Continued coverage pending an appeal

Revised date
Purpose statement

To explain how to receive continued when an administrative appeal is pending and how continued coverage works.

WAC 182-504-0130 Washington apple health -- Continued coverage pending an appeal.

WAC 182-504-0130 Washington apple health -- Continued coverage pending an appeal.

Effective December 1, 2016

  1. Continued coverage is when you continue to receive Washington apple health benefits while appealing a medicaid agency adverse action to terminate, suspend, or reduce your:
    1. Medicaid eligibility; or
    2. Authorization for a covered service.
  2. To qualify for continued coverage, you must request a hearing on the adverse action no later than:
    1. The tenth day after we (the medicaid agency or its designee) sent a notice of the action to you; or
    2. The last day of the month before the action takes effect.
  3. If your last day to request a hearing and still qualify for continued coverage falls on a Saturday, Sunday, or a designated holiday under WAC 357-31-005, you have until 5:00 p.m. on the next business day to request the hearing.
  4. Continued coverage ends when:
    1. You state in writing you no longer wish to receive continued coverage;
    2. You withdraw the appeal;
    3. You default and an order of dismissal is entered;
    4. An administrative law judge or a review judge issues an adverse ruling or written decision:
      1. Terminating your continued coverage; or
      2. Ruling you do not qualify for benefits.
  5. You cannot receive continued coverage if the adverse action was solely to a change in statute, federal regulation, or administrative rule, unless there is a question about whether you are in the class of people affected by the change.
  6. If you are receiving medically needy coverage, you cannot receive continued coverage past the end of the certification period described in WAC 182-504-0020.
  7. If you are receiving coverage under an alien medical program, you cannot receive continued coverage past the end of the certification period described in chapter 182-507 WAC.

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

  1. When Apple Health coverage is terminated, an individual can request an administrative appeal. This appeal must be requested by the end of the month their coverage is to be terminated in order to be considered timely and to receive continued coverage.
  2. When an individual requests an administrative hearing, the agency sends a notice that includes the approval or denial of continued coverage, the reason for denial of continued coverage (if applicable), and that the individual might be liable for up to two months of medical expenses (overpayments) if continued coverage is received and the agency’s termination is upheld.
  3. An individual is eligible for continued coverage if:
    1. An appeal is received by the agency, its designee (including the Health Benefits Exchange), or the Office of Administrative Hearings by 5:00PM on the last day of the month; or
    2. If the last day of the month falls on a weekend or holiday, the appeal is received by 5:00PM on the following business day; or
    3. An administrative law judge issues an order granting continued coverage.
  4. Continued coverage ends the last day of the month when:
    1. The individual fails to appear for his or her hearing.
    2. An administrative law judge issues an order upholding the agency’s decision;
    3. The individual withdraws their appeal.
    4. The individual declines continued coverage in writing; or
    5. An administrative law judge issues an order stopping continued coverage.
  5. If an individual fails to appear for the hearing or if an order is issued upholding the agency’s decision, the agency may seek reimbursement for the cost of the two months of continued coverage received. See WAC 182-520-0010 for more information.
  6. Continued coverage is not an option when a termination is caused by a change in rule. There is also not an option for continued coverage for medically needy coverage after the original certification period.

Worker responsibilities

Administrative hearing coordinator

  1. Review each hearing request to determine eligibility for continued benefits. An individual may have noted on the request that they do not want continued coverage.
  2. If an individual is eligible for continued coverage:
    • Reopen health care coverage.
    • Document in ACES why coverage was reopened;
    • Send a notice to the individual with the following text:

      You have requested an administrative hearing and will receive continued health care coverage unless you tell us you do not want it (WAC 182-504-0130).

      You may have to pay back the agency’s costs for the two months of continued coverage after you requested a hearing if the Administrative Law Judge (ALJ) agrees with our decision (WAC 182-520-0010).

      You will receive continued coverage through the end of the month an administrative hearing decision is sent to you unless:

      a) An ALJ or our presiding officer serves an order ending continued coverage; or

      b) You:

      1. Tell us in writing that you do not want continued health care coverage; or

      2. Withdraw your request for an administrative hearing in writing or during the hearing.

  3. If an individual is not eligible for continued coverage:
    1. Document in ACES why they are not eligible; and
    2. Send a notice to the individual with the following text:

      “You have requested an administrative hearing regarding your health care coverage. Your request has been sent to the Office of Administrative Hearings.

      You requested continued coverage pending the outcome of your appeal. You are not eligible because _______. See WAC 182-504-0130.

      If you disagree with the decision to deny continued coverage, you may contact the Office of Administrative Hearings at 360-407-2700 and request a prehearing conference. The prehearing conference will be with an Administrative Law Judge who will determine only if you are or are not eligible for continued coverage.”

  4. If the individual is on continued coverage for any long-term care, COPES or other services through ALTSA, notify the case manager of the reopening of coverage pending the appeal.

Example: Mohamed is on WAH for adults. He is terminated 6/30 for being over income. He submits a request for a hearing on 6/29. He is eligible for continued coverage.

Example: Gloria receives WAH for her children. Coverage ends 1/31. She submits a request for a hearing on 2/15. Deny continued coverage as the request was not timely.

Example: Giuseppe receives WAH for adults. Coverage ends Sunday, 12/31. He submits a request for a hearing on 1/2. He is eligible for continued coverage as the last day of the month falls on a weekend, the next day is a holiday, and the hearing request was received on the next business day.

Example: Jacques applies for WAH and is denied for not meeting the immigration criteria. He submits a timely appeal and wants continued coverage. He is not eligible because he was not a recipient of WAH at the time of the denial.

Example: Walter was on an active WAH MN spenddown for 9/14 to 11/30. He submits an appeal on 11/15 about having to meet a new spenddown as of 12/1. He asks for continued coverage. He is not eligible as continued coverage for MN programs does not extend past the certification period end date.

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