WAC 182-511-1000 Health care for workers with disabilities (HWD) -- Program description.

Effective January 1, 2020

This section describes the apple health for workers with disabilities (HWD) program.

1. The HWD program provides categorically needy (CN) scope of care as described in WAC 182-501-0060.
2. The HWD program also provides long-term services and supports described in chapters 182-513 and 182-515 WAC for a client who meets the functional requirements for those programs, are approved for those services, and choose to enroll in HWD.
3. The medicaid agency approves HWD coverage for twelve months effective the first of the month in which a person applies and meets program requirements. See WAC 182-511-1100 for retroactive coverage for months before the month of application.
4. A person who is eligible for another medicaid program may choose not to participate in the HWD program.
5. A person is not eligible for HWD coverage for a month in which the person received benefits under the medically needy (MN) program.

WAC 182-510-0010 Eligibility after supplemental security income ends.

Effective July 11, 2015

1. Your categorically needy (CN) coverage (WAC 182-512-0100) continues after supplemental security income (SSI) ends if:
   1. Countable income exceeds the SSI income standard due solely to the annual cost-of-living adjustment (COLA); or
   2. A timely request for a hearing has been filed. CN coverage is continued until the Social Security Administration (SSA) makes a final decision on the hearing request and on any subsequent timely appeals.
2. If your SSI ends, your CN coverage continues for a period of up to one hundred twenty days while the agency reviews your eligibility for other cash or medical programs.
3. If you are a terminated SSI or SSI-related recipient, the agency will review your disability status when:
   1. You present new medical evidence;
   2. Your medical condition changes significantly; or
   3. Your termination from SSI was not based on a review of current medical evidence.
4. Children terminated from SSI due to loss of disabled status may be eligible for medical benefits under WAC 182-505-0210.

WAC 182-510-0001 Supplemental security income and associated categorically needy coverage.

Effective July 11, 2015.

1. Supplemental security income (SSI) is a federal cash benefit administered by the Social Security Administration (SSA) under the Social Security Act, 42 U.S.C. Sec. 1381-1383f. The SSI program replaces state programs for the aged, blind and disabled individuals beginning January 1974. An individual who received state assistance in December 1973 who became eligible for SSI in January 1974 is considered a grandfathered client by the medicaid agency, and a mandatory income level (MIL) client by SSI. The individual must continue to meet the definition of blind or disabled that was in effect under the state plan in December 1973. See chapter 182-500 WAC for additional definitions.
2. An essential person is someone needed in the home to care for an SSI recipient. An essential person is eligible for categorically needy (CN) coverage as long as he or she has lived continuously with the eligible person since January 1974.
3. An ineligible spouse is the spouse of an SSI recipient who is not eligible for SSI-related CN coverage. An ineligible spouse must have his or her eligibility for Washington apple health (WAH) determined separately under WAC 182-519-0100.
4. When an individual receives SSI, the agency accepts the SSA's determination of medicaid entitlement. The individual is eligible for CN coverage without submitting an additional application as long as he or she:
   1. Remains entitled to SSI;
   2. Is no longer entitled to SSI, but the SSA is in the process of determining eligibility under the Social Security Act, 42 U.S.C. Sec. 1619(b); or
   3. Currently has 1619(b) status as described in WAC 182-512-0880(3).
5. An SSI recipient may be terminated from CN coverage when he or she:
   1. Does not provide the agency with information necessary for the agency to determine if he or she has other medical insurance; or
   2. Does not assign the right to recover insurance funds to the agency as required in WAC 182-503-0540.
6. CN coverage eligibility continues if the SSA stops an individual's SSI for one of the following reasons:
   1. The individual's countable income exceeds the SSI income standard due solely to the annual cost-of-living adjustment (COLA) under WAC 182-512-0880(1);
   2. The individual is a "deemed" eligible SSI recipient on the basis of eligibility for a special income disregard under WAC 182-512-0880; or
   3. The individual has an appeal of an SSA termination pending which has not yet resulted in a final determination.
7. If an individual's SSI stops due to an SSA determination that the individual is no longer disabled, and any appeal of this determination has resulted in a final decision, the agency:
   1. Redetermines eligibility for all other WAH programs that are not based on receipt of SSI; and
   2. Continues CN coverage until the agency completes the redetermination process described in WAC 182-504-0125.
8. If an individual's SSI stops for a reason not addressed elsewhere in this section, the agency considers the individual to meet disability requirements through the SSA's original disability review date. The agency:
   1. Redetermines eligibility for other WAH programs, which may or may not be based on disability; and
   2. Continues CN coverage until the agency completes the redetermination process in WAC 182-504-0125.

WAC 182-509-0375 MAGI income -- Lump sums.

Effective September 13, 2021.

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

1. A lump sum payment is money that a person receives but does not expect to receive on a continuing basis, such as an insurance settlement.
2. A lump sum payment is only counted as income if it is received in the month of application, and it otherwise qualifies as countable income under another rule.

WAC 182-509-0370 MAGI income -- How self-employment income is counted.

Effective September 13, 2021.

For purposes of determining eligibility for modified adjusted gross income (MAGI)–based Washington apple health, the medicaid agency counts self-employment income by:

1. Adding together gross self-employment income and any profit made from selling business property or equipment over a period of time; and 
2. Subtracting business expenses and income deductions allowed by the Internal Revenue Service that the person would be entitled to if they were filing a federal tax return and either:
   1. Averaging the income to come up with a monthly amount based on the period of time the business has been in operation within the last year; or
   2. Averaging the income over a representative period of time if the current income does not represent the person's projected income as shown by clear indications of future changes in income; or
   3. By averaging the self-employed income and deductions claimed on the previous year's tax return over a representative period of time.

