Receive a cash grant under the Temporary Assistance for Needy Families (TANF);
Be eligible for TANF but choose not to receive cash assistance, such as recipients of diversion cash assistance; or
Be determined ineligible for TANF cash assistance for a reason that does not apply to medical programs as described in WAC 388-505-0220.
Consider the family as described in Assistance Units - Medical programs, including the establishment of separate medical assistance units (MAUs), if necessary.
All family members may not be eligible for a medical program. Some members may enroll in Healthy Options and others may not.
For family members who are not eligible under this category, refer to the following categories:
SSI-related Medical for children and adults who may meet SSI disability criteria services and is ineligible for any other medical program;
Pregnancy for medical programs for pregnant women;
Emergency Assistance: Alien Emergency Medical Program for an alien adult or child who is related to a Medicaid program including the aged, blind, and disabled;
Long Term Care for family members requiring nursing facility or home and community-based services;
Medical Extensions for a family who has an increase in earned income, spousal support, or child support;
Spenddown for a child, pregnant woman, or an SSI-related adult whose income exceeds program standards. They may be eligible to receive Medically Needy (MN) coverage.
WAC 388-505-0210
WAC 388-505-0210
Effective March 14, 2008
WAC 388-505-0210 Children's healthcare programs.
Funding for children's healthcare coverage may come through Title XIX (Medicaid) or Title XXI of the Social Security Act (SCHIP), or through state-funded programs. There are no resource limits for children's medical programs, but children must meet the eligibility criteria listed below to qualify for these programs.
1. Newborns are eligible for federally matched categorically needy (CN) coverage through their first birthday when:
a. The child's mother was eligible for and receiving medical assistance at the time of the child's birth.
b. The child remains with the mother and resides in the state.
2. Children under the age of nineteen who are U.S. citizens, U.S. nationals, or qualified aliens as described in WAC 388-424-0001 and WAC 388-424-0006 (1) and (4) are eligible for federally matched CN coverage under children's healthcare programs when they meet the following criteria:
a. State residence as described in chapter 388-468 WAC;
b. A social security number or application as described in chapter 388-476 WAC;
c. Proof of citizenship or immigrant status and identity as required by WAC 388-490-0005(11);
d. Family income is at or below two-hundred percent Federal Poverty Level (FPL) as described in WAC 388-478-0075 at each application or review; or
e. They received supplemental security income (SSI) cash payments in August 1996 and would continue to be eligible for those payments except for the August 1996 passage of amendments to federal disability definitions.
f. They are eligible for SSI-related CN or MN coverage.
3. Non-citizen children under the age of nineteen, who do not meet qualified alien status as described in WAC 388-424-0006 (1) or (4), or are ineligible due to the five year ban as described in WAC 388-424-0006 (3), are eligible for state funded CN coverage under children's healthcare programs when they meet the following criteria:
a. State residence as described in chapter 388-468 WAC; and
b. Family income is at or below two hundred percent FPL at each application or review.
4. Children under the age of nineteen are eligible for premium-based CN coverage under children's healthcare programs as described in chapter 388-542 WAC when they meet the following criteria:
a. State residence as described in chapter 388-468 WAC;
b. Family income is over two-hundred percent FPL, as described in WAC 388-478-0075, but not over two-hundred fifty percent FPL at each application or review;
c. They do not have other creditable health insurance as described in WAC 388-542-0050; and
d. They pay the required monthly premiums as described in WAC 388-505-0211.
5. Children under the age of nineteen are eligible for the medically needy (MN) medicaid program when they meet the following criteria:
a. Citizenship or immigrant status, state residence, and social security number requirements as described in subsection (2) (a), (b), and (c); and
b. They are ineligible for other federal Medicaid programs; and
6. Children under the age of twenty-one who reside or expect to reside in a medical institution, intermediate care facility for the mentally retarded (ICF/MR), nursing home, or psychiatric facility, may be eligible for medical coverage. See WAC 388-505-0230 "Family related institutional medical" and WAC 388-513-1320 "Determining institutional status for long-term care".
