WAC 182-506-0015 Medical assistance units for non-MAGI-based Washington apple health programs.

Effective November 12, 2020.

This section explains how medical assistance units (MAUs) are constructed for programs not based on modified adjusted gross income (MAGI) methodologies.(MAGI-based programs are described in WAC 182-503-0510.)

1. An MAU is a person or group of people who must be included together when determining eligibility. MAUs are established based on each person's relationship to other family members and the person's financial responsibility for the other family members. MAUs for non-MAGI-based programs include an applicant and persons financially responsible for the applicant as described in subsection (2) of this section (as limited by subsection (3) of this section).
2. Financial responsibility applies as follows:
   1. Married persons living together are financially responsible for each other;
   2. Natural, adoptive, or step-parents are financially responsible for their unmarried, minor children living in the same household;
   3. Minor children are financially responsible for only themselves;
   4. Married persons not living together are financially responsible for each other to the extent described in WAC 182-512-0960 and chapters 182-513 and 182-515 WAC when one or both are residing in a medical institution, or one or both are applying for or receiving home and community-based services.
3. The number of persons in the MAU is increased by one for each verified unborn child for each pregnant person already included in the MAU under this section.
4. A separate SSI-related MAU is required for:
   1. SSI recipients, except for spouses who both receive SSI;
   2. SSI-related persons, except spouses whose eligibility is determined as a couple in chapters 182-511, 182-512, and 182-513 WAC;
   3. Institutionalized persons;
   4. The purpose of applying medical income and resource standards for an:
      1. SSI-related applicant whose spouse is not relatable to SSI or is not applying for SSI-related medical; and
      2. Ineligible spouse of an SSI recipient.

WAC 182-506-0012 Determining a person's medical assistance unit.

​Effective April 3, 2016

This section applies to people whose financial eligibility for Washington apple health coverage is based on modified adjusted gross income
methodology.

1. Determining a tax filer's medical assistance unit (MAU).
   1. A tax filer is a person who:
      1. Expects to file a federal income tax return; and
      2. Does not expect to be claimed as a tax dependent on a federal income tax return.
   2. If the applicant or recipient is a tax filer, the following people constitute the applicant's or recipient's MAU:
      1. The tax filer;
      2. The tax filer's spouse, if residing with the tax filer; and
      3. Everyone the tax filer expects to claim as a tax dependent.
2. Determining a tax dependent's MAU.
   1. A tax dependent is a person who expects to be claimed as a tax dependent on a tax filer's federal income tax return.
   2. If the applicant or recipient is a tax dependent:
      1. The following people constitute the tax dependent's MAU unless the tax dependent meets one of the exceptions in (b)(ii) of this
         subsection:
         1. The tax dependent;
         2. The tax dependent's spouse, if living with the tax dependent;
         3. The tax filer who claims the tax dependent;
         4. The spouse of the tax filer who claims the tax dependent, if living with the tax filer; and
         5. All tax dependents claimed by the tax filer.
      2. A tax dependent who meets one of the exceptions below is treated as a nonfiler under subsection (3) of this section:
         1. A tax dependent who is neither the spouse nor the child of the tax filer;
         2. A child under age nineteen who resides with both parents and
            those parents do not file a joint tax return; or
         3. The tax dependent expects to be claimed by a noncustodial parent.
3. Determining a nonfiler's MAU.
   1. A nonfiler is a person who does not expect to file a federal income tax return and either:
      1. Does not expect to be claimed as a dependent; or
      2. Meets one of the exceptions listed in subsection (2)(b)(ii) of this section.
   2. If the applicant or recipient is a nonfiler, the nonfiler and the following people constitute the applicant's or recipient's MAU,
      but only if residing with the nonfiler:
      1. The nonfiler's spouse;
      2. The nonfiler's children under age nineteen; and
      3. If the nonfiler is under age nineteen, the nonfiler's parents and the nonfiler's siblings under age nineteen.

WAC 182-506-0010 Medical assistance units for MAGI-based programs.

Effective April 3, 2016

This section applies to applicants or recipients whose financial eligibility for Washington apple health coverage is based on modified adjusted gross income methodology under WAC 182-503-0510 and 182-509-0300.

