WAC 182-503-0515 Washington apple health -- Social Security number requirements.

Effective October 23, 2021

1. To be eligible for Washington apple health (medicaid), or tailored supports for older adults (TSOA) described in WAC 182-513-1610, you (the applicant or recipient) must provide your valid Social Security number (SSN) or proof of application for an SSN to the medicaid agency or the agency's designee, except as provided in subsections (2) and (6) of this section.
2. An SSN is not required if you are:
   1. Not eligible to receive an SSN or may only be issued or may only be issued an SSN for a valid nonwork reason described in 20 C.F.R. 422.104;
   2. A household member who is not applying for apple health coverage, unless verification of that household member's resources is required to determine the eligibility of the client;
   3. Refusing to obtain an SSN for well-established religious objections as defined in 42 C.F.R. 435.910 (h) (3); or 
   4. Not able to obtain or provide an SSN because you are a victim of domestic violence.
3. If you are receiving coverage because you meet an exception under either subsection (2) (c) or (d) of this section, we (the agency) will confirm with you at your apple health renewal, consistent with WAC 182-503-0050, that you still meet the exception.
4. If we ask for confirmation that you continue to meet an exception in subsection (2) of this section and you do not respond in accordance with subsection (3) of this section, or if you no longer meet an exception and do not provide your SSN, we will terminate your apple health coverage according to WAC 182-518-0025.
5. If you are not able to provide your SSN, either because you do not know it or it has not been issued, you must provide:
   1. Proof from the Social Security Administration (SSA) that you turned in an application for an SSN; and
   2. The SSN when you receive it.
      1. Your apple health coverage will not be delayed, denied, or terminated while waiting for SSA to send you your SSN. If you need help applying for an SSN, assistance will be provided to you.
      2. We will ask you every ninety days if your SSN has been issued.
6. An SSN is not required for the following apple health programs:
   1. Refugee medical assistance program described in WAC 182-507-0120, and 182-507-0125;
   2. Alien medical programs described in WAC 182-507-0115, 182-507-0120, and 182-507-0125;
   3. Newborn medical program described in WAC 182-505-0210 (2)(a);
   4. Foster care program for a child age eighteen and younger as described in WAC 182-505-0211(1); or
   5. Medical programs for children and pregnant women who do not meet citizenship or immigration status described in WAC 182-503-0535 (2)(e)(ii) and (iii); or
   6. Family planning only program described in WAC 182-532-510 if you do not meet citizenship or immigration status for Washington apple health or you have made an informed choice to apply for family planning services only.
7. If you are required to provide an SSN under this section, and you do not meet an exception under subsection (2) of this section, failure to provide an SSN may result in:
   1. Denial of your application or termination of your coverage because we cannot determine your household's eligibility; or 
   2. Inability to apply the community spouse resource allocation (CSRA) or monthly maintenance needs allowance (MMNA) for a client of long-term services and supports (LTSS).

WAC 182-503-0510 Washington apple health -- Program summary.

