HCS state-funded residential program through the Medical Care Service (MCS) program

Revised date

State-funded residential

Home and Community Services (HCS) has a state-funded residential program for those eligible for Medical Care Services (MCS). The functional requirements are the same as for Medical Personal Care (MPC).

Note:

MCS does cover nursing facility claims as long as the client meets nursing facility level of care (NFLOC). The NF claim process for MCS is automated and no NF award letter is needed. The social service process is described in the HCS LTC manual.

ACES medical coverage group is A01, A05, or A24. The state-funded LTSS program is described in WAC 388-106-0905.

What services may I receive under state funded residential care? WAC 388-106-0900

Clarifying Information

  • A01 is used for clients who meet aged, blind or disabled criteria.
  • A05 is used for clients meeting ABD incapacity, but not disability criteria.
  • A24 is used for victims of human trafficking. Public Benefit Eligibility for Survivors of Certain Crimes | DSHS (wa.gov)
  • To be eligible for A01, A05, or A24, the client must be eligible for the HEN referral program or the ABD cash assistance program.
  • Room and Board calculations for clients in an alternate living facility (ALF) are not calculated in ACES and notices to clients will need to be sent by social services.

Am I eligible to receive state-funded residential care services? WAC 388-106-0905

  • Lawfully present clients, not subject to the 5-year bar, who permanently reside in the US under color of law (PRUCOL) (NQ).
  • Must be eligible for ABD cash or HEN referral program.
  • One applicant/recipient per AU.
  • Scope of care is state-funded Medical Care Services (MCS).
  • Covers the state-funded residential program and state-funded nursing facility program.
  • Undocumented individuals are not eligible for A01/A05 coverage.

How do I approve a new A01/A05/A24 case?

  • Applications: The client must apply for ABD cash assistance to be able to look at the MCS eligibility.
  • Screening: 'A' track AU's will not auto populate in screening; however the medical coverage group will be allowed as a selection in the dropdown list.
  • Default will be MA/D/A01 and will switch to the correct coverage type when finalizing the AU.
    • Determine if the client is an eligible noncitizen who needs LTC residential or nursing home services.
    • Did the client apply for cash assistance?
    • Is the client functionally eligible for LTC services?
    • If the answer is yes to 1, 2, and 3 screen in a HEN AU and an A01 AU. (Clients who are eligible for LTC services meet the incapacity criteria for HEN).
    • Process the HEN AU first then finalize the A01/A05 AU.
    • Determine 'durational' requirements for ABD/HEN program for clients under 65, not blind or disabled.
      • Regions 1 and 3: Using Barcode, complete a 14-084 referral to the CSD incapacity worker.
      • Region 2: Complete a referral to the Region 2 HCS social worker for a disability determination.
      • Indicate on the 14-084 the following;
        • "Per approved ETR to WAC 388-400-0070, HCS has approved HEN/MCS case. Client meets LTSS functional requirements-disability determination is needed".
    • Notify the HCS social worker that client has been opened on HEN/MCS medical coverage so they can issue a notice to the client regarding the room and board calculation.
      • Indicate the client's current income to the social worker.
    • Set a reminder to check on disability/duration with the CSD incapacity worker if applicable.
  • WAC 182-508-0005 for the state funded MCS program.
  • WAC 388-400-0060 for the ABD cash program.
  • WAC 388-513-1315 (11) which describes the ABD cash and MCS program as it applies to ALTSA services.

Disability instructions for ABD cash are found in the EAZ social service manual.

State-Funded Long Term Care Program for Noncitizens

State-funded LTC for noncitizens not eligible under ABD cash or MCS. This program is limited to 45 slots due to legislative funding limitations and requires a preapproval by ALTSA HQ. The state-funded LTC program can be used in a nursing facility, residential or home setting.

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Reverse mortgage and loans

Revised date
Purpose statement

To explain how reverse mortgages and loans or mortgages affect SSI related Medicaid and Long-term care programs.

Reverse mortgages and loans

Reverse mortgage monthly payments are not considered income. If the client retains the payment from the reverse mortgage it would be considered a resource the month following the month of receipt and would affect eligibility if the client’s resources are over the standard. The client can’t give the funds away without receiving adequate consideration without imposing a penalty.

