WAC 182-507-0125 State-funded long-term care services.

Effective August 26, 2024

1. Caseload limits.
   1. The state-funded long-term care services program is subject to caseload limits determined by legislative funding.
   2. The aging and long-term support administration (ALTSA) or the developmental disabilities administration (DDA) must preauthorize state-funded long-term care service before payments begin.
   3. ALTSA or DDA cannot authorize a service, under chapter 388-106 WAC or under chapter 388-825 WAC, if doing so would exceed statutory caseload limits.
2. Location of services. State-funded long-term care services may be provided in:
   1. The person's own home, defined in WAC 388-106-0010;
   2. An adult family home, defined in WAC 182-513-1100;
   3. An assisted living facility, defined in WAC 182-513-1100;
   4. An enhanced adult residential care facility, defined in WAC 182-513-1100;
   5. An adult residential care facility, defined in WAC 182-513-1100; or
   6. A nursing facility, defined in WAC 182-500-0050, but only if nursing facility care is necessary to sustain life; or
   7. A residential habilitation center, defined in WAC 388-835-0010, that is an intermediate care facility for individuals with intellectual disabilities (ICF/IID), defined in WAC 182-500-0050.
3. Client eligibility. To be eligible for the state-funded long-term care services program, a person must meet all of the following conditions:
   1. General eligibility requirements for medical programs under WAC 182-503-0505, except (c) and (d) of this subsection;
   2. Be age 19 or older;
   3. Reside in one of the locations under subsection (2) of this section;
   4. Attain institutional status under WAC 182-513-1320;
   5. Meet the functional eligibility requirements under WAC 388-106-0355 for nursing facility level of care or under WAC 388-845-0030 for ICF/IDD level of care;
   6. Not have a penalty period due to a transfer of assets under WAC 182-513-1363;
   7. Not have equity interest in a primary residence more than the amount under WAC 182-513-1350; and
   8. Meet the requirements under chapter 182-516 WAC for annuities owned by the person or the person's spouse.
4. General limitations.
   1. If a person entered Washington only to obtain medical care, the person is ineligible for state-funded long-term care services.
   2. The certification period for state-funded long-term care services may not exceed 12 months.
   3. People who qualify for state-funded long-term care services receive categorically needy (CN) medical coverage under WAC 182-501-0060.
5. Supplemental security income (SSI)-related program limitations.
   1. A person who is related to the SSI program under WAC 182-512-0050 (1), (2), and (3) must meet the financial requirements under WAC 182-513-1315 to be eligible for state-funded long-term care services.
   2. An SSI-related person who is not eligible for the state-funded long-term care services program under CN rules may qualify under medically needy (MN) rules under WAC 182-513-1395.
   3. The agency determines how much an SSI-related person is required to pay toward the cost of care, using:
      1. WAC 182-513-1380, if the person resides in a nursing facility or residential habilitation center.
      2. WAC 182-515-1505 or 182-515-1510, if the person resides in one of the locations listed in subsection (2)(a) through (e) of this section.
6. Modified adjusted gross income (MAGI)-based program limitations.
   1. A person who is related to the MAGI-based program may be eligible for state-funded long-term care services under this section and chapter 182-514 WAC if the person resides in a nursing facility.
   2. A MAGI-related person is not eligible for residential or in-home care state-funded long-term care services unless the person also meets the SSI-related eligibility criteria under subsection (5)(a) of this section.
   3. A MAGI-based person does not pay toward the cost of care in a nursing facility.
7. Current resource, income, PNA, and room and board standards are found at www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/program-standard-income-and-resources.

WAC 182-507-0120 Alien medical for dialysis and cancer treatment, and treatment of life-threatening benign tumors.

Effective March 8, 2015

In addition to the provisions for emergency care described in WAC 182-507-0115, the medicaid agency also considers the conditions in this section as an emergency, as defined in WAC 182-500-0030.