7. Children who are in foster care under the legal responsibility of the state, or a federally recognized tribe located within the state, are eligible for federally matched CN medicaid coverage through the month of their:
a. Eighteenth birthday;
b. Twenty-first birthday if Children's Administration determines they remain eligible for continued foster care services; or
c. Twenty-first birthday if they were in foster care on their eighteenth birthday and that birthday was on or after July 22, 2007.
8. Children who receive subsidized adoption services are eligible for federally matched CN Medicaid coverage.
9. Children under the age of nineteen may also be eligible for:
i. Meet the blind and/or disability criteria of the federal SSI program, or the condition of subsection (2) (e); and
ii. Have countable income above the level described in WAC 388-478-0070(1).
10. Children who are ineligible for other children's healthcare programs due to citizenship or immigrant status may be eligible for the Alien Emergency Medical program (AEM) if they meet the following criteria:
a. They have a documented emergent medical condition as defined in WAC 388-500-0005; and
b. They meet the other AEM program requirements as described in WAC 388-438-0110; and
c. They have income that exceeds children's healthcare program standards.
d. They are disqualified from receiving premium-based children's healthcare coverage as described in subsection (4) of this section because of creditable coverage or non-payment of premiums.
11. Except for a client described in subsection (6), an inmate of a public institution, as defined in WAC 388-500-0005, is not eligible for children's medical programs.
Children found eligible for a categorically needy scope of care medical program (F05, F06, F07, F08) are continuously eligible for CN medical for 12 months regardless of changes; except for aging out of the program, moving out of state, failing to pay a required premium, incarceration, or death. The scope of coverage is identical for these programs regardless of the source of funding.
Newborn Medical (F05): See WAC 388-505-0210 (1). Newborns are automatically entitled to receive CN Medicaid through their first birthday as long as they live with their mother, their mother was receiving Medicaid at the time of delivery, and the mother maintains Washington State residency.
Children’s healthcare coverage:
(F06): See WAC 388-505-0210 (2). These children receive federally funded CN Medicaid and enroll in Healthy Options or Basic Health Plus managed care.
(F08): See WAC 388-505-0210 (3). These children receive state funded CN medical, but they are not enrolled in managed care.
(F07, F08): SeeWAC 388-505-0210 (4). These children receive CN medical, but are required to pay a premium. The premium is $15/mo per child, up to a maximum of $45/mo per family. Children in the F07 program are enrolled in managed care.
Children’s Medically Needy (F99 or S99): See WAC 388-505-0210 (5). These children receive slightly less coverage than CN Medicaid and do not enroll in Healthy Options. They must first meet a spenddown. See Spenddown for more information.
Institutional residence: See WAC 388-505-0210 (6): These children are approved for medical assistance based on institutional rules once they reside, or are expected to reside, in a medical institution for 30 days or longer. Children under the age of eighteeen who are admitted to a psychiatric facility come under special rules found in Family related institutional medical. See WAC 388-505-0230 for more information.
Twelve Month Continuous Eligibility for Children
The eligibility system tracks children under 19 for 12 months of continuous CN eligibility.
The 12 month continuous range is based on the begin date of the most recent certification period.
Each completed review starts the 12 month count over again.
A child retains this 12 month CN eligibility regardless of the assistance unit the child is in or the length of certification.
When an active assistance unit in one of the following CN medical coverage groups closes, the child or children will automatically trickle to CN continuous F06 medical coverage:
F01
TANF cash/CN
F02
CN 12-month extension
F03
CN 4-month extension
F04
CN Family
F06
CN Children
F10
CN Family 2 mo extension
G01-R
GA cash/CN child under 19
G02-B/D/X
GA cash/CN child under 19
P02
CN pregnancy
R01
Refugee cash/CN
R02
Refugee extended CN
R03
Refugee CN
EXAMPLE
A child and parents are on an F02 AU. The parents do not turn in the medical extension report due in the 4th month. F02 closes at the end of the 6th month. ACES auto opens the child on F06 for the remainder of the 12 month certification.
When a child is terminated from a CN program because the head of household left the home, the child left the home, out of state residence, citizenship, whereabouts unknown, or no longer in institutional care, the system does not auto-open F06 but does track the 12 month eligibility for that child. When the child reapplies at any time during the remainder of the 12 calendar months of tracking and satisfies non-financial eligibility requirements, the system will approve CN under medical coverage group F06 for the remainder of the 12 month period regardless of income.
