WAC 182-504-0130 Washington apple health -- Continued coverage pending an appeal.

Effective December 1, 2016

1. Continued coverage is when you continue to receive Washington apple health benefits while appealing a medicaid agency adverse action to terminate, suspend, or reduce your:
   1. Medicaid eligibility; or
   2. Authorization for a covered service.
2. To qualify for continued coverage, you must request a hearing on the adverse action no later than:
   1. The tenth day after we (the medicaid agency or its designee) sent a notice of the action to you; or
   2. The last day of the month before the action takes effect.
3. If your last day to request a hearing and still qualify for continued coverage falls on a Saturday, Sunday, or a designated holiday under WAC 357-31-005, you have until 5:00 p.m. on the next business day to request the hearing.
4. Continued coverage ends when:
   1. You state in writing you no longer wish to receive continued coverage;
   2. You withdraw the appeal;
   3. You default and an order of dismissal is entered;
   4. An administrative law judge or a review judge issues an adverse ruling or written decision:
      1. Terminating your continued coverage; or
      2. Ruling you do not qualify for benefits.
5. You cannot receive continued coverage if the adverse action was solely to a change in statute, federal regulation, or administrative rule, unless there is a question about whether you are in the class of people affected by the change.
6. If you are receiving medically needy coverage, you cannot receive continued coverage past the end of the certification period described in WAC 182-504-0020.
7. If you are receiving coverage under an alien medical program, you cannot receive continued coverage past the end of the certification period described in chapter 182-507 WAC.

WAC 182-504-0125 Washington apple health -- Effect of reported changes.

Effective October 1, 2017.

1. If you report a change required under WAC 182-504-0105 during a certification period, you continue to be eligible for Washington apple health coverage until we decide if you can keep getting apple health coverage under your current apple health program or a different apple health program.
2. If your apple health categorically needy (CN) coverage ends due to a reported change and you meet all the eligibility requirements for a different apple health CN program, we will approve your coverage under the new apple health CN program. If you are not eligible for coverage under any apple health CN program but you meet the eligibility requirements for either apple health alternative benefits plan (ABP) coverage or apple health medically needy (MN) coverage, we will approve your coverage under the program you are eligible for. If you are not eligible for coverage under any apple health CN program but you meet the eligibility requirements for both apple health ABP coverage and apple health MN coverage, we will approve the apple health ABP coverage unless you notify us that you prefer  apple health MN coverage.
3. If your apple health coverage ends and you are not eligible for a different apple health program, we stop your apple health coverage after giving you advance and adequate notice unless the exception in subsection (4) of this section applies to you.
4. If you claim to have a disability and that is the only basis for you to be potentially eligible for apple health coverage, then we refer you to the division of disability determination services (within the department of social and health services) for a disability determination. Pending the outcome of the disability determination, we also determine if you are eligible for apple health coverage under the SSI-related medical program described in chapter 182-512 WAC. If you have countable income in excess of the SSI-related categorically needy income level (CNIL), then we look to see if you can get coverage under apple health MN with spenddown as described in chapter 182-519 WAC pending the final outcome of the disability determination.
5. If you are eligible for and receive coverage under the apple health parent and caretaker relative program described in WAC 182-505-0240, you may be eligible for the apple health medical extension program described in WAC 182-523-0100, if your coverage ends as a result of an increase in your earned income.
6. Changes in income during a certification period do not affect eligibility for the following programs:
   1. Apple health for pregnant women;
   2. Apple health for children, except as specified in subsection (7) of this section;
   3. Apple health for SSI recipients;
   4. Apple health refugee program; and
   5. Apple health medical extension program.
7. We redetermine eligibility for children receiving apple health for kids premium-based coverage described in WAC 182-505-0210 when the:
   1. Household's countable income decreases to a percentage of the federal poverty level (FPL) that would result in either a change in premium for apple health for kids with premiums or the children becoming eligible for apple health for kids (without premiums);
   2. Child becomes pregnant;
   3. Family size changes; or
   4. Child receives SSI.
8. If you get SSI-related apple health CN coverage and report a change in work or earned income which results in a determination by the division of disability determination services that you no longer meet the definition of a disabled person as described in WAC 182-512-0050 due to work or earnings at the level of substantial gainful activity (SGA), we redetermine your eligibility for coverage under the health care for workers with disabilities (HWD) program. The HWD program is a premium-based program that waives the SGA work or earnings test, and you must approve the premium amount before we can authorize coverage under this program. For HWD program rules, see chapter 182-511 WAC.

