Washington Administrative Code

(1) A client is financially eligible for home and community based (HCB) waiver services if the client:(a) Is receiving coverage under one of the following categorically needy (CN) medicaid programs:(i) SSI program under WAC 182-510-0001. This includes SSI clients under Section 16…

(1) If a person is not eligible for a categorically needy (CN) program under WAC 182-515-1507, the agency determines eligibility for home and community based (HCB) waiver services authorized by home and community services (HCS) using institutional medicaid rules. This section exp…

(1) A client eligible for home and community based (HCB) waiver services authorized by home and community services (HCS) under WAC 182-515-1508 must pay toward the cost of care and room and board under this section.(a) Post-eligibility treatment of income, participation, and part…

This chapter describes the general and financial eligibility requirements for categorically needy (CN) home and community based (HCB) waivers authorized by developmental disabilities community services (DDCS). The definitions in WAC 182-513-1100 and chapter 182-500 WAC apply thro…

(1) To be eligible for home and community based (HCB) waiver services authorized by developmental disabilities community services (DDCS), a person must:(a) Meet specific program requirements under chapter 388-845 WAC;(b) Be an eligible client of DDCS;(c) Meet the disability crite…

(1) A client is financially eligible for home and community based (HCB) waiver services authorized by developmental disabilities community services (DDCS) if:(a) The client is receiving coverage under one of the following categorically needy (CN) medicaid programs:(i) Supplementa…

(1) If a person is not eligible for a categorically needy (CN) program under WAC 182-515-1512, the agency determines eligibility for home and community based (HCB) waiver services authorized by developmental disabilities community services (DDCS) using institutional medicaid rule…

(1) A client eligible for home and community based (HCB) waiver services authorized by developmental disabilities community services (DDCS) under WAC 182-515-1513 must pay toward the cost of care and room and board under this section.(a) Post-eligibility treatment of income, part…

"Acquire" means, in the context of trusts, to gain title to, or to gain ownership interest in an asset in a trust. Receiving payment or benefit from an asset in a trust is not acquiring the asset."Annuitant" means a person or entity that receives the stream of payments from an an…

The medicaid agency or the agency's designee applies the following rules to determine how trusts affect eligibility for medicaid:(1) WAC 182-516-0105 General rules that apply to all trusts.(2) WAC 182-516-0110 Self-settled trusts overview.(3) WAC 182-516-0115 Revocable self-settl…

(1) Regardless of treatment under this chapter, all trusts remain subject to Title 182 WAC, which include income and resource rules under chapter 182-512 WAC and asset transfer rules under WAC 182-513-1363, unless specified otherwise.(2) The medicaid agency or the agency's design…

(1) A trust containing the assets of a beneficiary's spouse may be a self-settled trust based on the date it was established. For specific rules regarding this, see WAC 182-516-0130.(2) To determine whether the assets of the self-settled trust should be counted as income, a resou…

(1) This section applies to revocable trusts that are self-settled and established on or after August 11, 1993.(2) This section does not apply to assets in a revocable trust established before August 11, 1993.(3) A revocable trust is a self-settled trust if:(a) The assets of the …

(1) This section governs how the agency or the agency's designee treats self-settled trusts, for a disabled client under age sixty-five established under 42 U.S.C. 1396p (d)(4)(a) on or after August 11, 1993, for medicaid eligibility purposes.(2) A self-settled trust established …

(1) This section governs how the agency or the agency's designee treats pooled self-settled trusts, for a disabled client established under 42 U.S.C. 1396p (d)(4)(c) on or after August 11, 1993, for medicaid eligibility purposes.(2) A pooled self-settled trust established on or a…

(1) This section governs irrevocable self-settled trusts established on or after August 11, 1993, that do not meet the rules under either WAC 182-516-0120 or 182-516-0125.(2) A trust established on or after August 1, 2003, is a self-settled trust if:(a) The assets of the trust ar…

(1) A revocable or irrevocable self-settled trust established before August 11, 1993, under this section is one:(a) Established other than by will by a beneficiary or that beneficiary's spouse;(b) Under which that beneficiary may be the beneficiary of all or part of the payments …

(1) This section governs third-party trust as defined under WAC 182-516-0001.(2) A trust containing the assets of a beneficiary's spouse may be a self-settled trust based on the date it was established. For specific rules regarding this, see WAC 182-516-0130.(3) A testamentary tr…

(1) For irrevocable trusts that contain both assets of the beneficiary and third-party assets, the medicaid agency or the agency's designee treats the assets of the beneficiary under the self-settled trust rule in effect as of the date of the trust's establishment:(a) After Augus…

(1) A revocable annuity is an available resource.(2) An irrevocable annuity established prior to May 1, 2001, is not an available resource when issued by an individual, insurer, or other body licensed and approved to do business in the jurisdiction in which the annuity is establi…

(1) The medicaid agency or the agency's designee determines how an annuity, purchased by or on behalf of an annuitant and established on or after April 1, 2009, affects eligibility for medicaid.(2) General information.(a) Clients of noninstitutional medicaid must disclose to the …

(1) "Life estate" means an ownership interest in real property only during the lifetime of a specified person.(2) Subject to subsection (3) of this section, a life estate is an available resource, unless it is either excluded or unavailable under chapter 182-512 WAC.(3) For someo…

(1) General.(a) In this section, note includes promissory note, loan or other obligation to pay.(b) The medicaid agency or the agency's designee determines the value of outstanding principal and interest payments using amortization schedules, unless otherwise stated in this secti…

(1) Available programs. The medicaid agency offers eligible clients the following medicare savings programs (MSPs):(a) The qualified medicare beneficiary (QMB) program;(b) The specified low-income medicare beneficiary (SLMB) program;(c) The qualified individual (QI-1) program; an…