1. A person nineteen years of age or older who is not pregnant and meets the eligibility criteria under WAC 182-507-0110 may be eligible for the scope of service categories under this program if the condition requires:
   1. Surgery, chemotherapy, and/or radiation therapy to treat cancer or life-threatening benign tumors;
   2. Dialysis to treat acute renal failure or end stage renal disease (ESRD); or
   3. Antirejection medication, if the person has had an organ transplant.
2. When related to treating the qualifying medical condition, covered services include but are not limited to:
   1. Physician and ARNP services, except when providing a service that is not within the scope of this medical program (as described in subsection (7) of this section);
   2. Inpatient and outpatient hospital care;
   3. Dialysis;
   4. Surgical procedures and care;
   5. Office or clinic based care;
   6. Pharmacy services;
   7. Laboratory, X ray, or other diagnostic studies;
   8. Oxygen services;
   9. Respiratory and intravenous (IV) therapy;
   10. Anesthesia services;
   11. Hospice services;
   12. Home health services, limited to two visits;
   13. Durable and nondurable medical equipment;
   14. Nonemergency transportation; and
   15. Interpreter services.
3. All hospice, home health, durable and nondurable medical equipment, oxygen and respiratory, IV therapy, and dialysis for acute renal disease services require prior authorization. Any prior authorization requirements applicable to the other services listed above must also be met according to specific program rules.
4. To be qualified and eligible for coverage for cancer treatment or treatment of life-threatening benign tumors under this program, the diagnosis must be already established or confirmed. There is no coverage for cancer screening or diagnostics for a workup to establish the presence of cancer or life-threatening benign tumors.
5. Coverage for dialysis under this program starts the date the person begins dialysis treatment, which includes fistula placement and other required access. There is no coverage for diagnostics or predialysis intervention, such as surgery for fistula placement anticipating the need for dialysis, or any services related to preparing for dialysis.
6. Certification for eligibility will range between one to twelve months depending on the qualifying condition, the proposed treatment plan, and whether the client if required to meet a spenddown liability.
7. The following are not within the scope of service categories for this program:
   1. Cancer screening or work-ups to detect or diagnose the presence of cancer or life-threatening benign tumors;
   2. Fistula placement while the person waits to see if dialysis will be required;
   3. Services provided by any health care professional to treat a condition not related to, or medically necessary to, treat the qualifying condition;
   4. Organ transplants, including preevaluations and post operative care;
   5. Health department services;
   6. School-based services;
   7. Personal care services;
   8. Physical, occupational, and speech therapy services;
   9. Audiology services;
   10. Neurodevelopmental services;
   11. Waiver services;
   12. Nursing facility services;
   13. Home health services, more than two visits;
   14. Vision services;
   15. Hearing services;
   16. Dental services, unless prior authorized and directly related to dialysis or cancer treatment;
   17. Mental health services;
   18. Podiatry services;
   19. Substance abuse services; and
   20. Smoking cessation services.
8. The services listed in subsection (7) of this section are not within the scope of service categories for this program. The exception to rule process is not available.
9. Providers must not bill the agency for visits or services that do not meet the qualifying criteria described in this section.

WAC 182-507-0110 Washington apple health -- Alien medical programs.

Effective March 31, 2014.

1. To qualify for an alien medical program (AMP) a person must:
   1. Be ineligible for federally funded Washington apple health (WAH) programs due to the citizenship/alien status requirements described in WAC 182-503-0535;
   2. Meet the requirements described in WAC 182-507-0115, 182-507-0120, or 182-507-0125; and
   3. Meet all categorical and financial eligibility criteria for one of the following programs, except for the Social Security number or citizenship/alien status requirements:
      1. An SSI-related medical program described in chapters 182-511 and 182-512 WAC;
      2. A MAGI-based program referred to in WAC 182-503-0510; or
      3. The breast and cervical cancer treatment program for women described in WAC 182-505-0120; or
      4. A medical extension described in WAC 182-523-0100.
2. AMP medically needy (MN) health care coverage is available only for children, pregnant women and persons who meet SSI-related criteria. See WAC 182-519-0100 for MN eligibility and WAC 182-519-0110 for spending down excess income under the MN program.
3. The agency or its designee does not consider a person's date of arrival in the United States when determining eligibility for AMP.
4. For non-MAGI-based programs, the agency or its designee does not consider a sponsor's income and resources when determining eligibility for AMP, unless the sponsor makes the income or resources available. Sponsor deeming does not apply to MAGI-based programs.
5. A person is not eligible for AMP if that person entered the state specifically to obtain medical care.
6. A person who the agency or its designee determines is eligible for AMP may be eligible for retroactive coverage as described in WAC 182-504-0005.
7. Once the agency or its designee determines financial and categorical eligibility for AMP, the agency or its designee then determines whether a person meets the requirements described in WAC 182-507-0115, 182-507-0120, or 182-507-0125.

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).