EXAMPLE
A child is in the hospital and receiving CN coverage under medical coverage group K01. The child is released to return home .The system does not have enough information on the household to automatically open the child on F06. The system closes the case and the letter informs the household to contact the office for continued coverage. When a request for medical for this child is screened into the system, the system looks at all eligibility factors. If non-financial and financial requirements are met, the system opens a new 12 month certification period and the child begins a new tracking period. If non-financial requirements are met but financial requirements are not met, the system's tracking approves F06 through the remainder of the 12 month tracking period from the most recent certification period.
When a child is added to an existing F06 assistance unit, the child may have a different certification period than the rest of the children already on CN F06 medical. Initiate a review for all members of the AU when processing an application to add a child. The system will look at eligibility for all children. If eligibility is established a new 12 month period is set. If eligibility is not established, The approval letter will state each child's certification period. The system certification end date is set to the earliest of all the children's continuous end dates. The system will send a review for that child and reset the certification end date for the next earliest end date. If a completed review establishes F06 eligibility, the system will reset a new 12 month certification period for all members of the AU.
EXAMPLE
Two children are on one F06 AU with a cert date ending 04/07. A child comes into the home who had been receiving CN with another household. The new child's certification end date on that former AU is 11/07. The mother applies for medical for this child. Add the child to the sibling's AU and initiate review. Eligibility for all three children is established, and a new certification period for 12 months is set for all three children.
EXAMPLE
Above scenario but eligibility is not established due to current income. The cert end date is set for 04/07 for the remaining months for children one and two. A new review will be sent at that time. If eligibility is not established for all children with that review, the cert period will be reset for 11/07 allowing 12 months for number three child, the newcomer. The other two children would sprout to a pending F07 (or to F99 with spenddown).
Basic Health (BH) and BH Plus
BH provides affordable health insurance to any Washington resident, and is administered by the Washington State Health Care Authority (HCA).
An application for BH is only considered a joint application for BH Plus (Medicaid) for any child in the household as long as the family applying for BH coverage also requests BH Plus for their child. The child's coverage is through CN medical assistance.
BH Plus is CN medical (F06) for the children of BH members. It is called BH Plus because the children receiving CN medical get more medical coverage than adult BH members. The process of authorizing CN medical to BH children is intended to appear seamless and transparent to the BH family.
DSHS pays the BH premium for the child. There are no co-payments or deductibles for the child. Medical Eligibility Determination Services (MEDS) staff determine the eligibility for children in BH Plus.
Medical Eligibility Determination Services (MEDS)
Medical Eligibility Determination Services (MEDS) staff determine the eligibility for:
Children for BH Plus
Pregnant BH members, and
The following specialty programs:
State Children's Health Insurance Program (F07)
Children's Health Program (F08)
Breast and Cervical Cancer Treatment Program (S30)
Foster Care and
Take Charge Family Planning Waiver.
Applications received in the CSO that include children potentially eligible for Children's Health are processed by the CSO for other household members and then forwarded in DMS to 076 "F08 Pool" for processing of the Children's Health program.
EXAMPLE
A family applies in the CSO for medical. The family members are legal immigrants currently in the five-year bar for Medicaid. The family consists of pregnant mom, dad and two children. The father’s earned income is $1750.00 per month. The family is ineligible for CN family medical (F04) because of alien status and family income exceeds the standard. The children are ineligible for children’s medical (F06) due to alien status. The CSO will process pregnancy medical (P04) for mom and deny the other household members. CSO will forward the application to MEDS via DMS to process Children’s health (F08) for the children.
Applications received in the CSO with clients eligible for AEM are:
Forwarded to the Centralized Medical Unit (CMU) in the Region 4 Customer Service Center (132) if AEM is for a client age 19 or older, or under age 19 with family income over 250% FPL. The application should be reassigned in DMS to @AEM in CSO 132.
Forwarded to MEDS (76) if AEM is for a child under age 19 with family income under 250% FPL. The application should be reassigned in DMS to the "F08 Pool" in CSO 076.
