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.

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.

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

Effective July 23, 2016

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

WAC 182-517-0100 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.
      5. 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.
      6. When calculating income under this section:
         1. The agency subtracts client participation from a long-term care client's countable income under WAC 182-513-1380, 182-515-1509, or 182-515-1514.
         2. The agency counts the annual Social Security cost-of-living increase beginning April 1st each year.
4. Covered costs.
   1. The QMB program pays:
      1. Medicare Part A and Part B premiums using the start date in WAC 182-504-0025; and
      2. Medicare coinsurance, copayments, and deductibles for Part A, Part B, and Part C, subject to the limitations in WAC 182-502-0110.
   2. If the client is eligible for both SLMB and another medicaid program:
      1. The SLMB program pays the Part B premiums using the start date in WAC 182-504-0025; and
      2. The medicaid program pays medicare coinsurance, copayments, and deductibles for Part A, Part B, and Part C subject to the limitations in WAC 182-502-0110.
   3. If the client is only eligible for SLMB, the SLMB program covers medicare Part B premiums using the start date in WAC 182-504-0025.
   4. The QI-1 program pays medicare Part B premiums using the start date in WAC 182-504-0025 until the agency's federal funding allotment is spent. The agency resumes QI-1 benefit payments the beginning of the next calendar year.
   5. The QDWI program covers medicare Part A premiums using the start date in WAC 182-504-0025.
5. MSP eligibility. Medicaid eligibility may affect MSP eligibility:
   1. QMB and SLMB clients may receive medicaid and still be eligible to receive QMB or SLMB benefits.
   2. QI-1 and QDWI clients who begin receiving medicaid are no longer eligible for QI-1 or QDWI benefits, but may be eligible for the state-funded medicare buy-in program under WAC 182-517-0300.
6. Right to request administrative hearing. A person who disagrees with agency action under this section may request an administrative hearing under chapter 182-526 WAC.

WAC 182-516-0300 Life estates

Effective March 2, 2018

1. "Life estate" means an ownership interest in real property only during the lifetime of a specified person.
2. Subject to subsection (3) of this section, a life estate is an available resource, unless it is either excluded or unavailable un­der chapter 182-512 WAC.
3. For someone applying for or receiving long-term services and supports, a life estate interest is subject to the home equity limits under:
   1. WAC 182-513-1350 for institutional and home and community- based (HCB) waiver programs; and
   2. WAC 182-513-1215 for community first choice.
4. For clients of institutional or HCB waiver services:
   1. If the remainder interest was transferred for less than fair market value, the medicaid agency or the agency's designee will evalu­ate the transaction as an asset transfer under WAC 182-513-1363. "Re­mainder interest" is the fair market value of the property at the time the client transferred it and retained a life estate, minus the value of the life estate at the time of that transfer.
   2. If a client purchased a life estate but has not lived in the property for at least one year after the purchase, the purchase price of the life estate is an uncompensated asset transfer under WAC 182-513-1363.
   3. If a client purchased a life estate and has lived in the property for more than one year, it is not an uncompensated transfer, unless the purchase price for the life estate exceeded the value of the life estate. Any amount paid for a life estate in excess of the value of the life estate is an uncompensated transfer under WAC 182-513-1363.
5. To calculate the value of a life estate:
   1. Identify the person whose life determines the length of the life estate;
   2. Identify whether uncompensated value or home equity is being calculated:
      1. If calculating uncompensated value under subsection (4)(a) or (c) of this section, identify that person's age on the person's last birthday before the transfer; or
      2. If determining whether home equity requirements are met un­ der subsection (3) of this section, identify that person's age on the person's most recent birthday; and
   3. Multiply the property's fair market value by the life estate factor corresponding to that person's age in the Life Estate and Re­mainder Interest Tables maintained by the Social Security Administra­tion.
6. To calculate the remainder interest, subtract the value in subsection (5) of this section from the property's fair market value at the time of the transaction that created the life estate.

