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

Effective April 14, 2014.

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

WAC 182-512-0010 Supplemental security income (SSI) standards, SSI-related categorically needy income level (CNIL), and countable resource standards.

Effective January 27, 2019

1. The SSI payment standards, also known as the federal benefit rate (FBR), change each January 1st.
2. See WAC 388-478-0055 for the amount of the state supplemental payments (SSP) for SSI recipients.
3. See WAC 182-513-1205 for standards of clients living in an alternate living facility.
4. The SSI-related CNIL standards are the same as the SSI payment standards for single persons and couples. Those paying out shelter costs have a higher standard than people who have supplied shelter.
5. The countable resource standards for SSI and SSI-related CN medical programs are:
   1. One person                          $2,000
   2. A legally married couple        $3,000

WAC 182-511-1250 Apple health for workers with disabilities (HWD) -- Premium payments.

Effective June 3, 2025

This section describes how the Medicaid agency calculates the premium amount a person must pay for apple health for workers with disabilities (HWD) coverage. This section also describes program requirements regarding the billing and payment of HWD premiums.

1. When determining the HWD premium amount, the agency counts only the income of the person approved for the program. It does not count the income of another household member.
2. When determining countable income used to calculate the HWD premium, the agency applies the following rules:
   1. Income is considered available and owned when it is:
      1. Received; and
      2. Can be used to meet the person's needs for food, clothing, and shelter, except as described in WAC 182-512-0600(5) and 182-512-0650.
   2. Income is considered unavailable when it is:
      1. Described in 20 C.F.R. Sec. 416.1103.
      2. Used to pay the fee described in WAC 182-512-0800 (5).
3. The HWD premium amount equals the lesser of the two following amounts:
   1. A total of the following (rounded down to the nearest whole dollar):
      1. Fifty percent of unearned income above the medically needy income level (MNIL) described in WAC 182-519-0050; plus
      2. Five percent of total unearned income; plus
      3. Two and one-half percent of earned income after first deducting $65; or
   2. Seven and one-half percent of countable income described in subsection (2) of this section, including both earned and unearned income.
4. When determining the premium amount, the agency will use the currently verified income amount until a change in income is reported and processed, unless good cause for delay in verifying changes exists.
5. A change in the premium amount is effective the month after the change in income is reported and processed.
6. For current and ongoing coverage, the agency will bill for HWD premiums during the month following the benefit month.
7. For retroactive coverage, the agency will bill the HWD premiums during the month following the month in which coverage is requested and necessary information that establishes eligibility is received by the agency.
8. If initial coverage for the HWD program is approved in a month that follows the month of application, the first monthly premium includes the costs for both the month of application and any following months that have passed during determination of eligibility.
9. As described in WAC 182-511-1050 (3)(b), the agency will close HWD coverage if premiums are not paid in full for four consecutive months.
10. The person must pay the monthly premium in full to avoid losing HWD coverage. If a person makes a partial payment, the payment does not count as a full payment toward the premium.
11. Payments received are applied to premiums owed in the following order:
    1. If retroactive coverage is requested, the retroactive coverage month(s);
    2. Past due months, beginning with the most delinquent month;
    3. The current coverage month that has been invoiced; then
    4. Future coverage months.
12. A person must pay a premium for any month that HWD coverage is provided. This includes months when a redetermination of coverage is made, and months when continued coverage that is requested, pending the outcome of an administrative hearing.

WAC 182-511-1200 Health care for workers with disabilities (HWD) -- Employment requirements.

Effective January 1, 2020

This section describes the employment requirements for the basic coverage group (BCG) and the medical improvement group (MIG) for the apple health for workers with disabilities (HWD) program.