WAC 182-504-0110 Washington apple health -- When to report changes.

Effective August 29, 2014.

1. All changes you report to us (the agency or its designee), as required by WAC 182-504-0105, are used to decide if you can receive or keep receiving Washington apple health (WAH) coverage.
2. You must report changes during your certification period within thirty days of when the change happened.
3. You must report all changes during application, renewal, or redetermination of your WAH eligibility, regardless of when the change happened.
4. For a change in income, the date a change happened is the first date you received income based on the change. For example, the date you receive your first paycheck for a new job or the date you got a paycheck with a wage increase is the date the change happened.
5. If you do not report a change or you report a change late, we will decide if you can receive or keep receiving WAH coverage based on the date the change was required to be reported.
6. If you do not report a change or you report a change late, and if it affects the amount you must pay toward your cost of care as described in WAC 182-513-1380 or chapter 182-515 WAC, you may become liable for overpayments we make on your behalf and you may need to pay more to your care provider.
7. If you do not report a change or you report a change late, it may result in us overpaying you and you having to pay us back for the health care costs we overpaid. See chapter 182-520 WAC.

WAC 182-504-0105 Washington apple health -- Changes that must be reported.

Effective August 29, 2014.

1. You must report changes in your household and family circumstances to us (the agency or its designee) timely according to WAC 182-504-0110.
2. We tell you what you are required to report at the time you are approved for WAH coverage. We also will tell you if the reporting requirements change.
3. You must report the following:
   1. Change in residential address;
   2. Change in mailing address;
   3. Change in marital status;
   4. When family members or dependents move in or out of the residence;
   5. Pregnancy;
   6. Incarceration;
   7. Change in institutional status;
   8. Change in health insurance coverage including medicare eligibility; and
   9. Change in immigration or citizenship status.
4. If you are eligible for a WAH long-term care program described in chapter 182-513 or 182-515 WAC, you must also report changes to the following:
   1. Income;
   2. Resources;
   3. Medical expenses; and
   4. Spouse or dependent changes in income or shelter cost when expenses are allowed for either.
5. If you get WAH parent or caretaker (as described in WAC 182-505-0240) or WAH modified adjusted gross income (MAGI)-based adult coverage (as described in WAC 182-505-0250), you must also report changes to the following:
   1. When total income increases or total deductions decrease by one hundred fifty dollars or more a month and the change will continue for at least two months;
   2. Your federal income tax filing status that you expect to use when you file your taxes for the current tax filing year (such as changing from "married filing separately" to "married filing jointly"); and
   3. The tax dependents you expect to claim when you file your federal income tax return for the current tax filing year.
6. If you get WAH based on age, blindness, or disability (SSI-related medical), then you must also report changes to the following:
   1. Income; and
   2. Resources. 

WAC 182-504-0035 Washington apple health -- Renewals.