WAC 182-516-0201 Annuities established on or after April 1, 2009

Effective March 2, 2018

1. The medicaid agency or the agency's designee determines how an annui­ty, purchased by or on behalf of an annuitant and established on or after April 1, 2009, affects eligibility for medicaid.
2. General information.
   1. Clients of noninstitutional medicaid must disclose to the agency or the agency's designee any interest that client, or the fi­nancially responsible members of that client's assistance unit, has in an annuity.
   2. Clients of institutional or home and community-based (HCB) waiver services must disclose to the agency or the agency's designee any interest that client, or that client's community spouse, has in an annuity.
   3. Subject to (d) of this subsection, this section applies when the annuitant is:
      1. The client of medicaid;
      2. That client's spouse, if that spouse is financially respon­sible for that client; or
      3. That client's community spouse.
   4. If this section does not apply because of (c) of this subsec­tion, but the client of institutional or HCB waiver services, or that client's community spouse, is the owner of the annuity, then the pur­chase of the annuity is evaluated as an asset transfer under WAC 182-513-1363.
   5. For the definition of "disabled," see WAC 182-512-0050 (1)(b) and (c).
   6. Actuarial life expectancy in this section is rounded up to the nearest whole year.
3. Annuities as resources.
   1. Subject to (b) of this subsection, a revocable annuity is an available resource.
   2. The following annuities are not available resources, even if revocable:
      1. An annuity described under 26 U.S.C. Sec. 408(b) or (q); or
      2. An annuity purchased with proceeds from:
         1. An account or trust described under 26 U.S.C. Sec. 408(a), (c), or (p);
         2. A simplified employee pension (within the meaning of 26 U.S.C. Sec. 408(k)); or
         3. A Roth IRA described under 26 U.S.C. Sec. 408A.
   3. An annuity not described under (b) of this subsection is an available resource unless the annuity:
      1. Is issued by an entity licensed and approved to issue annui­ties in the jurisdiction in which the annuity is established;
      2. Is immediate, irrevocable, nonassignable; and
      3. Is paid out, in equal monthly amounts with no deferral and no balloon payments, over a term:
         1. Of at least five years, if the actuarial life expectancy of the annuitant is at least five years; or
         2. Not less than the actuarial life expectancy of the annuitant, if the actuarial life expectancy of the annuitant is less than five years.
   4. If an annuity fails either the immediate requirement under (c)(ii) of this subsection or the monthly payout requirement under (c)(iii) of this subsection, the annuity is not a resource if:
      1. The annuity is fully paid out within the actuarial life ex­pectancy of the annuitant; and
      2. The annuitant:
         1. Changes the scheduled payout to equal monthly payments; or
         2. Asks the agency or the agency's designee to calculate and budget the periodic payments as equal monthly payments beginning the month of eligibility. Periodic payments made before the month of eli­gibility are not included in the calculation.
      3. Nothing under (d) of this subsection affects the deferral or balloon payment requirements under (c)(iii) of this subsection, or the payment term requirements under (c)(iii)(A) or (B) of this subsec­tion.
4. Annuities as income.
   1. If an annuity is not an available resource under subsection (3) of this section, the payments from the annuity are unearned income to the annuitant.
   2. If an annuity is an available resource under subsection (3) of this section, the payments from the annuity are not income to the annuitant.
5. An annuity as a transfer of assets.
   1. The purchase of an annuity is an uncompensated asset trans­fer, unless the annuity designates the state of Washington as remain­der beneficiary under subsection (6) of this section.
   2. The purchase of an annuity by the client of institutional or HCB waiver services is an uncompensated asset transfer, unless the an­nuity is an annuity under subsection (3)(b)(i) or (ii) of this sec­tion, or the annuity:
      1. Is issued by an entity licensed and approved to issue annui­ties in the jurisdiction in which the annuity is established;
      2. Is immediate, irrevocable, nonassignable; and
      3. Is paid out, in equal periodic amounts with no deferral and no balloon payments, over a term that is actuarially sound (i.e., a term that is not greater than the actuarial life expectancy of that client).
6. Beneficiary designation requirements.
   1. Subject to (b) of this subsection, to satisfy subsection (5)(a) of this section, when the client of institutional or HCB waiver services, or that client's community spouse, is the annuitant, the an­nuity must:
      1. Name the states as the remainder beneficiary, for at least the total amount of services covered under medicaid, paid on behalf of the client of institutional or HCB waiver services; and
      2. The remainder beneficiary must be listed in the annuity in the:
         1. First position;
         2. Next position, after the community spouse, and any minor or disabled children; or
         3. First position, if either the community spouse, or any minor or disabled children, or a representative for such children, named as beneficiary in the first position under (a)(ii)(B) of this subsection, transfers the right to receive payments from the annuity for less than fair market value.
   2. When the community spouse is the annuitant, the community spouse, or the community spouse's estate, cannot be named as remainder beneficiary under (a)(ii)(A) of this subsection.
   3. If a change of circumstance requires a change in beneficiary designation under (a) of this subsection, the agency or the agency's designee reevaluates the annuity's beneficiary designation.
7. Actuarial life expectancy is determined by tables that are published by the office of the chief actuary of the Social Security Administration.