Maintenance of a BH Plus, Children's Health, SCHIP or Breast and Cervical Cancer AU is the responsibility of MEDS. However, when CSO's open other types of assistance which include any of these AU member(s) it may result in a "case" being shared between MEDS and CSO's. Coordination between MEDS and the CSO's is very important for shared cases. (See Worker Responsibilities)
MEDS will only maintain F06, F05, P02 or P04 AU's if the AU is a BH Plus AU or there is a member of the household that is receiving BH plus on another AU.
EXAMPLE
A family applies at MEDS for BH Plus for their children. Mom is already receiving Pregnancy Medical (P02) in the local CSO. MEDS will process and approve BH plus for the children and transfer and maintain the non BH P02 AU at MEDS.
EXAMPLE
A family applies at MEDS for Children's Health. The household includes citizen children already receiving Children's Medical (F06) in the local CSO. MEDS will process the Children's Health either approving or denying and placing on the wait list. MEDS will maintain any Children's Health approval and the CSO will maintain the existing F06 AU.
MEDS will process eligibility for any citizen child included on a CHP application and will transfer to the appropriate CSO once processed.
How To Contact MEDS:
Mail:
MEDS
PO Box or Mail Stop 45531
Olympia, Washington 98504-5531
Phone:
General Information: 1-800-204-6429
FAX: (360) 586-2042
TTY: 1-800-204-6430
DMS: AEM Applications
forward in DMS to CSO 132 @AEM.
WORKER RESPONSIBILITIES
Program priorities for children: Consider program eligibility in the following order:
Children’s (F06)
Pregnancy (P02, P04);
Children’s Health Insurance Program (F07);
Medically needy coverage (F99, P99);
Children's health program (F08);
Alien Emergency Medical (F09).
Age: Ensure eligibility runs through the end of the month of the appropriate birthday, by program (i.e., age one for newborns, eighteenth, nineteenth or twenty-first birthdays).
When a client applies in the same month when they reach the age limit for the specific program, they can still be approved even though they may have already had their birthday.
EXAMPLE
The client turns nineteen on March 15 and applies for medical assistance on March 20. If the client meets all other eligibility factors for children's CN medical assistance, the application can be authorized for the entire month of March. (If the client had medical needs during the prior three months, determine eligibility for the retroactive period.)
Continuous twelve month eligibility for children:
When a child's 12 month certification under F06 is completed, and they have siblings open on an F07 AU, the child will be opened on the active F07 assistance unit. No review will go out for a child who will be transferred to an existing F07 AU.
NOTE:
The F06 child must be shown as a [SC] child on the F07 assistance unit for this transfer to occur.
EXAMPLE
A child on F06 leaves mother's home in the 4th month of a certification period and goes to live with dad whose income is over 200%FPL. Dad has another child active on F07. Screen the child into F06 so the system can continue the child on CN for the remainder of the 12 month certification period. Add the child as [SC] on the F07 Assistance unit so when the child has completed the 12 month period, the system can transfer the child into F07 with no review and no additional input by a worker.
There is a new ACES mainframe screen that tracks children's CN eligibility. To see if a child is being tracked by the system, go to the AMEN, selection 2 "Childrens Tracking CN". A client ID is required. The tracking information is also accessible in aces on-line from the Welcome page under a new option "Childrens Tracking CN Medicaid". A child currently in continuous eligibility status due to the CN Medicaid 12 month tracking is also identified on the STAT screen. The child will have a [CC] in the field shared with the [OP] used for F07 cases.
If an error has been made in opening a CN medical coverage group and eligibility should never have been approved, there is an internal code that will tell the system not to put this segment of eligibility into the tracking system. This code can only be used for the ongoing month and must be used only for this reason as it does not carry any WAC or text into the letter. Either letter 006-01 or 006-08 is generated but you must add free-form text with the real reason for termination and the WAC reference.
See the ACES user manual for details about this change to the system
Living arrangements for children’s medical programs: There are no required living arrangements. Children may live with parents, relatives, non-relatives, or on their own.