1. General medical assistance unit (MAU) rules.
   1. The rules in this section describe how the medicaid agency must determine who is in an applicant's or recipient's MAU.
   2. Each person will have an individualized MAU and may have different eligibility results than other people on the same application.
   3. The countable income used to determine a person's eligibility is the sum of the countable income of everyone in the person's MAU.
2. Rules regardless of tax filing status.
   1. If a married couple resides together, the agency must include both people in each other's MAU regardless of tax filing status.
   2. If a member of the MAU is pregnant, the number of people in the MAU increases by one for each unborn child.
   3. A deceased person does not count in the MAU of other applicants or recipients except in the month the person died.
3. Children residing in an institution under chapter 182-514 WAC. An applicant or recipient is the only person in the MAU if the applicant or recipient:
   1. Has resided in a medical institution, institution for mental diseases (IMD), or inpatient psychiatric facility for thirty consecutive days; or
   2. Based on an assessment by the department of social and health services, is likely to reside in a medical institution, IMD, or inpatient
      psychiatric facility for thirty consecutive days.

WAC 182-505-0250 Washington apple health -- MAGI-based adult medical.

Effective August 29, 2014.

1. Effective on or after January 1, 2014, a person is eligible for Washington apple health (WAH) modified adjusted gross income (MAGI)-based adult coverage when he or she meets the following requirements:
   1. Is age nineteen or older and under the age of sixty-five;
   2. Is not entitled to, or enrolled in, medicare benefits under Part A or B of Title XVIII of the Social Security Act;
   3. Is not otherwise eligible for and enrolled in mandatory coverage under one of the following programs:
      1. WAH SSI-related categorically needy (CN);
      2. WAH foster care program; or
      3. WAH adoption support program;
   4. Meets citizenship and immigration status requirements described in WAC 182-503-0535;
   5. Meets general eligibility requirements described in WAC 182-503-0505; and
   6. Has net countable income that is at or below one hundred thirty-three percent of the federal poverty level for a household of the applicable size.
2. Parents or caretaker relatives of an eligible dependent child as described in WAC 182-503-0565 are first considered for WAH for families as described in WAC 182-505-0240. A person whose countable income exceeds the standard to qualify for family coverage is considered for coverage under this section.
3. Persons who are eligible under this section are eligible for WAH alternative benefit plan as defined in WAC 182-500-0010 coverage. A person described in this section is not eligible for medically needy WAH.
4. Other coverage options for adults not eligible under this section are described in WAC 182-508-0001.

WAC 182-505-0240 Parents and caretaker relatives.

Effective July 1, 2017.

1. A person is eligible for Washington apple health categorically needy (CN) coverage when the person:
   1. Is a parent or caretaker relative of a dependent child who meets the criteria described in WAC 182-503-0565(2);
   2. Meets citizenship and immigration status requirements described in WAC 182-503-0535;
   3. Meets general eligibility requirements described in WAC 182-503-0505; and
   4. Has countable income below the standard in WAC 182-505-0100 (2).
2. To be eligible for coverage as a caretaker relative, a person must be related to a dependent child who meets the criteria described in WAC 182-503-0565(2).
3. A person must cooperate with the state of Washington in the identification, use and collection of medical support from responsible third parties as described in WAC 182-503-0540.
4. A person who does not cooperate with the requirements in subsection (3) of this section is not eligible for coverage.

WAC 182-505-0225 Children's Washington apple health with premiums - Calculation and determination of premium amount.

Effective October 25, 2024.

1. For the purposes of this chapter, "premium" means an amount paid for health care coverage under WAC 182-505-0215.
2. Premium requirement. The Washington apple health premium-based program under WAC 182-505-0215 requires payment of a monthly premium.
   1. The first monthly premium is due in the month following the determination of eligibility.
   2. There is no premium requirement for health care coverage received in the month eligibility is determined or in any prior month.
   3. A child who is American Indian or Alaska native is exempt from the monthly premium requirement.
3. Monthly premium amount.
   1. The premium amount for the medical assistance unit (MAU) is based on countable income under chapter 182-509 WAC and the number of people in the MAU under chapter 182-506 WAC.
   2. The premium amount is as follows:
      1. If the MAU's countable income exceeds 210 percent of the federal poverty level (FPL) but does not exceed 260 percent of the FPL, the monthly premium for each child is $20.
      2. If the MAU's countable income exceeds 260 percent of the FPL but does not exceed 312 percent of the FPL, the monthly premium for each child is $30.
      3. The medicaid agency charges a monthly premium for no more than two children per household.
      4. Payment of the full premium is required. Partial payments cannot be designated for a specific child or month.
      5. Any third party may pay the premium on behalf of the household. Failure of a third party to pay the premium does not eliminate the obligation of the household to pay past due premiums.
   3. A change that affects the premium amount takes effect the month after the change is reported.
4. Nonpayment of premiums.
   1. The agency writes off past-due premiums after 12 months.

WAC 182-505-0215 Children's Washington apple health with premiums.

Effective January 23, 2021.