Effective September 6, 2025

1. For all Washington apple health programs, the following applies:
   1. You are required to complete a renewal of eligibility at least every 12 months with the following exceptions:
      1. If you are eligible for apple health medically needy with spenddown, then you must complete a new application at the end of each three- or six-month base period;
      2. If you are eligible for apple health alien emergency medical, then you are certified for a specific period of time to cover emergency inpatient hospitalization costs only (see WAC 182-507-0115(8));
      3. If you are eligible for apple health refugee coverage, you must complete a renewal of eligibility after four months; or
      4. If you are a child on apple health for kids without premiums or apple health for kids with premiums, your first renewal is due the month of your sixth birthday.
   2. You may complete renewals online, by phone, or by paper application that you mail or fax to us (the agency or its designee).
   3. If your apple health is renewed, we decide the certification period according to WAC 182-504-0015.
   4. We review all eligibility factors subject to change during the renewal process.
   5. We redetermine eligibility as described in WAC 182-504-0125 and send you written notice as described in WAC 182-518-0005 before apple health is terminated.
   6. If you need help meeting the requirements of this section, we provide equal access services as described in WAC 182-503-0120.
2. For programs based on modified adjusted gross income (MAGI) as described in WAC 182-503-0510:
   1. Sixty days prior to the end of the certification period:
      1. When information from electronic sources shows income is reasonably compatible (as defined in WAC 182-500-0095), we administratively renew your coverage (as defined in WAC 182-500-0010) for a new certification period and send you a notice of renewal with the information used. You are required to inform us if any of the information we used is wrong.
      2. If we are unable to complete an administrative renewal (as defined in WAC 182-500-0010), you must give us a signed renewal in order for us to decide if you will continue to get apple health coverage beyond the current certification period.
      3. We follow the requirements described in WAC 182-518-0015 to request any additional information needed to complete the renewal process or to terminate coverage for failure to renew.
   2. If your apple health coverage is terminated because you did not renew, you have 90 days from the termination date to give us a completed renewal. If we decide you are still eligible to get apple health coverage, we will restore your apple health without a gap in coverage.
3. For non-MAGI based programs (as described in WAC 182-503-0510):
   1. Forty-five days prior to the end of the certification period, we send notice with a renewal form. You must renew before the end of the certification period by either calling the department of social and health services at the number listed on the form to renew by telephone, renew online at www.washingtonconnection.org, or mailing or delivering to the department of social and health services a signed renewal form with the information required by WAC 182-503-0005.
   2. We follow the requirements in WAC 182-518-0015 to request any additional information needed to complete the renewal process or to terminate coverage for failure to renew.
   3. To complete your renewal, you must give us all the other information requested on the application that is needed to determine your eligibility.
   4. If you are terminated for failure to renew, you have 30 days from the termination date to submit a completed renewal. If still eligible, we will restore your apple health without a gap in coverage.
4. If we determine that you are not eligible for renewal of your apple health coverage, we:
   1. Consider your eligibility for all other WAH programs before ending your apple health coverage; and
   2. Coordinate with the health benefit exchange any request for information that is necessary to determine your eligibility for:
      1. Other apple health programs; and
      2. With respect to qualified health plans, health insurance premium tax credits (as defined in WAC 182-500-0045) and cost-sharing reductions (as defined in WAC 182-500-0020).
5. We reconsider our decision that you are not eligible for 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 30 days of the date on the termination notice; or
   2. You request a hearing within 90 days of the date on the renewal denial letter and an administrative law judge (ALJ) or HCA review judge decides our decision was wrong (per chapter 182-526 WAC).
6. If you disagree with our decision, you can ask for a hearing. If we decided that you are not eligible for renewal because we do not have enough information, the ALJ will consider the information we already have and anymore information you give us. The ALJ does not consider the previous absence of information or failure to respond in determining if you are eligible.

WAC 182-504-0025 Medicare savings program certification periods.

Effective December 1, 2011

Certification periods for the different kinds of Medicare Savings Programs are not all the same. The chart below explains the differences.

WAC 182-504-0020 Certification periods for the noninstitutional medically needy program.

Effective July 11, 2015

1. The certification period for the noninstitutional medically needy (MN) program for clients with countable income equal to or below the medically needy income level (MNIL):
   1. Begins on the first day of the month in which eligibility is established; and
   2. Is approved for twelve calendar months.
2. The certification period for the noninstitutional MN program for clients with countable income above the MNIL:
   1. Begins on the day that spenddown is met; and
   2. Continues through the last day of the final month of the base period as described in WAC 182-519-0110.
3. A retroactive MN certification period may be established for up to three months preceding the month of application.
4. Expenses used to meet the spenddown liability for the current or the retroactive certification periods are the responsibility of the client. The agency is not responsible for paying any expense or portion of an expense which has been used to meet the spenddown liability. See WAC 182-519-0110.
5. A new application must be submitted for each subsequent certification period for which medically needy coverage is requested.

WAC 182-504-0015 Washington apple health -- Certification periods for categorically needy programs.