Coordination of shared cases between CSOs and MEDS:
CSO and MEDS staff must coordinate actions taken on shared cases. Shared cases exist when MEDS has a BH Plus (F06, F05 or P02), Children’s health (F08), or Breast and Cervical (S30) AU and the CSO has other assistance active for the household.
Before taking action on an open case:
CSO staff needs to examine the STAT screens to determine if the household includes an F07, F08 or S30 AU or the ACES "MISC" screen to determine if there is a BH Plus AU in the household. BH Plus is identified with a “Y” in the BH Plus indicator field in the upper right section of the MISC screen.
MEDS staff needs to examine the STAT screens to determine if the household is receiving other benefits in the CSO.
For the CSO if the action taken closes or changes household size to a shared AU in the ongoing month, verify on the DONE screen warning message 1737 or 1738 appears. This will verify alert 405 will be generated.
If these messages do not appear send a DMS tickler to the MEDS worker.
Do not close a shared MEDS AU while the CSO AU is still pending.
If the CSO needs a shared case transferred call the worker of record in ACES. If they are unavailable and the case needs transferred immediately press “0” when the message begins and the MEDS call director will assist the CSO worker.
For MEDS if the shared case is for any program other than F06, prior contact with the CSO is required before making any change.
Eligibility reviews for shared F06 and F08 AU's can be processed at either the CSO or MEDS without coordination.
EXAMPLE
Family submits an eligibility review due for their F08 AU at MEDS. Household also consist of children on F06 at the local CSO. MEDS will initiate and complete the review for the F08 and F06 AU's. No contact is needed with the CSO.
EXAMPLE
Same household as above submits an eligibility review for the F06 AU at the CSO. CSO will initiate and complete the review for the F06 and F08 AU's. No contact is needed with MEDS.
If MEDS staff are unable to reach the CSO to transfer or take action on a shared case they will contact the CSO supervisor of record for action.
When a change is made in the ongoing month to a shared case ACES generates alerts 404 and 405 to the CSO or MEDS. These alerts are only generated when a shared user accesses the case, a change to the AU composition occurs and no transfer of CSO has occurred in the ongoing month.
WAC 388-505-0211
WAC 388-505-0211
Effective March 14, 2008
WAC 388-505-0211 Premium requirements for premium-based children's healthcare programs.
For the purposes of this chapter, "premium" means an amount paid for medical coverage.
Payment of a premium is required as a condition of eligibility for premium-based children's healthcare coverage, as described in WAC 388-505-0210 (4), unless the child is:
Pregnant; or
An American Indian or Alaska Native.
The premium requirement begins the first of the month following the determination of eligibility. There is no premium requirement for medical coverage received in a month or months before the determination of eligibility.
The premium amount for the assistance unit is based on the net available income as described in WAC 388-450-0005. If the household includes more than one assistance unit, the premium amount billed for the assistance units may be different amounts.
The premium amount for each eligible child is fifteen dollars per month per child, up to a maximum of forty-five dollars per month, per household.
All children in an assistance unit are ineligible for medical coverage when the head of household fails to pay required premium payments for three consecutive months.
When the department terminates the medical coverage of a child due to nonpayment of premiums, the child has a three-month period of ineligibility beginning the first of the following month. The three-month period of ineligibility is rescinded only when the:
Past due premiums are paid in full prior to the begin date of the period of ineligibility; or
The child becomes eligible for a nonpremium-based medical program. The department will not rescind the three-month period of ineligibility for reasons other than the criteria described in this subsection.
The department writes off past-due premiums after twelve months.
When the designated three-month period of ineligibility is over, all past due premiums that are an obligation of the head of household must be paid or written off before a child can become eligible for premium-based children's healthcare.
A family cannot designate partial payment of the billed premium amount as payment for a specific child in the assistance unit. The full premium amount is the obligation of the head of household of the assistance unit. A family can decide to request medical coverage only for certain children in the assistance unit, if they want to reduce premium obligation.
A change that affects the premium amount is effective the month after the change is reported and processed.
A sponsor or other third party may pay the premium on behalf of the child or children in the assistance unit. The premium payment requirement remains the obligation of head of household of the assistance unit. The failure of a sponsor or other third party to pay the premium does not eliminate the:
Establishment of the period of ineligibility described in subsection (7) of this section; or
Obligation of the head of household to pay past-due premiums.
