Medical Assistance - Adult Medical

Revised October 2, 2008

Purpose: This section provides information about medical programs for adults who do not qualify for family medical programs.

WAC 388-505-0110

Medical assistance coverage for adults not covered under family medical programs

WAC 388-505-0110

Effective September 1, 1998

WAC 388-505-0110 Medical assistance coverage for adults not covered under family medical programs

An adult who does not meet the institutional status requirements as defined in WAC 388-513-1320 and who does not receive waiver services as described in chapter 388-515 WAC is considered for categorically needy (CN) coverage under this chapter. Persons excluded from this section have rules applied to eligibility from chapter 388-513 WAC. Under this section a person is eligible for CN coverage when the person:
1. Meets citizenship/immigrant, residency, and Social Security number requirements as described in WAC 388-503-0505; and
2. Has CN countable income and resources that do not exceed the income and resource standards in WAC 388-478-0080; and
3. Is sixty-five years of age or older, or meets the blind and/or disability criteria of the federal SSI program.
An adult not meeting the conditions of subsection (1)(b) is eligible for CN medical coverage if the person:
1. Is a current beneficiary of Title II of the Social Security Act (SSA) benefits who:
  1. Was a concurrent beneficiary of Title II and Supplemental Security Income (SSI) benefits;
  2. Is ineligible for SSI benefits and/or state supplementary payments (SSP); and
  3. Would be eligible for SSI benefits if certain cost-of-living (COLA) increases are deducted from the client's current Title II benefit amount:
    1. All Title II COLA increases under P.L. 94-566, section 503 received by the client since their termination from SSI/SSP; and
    2. All Title II COLA increases received during the time period in subsection (1)(d)(iii)(A) of this section by the client's spouse or other financially responsible family member living in the same household.
2. Is an SSI beneficiary, no longer receiving a cash benefit due to employment, who meets the provisions of section 1619(b) of Title XVI of the SSA;
3. Is a currently disabled client receiving widow's or widower's benefits under section 202(e) or (f) of the SSA if the disabled client:
  1. Was entitled to a monthly insurance benefit under Title II of the SSA for December 1983; and
  2. Was entitled to and received a widow's or widower's benefit based on a disability under section 202(e) or (f) of the SSA for January 1984;
  3. Became ineligible for SSI/SSP in the first month in which the increase provided under section 134 of P.L. 98-21 was paid to the client;
  4. Has been continuously entitled to a widow's or widower's benefit under section 202(e) or (f) of the SSA;
  5. Would be eligible for SSI/SSP benefits if the amount of that increase, and any subsequent COLA increases provided under section 215(i) of the SSA, were disregarded;
  6. Is fifty through fifty-nine years of age; and
  7. Filed an application for Medicaid coverage before July 1, 1988.
4. Was receiving, as of January 1, 1991, Title II disabled widow or widower benefits under section 202(e) or (f) of the SSA if the person:
  1. Is not eligible for the hospital insurance benefits under Medicare Part A;
  2. Received SSI/SSP payments in the month before receiving such Title II benefits;
  3. Became ineligible for SSI/SSP due to receipt of or increase in such Title II benefits; and
  4. Would be eligible for SSI.SSP if the amount of such Title II benefits or increase in such Title II benefits under section 202(e) or (f) of the SSA, and any subsequent COLA increases provided under section 215(i) of the act were disregarded.
5. Is a disabled or blind client receiving Title II Disabled Adult Childhood (DAC) benefits under section 202(d) of the SSA if the client:
  1. Is at least eighteen years old;
  2. Lost SSI/SSP benefits on or after July 1, 1988, due to receipt of or increase in DAC benefits; and
  3. Would be eligible for SSI/SSP if the amount of the DAC benefits or increase under section 202(d) of the DAC and any subsequent COLA increases provided under section 215(i) of the SSA were disregarded.
6. Is a client who:
  1. In August 1972, received:
    1. Old age assistance (OAA);
    2. Aid to blind (AB);
    3. Aid to families with dependent children (AFDC); or
    4. Aid to the permanently and totally disabled (APTD); and
  2. Was entitled to or received retirement, survivors, and disability insurance (RSDI) benefits; or
  3. Is eligible for OAA, AB, AFDC, SSI, or APRD solely because of the twenty percent increase in Social Security benefits under P.L. 92-336.
An adult who does not meet the institutional status requirement as defined in WAC 388-513-1320 and who does not receive waiver services as described in chapter 388-515 WAC is considered for medically needy (MN) coverage under this chapter. Persons excluded from this section have rules applied to eligibility from chapter 388-513 WAC. Under this section a person is eligible for MN coverage when the person:
1. Meets citizenship/immigrant, residency, and Social Security number requirements as described in WAC 388-503-0505; and
2. Has MN countable income that does not exceed the income standards in WAC 388-478-0080, or meets the excess income spenddown requirements in WAC 388-519-0110; and
3. Meets the countable resource standards in WAC 388-478-0070; and
4. Is sixty-five years of age or older or meets the blind and/or disability criteria of the federal SSI program.
MN coverage is available for an aged, blind, or disabled ineligible spouse of an SSI recipient. See WAC 388-519-0100 for additional information.
An adult may be eligible for the alien emergency medical program as described in WAC 388-438-0110.
An adult is eligible for the state-funded general assistance - expedited Medicaid disability (GA-X) program when they:
1. Meet the requirements of the cash program in WAC 388-400-0025 and 388-478-0030; or
2. Meet the SSI-related disability standards but cannot get the SSI cash grant due to immigration status or sponsor deeming issues. Clients may be eligible for GA cash benefits and CN medical coverage due to different sponsor deeming requirements.
An adult is eligible for the state-funded medical care services (MCS) program when the person is eligible for GAU or ADATSA program coverage as described in WAC 388-400-0025 and 388-800-0048. GAU clients residing in counties designated as mandatory managed care plan counties must enroll in a plan, pursuant to WAC 388-538-063.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

