This section describes how the medicaid agency calculates the premium amount a person must pay for apple health for workers with disabilities (HWD) coverage. This section also describes program requirements regarding the billing and payment of HWD premiums.
(1) When determining the HWD premium amount, the agency counts only the income of the person approved for the program. It does not count the income of another household member.
(2) When determining countable income used to calculate the HWD premium, the agency applies the following rules:
(a) Income is considered available and owned when it is:
(i) Received; and
(b) Certain receipts are not income as described in 20 C.F.R. Sec. 416.1103.
(3) The HWD premium amount equals the lesser of the two following amounts:
(a) A total of the following (rounded down to the nearest whole dollar):
(i) Fifty percent of unearned income above the medically needy income level (MNIL) described in WAC
182-519-0050; plus
(ii) Five percent of total unearned income; plus
(iii) Two and one-half percent of earned income after first deducting sixty-five dollars; or
(b) Seven and one-half percent of countable income described in subsection (2) of this section, including both earned and unearned income.
(4) When determining the premium amount, the agency will use the currently verified income amount until a change in income is reported and processed, unless good cause for delay in verifying changes exists.
(5) A change in the premium amount is effective the month after the change in income is reported and processed.
(6) For current and ongoing coverage, the agency will bill for HWD premiums during the month following the benefit month.
(7) For retroactive coverage, the agency will bill the HWD premiums during the month following the month in which coverage is requested and necessary information that establishes eligibility is received by the agency.
(8) If initial coverage for the HWD program is approved in a month that follows the month of application, the first monthly premium includes the costs for both the month of application and any following months that have passed during determination of eligibility.
(9) As described in WAC
182-511-1050 (3)(b), the agency will close HWD coverage if premiums are not paid in full for four consecutive months.
(10) The person must pay the monthly premium in full to avoid losing HWD coverage. If a person makes a partial payment, the payment does not count as a full payment toward the premium.
(11) Payments received are applied to premiums owed in the following order:
(a) If retroactive coverage is requested, the retroactive coverage month(s);
(b) Past due months, beginning with the most delinquent month;
(c) The current coverage month that has been invoiced; then
(d) Future coverage months.
(12) A person must pay a premium for any month that HWD coverage is provided. This includes months when a redetermination of coverage is made, and months when continued coverage that is requested, pending the outcome of an administrative hearing.
[Statutory Authority: RCW
41.05.021,
41.05.160 and 2019 c 70. WSR 19-23-063, § 182-511-1250, filed 11/15/19, effective 1/1/20. Statutory Authority: RCW
41.05.021 and
41.05.160. WSR 15-14-080, § 182-511-1250, filed 6/29/15, effective 7/30/15. WSR 11-24-018, recodified as § 182-511-1250, filed 11/29/11, effective 12/1/11. Statutory Authority: RCW
74.08.090,
34.05.353 and Section 1902 (a)(10)(A)(ii) of the Social Security Act. WSR 04-15-002, § 388-475-1250, filed 7/7/04, effective 8/7/04. Statutory Authority: RCW
74.08.090, Section 1902 (a)(10)(A)(ii) of the Social Security Act, and 2001 c 7 § 209(5), Part II. WSR 02-01-073, § 388-475-1250, filed 12/14/01, effective 1/14/02.]