WAC 182-516-0200 Annuities established prior to April 1, 2009

Effective March 2, 2018

1. A revocable annuity is considered an available resource.
2. An irrevocable annuity established prior to May 1, 2001, is not an available resource when issued by an individual, in­ surer, or other body licensed and approved to do business in the ju­risdiction in which the annuity is established.
3. The income from an irrevocable annuity that meets the requirements of this section is income for determining eligibility and the amount of participation in the total cost of care. The annuity itself is not a re­source.
4. Subject to subsection (5) of this section, an annuity established on or after May 1, 2001, and before April 1, 2009, is an available resource unless it:
   1. Is irrevocable;
   2. Is paid out in equal monthly amounts within the actuarial life expectancy of the annuitant;
   3. Is issued by an individual, insurer, or other body licensed and approved to do business in the jurisdiction in which the annuity is established; and
   4. Names the state of Washington as the benefi­ciary of the remaining funds up to the total of medicaid funds spent on the client during the client's lifetime. This subsection only ap­plies if the annuity is in the client's name.
5. If an irrevocable annuity is an availa­ble resource under subsection (4) of this section because it does not pay out in equal monthly amounts, it is an unavailable resource if:
   1. The full pay out is within the actuarial life expectancy of the client; and
   2. The client:
      1. Changes the scheduled pay out into equal monthly payments within the actuarial life expectancy of the annuitant; or
      2. Requests that the medicaid agency or the agency's designee calculate and budget the payments as equal monthly payments within the actuarial life expectancy of the annuitant. The income from the annuity remains unearned income to the annuitant.
6. An irrevocable annuity is unearned income when the annuitant is:
   1. The client;
   2. The spouse of the client;
   3. The blind or disabled child, as defined in WAC 182-512-0050 (1)(b) and (c), of the client; or
   4. A person designated to use the annuity for the sole benefit of the client, client's spouse, or a blind or disabled child, as de­ fined in WAC 182-512-0050 (1)(b) and (c), of the client.
7. An annuity is not an available resource when there is a joint owner, co-annuitant or an irrevocable beneficiary who will not agree to allow the annuity to be cashed, unless the joint owner or irrevocable beneficiary is the community spouse. In the case of a community spouse, the value of the annuity is an available resource and counts toward the maximum community spouse resource allowance.

WAC 182-516-0100 Trust index

Effective March 2, 2018

The medicaid agency or the agency's designee applies the following rules to determine how trusts affect eligibility for medicaid:

1. WAC 182-516-0105 General rules that apply to all trusts.
2. WAC 182-516-0110 Self-settled trusts overview.
3. WAC 182-516-0115 Revocable self-settled trusts established on or after August 11, 1993.
4. WAC 182-516-0120 Irrevocable self-settled trusts for a disabled client under age sixty-five established on or after August 11, 1993.
5. WAC 182-516-0125 Irrevocable pooled self-settled trusts for a disabled client established on or after August 11, 1993.
6. WAC 182-516-0130 Irrevocable self-settled trusts established on or after August 11, 1993.
7. WAC 182-516-0135 Self-settled trusts established before August 11, 1993.
8. WAC 182-516-0140 Third-party trusts.
9. WAC 182-516-0145 Trusts containing both assets of the beneficiary and third-party assets.

WAC 182-515-1514 Home and community based (HCB) services authorized by the developmental disabilities administration (DDA)- Client financial responsibility

