Services, such as Nursing Facility Care, COPES or CAP/OBRA Services. See WAC rule (Washington Administrative Code):

388-450-0005

None Required

    

341

The state supplemental payment rate for all SSI recipients has changed. See WAC rule (Washington Administrative Code):

388-478-0055

None required

    

342

Medical coverage stopped because you are 3 months behind in premium payments. Medical can't start again until the premiums are paid.

Premiums aren't required for a child who is pregnant, an American Indian or Alaska Native. If your family income decreases, medical coverage without a premium may be available.

HPF

Health care coverage stopped because you are three months behind in premium payments. Washington Apple Health with premiums coverage can't start again until the premiums are paid.

182-505-0225

None required

182-505-0225

None required

343

The amount of Third-Party Resources you get has changed. See WAC rule (Washington Administrative Code):

388-501-0200

The amount of your third party resource has changed from $ __ to $ __.

    
388

WA Fund CAP For Q1 Already Reached

Washington gets a limited amount of money for the Qualified Individual (QI-1) Program. There are no more funds available for this year. You can reapply in December for next year. See WAC rule (Washington Administrative Code):

 182-517-0300 None required    

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Non-Grant Medical Assistance (NGMA) overview

Revised date
Purpose statement

To describe the procedures to obtain a determination of disability or blindness that enables adults not receiving other assistance to be related to Medicaid on the basis of disability or blindness.

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

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

Effective April 14, 2014.

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

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

Clarifying information

An applicant who isn’t receiving a social security (Title II) cash payment based on a disability established by the Social Security Administration (SSA) may be eligible for SSI-related medical coverage under the Non Grant Medical Assistance (NGMA) program. Eligibility staff submit a request to Disability Determination Services (DDS) to determine whether a disability exists for the purposes of medical coverage only. If the individual is claiming disability, but is eligible for Medicaid through another program such as Apple Health for Adults or children’s medical, a NGMA decision is only necessary if the individual is applying for long-term services and supports based on disability (such as a Home and Community Services (HCS) or Developmental Disabilities Community Services (DDCS) home and community based waiver) or for the Healthcare for Workers with disabilities (HWD) program. See more information about HWD below.

When an individual who receives SSA is admitted to an Institute of Mental Disease (IMD), SSA suspends cash benefits, but they are still considered disabled until SSA completes a disability review. This status continues for the individual even if their disability review date has passed during their treatment. A request for a NGMA disability determination is not required if SSDI benefits are suspended due to reasons not related to disability: S6 (address unknown or payee being established), S7 (Inmate of Public Institution) or S8 (pending for a representative payee)

For more information on how SSA determines a qualifying disability see the SSA document called How we decide if you still have a qualifying disability.

When exiting an IMD, Supplemental Security Income (SSI) clients continue to meet disability requirements for Medicaid or waiver services unless terminated for a reason not related to the IMD. SSA terminates SSI after an individual has been in nonpay status for one year. These clients require a NGMA if one is needed for Medicaid eligibility.

The elimination of the NGMA process for individuals whose SSDI has been suspended due to hospitalization will help streamline approvals for coverage and services needed to support a successful return to the community.

When not to refer to NGMA

If an applicant is receiving SSI or SSDI, do not refer for a NGMA decision. If an individual has been denied for SSI or SSDI in the last year, do not refer for a NGMA unless the individual reports that their medical condition has worsened or that they have a new disabling condition.

DDS doesn’t consider the Substantial Gainful Activity (SGA) test when determining if an individual meets the functional disability criteria, but it can affect Medicaid eligibility. If earned income is above SGA and the individual does not receive federal cash benefits, then Apple Health for Workers with Disabilities (HWD) (S08), which waives the SGA test, may provide coverage.

HWD and individuals with assets exceeding resource limit

HWD may also provide coverage for an individual meeting program requirements when the individual has assets exceeding the resource limit.