Home equity conversions and reverse mortgages HEC

Home equity conversion plans are designed to allow elderly homeowners to convert the value of their homes into cash without being forced to leave their homes. Under these plans, the home is either mortgaged or sold to a financial institution or other buyer in exchange for a regular cash payment or line of credit. The most common HEC is the reverse mortgage. They allow the homeowner to borrow equity out of their home with no repayment as long as they live in the home. The notes are due when the house ceases to be the borrower’s main residence. Proceeds from a reverse mortgage are loan proceeds, which do not meet the definition of income per SI 00815.350. (SI 00815.350 is the SSA Policy Manual)

Reverse mortgages and lines of credit

We do not count a line of credit as an available resource beyond the idea that it comprises home equity. It is not a resource all by itself. A line of credit is simply one method someone can access their home’s equity in a reverse mortgage. The equity is still in the home until the credit line is used. Once the client takes a cash advance payment from the line of credit, the cash they take could become an available resource if they still have it on the first of the month after receiving the payment. A client takes out a reverse mortgage of $150,000 (principle before fees) and took the proceeds as a $150,000 line of credit. Until the client actually uses the line of credit, it is still part of the home’s equity. In that sense, it is a resource, but the client does not have a separate available resource of $150,000. If on March 2 they take a cash advance of $50,000 on their line of credit the home’s equity has been reduced by $50,000. The remaining $100,000 in the line of credit is still part of the home’s equity until it is accessed. If they put that $50,000 from the line of credit into a bank account, whatever is still in the account on April 1 is an available resource. If a client has $555,000 equity in their home, had taken out a reverse mortgage line of credit of $150,000 but had not accessed the credit, the client still had $555,000 equity (less any loan fees). If the client did not have a spouse, minor child, or dependent child residing in the home, then the client would not be eligible. The client still has equity in excess of $552,000. However, if the client had accessed their line of credit and had used $60,000 on debts, the home’s equity is reduced by $60,000 by the time they request LTC, then the client’s equity is less than $555,000 and is potentially eligible.

Reverse mortgages and cash proceeds

If they took the option of a cash payment as proceeds from the reverse mortgage, any portion of the cash they received that is still available on the first of the month following the receipt can be considered an available resource. Same client as above but instead of taking the proceeds as a line of credit they took it as a $150,000 lump sum. On March 2 they client received the $150,000 proceeds from the loan. They have now reduced their home’s equity to $405,000. However, you need to determine what happened to the cash proceeds. If on April 1 all $150,000 was still in the checking account then it is an available resource on April 1.

Transfer of certain notes and loans

The term "assets" includes funds used to purchase a loan or mortgage unless the note, loan or mortgage:

  1. Has a repayment term that is actuarially sounds (as determined in accordance with actuarial publications of the Office of Chief Actuary of the Social Security Administration);
  2. Provides for payments to be made in equal amounts during the term of the loan, with no deferral and no balloon payments made; and
  3. prohibits the cancellation of the balance upon the death of the lender.

If the loan, or mortgage does not meet the criteria above, the value of the note, loan or mortgage as of the date of the LTC medicaid application is counted as a resource.

Federal guidance on reverse mortgages and loans

Social Security Procedural manual (POMS)

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Address Confidentiality Program (ACP) for domestic violence victims

Revised date
Purpose statement

To describe the Address Confidentiality Program (ACP), run by the Office of the Secretary of State.

Overview

The ACP program is in place to protect the address of survivors of domestic violence, sexual assault, stalking or trafficking. Participants use a substitute address in place of their actual physical or mailing address.

Rules for the Address Confidentiality program are found in WAC 434-840-001 through WAC 434-840-310 and are governed by the Office of the Secretary of State.

Clarifying information

The ACP provides the following services to victims of domestic violence, sexual assault, trafficking, or stalking:

  1. Helps the participant maintain the secrecy of home, work, or school address.
  2. Provides the participant a substitute mailing address.
  3. Forwards first class mail from the substitute address.
  4. Helps the participant obtain many state and local agency services without revealing the physical or mailing address.
  5. Helps the participant to register to vote or obtain a marriage license without having those records available to the public.