Effective September 6, 2025

1. A certification period is the period of time we determine that you are eligible for a categorically needy (CN) Washington apple health program. Unless otherwise stated in this section, the certification period begins on the first day of the month of application and continues through the end of the last month of the certification period.
2. Newborn coverage begins on the child's date of birth and continues through the end of the month of the child's first birthday.
3. If you are eligible for apple health based on pregnancy, the certification period continues through the last day of the month the pregnancy ends. After-pregnancy coverage begins the first day of the month, following the ends of the pregnancy, and ends the last day of the 12th month from the time after-pregnancy coverage began.
4. If you are newly eligible for apple health coverage and had a pregnancy end within the last 12 months, your certification period for after-pregnancy coverage:
   1. Begins the first day of the month you are eligible; and
   2. Ends the last day of the 12th month following the end of your pregnancy.
5. If you are eligible for the refugee program, the certification period ends at the end of the fourth month following your date of entry to the United States.
6. If you are a child under age six receiving apple health for kids without a premium or apple health for kids with premiums, your certification period ends the month of your sixth birthday.
7. If you are eligible for newborn coverage, your coverage continues through the last day of the month of your first birthday. Apple health for kids coverage begins the first day of the month after your newborn coverage ends and the certification period ends the last day of the month of your sixth birthday.
8. For all other CN coverage, the certification period is 12 months.
9. If you are a child, eligibility is continuous throughout the certification period regardless of a change in circumstances, unless you:
   1. Turn age 19;
   2. Move out-of-state; or
   3. Die.
10. When you turn 19, the certification period ends after the redetermination process described in WAC 182-504-0125 is completed, even if the 12-month period is not over, unless:
    1. You are receiving inpatient  services (described in WAC 182-514-0230) on the last day of the month you turn 19;
    2. The inpatient stay continues into the following month or months; and
    3. You remain eligible except for turning age 19.
11. A retroactive certification period is described in WAC 182-504-0005.
12. Coverage under premium-based programs included in apple health for kids as described in chapter 182-505 WAC begins no sooner than the month after creditable coverage ends.

WAC 182-504-0005 Washington apple health -- Retroactive certification period.

Effective November 14, 2022.

1. The medicaid agency approves a retroactive Washington apple health (WAH) certification period for the three months immediately before the month of application when an individual:
   1. Requests retroactive WAH on the application, within the certification period following the retroactive period, or before the determination of benefits and any appeal process is final;
   2. Would have been eligible for WAH for any or all of the three months if the individual had applied during the retroactive period; and
   3. The individual received covered medical services as described in WAC 182-501-0060 and 182-501-0065.
2. When an individual is eligible only during the three-month retroactive certification period, that period is the only period of certification, except when:
   1. A pregnant individual is eligible in one of the three months immediately before the month of application, but no earlier than the month of conception. Eligibility continues as described in WAC 182-504-0015 (3) and (4).
   2. An individual who is applying within 12 months of their last pregnancy end date is eligible for after pregnancy coverage in any of the three months immediately before the month of application. Continuous eligibility begins from the earliest month the individual is found eligible as described in WAC 182-504-0015 (3) and (4).
   3. A child is eligible for categorically needy (CN) WAH as described in WAC 182-505-0210 (1) through (5) and (7) in at least one of the three months immediately before the month of application. Eligibility after the retroactive period continues as described in WAC 182-504-0015 (9).
3. An individual applying for the medically needy (MN) spenddown program may be eligible for a retroactive certification period as described in WAC 182-504-0020.
4. An individual applying for a medicare savings program may be eligible for a retroactive certification period as described in WAC 182-504-0025.

WAC 182-503-0565 Washington apple health -- Age requirements for medical programs based on modified adjusted gross income (MAGI).

​Effective August 29, 2014

The following age requirements apply to persons whose eligibility for Washington apple health (WAH) is based on modified adjusted gross income (MAGI) methodology per WAC 182-509-0305.

1. You must be age sixty-four or younger to be eligible for WAH MAGI-based adult coverage as described in WAC 182-505-0250.
2. Your household must include an eligible dependent child age seventeen or younger to be eligible for WAH parent or caretaker relative coverage as described in WAC 182-505-0240. For purposes of this subsection, an "eligible dependent child" is a child related to you in one of the ways described in WAC 182-500-0020.
3. A child must be age eighteen or younger to be eligible for WAH for kids as described in WAC 182-505-0210 with the following exceptions:
   1. An institutionalized child may still qualify under a children's health care program through the age of twenty-one (see WAC 182-514-0230);
   2. A foster care child may qualify for WAH foster care coverage through the age of twenty-six (see WAC 182-505-0211).