Washington Administrative Code

(1) Caseload limits.(a) The state-funded long-term care services program is subject to caseload limits determined by legislative funding.(b) The home and community living administration (HCLA) must preauthorize state-funded long-term care service before payments begin.(c) HCLA ca…

(1) You are eligible for refugee medical assistance (RMA) if all the following conditions are met. You:(a) Meet immigration status requirements of WAC 182-507-0135;(b) Have countable resources below $2,000 on the date of application;(c) Have countable income equal to or below 200…

(1) An individual is eligible for refugee medical assistance (RMA) if the individual provides documentation issued by the United States Citizenship and Immigration Services (USCIS) to show that the individual is:(a) Admitted as a refugee under section 207 of the Immigration and N…

(1) This chapter provides information on eligibility determinations for adults who:(a) Need a determination of eligibility on the basis of being aged, blind, or disabled;(b) Need a determination of eligibility based on the need for long-term institutional care or home and communi…

(1) A person is eligible for state-funded Washington apple health medical care services (MCS) coverage to the extent of available funds if the person is:(a) Determined by the department of social and health services to be eligible for benefits under:(i) The aged, blind, or disabl…

(1) Enrollment in medical care services (MCS) coverage is subject to available funds.(2) The medicaid agency may limit enrollment into MCS coverage by implementing an enrollment cap and waitlist. (3) If a person is denied MCS coverage due to an enrollment cap:(a) The person is ad…

(1) The civil transition program (CTP) is a state-funded, fee-for-service program that requires the department of social and health services (department) to provide wraparound services and supports in community-based settings, which may include residential supports, to persons wh…

(1) For purposes of Washington apple health program eligibility, a person's countable income is income which remains when:(a) The income cannot be specifically excluded; and(b) All appropriate deductions and disregards allowed by a specific program have been applied.(2) A person'…

(1) A resource is any cash, other personal property, or real property that a person:(a) Owns;(b) Has the right, authority, or power to convert to cash (if not already cash); and(c) Has the legal right to use for his or her support and maintenance.(2) There is no resource limit fo…

(1) The agency uses the modified adjusted gross income (MAGI) methodology to determine eligibility for MAGI-based Washington apple health programs described in WAC 182-509-0305.(2) MAGI methodology is described in WAC 182-509-0300 through 182-509-0375. Generally, MAGI includes ad…

(1) Eligibility for Washington apple health for the following people is determined using the modified adjusted gross income (MAGI) methodology described in WAC 182-509-0300:(a) Parents or caretaker relatives with an eligible dependent child (described in WAC 182-503-0565) whose n…

For purposes of determining eligibility for modified adjusted gross income (MAGI)–based Washington apple health (WAH) (see WAC 182-509-0300):(1) The agency uses a point-in-time estimate to determine a person's countable income.(2) Point-in-time means that the income is received, …

(1) For purposes of determining eligibility for modified adjusted gross income (MAGI)–based Washington apple health (WAH) (see WAC 182-509-0300) income is considered available to a person if:(a) An individual in the person's medical assistance unit receives or can reasonably pred…

For purposes of determining eligibility for modified adjusted gross income (MAGI)–based Washington apple health (see WAC 182-509-0300):(1) Some types of income are not counted when determining eligibility for MAGI-based apple health. Under the MAGI income methodology described in…

For purposes of determining eligibility for modified adjusted gross income (MAGI)–based Washington apple health (WAH) (see WAC 182-509-0300):(1) Unearned income is income received from a source other than employment or self-employment. Examples of unearned income include, but are…

For purposes of determining eligibility for modified adjusted gross income (MAGI)–based Washington apple health (WAH) (see WAC 182-509-0300):(1) Earned income is income received from working. This includes, but is not limited to:(a) Wages;(b) Salaries;(c) Tips;(d) Commissions;(e)…

For purposes of determining eligibility for modified adjusted gross income (MAGI)–based Washington apple health (see WAC 182-509-0300), the agency or its designee does not count educational benefits as income when they are used for education expenses, unless the educational benef…

For the purposes of determining eligibility of American Indians/Alaska Natives for modified adjusted gross income (MAGI)-based Washington apple health (WAH) (see WAC 182-509-0300), the agency excludes from MAGI the following:(1) Distributions from Alaska Native corporations and s…

The medicaid agency determines what income is counted when determining eligibility for modified adjusted gross income (MAGI)–based Washington apple health under WAC 182-509-0300.(1) When determining countable income for persons described in subsections (2) through (4) of this sec…

For purposes of determining eligibility for modified adjusted gross income (MAGI)–based Washington apple health (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 …

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 o…

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) …

(1) Under the authority of chapter 43.71C RCW, this chapter implements the Washington drug price transparency program.(2) The purpose of the Washington drug price transparency program is to improve transparency relating to the cost and price of prescription drugs to provide accou…