Effective June 11, 2023

1. The agency categorizes Washington apple health programs into three groups based on the income methodology used to determine eligibility:
   1. Those that use a modified adjusted gross income (MAGI)-based methodology described in WAC 182-509-0300, called MAGI-based apple health programs;
   2. Those that use an income methodology other than MAGI, called non-MAGI-based apple health programs, which include:
      1. Supplemental security income (SSI)-related apple health programs;
      2. Temporary assistance for needy families (TANF)-related apple health programs; and
      3. Other apple health programs not based on MAGI, SSI, or TANF methodologies.
   3. Those that provide coverage based on a specific status or entitlement in federal rule and not on countable income, called deemed eligible apple health programs.
2. MAGI-based apple health programs include the following:
   1. Apple health parent and caretaker relative program described in WAC 182-505-0240;
   2. MAGI-based apple health adult medical program described in WAC 182-505-0250, for which the scope of coverage is called the alternative benefits plan (ABP) described in WAC 182-500-0010;
   3. Apple health for pregnant women program described in WAC 182-505-0115;
   4. Apple health for kids program described in WAC 182-505-0210 (3)(a);
   5. Premium-based apple health for kids described in WAC 182-505-0215;
   6. Apple health long-term care for children and adults described in chapter 182-514 WAC; and
   7. Apple health alien emergency medical program described in WAC 182-507-0110 through 182-507-0125 when the person is eligible based on criteria for a MAGI-based apple health program.
3. Non-MAGI-based apple health programs include the following:
   1. SSI-related programs which use the income methodologies of the SSI program (except where the agency has adopted more liberal rules than SSI) described in chapter 182-512 WAC to determine eligibility:
      1. Apple health for workers with disabilities (HWD) described in chapter 182-511 WAC;
      2. Apple health SSI-related programs described in chapters 182-512 and 182-519 WAC;
      3. Apple health long-term care and hospice programs described in chapters 182-513 and 182-515 WAC;
      4. Apple health medicare savings programs described in chapter 182-517 WAC; and
      5. Apple health alien emergency medical (AEM) programs described in WAC 182-507-0110 and 182-507-0125 when the person meets the age, blindness or disability criteria specified in WAC 182-512-0050.
   2. TANF-related programs which use the income methodologies based on the TANF cash program described in WAC 388-450-0170 to determine eligibility, with variations as specified in WAC 182-509-0001(5) and program specific rules:
      1. Apple health refugee medical assistance (RMA) program described in WAC 182-507-0130; and
      2. Apple health medically needy (MN) coverage for pregnant women and children who do not meet SSI-related criteria.
   3. Other programs:
      1. Breast and cervical cancer program described in WAC 182-505-0120;
      2. Family planning only programs described in chapter 182-532;
      3. Medical care services described in WAC 182-508-0005;
      4. Apple health for pregnant minors described in WAC 182-505-0117; and
      5. Apple health kidney disease program described in chapter 182-540 WAC.
4. Deemed eligible apple health programs include:
   1. Apple health SSI medical program described in chapter 182-510 WAC, or a person who meets the medicaid eligibility criteria in 1619b of the Social Security Act;
   2. Newborn medical program described in WAC 182-505-0210(2);
   3. Foster care program described in WAC 182-505-0211;
   4. Medical extension program described in WAC 182-523-0100; and
   5. Family planning extension described in WAC 182-505-0115(5).
5. A person is eligible for categorically needy (CN) health care coverage when the household's countable income is at or below the categorically needy income level (CNIL) for the specific program.
6. If income is above the CNIL, a person is eligible for the MN program if the person is:
   1. A child;
   2. A pregnant woman; or
   3. SSI-related (aged sixty-five, blind or disabled).
7. MN health care coverage is not available to parents, caretaker relatives, or adults unless they are eligible under subsection (6) of this section.
8. A person who is eligible for the apple health MAGI-based adult program listed in subsection (2)(b) of this section is eligible for ABP health care coverage as defined in WAC 182-500-0010. Such a person may apply for more comprehensive coverage through another apple health program at any time.
9. For the other specific program requirements a person must meet to qualify for apple health, see chapters 182-503 through 182-527 WAC.

WAC 182-503-0505 Washington apple health -- General eligibility requirements.

Effective April 27, 2019.

1. When you apply for Washington apple health programs established under chapter 74.09 RCW, you must meet the eligibility criteria in chapters 182-500 through 182-527 WAC.
2. When you apply for apple health, we first consider you for federally funded or federally matched programs. We consider you for state-funded programs after we have determined that you are ineligible for federally funded and federally matched programs.
3. Unless otherwise specified in a program specific WAC, the eligibility criteria for each program are as follows:
   1. Age (WAC 182-503-0050);
   2. Residence in Washington state (WAC 182-503-0520 and 182-503-0525);
   3. Citizenship or immigration status in the United States (WAC 182-503-0535);
   4. Possession of a valid Social Security account number (WAC 182-503-0515);
   5. Assignment of medical support rights to the state of Washington (WAC 182-503-0540);
   6. Application for medicare and enrollment into medicare's prescription drug program if:
      1. You are likely entitled to medicare; and
      2. We have authority to pay medicare cost sharing as described in chapter 182-517 WAC.
   7. If your eligibility is not based on modified adjusted gross income (MAGI) methodology, your countable resources must be within specific program limits (chapters 182-512, 182-513, 182-515, 182-517, and 182-519 WAC); and
   8. Countable income within program limits:
      1. For MAGI-based programs, see WAC 182-505-0100;
      2. For the refugee program, see WAC 182-507-0130;
      3. For the medical care services program, see WAC 182-508-0005;
      4. For the health care for workers with disabilities (HWD) program, see WAC 182-511-1000;
      5. For the SSI-related program, see WAC 182-512-0010;
      6. For long-term care programs, see chapters 182-513 and 182-515 WAC;
      7. For medicare savings programs, see WAC 182-517-0100; and
      8. For the medically needy program, see WAC 182-519-0050.
4. In addition to the general eligibility requirements in subsection (3) of this section, each program has specific eligibility requirements as described in applicable WAC.
5. If you are in a public institution, including a correctional facility, you are not eligible for full scope apple health coverage, except in the following situations:
   1. If you are age twenty-one or younger or age sixty-five or older and are a patient in an institution for mental disease (see WAC 182-513-1317(5)); or
   2. You receive inpatient hospital services outside of the public institution or correctional facility.
6. We limit coverage for people who become residents in a public institution, under subsection (5) of this section, until they are released.
7. If you are terminated from SSI or lose eligibility for categorically needy (CN) or alternative benefits plan (ABP) coverage, you receive coverage under the apple health program with the highest scope of care for which you may be eligible while  we determine your eligibility for other health care programs.  See WAC 182-504-0125. 