A person is eligible for categorically needy (CN) medical assistance when they are:
Receiving temporary assistance for needy families (TANF) cash benefits;
Receiving Tribal TANF;
Receiving cash diversion assistance, except SFA relatable families described in chapter 388-222 WAC;
Eligible for TANF cash benefits but chooses not to receive; or
Not eligible for or receiving TANF cash assistance, but meet the eligibility criteria for aid to families with dependent children (AFDC) in effect on July 16, 1996 except that:
Is an unmarried minor parent who is not in a department-approved living situation;
Is a parent or caretaker relative who fails to notify the department within five days of the date the child leaves the home and the child's absence will exceed one hundred eighty days;
Is a fleeing felon or fleeing to avoid prosecution for a felony charge, or is a probation and parole violator;
Was convicted of a drug related felony;
Was convicted of receiving benefits unlawfully;
Was convicted of misrepresenting residence to obtain assistance in two or more states;
Has gross earnings exceeding the TANF gross income level; or
Is not cooperating with WorkFirst requirements.
An adult must cooperate with the division of child support in the identification, use, and collection of medical support from responsible third parties, unless the person meets the medical exemption criteria described in WAC 388-505-0540 or the medical good cause criteria described in chapter 388-422 WAC.
Except for a client described in WAC 388-505-0210(4)(c)(i) and (ii), a person who is an inmate of a public institution, as defined in WAC 388-500-0005, is not eligible for CN or MN medical coverage.
A family may be eligible for one of the following programs:
Family medical attached to TANF cash (F01): All family members eligible for this cash program are eligible for CN medical, with the exception of an adult under DCS sanction. F01 clients may enroll in Healthy Options.
NOTE:
Effective October 1, 2002, children and adults who do not meet federal Medicaid criteria do not have family medical coverage unless they are pregnant or meet the criteria for the Alien Emergency Medical Program.
Family medical (F04): Families who do not want cash assistance or who are ineligible due to the reasons described in WAC 388-505-0220 (2) may be eligible for family medical.
A family must include an “eligible dependent child” meeting the Age Requirements described in WAC 388-404-0005 (1).
NOTE:
School attendance of children under the age of eighteen is not an eligibility requirement for a family medical program. For the purposes of a family medical program, a child who is age eighteen and has already graduated or who does not meet the criteria of WAC 388-404-0005(1) is not considered an “eligible dependent child”. When the only child in the household is NOT an “eligible dependent child”, the family is not eligible for a family medical program. The child may still be eligible under a medical program for children. Determine whether the adults are eligible for another medical program.
EXAMPLE
A family applying for Family Medical (F04) includes a citizen father and a mother with “qualified alien” status that has resided in the country for many years. The only child in the home is undocumented. The family meets eligibility criteria except the child is not eligible to receive benefits. The adults in the family cannot be certified as eligible for (F04).
EXAMPLE
A mother and her son are receiving Family Medical (F04). The son graduates in June and has his 18th birthday in July. The son no longer meets the definition of an eligible “dependent child”. Effective August 1, the mother is not eligible for F04. However, the Children’s Medical program (F06) covers the child until he reaches age 19. In this situation, the mother is not eligible based on the age of the child, even though the child is eligible to receive benefits under another program.
Family Medical MN coverage is not available for caretaker adults. If the caretaker adult in the household is pregnant, review for a pregnancy program. If the caretaker adult is aged, blind, or disabled, review for an SSI-related program.
Adults may be eligible for Family Medical (F04) as a separate MAU when certain conditions exist. See Assistance Units for those conditions and instructions concerning financial responsibility and the establishment of separate MAUs as required by the Sneede V. Kizer Ninth Circuit Court decision.
NOTE:
A family eligible for TANF cash diversion is eligible for Family Medical (F04) with a twelve-month certification period. Should the family report a change in the family's circumstances, refer to the Change of Circumstances category.
Alien Emergency Medical Program (F09): A child under age 19 or an adult who is the caretaker of a dependent child may be eligible for the Alien