1. A child is eligible for Washington apple health with premiums if the child:
   1. Meets the requirements in WAC 182-505-0210(1);
   2. Has countable income below the standard in WAC 182-505-0100 (6)(b); and
   3. Pays the required premium under WAC 182-505-0225, unless the child is exempt under WAC 182-505-0225 (2)(c).
2. A child is not eligible for Washington apple health with premiums if the child:
   1. Is eligible for no-cost Washington apple health;
   2. Has creditable health insurance coverage as defined in WAC 182-500-0020.
3. A child with creditable health insurance coverage may be eligible for Washington apple health with premiums if the child is eligible for either:
   1. Public employees benefits board (PEBB) health insurance coverage based on a family member's employment with a Washington state agency, or a Washington state university, community college, or technical college; or
   2. School employees benefits board (SEBB) health insurance coverage based on a family member's employment with a Washington school district, charter school, or educational service district; and
   3. Meets the requirements in WAC 182-505-0210 (1).

WAC 182-505-0211 Washington apple health -- Foster Care.

Effective January 1, 2023.

1. A client under the age of 18 is eligible for Washington apple health foster care coverage when they:
   1. Are in foster care as determined by the department of children, youth, and families (DCYF) under the legal responsibility of the state, or a federally recognized tribe located within the state; and
   2. Meet Washington residency requirements as described in WAC 182-503-0520 or 182-503-0525.
2. A client age 20 or younger is eligible for coverage when the client meets:
   1. Washington residency requirements as described in WAC 182-503-0520 or 182-503-0525;
   2. Citizenship or immigration status requirements as described in WAC 182-503-0535;
   3. Social Security number requirements as described in WAC 182-503-0515; and
   4. One of the following requirements:
      1. Is in foster care, or is eligible for continued foster care services as determined by the children's administration, under the legal responsibility of the state, or a federally recognized tribe located within the state; or
      2. Receives subsidized adoption services through the children's administration; or
      3. Is enrolled in the unaccompanied refugee minor (URM) program as authorized by the office of refugee and immigrant assistance (ORIA); or
      4. Is living in a community facility (as defined in WAC 110-700-005) operated or contracted by DCYF's juvenile rehabilitation.
3. A client age 18 or older but under age 26 is eligible for Washington Apple Health coverage when a client:
   1. Was in foster care under the legal responsibility of any state or a federally recognized tribe located within any state.
      1. On the client's 18th birthday; or
      2. At such higher age as to when the state or tribe extends foster care coverage; and
   2. Meets residency, Social Security number, and citizenship requirements as described in subsection (2) of this section.
4. A client described in subsections (1) through (3) of this section is not eligible for full-scope coverage if the client is confined to a public institution as defined in WAC 182-500-0050, except:
   1. If the client is under age 21;
   2. Resides in an institution for mental disease (IMD); and
   3. Meets the institutional status requirements in WAC 182-513-1320, 182-514-0250, or 182-514-0260.

WAC 182-505-0210 Eligibility for children.

