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

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

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

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.

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

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

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.
1 2 3 4 5 6 7 8 9 10
914 914 914 914 914 975 1125 1242 1358 1483

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

WAC 182-518-0030 Washington apple health -- Notice requirements -- Electronic notices

WAC 182-518-0030 Washington apple health -- Notice requirements -- Electronic notices.

Effective May 20, 2017.

  1. For programs based on modified adjusted gross income (MAGI), you may choose to get notices by regular mail or in an electronic format through Washington Healthplanfinder.
  2. We send you letters (notices) about your eligibility for Washington apple health programs as described in WAC 182-518-0005 through 182-518-0025.
  3. When you select electronic notifications, also referred to as "paperless," we:
    1. Confirm your selection by regular mail;
    2. Notify you by email when a new notice has posted to your account; and 
    3. Consider the notice received by you as of the date on the notice as described in WAC 182-518-0005.
  4. To read the notice, you must log in to your Washington Healthplanfinder account, as email messages do not include the content of the notice or other confidential information.
  5. If an email message is returned as undeliverable, we send the message to you by regular mail no later than three business days after the date of the undeliverable email response.
  6. You may ask at any time to stop receiving electronic notices from us.

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

WAC 182-518-0025 Washington apple health -- Notice requirements -- Actions to terminate, suspend, or reduce eligibility or authorization for a covered service.

WAC 182-518-0025 Washington apple health -- Notice requirements -- Actions to terminate, suspend, or reduce eligibility or authorization for a covered service.

Effective December 1, 2016.

  1. General rule.
    1. We send written notice to you at least ten days before taking adverse action to terminate, suspend, or reduce your:
      1. Medicaid eligibility; or
      2. Authorization for a covered service.
    2. The ten-day notice period starts on the day we sent the notice.
  2. Exceptions to ten-day notice period. We may send a notice fewer than ten days before the date of the action in the following circumstances.
    1. We send written notice to you at least five days before taking action to terminate, suspend, or reduce your medicaid eligibility or authorization for a covered service if:
      1. We have facts indicating fraud by you or on your behalf; and
      2. We have verified the facts, if possible, through secondary sources.
    2. We send written notice to you no later than the date we took action to terminate, suspend, or reduce your medicaid eligibility or authorization for a covered service if:
      1. You requested the action;
      2. A change in statute, federal regulation or administrative rule is the sole cause of the action;
      3. You are incarcerated and expected to remain incarcerated at least thirty days;
      4. Mail sent to you has been returned without a forwarding address, and we do not have a more current address for you; or
      5. We are terminating your eligibility because you:
        1. Died; or
        2. Began receiving medicaid from a jurisdiction other than Washington
          state.
  3. Notice contents. Written notice under this section states:
    1. The nature of the action;
    2. The effective date of the action;
    3. The facts and reason(s) for the action;
    4. The specific regulation on which the action is based;
    5. Your appeal rights, if any;
    6. Your right to continued coverage, if any; and
    7. Information found in WAC 182-518-0005(4).
  4. Reinstated coverage.
    1. If we do not meet the advance notice requirements under this
      section, we reinstate your coverage back to the date of the action. We
      may still take action once we meet notice requirements under this section.
    2. If you are receiving medically needy coverage, you cannot receive
      reinstated coverage past the end of the certification period described
      in WAC 182-504-0020.
    3. We may end your coverage if a notice we mailed to you is returned
      with no forwarding address. We reinstate your coverage if we
      learn your new address and you meet eligibility requirements.
  5. Hearing rights. If you do not agree with agency action under
    this section, you may request an administrative hearing under chapter
    182-526 WAC, and you may be entitled to continued coverage under WAC
    182-504-0130.

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

WAC 182-518-0020 Washington apple health -Notice requirements -- Renewals

WAC 182-518-0020 Washington apple health -Notice requirements -- Renewals.

Effective August 29, 2014.

  1. We send you written notice before we stop your WAH coverage at the end of your certification period as described in WAC 182-504-0035.
  2. When we can administratively renew your coverage (as defined in WAC 182-500-0010), the notice includes:
    1. Your new certification period;
    2. The information we used to renew your coverage; and
    3. A request for you to give us updated information, if any of the information we used is inaccurate.
  3. When we cannot administratively renew your coverage, the notice includes:
    1. Information we currently have on record;
    2. How to complete the renewal using any of the methods described in WAC 182-504-0035 (1)(b);
    3. What action we will take on what date if we do not receive your completed renewal application on time; and
    4. That we follow the rules in WAC 182-518-0015.
  4. We send your renewal notice following the timeline in:
    1. WAC 182-504-0035(2) for programs based on modified adjusted gross income (MAGI); or
    2. WAC 182-504-0035(3) for non-MAGI based programs.

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

WAC 182-518-0015 Washington apple health -- Notice requirements verification requests

WAC 182-518-0015 Washington apple health -- Notice requirements verification requests

Effective August 29, 2014.

  1. We send you written notice when we need more information as described in WAC 182-503-0050 to decide if you are eligible to receive or continue receiving Washington apple health (WAH) coverage. The notice includes:
    1. A description or list of the information that we need;
    2. When we must have the information (see WAC 182-503-0060 for applications and WAC 182-504-0035 for renewals);
    3. What action we will take and on what date, if we do not receive the information; and
    4. Information required in WAC 182-518-0005(4).
  2. If we have received conflicting information about facts we need to determine your coverage, the notice will also include:
    1. The information we received that does not match what you gave us and the source; and
    2. A request that you send us a statement explaining the difference(s) between the information from you and the information from the other source.
  3. We allow you at least ten days to return the information. If you ask, we may allow you more time to get us the information. If the tenth day falls on a weekend or holiday, the due date is the next business day.
  4. If the information we ask for costs money, we will pay for it or help you get the information in another way.

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

WAC 182-518-0005 Washington apple health -- Notice requirements -- General

WAC 182-518-0005 Washington apple health -- Notice requirements -- General.

Effective August 29, 2014.

  1. For the purposes of this chapter, "we" refers to the agency or its designee and "you" refers to the applicant for, or recipient of, health care coverage.
  2. This section applies only to notices and letters that we send about eligibility for Washington apple health (WAH) programs. WAC 182-501-0165 applies to notices and letters regarding prior authorization or other action on requests to cover specific fee-for-service health care services.
  3. We send you written notices (letters) when we:
    1. Approve you for health care coverage for any program;
    2. Reconsider your application for other types of health care coverage based on new information;
    3. Deny you health care coverage (including because you withdrew your application) for any program (according to rules in WAC 182-503-0080);
    4. Ask you for more information to decide if you can start or renew health care coverage;
    5. Renew your health care coverage; or
    6. Change or terminate your health care coverage, even if we approve you for another kind of coverage.
  4. We send notices to you in your primary language if you ask us to and in English according to the rules in WAC 182-503-0110. If you need help to apply for or access your health care coverage due to a disability, we follow the equal access rules in WAC 182-503-0120.
  5. All WAH notices we send you include the following information:
    1. The date of the notice;
    2. Specific contact information for you if you have questions or need help with the notice;
    3. Your appeal rights, if an appeal is available, and the availability of potentially free legal assistance; and
    4. Other information required by state or federal law.

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

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

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.

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

WAC 182-517-0100 Federal medicare savings programs.

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.

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

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