WAC 182-503-0050 ((Washington apple health-Verification requirements.)) Verification of eligibility factors.
For the purposes of this section, "we" refers to the medicaid agency or its designee and "you" refers to the applicant for, or recipient of, health care coverage. ((We have different eligibility verification processes and standards depending on whether the Washington apple health (WAH) program is a modified adjusted gross income (MAGI)-based WAH program, a non-MAGI-based WAH program, or a deemed eligible program as described in WAC 182-503-0510.
(1) We may ask for verification of information that you give us when you apply, renew, or report a change in your household circumstances.
(2) The following provisions apply to all WAH programs.
(a) We will only require information from you that is both needed to determine eligibility and readily available, which means information that you can get within three business days. If the verification we require costs money, we will pay for it or get the information in another way. After we approve your WAH coverage based on information that is readily available, we may ask for verification information that is more determinative of your eligibility but that may require more than three working days to obtain.
(b) We may consider information from various data sources before asking you to provide verification information. These various data sources include, but are not limited to, those listed below:
(i) Washington state employment security department;
(ii) The Internal Revenue Service;
(iii) United States Department of Homeland Security;
(iv) The Social Security Administration;
(v) Other state and federal data bases; and
(vi) Other commercially available electronic data bases.
(c) After we attempt to verify your information with information from various data sources listed in (b) of this subsection, we may ask you for more information or consider information from third-party contacts, such as employers, landlords, and insurance companies if:
(i) The information you provided cannot be verified through our data sources;
(ii) The data-match is not reasonably compatible (as defined in WAC 182-500-0095) with the information you self-attested to or other sources; or
(iii) The information you self-attested to is contradictory, confusing, or outdated.
(d) When we need more information from you to determine your eligibility for WAH coverage, we send all notices according to the requirements of WAC 182-518-0015 and follow the rules below:
(i) If you are eligible for equal access services as described in WAC 182-503-0120 or limited-English proficiency services as described in WAC 182-503-0110, we help you comply with the requirements of this section.
(ii) We will not deny or delay your application because you fail to provide the information in a particular type or form. We must accept and consider alternative verification.
(iii) If you request more time to provide information, we allow you the time requested.
(iv) We will not deny you eligibility during any time period we have given you to provide more information unless we have conclusive evidence of your ineligibility.
(v) If we do not timely receive your information, we determine your eligibility based on all the information we have received on or before the date of the decision, including information we obtained from the various data sources listed in (b) of this subsection. If we cannot determine your eligibility, we deny or terminate your WAH coverage and send you a notice that states when we will reconsider the application as described in WAC 182-503-0080.
(vi) Once we verify an eligibility factor that is not subject to change, we will not require ongoing or additional verification of that factor. This includes, but is not limited to, citizenship, family relationships; Social Security numbers; and dates of birth, death, marriage, dissolution of marriage, or legal separation.
(3) If you are applying for MAGI-based programs:
(a) Except as described in (b) of this subsection, we must accept your self-attestation (defined in WAC 182-500-0100) of eligibility factors (including your income and tax deductions). If your self-attestation indicates eligibility, we find you eligible for MAGI-based WAH.
(b) We follow the procedures in subsection (1) of this section and use data-matching to verify your citizenship or immigration status, and Social Security number. If we are unable to verify a required eligibility factor through data-matching, we ask you to provide the verification we need.
(c) After we have determined your eligibility, we may conduct a post-eligibility review to verify your self-attestation. We use various means to verify your circumstances including, but not limited to, information that is available from the sources listed in subsection (2)(b) and (c) of this section and from the following sources:
(i) The supplemental nutrition assistance program (SNAP).
(ii) Department of social and health services cash programs, including temporary assistance for needy families (TANF), diversion cash assistance (DCA), refugee cash assistance (RCA), aged, blind, and disabled cash assistance (ABD), and pregnant women's cash assistance (PWA).
(d) If we are unable to verify your self-attested information using the procedures in subsection (1) of this section, we will contact you and may request documentation. If you give us a reasonable explanation that confirms your eligibility, we may not require additional documentation.
(4) If you are applying for non-MAGI-based programs:
(a) We must first verify your eligibility factors according to MAGI-based standards described in subsection (2) of this section. If you are eligible for a MAGI-based WAH program, we must find you eligible for that program.
(b) Even if you are eligible for MAGI-based coverage, we will still consider you for non-MAGI-based programs if the programs offer you services or coverage options that are not available in MAGI-based programs.
(c) We may need additional verification to determine eligibility for non-MAGI-based programs including, but not limited to:
(i) Income and income deductions;
(ii) Medical expenses required to meet a spenddown liability (see WAC 182-519-0110);
(iii) Medical expenses and other post-eligibility deductions used to determine eligibility for long-term care programs (see WAC 182-513-1380);
(iv) Resources; and
(v) Any other questionable information.