1. For the purpose of the HWD program, employment means a person:
   1. Gets paid for working;
   2. Has earnings that are subject to federal income tax; and
   3. Has payroll taxes taken out of earnings received, unless self-employed.
2. To qualify for HWD coverage as a member of the BCG, a person must be employed full or part time.
3. To qualify for HWD coverage as a member of the MIG, a person must be:
   1. Working at least forty hours per month; and
   2. Earning at least the local minimum wage as described under section 6 of the Fair Labor Standards Act (29 U.S.C. 206).
4. For a person who is self-employed, the examples described in the Social Security Administration Program Operations Manual System (POMS) provide guidance when determining whether someone meets the HWD work requirements. (See SSA POMS Section SI 00820.200, https://secure.ssa.gov/apps10/poms.nsf/lnx/0500820200). The guidelines described in POMS for determining the existence of a trade or business may also be used when making this determination. (See SSA POMS Section RS 01802.010, https://secure.ssa.gov/apps10/poms.nsf/lnx/0301802010).

WAC 182-511-1150 Apple health for workers with disabilities (HWD) -- Disability requirements.

Effective January 1, 2020

This section describes the disability requirements for the following groups of individuals who may qualify for the apple health for workers with disabilities (HWD) program.

1. A person age sixteen through age sixty-four must meet the requirements of the Social Security Act in section 1902 (a) (10) (A) (ii):
   1. (XV) for the basic coverage group (BCG); or
   2. (XVI) for the medical improvement group (MIG).
2. The BCG consists of individuals who:
   1. Meet federal disability requirements for the Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) program; or
   2. Are determined by the department of social and health services (DSHS), division of disability determination services (DDDS), to meet federal disability requirements for the HWD program.
3. The MIG consists of individuals who:
   1. Were previously eligible and approved for the HWD program as a member of the BCG; and
   2. Are determined by DDDS to have a medically improved disability. The term "medically improved disability" refers to the particular status granted to persons described in subsection (1) (b). For these people, a continuation of HWD coverage is provided to help them maintain their employment.
4. A person sixty-five or older, must meet federal disability requirements as determined by the DSHS DDDS. Coverage under the MIG is not available under federal law for persons age sixty-five or older. Coverage for this age group is authorized under the Balanced Budget Act of 1997 as described under section 1902 (a)(10)(A)(ii)(XIII).
5. When completing a disability determination for the HWD program, DDDS will not determine a person not disabled based only on earnings or the performance of substantial gainful activity (SGA). (See SSA POMS Section DI 10501.001, https://secure.ssa.gov/apps10/poms.nsf/Home?readform).

WAC 182-511-1100 Health care for workers with disabilities (HWD) -- Retroactive coverage.

Effective January 1, 2020

This section describes requirements for retroactive coverage provided under the apple health for workers with disabilities (HWD) program.

1. Retroactive coverage refers to the period of up to three months before the month in which a person applies for the HWD program.
2. To qualify for retroactive coverage under the HWD program, a person must first:
   1. Meet all program requirements described in WAC 182-511-1050 for each month of the retroactive period; and
   2. Pay the premium amount for each month requested within one hundred twenty days of being billed for such coverage.
3. Payment must be received for each month requested of retroactive coverage before such coverage is approved.

WAC 182-511-1050 Health care for workers with disabilities (HWD) -- Program requirements.

Effective January 1, 2020

This section describes requirements a person must meet to be eligible for the apple health for workers with disabilities (HWD) program.

1. To qualify for the HWD program, a person must:
   1. Meet the general requirements for a medical program described in WAC 182-503-0505(3)(a) through (f);
   2. Be at least age sixteen;
   3. Meet the federal disability requirements described in WAC 182-511-1150;
   4. Be employed full or part time (including self-employment) as described in WAC 182-511-1200.
2. The HWD program does not require a resource test.
3. Once approved for HWD coverage, a person must pay the monthly premium in order to continue to qualify.
   1. The agency calculates the premium for HWD coverage according to WAC 182-511-1250.
   2. If a person does not pay four consecutive monthly premiums, the person is not eligible for HWD coverage for the next four months and must pay all premium amounts owed before HWD coverage can be approved again.
   3. Once approved for HWD coverage, a person who experiences a job loss can choose to continue HWD coverage through the original twelve months of eligibility, if the following requirements are met:
      1. The job less results from an involuntary dismissal or health crisis; and
      2. The person continues to pay the monthly premium.

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.