For the purposes of this chapter:(1) "Authority" means the health care authority.(2) "Calendar days" means the same as in WAC 182-526-0010.(3) "Calendar year" means the period from January 1st to December 31st of each year.(4) "Confidential information" means information collecte…

(1) A reporting entity must register with the authority and provide the required contact information as defined in the applicable data submission guide. Reregistration is required only if the contact information previously provided has changed.(2) It is the responsibility of the …

(1) No later than October 16, 2020, a health carrier must submit to the authority the prescription drug cost and utilization data for calendar years 2018 and 2019, for each health plan it offered in Washington state in calendar years 2018 and 2019, following the guidelines set in…

(1) No later than March 1st of each year, a pharmacy benefit manager must submit to the authority all data specified in RCW 43.71C.030, following the guidelines set in the authority's applicable data submission guide.(2) The authority may examine or audit a pharmacy benefit manag…

(1) No later than March 1st of each year, each pharmacy benefit manager must file with the authority an attestation in the format required by the authority for the preceding calendar year, stating that the pharmacy benefit manager is in compliance with this chapter.(2) A pharmacy…

(1) On or before December 31, 2020, a covered manufacturer must submit to the authority all data specified in RCW 43.71C.050 and 43.71C.070, following the guidelines set in the authority's applicable data submission guide for each new covered drug introduced to market, or a cover…

(1) On or before December 31, 2020, a manufacturer must submit to the authority all data specified in RCW 43.71C.060(1), following the guidelines set in the authority's applicable data submission guide for all new drug applications or biologic license applications for pipeline dr…

(1) No later than October 16, 2020, and October 1st of each year thereafter, a pharmacy services administrative organization representing a pharmacy or pharmacy chain in Washington state must submit to the authority the data specified in RCW 43.71C.080 following the guidelines se…

(1) For the purpose of reviewing drug prices and conducting affordability reviews, the following boards may access all data collected under RCW 43.71C.020 through 43.71C.080 and any analysis prepared by the authority:(a) The prescription drug affordability board, as established i…

(1) All data and data files must be submitted to the authority in accordance with the requirements in this chapter and the respective data submission guide for the respective reporting period. Data submission guides are located on the authority's website.(2) The authority develop…

(1) RCW 43.71C.090 allows the authority to assess a fine of up to one thousand dollars per day for failure to comply with the requirements of RCW 43.71C.020 through 43.71C.080 and the requirements of this chapter. See WAC 182-51-1300 for fines for failing to comply with reporting…

(1) The authority may grant:(a) An extension of time to a reporting requirement deadline; or(b) Permission to correct a previously submitted and accepted report.(2) Extensions.(a) A reporting entity may request an extension of time for submitting a report or the resubmission of a…

(1) The authority may assess fines for failure to comply with the general reporting requirements of this chapter including, but not limited to, failing to report data or reporting erroneous or inaccurate data.(2) Unless the authority has approved an extension or has received a re…

(1) In determining the amount of any fine, the authority considers the level of culpability associated with the violation. The levels of culpability, in the order of least severe to most severe, are as follows:(a) Did not know. The reporting entity did not know and by exercising …

(1) Upon failing to comply with a reporting requirement in this chapter, the authority first issues a warning notice to a reporting entity. The authority sends the warning notice to the reporting entity's last known email or physical address. The warning notice describes the fail…

(1) Each reporting entity to whom the authority issues a preliminary notice of a violation and fine(s) may request an informal dispute resolution conference under WAC 182-51-1700.(2) If the reporting entity requests an informal dispute resolution conference under WAC 182-51-1700,…

(1) A reporting entity may informally dispute the authority's preliminary determination of a violation under this chapter.(2) A reporting entity must submit a request for an informal dispute resolution conference to the authority in writing, in a manner that provides proof of rec…

A reporting entity has a right to an administrative hearing (formal appeal), and any resulting appeals process available under chapters 34.05 RCW and 182-526 WAC, if the authority assesses a final notice of violation and fine(s) against the reporting entity under any section of c…

(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 Janua…

(1) If you are a supplemental security income (SSI) recipient, you automatically get categorically needy (CN) coverage (WAC 182-512-0100) unless you:(a) Refuse to provide private medical insurance information; or(b) Refuse to assign the right to recover insurance funds to the age…

(1) Your categorically needy (CN) coverage (WAC 182-512-0100) continues after supplemental security income (SSI) ends if:(a) Countable income exceeds the SSI income standard due solely to the annual cost-of-living adjustment (COLA); or(b) A timely request for a hearing has been f…

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…

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:(a) Meet the general requirements for a medical program described in WAC 182-503-0505 (3)(a) th…

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 quali…

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 sec…

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:(a) Gets paid for worki…

This section describes how the medicaid agency calculates the premium amount a person must pay for apple health for workers with disabilities (HWD) coverage. This section also describes program requirements regarding the billing and payment of HWD premiums.(1) When determining th…