Worker responsibilities

  1. On receipt of request for a Medicaid decision:
    1. Review the referral and Equal Access services information.
    2. Confirm the applicant is claiming blindness or disability. If the claim does not appear to meet SSA disability criteria, explains this to the applicant or representative and suggest the application be withdrawn. Obtain a withdrawal request if the applicant or representative agrees. Explain the following points about the determination process:
      • DDS makes the determination of blindness or disability.
      • The standard of promptness date is 60 days, but additional time may be required.
      • The individual has a right to request a hearing if they disagree with the decision and it will be the responsibility of DDS to defend the decision.
      • The individual is required to pay a monthly premium if earning more than the current SGA amount and eligible for coverage only under the HWD program.
  2. Review of financial information:
    • If the applicant is not working, and the applicant’s countable resources meet the following resource standards, complete a NGMA decision referral. The applicant is not eligible for HWD, if not working, but may be eligible for coverage under another Medicaid program. If the individual is under age 65 and not eligible for Medicare, coverage might also be available under the new adult group based on the MAGI methodology. See Health care for adults in the Apple Health eligibility manual.
  3. If the applicant is working, and their income is over SGA standard or their resources exceed the standard described in 2.(a) above, forward the application, using the contact information listed below. (WAC 182-511-1150 Health care for workers with disabilities (HWD) -- Disability requirements in the HWD chapter).
  4. Send the following forms to the applicant for completion and signature.
    • Medical Disability Report and Decision, DSHS 14-144A
    • Medical Information Release Form SSA 827
  5. Initiate a NGMA referral to DDS through the Barcode NGMA application. Each referral must contain the following:
    • Transmittal Summary, DSHS 14-144.
    • Medical Disability Report and Decision, DSHS 14-144A.
    • Medical Information Release Form SSA 827.
  6. Request retroactive approval if applicant had a medical need in any of the three months before the month of application and meets financial eligibility for each of the retroactive months.

Medical records

DDS support staff or adjudicators obtain medical records directly from DMS for initial applications and reconsiderations. DO NOT SEND PAPER MEDICAL RECORDS.

Paper copy to DDS adjudicator

The administrative hearing coordinator is still required to send a paper copy of an Administrative Hearings packet to the DDS adjudicator.

Previous NGMA packet

If the individual is reapplying or requesting continued NGMA benefits:

  1. Initiate a redetermination referral to DDS through the Barcode NGMA application.
  2. Document all actions in ACES.
  3. Pend the application until a decision is received from DDS. Document the reason for delays beyond 60 days from the date of application in ACES.
  4. When DDS returns the disability determination form 14-144:
    1. If the individual meets the disability criteria, open medical care in the appropriate category, based on income and resources per WAC 182-508-0001.
    2. Enter the end date and the determination date on the DEM2 ACES screen, and send a request for a redetermination to DDS at least 30 days prior to the review end date.
    3. If the reexam has been waived by DDS, no end date is required.
    4. If the applicant does not meet the disability criteria, consider the applicant for all other medical programs, or allow the individual to provide new medical information to be forwarded to DDS for reconsideration.

See Administrative Hearing chapter (Chapter 182-526 WAC) for hearing and reconsideration procedures.

For additional information, see Non-Grant Medical Assistance (NGMA) hearings and Special Procedures on Non-Grant Medical Assistance and Health Care Authority hearings.

Definitions

  • Aged: Age 65 or older.
  • Blind: A corrected central visual acuity of 20/200 or a 20 degree field of vision limitation.
  • Disability: The inability to engage in any substantial gainful activity (SGA) by reason of any medically determinable physical or mental impairment(s) which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.
  • Disability Determination Services (DDS):The state entity that uses federal criteria to determine disability or blindness under an agreement with the Social Security Administration.
  • Apple Health for Workers with Disabilities (HWD): An Apple Health program that enables many people with disabilities to work and keep their health care.
  • Non Grant Medical Assistance (NGMA): The process through which the department makes a disability determination for individuals who are not receiving Title II cash benefits based on disability.
  • Substantial Gainful Activity (SGA): A person who is earning more than a certain monthly amount (net of impairment-related work expenses) is ordinarily considered to be engaging in SGA.

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Time to process

Revised date
Purpose statement

To provide the time limits for processing applications for health care coverage.

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

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. 

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

Clarifying Information

Example: Olaf applies for SSI-Related Apple Health due to a disability. DSHS finds that he is financially eligible but Olaf does not provide any medical documentation. DSHS refers the application to the Division of Disability Determination Services (DDDS). DDDS sends a request for the medical information to Olaf’s doctor. The doctor does not respond. DDDS sends another request for the missing information, and the doctor gives the medical information more than 60 days after Olaf applied. There is good cause for not processing the application within 60 days because Olaf and his doctor, and not DSHS or DDDS, caused the delay.

Aces Procedures

Standards of Promptness

Standards of Promptness - When is there good cause for not processing an application by the SOP date?

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Care Delivery - managed care

Revised date
Purpose statement

To explain managed care and provide a link to the various services.

WAC 182-538-060 Managed care choice and assignment

WAC 182-538-060 Managed care choice and assignment.