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.

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

Effective March 31, 2014.

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 aging and long-term support 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 twenty 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).

WAC 182-503-0040 Washington apple health -- Interview requirements.

Effective July 25, 2013

1. An individual applying for Washington apple health (WAH) (as defined in WAC 182-500-0120) is not required to have an in-person interview to determine eligibility.
2. The agency or its designee may contact an individual by phone or in writing to gather any additional information that is needed to make an eligibility determination.
3. A phone or in-person interview is required to determine initial financial eligibility for WAH long-term care services.
4. The interview requirement described in subsection (3) of this section may be waived if the applicant is unable to comply:
   1. Due to his or her medical condition; or
   2. Because the applicant does not have a family member or another individual that is able to conduct the interview on his or her behalf.

WAC 182-503-0110 Washington apple health -- Limited-English proficient (LEP) services.

Effective March 31, 2014.

1. We provide interpreter and translation services (limited-English proficient or LEP services) free of charge to you if you have limited ability to read, write, and/or speak English. Interpreter services are those used for oral communication between two parties who do not speak the same language. Translation services are those used for written communication.
2. We provide LEP services in your primary language.
   1. A primary language is the language you tell us that you wish to use when communicating with us. You may designate at least one primary language for oral communications and at least one primary language for written communications, and you may designate a different primary language for oral and for written communications.
   2. We note your primary languages in a record available to the agency, its designee, and health benefit exchange employees.
3. We can provide LEP services through bilingual workers and/or contracted interpreters and translators who are expected to be competent. We consider a bilingual worker or a contracted interpreter or translator to be competent if he or she is:
   1. Certified for interpreting and/or translating in the language by the language testing and certification program of the department of social and health services;
   2. Certified or otherwise determined to be competent for interpreting and/or translating in the language by an association or organization with a regional or national reputation for certifying or determining the competence of interpreters and/or translators; or
   3. Determined competent for interpreting and/or translating in the language by us, taking into account his or her:
      1. Demonstrated proficiency in both English and the other language;
      2. Orientation and training that includes the skills and ethics of interpreting;
      3. Fundamental knowledge in both languages of any specialized terms or concepts peculiar to Washington apple health;
      4. Sensitivity to cultural differences; and
      5. Demonstrated ability to convey information accurately in both languages.
4. We provide notice of the availability of LEP services on printed applications and notices, in the Washington healthplanfinder web site, and during contact with persons who appear to need LEP services.
5. LEP services include:
   1. Spoken language interpreter (oral) services in person, over the telephone, or through other simultaneous audio or visual transmission (if available); and
   2. Translation of our forms, letters, and other text-based materials, whether printed in hard-copy or stored and presented by computer. These include, but are not limited to:
      1. Our pamphlets, brochures, and other informational material that describe our services and your health care rights and responsibilities;
      2. Our applications and other forms you need to complete and/or sign; and
      3. Notices of our actions affecting your eligibility for health care coverage.
   3. Direct provision of services by our bilingual employees.
6. We provide interpreter services and translated documents in a prompt manner that allows the timely processing of your eligibility for health care coverage within time frames defined in WAC 182-503-0060, 182-503-0035, and 182-504-0125.
7. If you believe that we have discriminated against you on the basis of race, color, national origin, birthplace, or another protected status, you may file a complaint with the U.S. Department of Health and Human Services or Regional Manager, Office of 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).

WAC 182-503-0100 Washington apple health -- Rights and responsibilities.

Effective March 31, 2014.

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.