Participants are given a laminated authorization card the size of a driver license. The card has the individual's signature, substitute address, expiration date, and a toll-free number to the ACP office for information. The toll-free number is 800-822-1065. The TTY number is 800-664-9677.

Worker responsibilities

When an individual states they are enrolled in ACP and have an assigned Private Mail Box (PMB) address:

  1. If the individual is currently certified in the ACP:
    1. Use the ACP mailing address and participant code number (PMB number) as shown on the card in place of the individual's physical address on the ACES address screen or in Washington Healthplanfinder.
      Example:
      • Jane Doe
        1453 (PMB number)
        PO Box 257
        Olympia, WA 98507-0257
    2. Mail all correspondence for the individual to the substitute address:
    3. Do not ask the individual to provide their actual address. Do not record the individual's physical address in Automated Client Eligibility System (ACES) Online, Barcode, Healthplanfinder (HPF) or Customer Service Application (CSA) or retain copies of any documents that list the individual's physical address.
    4. When verifying residency, household composition, or shelter costs, do not ask the individual to provide documents that state their physical address. Accept any document that lists the ACP address and reasonably verifies the eligibility factor. See verification for instructions on determining reasonableness.
    5. If the individual provides a document that lists the physical address:
      1. Do not keep the document.
      2. Explain to the individual that if we have anything in the case record that lists their physical address, we may have to reveal that information if we are issued a subpoena.
      3. Document in the narrative:
        1. What documents were used as verification.
        2. What eligibility factor the documents verify; and
        3. Why copies of the document are not in the record.
    6. Allow the individual to provide any document that has the physical address concealed.
  2. If the individual is not currently certified in the ACP:
    1. Do not enter the ACP mailing address and participant code into ACES.
    2. Require the individual to provide a current mailing address.
    3. Record the address in ACES or Washington Healthplanfinder; and 
    4. Follow the normal verification procedures as described in Verification.

Verification of active ACP participant

If the individual's enrollment in ACP is questionable or we get returned mail from their ACP address, government agencies may call the ACP office at 360-753-2972 to verify that the individual is an active ACP participant.

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Chart of acceptable documents

Revised date

Acceptable Forms of Verification Chart

The following table is a suggested list of reliable sources of verification for each eligibility factor. Any source, including verbal, written, and email statements, can be used as long as it meets the "Criteria for Evaluating Verification".

What to verify Acceptable verification
Child Support obligation
  • Court papers
  • Division of Child Support data
  • Statement from custodial parent
  • Receipt
Citizenship and identity See Citizenship and Identity Documents - Tier 1-4
Deductions for MAGI-based
  • IRS 1040 form showing allowed deduction
  • School verification showing allowable deduction
  • Verification showing moving costs, alimony paid, etc.
Dependent care expenses
  • Statement from the provider
  • Bills or receipts
  • SSPS data
Disability
  • Award letter from SSA
  • DDDS disability approval
  • Collateral contact with SSA
  • Collateral contact with VA
  • Decision from disability program specialist (ABD cash)
Immigration status
  • Permanent Resident Card (Form I-551)
  • Refugee Travel Document (Form I-571)
  • Valid foreign passport with I-94 stamp of admission
  • Visa with I-94 stamp of admission

See National Immigration Law Center (NILC) for documents used to verify immigration status
Income
  • Pay stubs
  • Employer statement by telephone or in writing
  • Division of Child Support data
  • ACES Interfaces
  • Bank statement that shows direct deposits (as long as amount shown is gross and not net)
  • Collateral contact
  • SOLQ
  • TALX/The Work Number
  • IRS 1040 if it is accurate of current income
  • Profit and loss statement
Medical expenses
  • Bills/Receipts
  • Statement from the provider
Pregnancy
  • Accept individual's statement of pregnancy and EDD
Residency
  • Accept individual's declaration unless questionable
  • Collateral statement
  • Rental or lease agreement
  • Statement from landlord
  • Mortgage papers
  • Utility company records or bills
Resources
  • Bank statements
  • Insurance documents
  • Vehicle registration
  • Stock certificates
  • Courthouse records
  • Property tax statement
Shelter costs
  • Landlord statement
  • Current lease
  • Rent or mortgage receipt
  • Utility bills
  • Collateral contact
Social Security number
  • Social Security card
  • Application for SSN
  • SSA printouts or documents
  • Birth document that states SSN was applied for
Tax filing status
  • Accept attestation unless questionable

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HCB waivers, room and board, ETRs, and bed holds

Revised date
Purpose statement

Individuals that reside in residential settings have certain issues that apply to residential settings only. This section describes special circumstances that apply to HCB services in residential settings.