Effective October 25, 2020

  1. The medicaid agency requires a client to enroll in integrated managed care (IMC) when that client:
    1. Is eligible for one of the Washington apple health programs for which enrollment is mandatory;
    2. Resides in an area where enrollment is mandatory; and
    3. Is not exempt from IMC enrollment and the agency has not ended the client's managed care enrollment, consistent with WAC 182-538-130.
  2. American Indian and Alaska native (AI/AN) clients and their descendants may choose one of the following:
    1. Enrollment with a managed care organization (MCO) available in their regional service area;
    2. Enrollment with a PCCM provider through a tribal clinic or urban Indian center available in their area; or
    3. The agency's fee-for-service system for physical health or behavioral health or both.
  3. To enroll with an MCO or PCCM provider, a client may:
    1. Enroll online via the Washington Healthplanfinder at https://www.wahealthplanfinder.org ;
    2. Call the agency's toll-free enrollment line at 800-562-3022; or
    3. Go to the ProviderOne client portal at https://www.waproviderone.org/client and follow the instructions.
  4. An enrollee in IMC must enroll with an MCO available in the regional service area where the enrollee resides.
  5. All family members will be enrolled with the same MCO, except family members of an enrollee placed in the patient review and coordination (PRC) program under WAC 182-501-0135 need not enroll in the same MCO as the family member placed in the PRC program.
  6. An enrollee may be placed into the PRC program by the MCO or the agency. An enrollee placed in the PRC program must follow the enrollment requirements of the program as stated in WAC 182-501-0135.
  7. When a client requests enrollment with an MCO or PCCM provider, the agency enrolls a client effective the earliest possible date given the requirements of the agency's enrollment system.
  8. The agency assigns a client who does not choose an MCO or PCCM provider as follows:
    1. If the client was enrolled with an MCO or PCCM provider within the previous six months, the client is reenrolled with the same MCO or PCCM provider;
    2. If (a) of this subsection does not apply and the client has a family member enrolled with an MCO, the client is enrolled with that MCO;
    3. The client is reenrolled within the previous six months with their prior MCO plan if:
      1. The agency identifies the prior MCO and the program is available; and
      2. The client does not have a family member enrolled with an agency-contracted MCO or PCCM provider.
    4. If the client has a break in eligibility of less than two months, the client will be automatically reenrolled with his or her previous MCO or PCCM provider and no notice will be sent; or
    5. If the client cannot be assigned according to (a), (b), (c), or (d) of this subsection, the agency:
      1. Assigns the client according to agency policy, or this rule, or both;
      2. Does not assign clients to any MCO that has a total statewide market share of forty percent or more of clients who are enrolled in apple health IMC. On a quarterly basis, the agency reviews enrollment data to determine each MCO's statewide market share in apple health IMC;
      3. Applies performance measures associated with increasing or reducing assignment consistent with this rule and agency policy or its contracts with MCOs.
    6. If the client cannot be assigned according to (a) or (b) of this subsection, the agency assigns the client as follows:
      1. If a client who is not AI/AN does not choose an MCO, the agency assigns the client to an MCO available in the area where the client resides. The MCO is responsible for primary care provider (PCP) choice and assignment.
      2. For clients who are newly eligible or who have had a break in eligibility of more than six months, the agency sends a written notice to each household of one or more clients who are assigned to an MCO. The assigned client has ten calendar days to contact the agency to change the MCO assignment before enrollment is effective. The notice includes:
        1. The agency's toll-free number;
        2. The toll-free number and name of the MCO to which each client has been assigned;
        3. The effective date of enrollment; and
        4. The date by which the client must respond in order to change the assignment.
  9. An MCO enrollee's selection of a PCP or assignment to a PCP occurs as follows:
    1. An MCO enrollee may choose:
      1. A PCP or clinic that is in the enrollee's MCO and accepting new enrollees; or
      2. A different PCP or clinic participating with the enrollee's MCO for different family members.
    2. The MCO assigns a PCP or clinic that meets the access standards set forth in the relevant managed care contract if the enrollee does not choose a PCP or clinic.
    3. An MCO enrollee may change PCPs or clinics in an MCO for any reason, with the change becoming effective no later than the beginning of the month following the enrollee's request.
    4. An MCO enrollee may file a grievance with the MCO if the MCO does not approve an enrollee's request to change PCPs or clinics.
    5. MCO enrollees required to participate in the agency's PRC program may be limited in their right to change PCPs (see WAC 182-501-0135).

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

Note: Information on managed care service areas including how to change plans can be found on the HCA managed care webpage.

182-538 Chapters

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