Effective June 9, 2025

1. General eligibility. For purposes of this section, a child must:
   1. Be a Washington state resident under WAC 182-503-0520 and 182-503-0525;
   2. Provide a Social Security number under WAC 182-503-0515, unless exempt; and
   3. Meet program-specific requirements.
2. Deemed eligibility groups. A child is automatically eligible for coverage without an application if the child meets the program-specific requirements in (a) through (c) of this subsection.
   1. Newborn coverage. A child younger than age one is eligible for categorically needy (CN) coverage if the birth parent was eligible for Washington apple health on the date of delivery:
      1. Including a retroactive eligibility determination; or
      2. By meeting a medically needy (MN) spenddown liability with expenses incurred by the date of the newborn's birth:
   2. Washington apple health for supplemental security income (SSI) recipients. A child who is eligible for SSI is automatically eligible for CN coverage under WAC 182-510-0001.
   3. Foster care coverage. A child age 20 and younger is eligible for CN coverage under WAC 182-505-0211 when the child is in foster care or receives subsidized adoption services. For children who age out of the foster care program, see WAC 182-505-0211(3).
3. Continuous eligibility for children under age six. A child is eligible for Washington apple health continuous eligibility for children under age six when they:
   1. Have household income at or below 210 percent of the federal poverty level at the time of application; or
   2. On or after January 8, 2025, have household income greater than 210 percent but equal to or less than 312 percent of the federal poverty level at the time of application; or
   3. Received coverage under subsection (5) of this section and are no longer eligible for deemed coverage under subsection (5) (b) or (c) of this section.
4. MAGI-based eligibility groups. A child age 18 or younger is eligible for CN coverage based on modified adjusted gross income (MAGI):
   1. At no cost when the child's countable income does not exceed the standard in WAC 182-505-0100 (6)(a);
   2. With payment of a premium when the child's countable income does not exceed the standard in WAC 182-505-0100 (6)(b), and the child meets additional eligibility criteria in WAC 182-505-0215;
   3. Under chapter 182-514 WAC, if the child needs long-term care services because the child resides or is expected to reside in an institution, as defined in WAC 182-500-0050, for 30 days or longer. An institutionalized child is eligible for coverage under the medically needy (MN) program if income exceeds the CN income standard for a person in an institution (special income level);
   4. Under WAC 182-505-0117, if a child is pregnant;
   5. When the child has household income at or below 215 percent of the federal poverty level at the time of application and is eligible for Washington apple health continuous eligibility for children under age six.
5. Non-MAGI-based children's programs. The agency determines eligibility for the:
   1. MN program according to WAC 182-519-0100. A child age 18 or younger is eligible if the child:
      1. Is not eligible for MAGI-based coverage under subsection (3) of this section;
      2. Meets citizenship or immigration requirements under WAC 182-503-0535 (2)(a), (b), (c), or (d); and
      3. Meets any spenddown liability required under WAC 182-519-0110.
   2. SSI-related program. A child age 18 or younger is eligible for CN or MN SSI-related coverage if the child meets:
      1. SSI-related eligibility under chapter 182-512 WAC;
      2. Citizenship or immigration requirements under WAC 182-503-0535 (2)(a), (b), (c), or (d); and
      3. Any MN spenddown liability under WAC 182-519-0110.
   3. SSI-related long-term care program.
      1. A child age 18 or younger is eligible for home and community based (HCB) waiver programs under chapter 182-515 WAC if the child meets:
         1. SSI-related eligibility under chapter 182-512 WAC;
         2. Citizenship or immigration requirements under WAC 182-503-0535 (2)(a), (b), (c), or (d); and
         3. Program-specific age and functional requirements under chapters 388-106 and 388-845 WAC.
      2. A child age 18 or younger who resides or is expected to reside in a medical institution as defined in WAC 182-500-0050 is eligible for institutional medical under chapter 182-513 WAC if the child meets:
         1. Citizenship or immigration requirements under WAC 182-503-0535 (2)(a), (b), (c), or (d);
         2. Blindness or disability criteria under WAC 182-512-0050; and
         3. Nursing facility level of care under chapter 388-106 WAC.
6. Alien emergency medical program. A child age 20 or younger who does not meet the eligibility requirements for a program described under subsections (2) through (5) of this section is eligible for the alien emergency medical (AEM) program if the child meets:
   1. The eligibility requirements of WAC 182-507-0110; and
   2. MN spenddown liability, if any, under WAC 182-519-0110.
7. Other provisions.
   1. A child residing in an institution for mental disease (IMD) as defined in WAC 182-500-0050 is not eligible for inpatient hospital services, unless the child is unconditionally discharged from the IMD before receiving the services.
   2. A child incarcerated in a public institution as defined in WAC 182-500-0050 is only eligible for inpatient hospital services.

WAC 182-505-0120 Washington apple health breast and cervical cancer treatment program for women--Client eligibility.

Effective September 14, 2015

1. Effective April 1, 2014, a woman is eligible for categorically needy (CN) coverage under the Washington apple health (WAH) breast and cervical cancer treatment program (BCCTP) only when she:
   1. Has been screened for breast or cervical cancer under the department of health's breast, cervical, and colon health program (BCCHP);
   2. Requires treatment for breast cancer, cervical cancer, or a related precancerous condition;
   3. Is under sixty-five years of age;
   4. Is not eligible for other WAH-CN coverage, including coverage under the MAGI-based adult group;
   5. Is uninsured or does not otherwise have creditable coverage;
   6. Meets residency requirements under WAC 182-503-0520;
   7. Meets Social Security number requirements under WAC 182-503-0515;
   8. Is a U.S. citizen, U.S. national, qualifying American Indian born abroad, or qualified alien under WAC 182-503-0535; and
   9. Meets the income standard set by the BCCHP in DOH form 342-031.
2. The certification period for breast and cervical cancer treatment covered under this section is twelve months, as provided in WAC 182-504-0015. To remain continuously enrolled, the client must renew her eligibility before the certification period ends. Eligibility for BCCTP coverage under subsection (1)(b) of this section continues throughout the course of treatment as certified by the BCCHP. Retroactive coverage may be available under WAC 182-504-0005.