HCS services in residential settings, room and board and ETRs

HCS and DDA authorizes Waiver services for individuals residing in contracted alternate living facilities (ALF) such as Assisted Living (AL), DDA Group Home or Adult Family Homes (AFH).

The total responsibility paid by the individual to the assisted living or adult family home provider is a combination of the Waiver service participation, room and board and VA third party responsibility. VA third party responsibility is an amount paid to the individual by VA for aid and attendance and/or unusual medical expenses or UME.

What does room and board mean?

Throughout the manual both terms, room and board and board and room are used to describe a living arrangement in which an individual purchases food, shelter, and household maintenance requirements from one vendor. There is a term used by ALTSA called the room and board standard This standard is based on the Federal Benefit Rate (FBR) minus the HCBS Waiver PNA in an ALF.

  • Individuals who reside in alternate living facilities pay room and board (R & B) in addition to their personal care participation.
  • R & B is all state-funded; therefore you cannot automatically reduce R &B with the deductions listed under the HCS Waiver/COPES program.
  • All deductions from room and board require an approved Exception to Rule (ETR)
  • For HCS services, approvals are made by the regional designee.
  • For DDA services, the DDA case-manager notifies the LTC specialty unit of an approved ETR via the DSHS 15-345
  • R & B should only be reduced when all other income has been allocated toward participation and the individual does not have enough income available to pay toward the expenses.
  • Limit requests for reducing R & B to those deductions that are allowed from participation. Don't reduce R & B for expenses that we would not allow from participation.
  • Before requesting an ETR to reduce R & B, ensure you have factored in other income the individual may have available that is not being used to pay toward participation. Ensure the individual is allowed to keep the appropriate PNA.

Is room and board different from participation?

Yes, participation is a term that an individual must pay toward the cost of personal care. We use WAC 182-515-1509 (HCS Waiver) and WAC 182-515-1514 (DDA Waivers) to determine how much an individual must pay toward the cost of personal care. The reality is most people, including social workers call the entire amount the individual has to pay toward the care as "participation". For the financial worker determining eligibility, it is important to know the difference between the cost of personal care (participation) and room and board. The reason for this is there are deductions that are allowable to reduce the cost of personal care (participation) and not allowed to reduce the room and board rate without an ETR.

Note: What does residential setting mean? It means an individual is placed in either a boarding home (assisted living, enhanced adult residential center (EARC), adult residential center (ARC), DDA group home or an adult family home (AFH). See definition of an alternate living facility.

What residential settings are used for the HCB CN (COPES) program? Assisted living, EARC and adult family homes. ARC settings are contracted for MPC only. DDA group homes are contracted for DDA services only.

These residential facilities, or "alternate living facilities" are not medical institutions. A bill incurred prior to medicaid eligibility cannot reduce participation or be applied toward a spenddown.

Why are they sometimes called boarding homes? Because assisted living facilities, EARC, ARC and DDA group home are licensed as "boarding homes". Adult family homes are licensed as adult family homes.

Search for an adult family home or boarding home.

Bed holds for residential settings (boarding homes and adult family homes)

Financial services determines the amount of the individual's payment towards room and board and their participation toward the cost of personal care. When determining this payment amount, the goals are to avoid making individuals pay room and board/participation to multiple facilities whenever possible, and to preserve funding by keeping room and board/participation at the residential (ALF) facility rather than sending it to the nursing home. Social Service LTC manual Chapter 8 Residential Services/Bed hold for Medical Leave describes this process.

Financial workers will:

  • Take no action until the bed hold has expired. The maximum length of the bed hold payment is 20 days.
  • Determine how much the individual should pay to the residential facility during the discharge month. Assign any remainder to the new facility. If the individual:
    • Did not return to the residential facility, change the individual's medical program to nursing facility coverage or other appropriate program and assign room and board/participation to the new facility after determining how much room and board/participation was used at the residential facility during the month the individual left.
    • Does return to the residential facility either in the same month or the next month, assign room and board/participation to that facility.
    • Returns to the residential facility, do not reassign any room and board/participation to the nursing home for any bed hold month(s) unless there are not enough days at the residential facility to account for it.

