Section 182-512-0050. SSI-related medical—General information.

(1) The agency (which includes its designee for purposes of this chapter) provides health care coverage under the Washington apple health (WAH) categorically needy (CN) and medically needy (MN) SSI-related programs for SSI-related people, meaning those who meet at least one of the federal SSI program criteria as being:

(a) Age sixty-five or older;

(b) Blind with:

(i) Central visual acuity of 20/200 or less in the better eye with the use of a correcting lens; or

(ii) A field of vision limitation so the widest diameter of the visual field subtends an angle no greater than twenty degrees.

(c) Disabled:

(i) "Disabled" means unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment, which:

(A) Can be expected to result in death; or

(B) Has lasted or can be expected to last for a continuous period of not less than twelve months; or

(C) In the case of a child seventeen years of age or younger, if the child suffers from any medically determinable physical or mental impairment of comparable severity.

(ii) Decisions on SSI-related disability are subject to the authority of:

(A) Federal statutes and regulations codified at 42 U.S.C. Section 1382c and 20 C.F.R., parts 404 and 416, as amended; and

(B) Controlling federal court decisions, which define the OASDI and SSI disability standard and determination process.

(2) A denial of Title II or Title XVI federal benefits by SSA solely due to failure to meet the blindness or disability criteria is binding on the agency unless the applicant's:

(a) Denial is under appeal in the reconsideration stage in SSA's administrative hearing process, or SSA's appeals council; or

(b) Medical condition has changed since the SSA denial was issued.

(3) The agency considers a person who meets the special requirements for SSI status under Sections 1619(a) or 1619(b) of the Social Security Act as an SSI recipient. Such a person is eligible for WAH CN health care coverage under WAC 182-510-0001.

(4) Persons referred to in subsection (1) must also meet appropriate eligibility criteria found in the following WAC and EA-Z Manual sections:

(a) For all programs:

(i) WAC 182-506-0015, Medical assistance units;

(ii) WAC 182-504-0015, Categorically needy and WAC 182-504-0020, Medically needy certification periods;

(iii) Program specific requirements in chapter 182-512 WAC;

(iv) WAC 182-503-0050, Verification;

(v) WAC 182-503-0505, General eligibility requirements for medical programs;

(vi) WAC 182-503-0540, Assignment of rights and cooperation;

(vii) Chapter 182-516 WAC, Trusts, annuities and life estates.

(b) For LTC programs:

(i) Chapter 182-513 WAC, Long-term care services;

(ii) Chapter 182-515 WAC, Waiver services.

(c) For WAH MN, chapter 182-519 WAC, Spenddown;

(d) For WAH HWD, program specific requirements in chapter 182-511 WAC.

(5) Aliens who qualify for medicaid coverage, but are determined ineligible because of alien status may be eligible for programs as specified in WAC 182-507-0110.

(6) The agency pays for a person's medical care outside of Washington according to WAC 182-501-0180.

(7) The agency follows income and resource methodologies of the supplemental security income (SSI) program defined in federal law when determining eligibility for SSI-related medical or medicare savings programs unless the agency adopts rules that are less restrictive than those of the SSI program.

(8) Refer to WAC 182-504-0125 for effects of changes on medical assistance for redetermination of eligibility.

[Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (Public Law 111-148), 42 C.F.R. §§ 431, 435, 457 and 45 C.F.R. § 155. WSR 14-07-059, § 182-512-0050, filed 3/14/14, effective 4/14/14. WSR 11-24-018, recodified as § 182-512-0050, filed 11/29/11, effective 12/1/11. Statutory Authority: RCW 74.04.050, 74.08.090. WSR 04-09-002, § 388-475-0050, filed 4/7/04, effective 6/1/04.]

RCW 41.05.021 and Patient Protection and Affordable Care Act (Public Law 111-148), 42 C.F.R. §§ 431, 435, 457 and 45 C.F.R. § 155. WSR 14-07-059, § 182-512-0050, filed 3/14/14, effective 4/14/14. WSR 11-24-018, recodified as § 182-512-0050, filed 11/29/11, effective 12/1/11. Statutory Authority: RCW 74.04.050, 74.08.090. WSR 04-09-002, § 388-475-0050, filed 4/7/04, effective 6/1/04.

Rules

182-510-0001,182-506-0015,182-504-0015,182-504-0020,182-512,182-503-0050,182-503-0505,182-503-0540,182-516,182-513,182-515,182-519,182-511,182-507-0110,182-501-0180,