1. If you are applying for or receiving health care coverage, you have the right to:
   1. Have your rights and responsibilities explained to you and given in writing;
   2. Be treated politely and fairly without regard to your race, color, political beliefs, national origin, religion, age, gender (including gender identity and sex stereotyping), sexual orientation, disability, honorably discharged veteran or military status, or birthplace;
   3. Ask for health care coverage using any method listed under WAC 182-503-0010 (if you ask us for a receipt or confirmation, we will provide one to you);
   4. Get help completing your application if you ask for it;
   5. Have an application processed promptly and no later than the timelines described in WAC 182-503-0060;
   6. Have at least ten calendar days to give the agency or its designee information needed to determine eligibility and be given more time if asked for;
   7. Have personal information kept confidential; we may share information with other state and federal agencies for purposes of eligibility and enrollment in Washington apple health;
   8. Get written notice, in most cases, at least ten calendar days before the agency or its designee denies, terminates, or changes coverage;
   9. Ask for an appeal if you disagree with a decision we make. You can also ask a supervisor or administrator to review our decision or action without affecting your right to a fair hearing;
   10. Ask for and get interpreter or translator services at no cost and without delay;
   11. Ask for voter registration assistance;
   12. Refuse to speak to an investigator if we audit your case. You do not have to let an investigator into your home. You may ask the investigator to come back at another time. Such a request will not affect your eligibility for health care coverage;
   13. Get equal access services under WAC 182-503-0120 if you are eligible;
   14. Ask for support enforcement services through the division of child support; and
   15. Refuse to cooperate with us in identifying, using, or collecting third-party benefits (such as medical support) if you fear, and can verify, that your cooperating with us could result in serious physical or emotional harm to you, your children, or a child in your care. Verification may include one of the following:
       1. A statement you sign, outlining your fears and concerns;
       2. Civil or criminal court orders (such as domestic violence protection orders, restraining orders, and no-contact orders);
       3. Medical, police, or court reports; or
       4. Written statement from clergy, friends, relatives, neighbors, or co-workers.
2. You are responsible to:
   1. Report changes in your household or family circumstances as required under WAC 182-504-0105 and 182-504-0110;
   2. Give us any information or proof needed to determine eligibility. If you have trouble getting proof, we help you get the proof or contact other persons or agencies for it;
   3. Assign the right to medical support as described in WAC 182-505-0540, unless you can submit verification (which may include one of the items listed in subsection (1)(o) of this section) that your cooperating with us could result in serious physical or emotional harm to you, your children, or a child in your care;
   4. Complete renewals when asked;
   5. Apply for and make a reasonable effort to get potential income from other sources when available;
   6. Give medical providers information needed to bill us for health care services; and
   7. Cooperate with quality assurance or post enrollment review staff when asked.

WAC 182-503-0090 Washington apple health -- Exceptions to rule.

Effective March 1, 2021.

1. A client or client's representative may request an exception to a Washington apple health financial eligibility rule in Title 182 WAC. The request for an exception to rule (ETR) may be submitted orally or in writing. The request must:
   1. Be received within ninety calendar days of the agency action with which the client disagrees or wants waived;
   2. Identify the rule for which an exception is being requested;
   3. State what the client is requesting; and
   4. Describe how the request meets subsection (2) of this section.
2. The agency director or designee has the discretion to grant an ETR if they determine that the client's circumstances satisfy the conditions below:
   1. The exception would not contradict a specific provision of federal or state law; and
   2. The client's situation differs from the majority; and
   3. It is in the interest of the overall economy and the client's welfare, and:
      1. It increases opportunity for the client to function effectively; or
      2. The client has an impairment or limitation that significantly interferes with the usual procedures required to determine eligibility and payment.
3. A client does not have a right to an administrative hearing on ETR decisions under chapter 182-526 WAC.
4. A client is mailed a decision in writing within ten calendar days when agency staff:
   1. Approve or deny an ETR request; or
   2. Request more information.
5. If the ETR is approved, the notice includes information on what is improved and for what time frame.
6. The agency designates staff at the aging and long-term support administration (ALTSA) and the developmental disabilities administration (DDA) to process all ETRs specifically relating to long-term services and supports programs described in Title 182 WAC.
7. This section does not apply to requests that the agency pay for noncovered medical or dental services or related equipment. WAC 182-501-0160 applies to such requests.

WAC 182-503-0080 Washington apple health -- Application denials and withdrawals.

Effective November 3, 2019. 

1. We follow the rules about notices and letters in chapter 182-518 WAC. We follow the rules about timelines in WAC 182-503-0060.
2. We deny your application for apple health coverage when:
   1. You tell us either orally or in writing to withdraw your request for coverage; or
   2. Based on all information we have received from you and other sources within the time frames stated in WAC 182-503-0060, including any extra time given at your request or to accommodate a disability or limited-English proficiency:
      1. We are unable to determine that you are eligible; or
      2. We determine that you are not eligible.
   3. You are subject to asset verification and do not provide authorization as described in WAC 182-503-0055.
3. We send you a written notice explaining why we denied your application (per chapter 182-518 WAC).
4. We reconsider our decision to deny your apple health coverage without a new application from you when:
   1. We receive the information that we need to decide if you are eligible within thirty days of the date on the denial notice;
   2. You give us authorization to verify your assets as described in WAC 182-503-0055 within thirty days of the date on the denial notice;
   3. You request a hearing within ninety days of the date on the denial letter and an administrative law judge (ALJ) or HCA review judge decides our denial was wrong (per chapter 182-526 WAC).
5. If you disagree with our decision, you can ask for a hearing. If we denied your application because we do not have enough information, the ALJ will consider the information we already have and any more information you give us. The ALJ does not consider the previous absence of information or failure to respond in determining if you are eligible.