Community Spouse paying private in a residential setting

Scenario: Community Spouse (CS) paying privately in a residential setting, usually an assisted living facility. Institutionalized spouse is in the nursing home or receiving COPES.

For this scenario the department is counting the private pay in the residential setting minus the 4 person SUA/LTC utility standard as the shelter cost for the purposes of determining excess shelter for the CS.

Whenever we are looking at spousal deeming for institutional programs (Waiver or residing in a medical institution) and the CS is paying privately at a residential facility (adult family home, assisted living facility) use this method to determine the community spouse's shelter cost.

Indicate the private pay cost minus the LTC utility standard as the shelter cost on the institutionalized spouse SHEL screen. Since ACES adds the 4 person SUA/LTC utility standard to the shelter cost in the calculation, we need to make sure we have subtracted that amount out from the cost of the private pay to the residential setting.

Example

Mrs. Smith is on COPES in an AFH. Her monthly income is $1500 per month. Mr. Smith is paying privately at the same AFH. His income is $2650 per month. The AFH is charging him a private rate of $2600 per month.

Mr. Smith is a community spouse. Although both Mr. and Mrs. are residing in the same facility, only Mrs. Smith is considered institutionalized because she is receiving Waiver services.

The department will deem some of Mrs. income to Mr. Smith since he has excess shelter costs and is considered the community spouse.

As of 1/2009 the 4 person SUA-LTC utility standard is $384. $2,600 private rate - $384 = $2,216.00 shelter cost for the community spouse. This is indicated on Mrs. (the one on COPES) shelter expense in ACES 3G.

Current LTC income and resource standards

Current LTC personal needs allowance (PNA) and room and board standards.

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Client notices overview

Revised date
Purpose statement

When applying for Apple Health coverage, letters are sent to inform you of current eligibility, denials, withdrawals, coverage dates, request information, updated eligibility, and when benefits cease.

WAC 182-518-0005 Washington apple health -- Notice requirements -- General

WAC 182-518-0005 Washington apple health -- Notice requirements -- General.

Effective August 29, 2014.

  1. For the purposes of this chapter, "we" refers to the agency or its designee and "you" refers to the applicant for, or recipient of, health care coverage.
  2. This section applies only to notices and letters that we send about eligibility for Washington apple health (WAH) programs. WAC 182-501-0165 applies to notices and letters regarding prior authorization or other action on requests to cover specific fee-for-service health care services.
  3. We send you written notices (letters) when we:
    1. Approve you for health care coverage for any program;
    2. Reconsider your application for other types of health care coverage based on new information;
    3. Deny you health care coverage (including because you withdrew your application) for any program (according to rules in WAC 182-503-0080);
    4. Ask you for more information to decide if you can start or renew health care coverage;
    5. Renew your health care coverage; or
    6. Change or terminate your health care coverage, even if we approve you for another kind of coverage.
  4. We send notices to you in your primary language if you ask us to and in English according to the rules in WAC 182-503-0110. If you need help to apply for or access your health care coverage due to a disability, we follow the equal access rules in WAC 182-503-0120.
  5. All WAH notices we send you include the following information:
    1. The date of the notice;
    2. Specific contact information for you if you have questions or need help with the notice;
    3. Your appeal rights, if an appeal is available, and the availability of potentially free legal assistance; and
    4. Other information required by state or federal law.

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

Letters are sent to individuals in their primary language. Letters are also available in the following eight supported languages:

Cambodian, Russian, Chinese, Spanish, Korean, Vietnamese, Laotian, and Somali.

Note: Letters are sent from Healthplanfinder or ACES depending on the type of health care coverage.

WAC 182-518-0010 Washington apple health -- Notice requirements approval and denial notices.

WAC 182-518-0010 Washington apple health -- Notice requirements approval and denial notices.

Effective August 29, 2014.

