Washington Administrative Code

This section applies to entities that contract with the medicaid agency to provide services in exchange for a capitated rate.(1) Managed care organizations (MCOs) must comply with and enforce all applicable program integrity:(a) Federal and state laws and regulations;(b) Terms of…

(1) For the purposes of this chapter, "we" or "us" refers to the agency or its designee and "you" refers to the applicant for, or recipient of, health care coverage.(2) A person may apply for all of the insurance affordability programs offered through the health care authority (H…

(1) You may apply for Washington apple health at any time.(2) For apple health programs for children, pregnant people, parents and caretaker relatives, and adults age 64 and under without medicare (including people who have a disability or are blind), you may apply:(a) Online via…

(1) You may apply for Washington apple health for yourself.(2) You may apply for apple health for another person if you are:(a) A legal guardian;(b) An authorized representative (as described in WAC 182-503-0130);(c) A parent or caretaker relative of a child age 18 or younger;(d)…

(1) An individual applying for Washington apple health (WAH) (as defined in WAC 182-500-0120) is not required to have an in-person interview to determine eligibility.(2) The agency or its designee may contact an individual by phone or in writing to gather any additional informati…

(1) General rules.(a) We may verify the information we use to determine, redetermine, or terminate your apple health eligibility.(b) We verify the eligibility factors listed in WAC 182-503-0505(3).(c) Before we ask you to provide records to verify an eligibility factor, we use in…

(1) This rule implements the asset verification system (AVS) outlined in section 1940 of the Social Security Act.(2) This rule applies to any client, or those financially responsible for them, who is subject to:(a) The disclosure of resources, as defined in WAC 182-512-0200, to d…

(1) We process applications for Washington apple health (medicaid) within 45 calendar days, with the following exceptions:(a) If you are pregnant, we process your application within fifteen calendar days;(b) If you are applying for a program that requires a disability decision, w…

(1) Your Washington apple health coverage starts on the first day of the month you applied for and we decided you are eligible to receive coverage, unless one of the exceptions in subsection (4) of this section applies to you.(2) Sometimes we can start your coverage up to three m…

(1) We follow the rules about notices and letters in chapter 182-518 WAC. We follow the rules about timelines in WAC 182-503-0060.(2) We deny your application for apple health coverage when:(a) You tell us either orally or in writing to withdraw your request for coverage; or(b) B…

(1) A client or client's representative may request an exception to a Washington apple health financial eligibility rule in Title 182 WAC. The request for an exception to rule (ETR) may be submitted orally or in writing. The request must:(a) Be received within 90 calendar days of…

For the purposes of this chapter, "we" refers to the agency or its designee and "you" refers to the applicant for, or recipient of, health care coverage.(1) If you are applying for or receiving health care coverage, you have the right to:(a) Have your rights and responsibilities …

(1) We provide interpreter and translation services (limited-English proficient or LEP services) free of charge to you if you have limited ability to read, write, and/or speak English. Interpreter services are those used for oral communication between two parties who do not speak…

(1) When you have a mental, neurological, cognitive, physical or sensory impairment, or limitation that prevents you from receiving health care coverage, we provide services to help you apply for, maintain, and understand the health care coverage options available and eligibility…

(1) Designating an authorized representative (AREP).(a) A person may designate an AREP to act on his or her behalf in eligibility-related interactions with the medicaid agency by completing the agency's Authorized Representative Designation Form (DSHS 14-532), or through any of t…

(1) When you apply for Washington apple health programs established under chapter 74.09 RCW, you must meet the eligibility criteria in chapters 182-500 through 182-527 WAC.(2) When you apply for apple health, we first consider you for federally funded or federally matched program…

(1) The agency categorizes Washington apple health programs into three groups based on the income methodology used to determine eligibility:(a) Those that use a modified adjusted gross income (MAGI)-based methodology described in WAC 182-509-0300, called MAGI-based apple health p…

(1) To be eligible for Washington apple health (medicaid), or tailored supports for older adults (TSOA) described in WAC 182-513-1610, you (the applicant or recipient) must provide your valid Social Security number (SSN) or proof of application for an SSN to the medicaid agency o…

(1) A resident is a person (including an emancipated person under age 18 and a married person under age 18 who is capable of indicating intent) who currently lives in Washington and:(a) Intends to reside here, including persons without a fixed address; or(b) Entered the state loo…

(1) An institutionalized person is a person who resides in an institution as defined in WAC 182-500-0050. The term "person" used in this section means an "institutionalized person" unless otherwise indicated. It does not include persons who receive services under a home and commu…