Effective March 1, 2025

1. A client eligible for home and community based (HCB) waiver services authorized by the developmental disabilities administration (DDA) under WAC 182-515-1513 must pay toward the cost of care and room and board under this section.
   1. Post-eligibility treatment of income, participation, and participate are all terms that refer to a client's responsibility towards cost of care.
   2. Room and board is a term that refers to a client's responsibility toward food and shelter in an alternate living facility (ALF).
2. The agency determines how much a client must pay toward the cost of care for home and community based (HCB) waiver services authorized by the DDA when the client is living at home, as follows:
   1. A single client who lives at home (as defined in WAC 388-106-0010) keeps a personal needs allowance (PNA) of up to the special income level (SIL) defined under WAC 182-513-1100.
   2. A single client who lives at home on the roads to community living program authorized by DDA keeps a PNA up to the SIL but must pay any remaining available income toward cost of care after allowable deductions described in subsection (4) of this section.
   3. A married client who lives with the client's spouse at home (as defined in WAC 388-106-0010) keeps a PNA of up to the SIL but must pay any remaining available income toward cost of care after allowable deductions under subsection (4) of this section.
   4. A married couple living at home where each client receives HCB waiver services, one authorized by DDA and the other authorized by home and community services (HCS) is allowed the following:
      1. The client authorized by DDA keeps a PNA of up to the SIL but must pay any remaining available income toward the client's cost of care after allowable deductions in subsection (4) of this section; and
      2. The client authorized by HCS pays toward the cost of care under WAC 182-515-1507 or 182-515-1509.
3. The agency determines how much a client must pay toward the cost of care for HCB wavier services authorized by DDA and room and board when the client is living in a department-contracted ALF defined under WAC 182-513-1100. A client:
   1. Keeps a PNA under WAC 182-513-1105;
   2. Pays room and board up to the room and board standard under WAC 182-513-1105; and
   3. Pays the remainder of available income toward the cost of care after allowable deductions under subsection (4) of this section.
4. If income remains after the PNA and room and board liability under subsection (2) or (3) of this section, the remaining available income must be paid toward the cost of care after it is reduced by allowable deductions in the following order:
   1. An earned income deduction of the first $65, plus one-half of the remaining earned income;
   2. Guardianship fees, conservatorship fees, and administrative costs including any attorney fees paid by the guardian or conservator only as allowed under chapter 388-79A WAC;
   3. Current or back child support garnished or withheld from the client's income according to a child support order in the month of the garnishment if it is for the current month. If the agency allows this as a deduction from income, the agency does not count it as the child's income when determining the family allocation amount in WAC 182-513-1385;
   4. A monthly maintenance-needs allowance for the community spouse under WAC 182-513-1385. If the community spouse is on long-term care services, the allocation is limited to an amount that brings the community spouse's income to the community spouse's PNA;
   5. A monthly maintenance-needs allowance for each dependent of the institutionalized client, or the client's spouse, as calculated under WAC 182-513-1385; and
   6. Incurred medical expenses which have not been used to reduce excess resources. Allowable medical expenses are under WAC 182-513-1350.
5. The total of the following deductions cannot exceed the SIL defined under WAC 182-513-1100:
   1. The PNA described in subsection (2) or (3) of this section, including room and board;
   2. The earned income deduction in subsection (4)(a) of this section; and
   3. The guardianship fees, conservatorship fees, and administrative costs in subsection (4)(b) of this section.
6. A client may have to pay third-party resources defined under WAC 182-513-1100 in addition to the room and board and participation.
7. A client must pay the client's provider the sum of the room and board amount, the cost of care after all allowable deductions, and any third-party resources defined under WAC 182-513-1100.
8. A client on HCB waiver services does not pay more than the state rate for cost of care.
9. When a client lives in multiple living arrangements in a month, the agency allows the highest PNA available based on all the living arrangements and services the client has received in a month.
10. Standards described in this section are found on www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/program-standard-income-and-resources.

WAC 182-515-1513 Home and community based (HCB) waiver services authorized by the developmental disabilities administration (DDA)—Financial eligibility using SSI-related institutional rules.

Effective February 25, 2023

1. If a person is not eligible for a categorically needy (CN) program under WAC 182-515-1512, the agency determines eligibility for home and community based (HCB) waiver services authorized by the developmental disabilities administration (DDA) using institutional medicaid rules. This section explains how a person may qualify using institutional rules.
2. A person must meet:
   1. General eligibility requirements under WAC 182-513-1315 and 182-515-1511;
   2. Resource requirements under WAC 182-513-1350; and
   3. Have available income at or below the special income level (SIL) defined under WAC 182-513-1100.
3. The agency determines available income and income exclusions according to WAC 182-513-1325, 182-513-1330, and 182-513-1340.
4. A person eligible under this section is responsible to pay income toward the cost of care and room and board, as described under WAC 182-515-1514.
5. Current resource, income standards 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.