CLARIFYING INFORMATION

There is no AFDC or TANF related Medically Needy program for adults. CSO staff may encounter an inappropriate MN option prompted by ACES. Such a prompt should be disregarded for adults not related to TANF or SSI.
Clients eligible for the GA-X program have the same medical coverage as SSI related clients while their determination for SSI eligibility is pending at the Social Security Administration.
When clients lose SSI medical (S01) because their SSI cash stops due to the seven year rule (non-citizen clients may receive SSI cash for a maximum of 7 years), their eligibility for other medical programs must be determined before their medical is terminated.
See SCOPE OF CARE for listings of medical services available to recipients of specific adult medical programs.
For information on the Refugee Medical program see REFUGEE.
The ALIEN EMERGENCY MEDICAL program requires an emergency medical condition or need. See EMERGENCY ASSISTANCE - MEDICAL for more information.
There are special programs (e.g., kidney centers and AIDS insurance program) for which an adult may be eligible. For the Kidney program see WAC 388-540. For the AIDS insurance program see THIRD PARTY LIABILITY.

WORKER RESPONSIBILITIES

1. Determine eligibility for federally-funded programs before considering a state-funded program. The order is as follows:

a. Categorically Needy

b. Medical Needy

c. Alien emergency medical

d. General Assistance - Expedited Medicaid Disability (GAX)

e. State-funded medical (GAU, ADATSA).

2. Continue SSI medical (S01) for clients who have lost their SSI cash payments due to the seven year rule (non-citizens may only receive SSI cash for up to 7 years) until their eligibility for other medical programs is determined. Clients are sent an eligibility review from state office. Follow these steps:

a. If the eligibility review is not returned, close the AU making sure to follow 10 day advance and adequate notice rules.

b. If the eligibility review is returned and the client wants:

Medical only, check the disability review end date, and

A. If the date is in the future and the client meets the eligibility requirements for SSI-related (S02) medical, open that program with a review end date matching the month of the disability end review date.

B. If the date is due or there is no end date, send a review referral to Social Services for a non-grant medical assistance (NGMA) review by DDDS. See subsection #3 below.

Both cash and medical, and the client appears eligible for General Assistance, open a GA-U AU. Code the ACES DEM2 screen Disaility/Incap type "D" 9or "A", if the client is 65 or older) and code the Approval Source:

A. "OP" for a 3 month certification, pending a DDDS disability decision, or

B. "OI" or "OW" if the future disability review end date is known.

C. Encourage the client to apply for citizenship, since the SSI can be reopened if the client is a citizen and aged or remains disabled. SSI is more beneficial to the client than GA-U; the client receives more cash and receives CN Medicaid.

3. Review the application to determine if a potential disability is claimed.

a. Refer for a disability determination if the client has claimed to have a disability or health problems that limit their ability to work.

b. Don’t refer for a disability determination based solely on unpaid medical bills or when no disability or health problems are claimed.

EXAMPLE

Emerald applied for food and medical benefits. She indicated a medical emergency on her application, and explained at her financial interview that she had gone to the emergency room after falling off a ladder and now has a large hospital bill. The ER took X-rays, stitched up a gash, and kept her overnight for observation. Emerald states she is feeling fine now and has returned to work without any problem. Don’t refer for disability determination.

EXAMPLE

Gregory applied for medical benefits. He did not list a disability but he did mark that he was unable to work because of a health problem. Refer for a disability determination.

EXAMPLE

Bethany applied for food and medical benefits. At her interview she states she is currently working, but has not been feeling well for a while now. Bethany states she is now missing work because of her health. Refer for a disability determination.

4. Initiate a disability determination referral if appropriate. Use the 65-01 Referral letter.

A disability referral is not appropriate if the client is already eligible for SSI or SSA due to a disability. Do not make a referral; refer to CN medical instructions.
A disability referral is not appropriate if the client has a disability determination referral pending.

5. Pend the application for 30 days and inform the client that a determination may take up to 60 days.

6. Take immediate action on the determination decision (DSHS 14-144(X). Social Services return the financial worker's copy as soon as it is received. The DSHS 14-144(X) is the Transmittal Summary and Disability Determination Notice issued by the Division of Disability Determination Services (DDDS).

	EAZ	Search for:

Acronyms Revisions WAC Number Index Site Map WCCC DSHS Home

EAZ