(1) Definitions.(a) Nonqualified alien means someone who is lawfully present in the United States (U.S.) but who is not a qualified alien, a U.S. citizen, a U.S. national, or a qualifying American Indian born abroad.(b) Qualified alien means someone who is lawfully present in the…

(1) When you become eligible for any of the agency's health care programs, you assign certain rights to the state of Washington. You assign all rights to any type of coverage or payment for health care that comes from:(a) A court order; (b) An administrative agency order; or(c) A…

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 64 or younger to be eligible for WAH MAGI-based adult coverage as described i…

(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:(a) Requests retroactive WAH on his or her application, within the certification period following …

(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 …

(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):(a) Begins on the first day of the month in which eligibility is established; and(b) Is approved for twel…

Certification periods for the different kinds of medicare savings programs are not all the same. The chart below explains the differences.Medicare Savings ProgramCertificationPeriodStart DateQMB (qualified medicare beneficiary)S0312 monthsOn the first day of the month following Q…

(1) For all Washington apple health programs, the following applies:(a) You are required to complete a renewal of eligibility at least every 12 months with the following exceptions:(i) If you are eligible for apple health medically needy with spenddown, then you must complete a n…

(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 req…

(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 t…

(1) We (the agency or its designee) determine the date a change affects your Washington apple health (WAH) coverage based on:(a) The date you report the change to us;(b) The date you give us the requested verification; and(c) The type of WAH you or your family is receiving.(2) Wh…

(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 he…

(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:(a) Medicaid eligibility; or(b) Authorization for a covered service.(2) To qualify for continued coverage…

(1) Each year, the federal government publishes new federal poverty level (FPL) income standards in the Federal Register found at https://aspe.hhs.gov/topics/poverty-economic-mobility/poverty-guidelines/prior-hhs-poverty-guidelines-federal-register-references.(a) The income stand…

(1) A pregnant person is eligible for Washington apple health pregnancy coverage if the person:(a) Meets citizenship or immigration status under WAC 182-503-0535;(b) Meets Social Security number requirements under WAC 182-503-0115;(c) Meets Washington state residency requirements…

(1) For the purposes of this rule, "minor" means a person under the age of 19.(2) A pregnant minor who meets Washington state residency requirements under WAC 182-503-0520 and 182-503-0525 is eligible for the Washington apple health for kids program.(3) The medical assistance uni…

(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:(a) Has been screened for breast or cervical cancer under the department of health's b…

(1) General eligibility. For purposes of this section, a child must:(a) Be a Washington state resident under WAC 182-503-0520 and 182-503-0525;(b) Provide a Social Security number under WAC 182-503-0515, unless exempt; and(c) Meet program-specific requirements.(2) Deemed eligibil…

(1) A client under the age of 18 is eligible for Washington apple health foster care coverage when they:(a) 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 lo…

(1) A child is eligible for Washington apple health with premiums if the child:(a) Meets the requirements in WAC 182-505-0210(1);(b) Has countable income below the standard in WAC 182-505-0100 (6)(b); and(c) Pays the required premium under WAC 182-505-0225, unless the child is ex…

(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.(a) The first monthly premi…

(1) A person is eligible for Washington apple health categorically needy (CN) coverage when the person:(a) Is a parent or caretaker relative of a dependent child who meets the criteria described in WAC 182-503-0565(2);(b) Meets citizenship and immigration status requirements desc…

(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:(a) Is age nineteen or older and under the age of sixty-five;(b) Is not ent…

(1) Purpose. The hospital presumptive eligibility (HPE) program provides temporary Washington apple health coverage to HPE-eligible persons who enroll through an HPE-qualified hospital.(2) HPE-eligible persons. To be HPE-eligible:(a) A person must:(i) Be younger than age 65; and(…

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.(a) The rules in this s…

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).(a) A tax filer is a person who:(i) Expects to file a federal income …

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…

(1) To qualify for an alien medical program (AMP) a person must:(a) Be ineligible for federally funded Washington apple health (WAH) programs due to the citizenship/alien status requirements described in WAC 182-503-0535;(b) Meet the requirements described in WAC 182-507-0115, 18…

(1) A person nineteen years of age or older who is not pregnant and meets the eligibility criteria under WAC 182-507-0110 is eligible for the alien emergency medical program's scope of covered services described in this section if the person meets (a) and (b) or (c) of this subse…

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 eligibil…