WAC 182-509-0365  MAGI income -- Self-employment income.

Effective September 13, 2021.

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

1. Self-employment income is income earned by a person from running a business, performing a service, selling items that are made, or reselling items with the intent to make a profit, after deducting allowable IRS self-employment expenses. This income can be earned if the person is carrying on a trade or business as a sole proprietor or an independent contractor; a member of a partnership that carries on a trade or business; or otherwise in business for themselves (including a part-time business). Examples of self-employment business structures include, but are not limited to:
   1. Sole proprietorship - An unincorporated business owned by one person.
   2. Partnership - A relationship between two or more people who conduct a trade or business.
   3. Corporation - An entity that conducts business, realizes net income or loss, pays taxes, and distributes profits to shareholders.
   4. S corporation - Similar to a corporation, but this structure passes corporate income, losses, deductions, and credits through to the shareholders for federal tax purposes.
   5. Limited liability company (LLC) - An entity formed by one or more people or entities through a special written agreement that details the organization of the LLC.
2. Self-employment income is counted as earned income as described in WAC 182-509-0330, except when it is earned by a child or tax dependent and the income is below the filing threshold, as described in WAC 182-509-0360(1). 
3. A person is considered to be self-employed if they earn income without having an employer/employee relationship with the individual who pays the income. Self-employed people do not work for a specific employer who pays them a consistent salary or wage. Factors to consider are whether:
   1. The person has primary control or has the right to control what they do and how they do their job;
   2. The business aspects of the person's job are controlled by the person and not the payer (this includes things like how the person is paid, whether expenses are reimbursed, or who provides tools/supplies);
   3. The person has a contract stating that they are an independent contractor; or
   4. The person reports their income using one or more IRS schedules or forms that include, but are not limited to:
      1. Schedule C;
      2. Schedule C-EZ;
      3. Schedule E;
      4. Schedule F;
      5. Schedule K-1;
      6. Schedule SE;
      7. Form 940;
      8. Form 941;
      9. Form 942;
      10. Form 943;
      11. Form 1065; or 
      12. Form 1120.
4. A person is considered to have an employer/employee relationship when:
   1. The individual the person provides services for has primary control of how the work is done; or
   2. The person receives an IRS Form W-2 to report the income that is earned.
5. Self-employment does not have to be a licensed business for a person's business or activity to qualify as self-employment. 
6. A person must keep records of his or her self-employment income and deductions and provide this information to the agency upon request.

WAC 182-509-0360 MAGI income -- How the income of a child age eighteen or younger or a tax dependent is counted.

Effective January 21, 2017

The medicaid agency determines what income is counted when determining eligibility for modified adjusted gross income (MAGI)-based Washington apple health under WAC 182-509-0300

1. When determining countable income for persons described in subsections (2) through (4) of this section, the countable income of a child age eighteen or younger or of a tax dependent is included only when it meets the threshold required for tax filing under 26 U.S.C. Sec. 6012 (a) (1). For purposes of this section, countable income of a child or tax dependent does not include Social Security dependent benefits.
2. Determining countable income of a tax filer. The countable income of a tax filer includes the countable income of each member in the tax filer's medical assistance unit (MAU) under WAC 182-506-0012 (1).
3. Determining countable income of a tax dependent. The countable income of a tax dependent includes the countable income of each member in the tax dependent's MAU under WAC 182-506-0012 (2).
4. Determining countable income of a nonfiler. The countable income of a nonfiler, including a person considered a nonfiler under WAC 182-506-0012 (2) (b) (ii), includes the countable income of each member in the nonfiler's MAU under WAC 182-506-0012 (3).

WAC 182-509-0340 MAGI income -- American Indian/Alaska Native excluded income.

Effective January 18, 2014.

For the purposes of determining eligibility of American Indians/Alaska Natives for modified adjusted gross income (MAGI)-based Washington apple health (WAH) (see WAC 182-509-0300), the agency excludes from MAGI the following:

1. Distributions from Alaska Native corporations and settlement trusts;
2. Distributions from any property held in trust, subject to federal restrictions, located within the most recent boundaries of a prior federal reservation, or otherwise under the supervision of the Secretary of the Interior;
3. Distributions and payments from rents, leases, rights of way, royalties, usage rights, or natural resource extraction and harvest from:
   1. Rights of ownership or possession in any lands described in (b) of this subsection; or
   2. Federally protected rights regarding off-reservation hunting, fishing, gathering, or usage of natural resources.
4. Distributions resulting from real property ownership interests related to natural resources and improvements that are:
   1. Located on or near a reservation or within the most recent boundaries of a prior federal reservation; or
   2. Resulting from the exercise of federally protected rights relating to such real property ownership interests.
5. Payments resulting from ownership interests in or usage rights to items that have unique religious, spiritual, traditional, or cultural significance or rights that support subsistence or a traditional lifestyle according to applicable tribal law or custom;
6. Student financial assistance provided under the Bureau of Indian Affairs education programs; and
7. Any other applicable income exclusion as provided by federal law, regulation, or rule, including the Internal Revenue Code, treasury regulations, and Internal Revenue Service revenue rulings, revenue procedures, notices, and other official tax guidance.

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

Effective September 18, 2020.

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

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

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

Effective January 9, 2014.

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

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