(1) A person is eligible for the state-funded medicare buy-in program (SBIP) if the person:(a) Is entitled to or receiving medicare;(b) Is not eligible for a federal medicare savings program under WAC 182-517-0100; and(c) Is eligible for coverage under:(i) The categorically needy…

(1) 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. (2) This section applies only to notices and letters that we send about eligibility for Washington apple health (WAH) prog…

(1) We send written notice when we approve, reopen, reinstate, or deny coverage for any Washington apple health (WAH) program. The notice includes the information described in WAC 182-518-0005(4) and all of the following:(a) The WAH coverage for each person approved, reopened or …

(1) We send you written notice when we need more information as described in WAC 182-503-0050 to decide if you are eligible to receive or continue receiving Washington apple health (WAH) coverage. The notice includes:(a) A description or list of the information that we need;(b) W…

(1) We send you written notice before we stop your WAH coverage at the end of your certification period as described in WAC 182-504-0035.(2) When we can administratively renew your coverage (as defined in WAC 182-500-0010), the notice includes:(a) Your new certification period;(b…

(1) General rule.(a) We send written notice to you at least ten days before taking adverse action to terminate, suspend, or reduce your:(i) Medicaid eligibility; or(ii) Authorization for a covered service.(b) The ten-day notice period starts on the day we sent the notice.(2) Exce…

(1) For programs based on modified adjusted gross income (MAGI), you may choose to get notices by regular mail or in an electronic format through Washington Healthplanfinder.(2) We send you letters (notices) about your eligibility for Washington apple health programs as described…

(1) Changes to the medically needy income level (MNIL) occur on January 1st of each calendar year when the Social Security Administration (SSA) issues a cost-of-living adjustment.(2) Medically needy (MN) standards for people who meet institutional status requirements are in WAC 1…

(1) A person who meets the following conditions may be eligible for medically needy (MN) coverage under the special rules in chapters 182-513 and 182-515 WAC:(a) Meets the institutional status requirements of WAC 182-513-1320; or(b) Resides in a medical institution as described i…

(1) A person who applies for Washington apple health (WAH) and is eligible for medically needy (MN) coverage with a spenddown may choose a three-month or a six-month base period. A base period is a time period used to compute the spenddown liability amount. The months must be con…

The prescription drug affordability board conducts reviews of drug prices, performs drug affordability reviews, and sets upper payment limits for prescription drugs.[Statutory Authority: RCW 41.05.021, 41.05.160, chapter 70.405 RCW, and 2022 c 153. WSR 24-02-078, § 182-52-0005, f…

The definitions in this section apply throughout this chapter unless the context clearly requires otherwise."Authority" means the health care authority, as defined in WAC 182-02-045."Biological product" has the same meaning as in 42 U.S.C. Sec. 262 (i)(1)."Biologics" means biolog…

(1) The prescription drug affordability board has five governor-appointed members with expertise in health care economics or clinical medicine. Once appointed, board members serve a five-year term.(2) The governor may reappoint board members for additional terms.(3) Board members…

(1) The board determines by member vote who will be the board chair and vice chair.(2) The board chair remains as the chair for the duration of their term unless there are violations as stated in WAC 182-52-0015(4).(3) The board chair may choose to step down from their chair resp…

(1) The board meets at least once annually, and additionally as defined by board policy.(2) All board meetings must be open and public, except that the board may hold executive sessions to the extent permitted by chapter 42.30 RCW.(a) Before convening an executive session, the bo…

(1) The prescription drug affordability board advisory groups provide stakeholder input to the board regarding the affordability of prescription drugs.(2) Utilizing administrative support from the authority, the board will establish advisory groups consisting of relevant stakehol…

(1) By June 30th of each year, using data considered relevant by the board, the board must identify legend drugs and biologics that:(a) Have been on the market for at least seven years;(b) Are dispensed at a retail, specialty, or mail-order pharmacy; and(c) Are not designated by …

(1) The board may choose to conduct an affordability review of up to 24 legend drugs or biologics per year and consider the following:(a) The class of the prescription drug and whether any therapeutically equivalent prescription drugs are available for sale;(b) Input from relevan…

Drugs selected for an affordability review are published on the board's website before initiating the affordability review.(1) When conducting an affordability review, the board will consider:(a) The relevant factors contributing to the price paid for the prescription drug, inclu…

(1) For the purpose of reviewing drug prices and conducting affordability reviews, the board (as established in chapter 70.405 RCW) and the health care cost transparency board (established in chapter 70.390 RCW) may share data with each other and access all data collected under R…

(1) RCW 70.405.040 allows the authority to assess a fine(s) against a manufacturer for failure to comply with the requirements of this chapter. See WAC 182-52-0065 for fine(s) for failing to comply with information request(s) and WAC 182-52-0070 for the amount of the fine(s) base…

(1) The authority may grant:(a) An extension of time for an information request submission deadline; or(b) Permission to correct a previously submitted and accepted request.(2) Extensions:(a) The manufacturer or subcontractor may request an extension of time for an information re…

(1) The authority may assess a fine of up to $100,000 against a manufacturer for each failure to comply with a request for information from the board or the authority as directed by the board.(2) The assessment of a fine under this section is subject to review under the Administr…

(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 manufacturer did not know (and, by exercising re…

(1) The authority will issue an advisory notice to the manufacturer for the initial request for information directing the manufacturer to comply within 30 calendar days of the request or request an extension of time to provide the required information, in accordance with WAC 182-…

(1) Each manufacturer to whom the authority issues a preliminary notice of violation and fine(s) may request an informal dispute resolution conference. If the manufacturer does request an informal dispute resolution conference, then the manufacturer must complete the process befo…