(d) Additional eligibility factors and verification standards are described in:
(i) Chapter 182-507 WAC, refugee medical and alien medical programs;
(ii) Chapter 182-508 WAC, medical care services;
(iii) Chapter 182-511 WAC, WAH for workers with disabilities;
(iv) Chapter 182-512 WAC, SSI-related medical programs;
(v) Chapters 182-513 and 182-515 WAC, SSI-related long-term care programs;
(vi) Chapter 182-517 WAC, medicare savings programs; and
(vii) Chapter 182-519 WAC, medically needy and spenddown programs.
(5) If you are deemed eligible for one of the programs described in WAC 182-503-0510(4), we do not require additional verification of information from you.))
(1) General rules.
(a) We may verify the information we use to determine, redetermine, or terminate your Washington apple health eligibility.
(b) We verify the eligibility factors listed in WAC 182-503-0505(3).
(c) Before we ask you to provide records to verify an eligibility factor, we use information available from state data bases, including data from the department of social and health services and the department of employment security, federal data bases, or commercially available data bases to verify the eligibility factor.
(d) We do not require you to submit a record unless it is necessary to determine or redetermine your eligibility.
(e) If you can obtain verification within three business days and we determine the verification is sufficient to confirm an eligibility factor, we base our initial eligibility decision upon that record.
(f) We may require information to verify an eligibility factor if the information we received:
(i) Cannot be verified through available data sources;
(ii) Did not verify an eligibility factor; or
(iii) Is contradictory, confusing, or outdated.
(g) If a fee is required to obtain a necessary record, we pay the fee.
(h) We do not deny or delay your application if you failed to provide information to verify an eligibility factor in a particular type or form.
(i) Unless there is only one way to verify an eligibility factor, we accept alternative forms of verification. If you give us a reasonable explanation that confirms your eligibility, we may not require additional documentation.
(j) Once we verify an eligibility factor that will not change, we may not require additional verification. Examples include:
(i) U.S. citizenship;
(ii) Family relationships by birth;
(iii) Social Security numbers; and
(iv) Dates of birth, death, marriage, dissolution of marriage, or legal separation.
(k) If we cannot verify your immigration status and you are otherwise eligible for Washington apple health, we approve coverage and give additional time to verify your immigration status.
(2) Submission timelines.
(a) We allow at least ten calendar days for you to submit requested information.
(b) If you request more time to provide information, we allow the time requested.
(c) If the tenth day falls on a weekend or a legal holiday as described in RCW 1.16.050, the due date is the next business day.
(d) We do not deny or terminate your eligibility when we give you more time to provide information.
(e) If we do not receive your information by the due date, we make a determination based on all the information available.
(3) Notice requirements.
(a) When we need more information from you to determine your eligibility for Washington apple health coverage, we send all notices according to the requirements of WAC 182-518-0015.
(b) If we cannot determine you are eligible, we send you a denial notice including information on when we reconsider a denied application under WAC 182-503-0080.
(4) Equal access and limited-English proficiency services. If you are eligible for equal access services under WAC 182-503-0120 or limited-English proficiency services under WAC 182-503-0110, we provide legally sufficient support services.
(5) Eligibility factors for nonmodified adjusted gross income (MAGI)-based programs. If you apply for a non-MAGI program under WAC 182-503-0510(3), we verify the factors in WAC 182-503-0505(3). In addition, we verify:
(a) Household composition, if spousal or dependent deeming under chapter 182-512 WAC or spousal or dependent allowance under chapters 182-513 and 182-515 WAC applies;
(b) Income and income deductions;
(c) Resources, including trusts, annuities, and life estates under chapters 182-512, 182-513, and 182-516 WAC;
(d) Medical expenses required to meet any spenddown liability under WAC 182-519-0110;
(e) All post-eligibility deductions used to determine cost of care for clients eligible for long-term services and supports under chapters 182-513 and 182-515 WAC;
(f) Transfers of assets under chapter 182-513 WAC when the program is subject to transfer of assets limitations;
(g) Shelter costs for long-term care cases where spousal and dependent allowances apply;
(h) Blindness or disability, if you claim either; and
(i) Social Security number for a community spouse if needed when you apply for long-term care.
(6) Post-eligibility review for MAGI-based programs.
(a) After we approve your coverage, we may conduct a post-eligibility review to verify your self-attested information.
(b) When conducting a post-eligibility review, we attempt to verify eligibility factors using your self-attested information available to us through state, federal, and commercially available data sources, or other third parties, before requiring you to provide information.
(c) You may be required to provide additional information if:
(i) We cannot verify an eligibility factor through other data sources listed in subsection (b) of this section; or
(ii) The information received from the data source is not reasonably compatible with your self-attestation.
(7) Reapplication following post-eligibility review. If your eligibility for MAGI-based Washington apple health terminates because of a post-eligibility review and you reapply, we may request verification of eligibility factors prior to determining eligibility.
