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.

WAC 182-509-0375 MAGI income -- Lump sums.

Effective September 13, 2021.

For purposes of determining eligibility for modified adjusted gross income (MAGI)–based Washington apple health (see WAC 182-509-0300):

1. A lump sum payment is money that a person receives but does not expect to receive on a continuing basis, such as an insurance settlement.
2. A lump sum payment is only counted as income if it is received in the month of application, and it otherwise qualifies as countable income under another rule.

WAC 182-509-0370 MAGI income -- How self-employment income is counted.

Effective September 13, 2021.

For purposes of determining eligibility for modified adjusted gross income (MAGI)–based Washington apple health, the medicaid agency counts self-employment income by:

1. Adding together gross self-employment income and any profit made from selling business property or equipment over a period of time; and 
2. Subtracting business expenses and income deductions allowed by the Internal Revenue Service that the person would be entitled to if they were filing a federal tax return and either:
   1. Averaging the income to come up with a monthly amount based on the period of time the business has been in operation within the last year; or
   2. Averaging the income over a representative period of time if the current income does not represent the person's projected income as shown by clear indications of future changes in income; or
   3. By averaging the self-employed income and deductions claimed on the previous year's tax return over a representative period of time.

WAC 182-509-0365  MAGI income -- Self-employment income.

Effective September 13, 2021.

For purposes of determining eligibility for modified adjusted gross income (MAGI)–based Washington apple health (WAH) (see WAC 182-509-0300):

1. Self-employment income is income earned by a person from running a business, performing a service, selling items that are made, or reselling items with the intent to make a profit, after deducting allowable IRS self-employment expenses. This income can be earned if the person is carrying on a trade or business as a sole proprietor or an independent contractor; a member of a partnership that carries on a trade or business; or otherwise in business for themselves (including a part-time business). Examples of self-employment business structures include, but are not limited to:
   1. Sole proprietorship - An unincorporated business owned by one person.
   2. Partnership - A relationship between two or more people who conduct a trade or business.
   3. Corporation - An entity that conducts business, realizes net income or loss, pays taxes, and distributes profits to shareholders.
   4. S corporation - Similar to a corporation, but this structure passes corporate income, losses, deductions, and credits through to the shareholders for federal tax purposes.
   5. Limited liability company (LLC) - An entity formed by one or more people or entities through a special written agreement that details the organization of the LLC.
2. Self-employment income is counted as earned income as described in WAC 182-509-0330, except when it is earned by a child or tax dependent and the income is below the filing threshold, as described in WAC 182-509-0360(1). 
3. A person is considered to be self-employed if they earn income without having an employer/employee relationship with the individual who pays the income. Self-employed people do not work for a specific employer who pays them a consistent salary or wage. Factors to consider are whether:
   1. The person has primary control or has the right to control what they do and how they do their job;
   2. The business aspects of the person's job are controlled by the person and not the payer (this includes things like how the person is paid, whether expenses are reimbursed, or who provides tools/supplies);
   3. The person has a contract stating that they are an independent contractor; or
   4. The person reports their income using one or more IRS schedules or forms that include, but are not limited to:
      1. Schedule C;
      2. Schedule C-EZ;
      3. Schedule E;
      4. Schedule F;
      5. Schedule K-1;
      6. Schedule SE;
      7. Form 940;
      8. Form 941;
      9. Form 942;
      10. Form 943;
      11. Form 1065; or 
      12. Form 1120.
4. A person is considered to have an employer/employee relationship when:
   1. The individual the person provides services for has primary control of how the work is done; or
   2. The person receives an IRS Form W-2 to report the income that is earned.
5. Self-employment does not have to be a licensed business for a person's business or activity to qualify as self-employment. 
6. A person must keep records of his or her self-employment income and deductions and provide this information to the agency upon request.