  1. We send written notice when we approve, reopen, reinstate, or deny coverage for any Washington apple health (WAH) program. The notice includes the information described in WAC 182-518-0005(4) and all of the following:
    1. The WAH coverage for each person approved, reopened or reinstated;
    2. The date that each person's coverage begins (the effective date); and
    3. The dates for which we approved each person's coverage (certification period).
  2. Denial and withdrawal notices include:
    1. The date of denial;
    2. Specific facts and reason(s) supporting the decision;
    3. Specific rules or statutes that support or require the decision; and
    4. Information to get help applying for nonmodified adjusted gross income (MAGI)-based WAH.
  3. If we deny your request for health care coverage or consider it withdrawn because you failed to give us requested information, the denial notice also includes:
    1. A list of the information you did not give us;
    2. The date we asked you for the information and the date it was due;
    3. Notice that we will reconsider your eligibility if we receive any information related to determining your eligibility, including any changes to information we have, within thirty days of the date of the notice;
    4. Information described in subsection (1) of this section; and
    5. Notice of administrative hearing rights.

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.

WAC 182-518-0015 Washington apple health -- Notice requirements verification requests

WAC 182-518-0015 Washington apple health -- Notice requirements verification requests

Effective August 29, 2014.

  1. We send you written notice when we need more information as described in WAC 182-503-0050 to decide if you are eligible to receive or continue receiving Washington apple health (WAH) coverage. The notice includes:
    1. A description or list of the information that we need;
    2. When we must have the information (see WAC 182-503-0060 for applications and WAC 182-504-0035 for renewals);
    3. What action we will take and on what date, if we do not receive the information; and
    4. Information required in WAC 182-518-0005(4).
  2. If we have received conflicting information about facts we need to determine your coverage, the notice will also include:
    1. The information we received that does not match what you gave us and the source; and
    2. A request that you send us a statement explaining the difference(s) between the information from you and the information from the other source.
  3. We allow you at least ten days to return the information. If you ask, we may allow you more time to get us the information. If the tenth day falls on a weekend or holiday, the due date is the next business day.
  4. If the information we ask for costs money, we will pay for it or help you get the information in another way.

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.

WAC 182-518-0025 Washington apple health -- Notice requirements -- Actions to terminate, suspend, or reduce eligibility or authorization for a covered service.

WAC 182-518-0025 Washington apple health -- Notice requirements -- Actions to terminate, suspend, or reduce eligibility or authorization for a covered service.

Effective December 1, 2016.

  1. General rule.
    1. We send written notice to you at least ten days before taking adverse action to terminate, suspend, or reduce your:
      1. Medicaid eligibility; or
      2. Authorization for a covered service.
    2. The ten-day notice period starts on the day we sent the notice.
  2. Exceptions to ten-day notice period. We may send a notice fewer than ten days before the date of the action in the following circumstances.
    1. We send written notice to you at least five days before taking action to terminate, suspend, or reduce your medicaid eligibility or authorization for a covered service if:
      1. We have facts indicating fraud by you or on your behalf; and
      2. We have verified the facts, if possible, through secondary sources.
    2. We send written notice to you no later than the date we took action to terminate, suspend, or reduce your medicaid eligibility or authorization for a covered service if:
      1. You requested the action;
      2. A change in statute, federal regulation or administrative rule is the sole cause of the action;
      3. You are incarcerated and expected to remain incarcerated at least thirty days;
      4. Mail sent to you has been returned without a forwarding address, and we do not have a more current address for you; or
      5. We are terminating your eligibility because you:
        1. Died; or
        2. Began receiving medicaid from a jurisdiction other than Washington
          state.
  3. Notice contents. Written notice under this section states:
    1. The nature of the action;
    2. The effective date of the action;
    3. The facts and reason(s) for the action;
    4. The specific regulation on which the action is based;
    5. Your appeal rights, if any;
    6. Your right to continued coverage, if any; and
    7. Information found in WAC 182-518-0005(4).
  4. Reinstated coverage.
    1. If we do not meet the advance notice requirements under this
      section, we reinstate your coverage back to the date of the action. We
      may still take action once we meet notice requirements under this section.
    2. If you are receiving medically needy coverage, you cannot receive
      reinstated coverage past the end of the certification period described
      in WAC 182-504-0020.
    3. We may end your coverage if a notice we mailed to you is returned
      with no forwarding address. We reinstate your coverage if we
      learn your new address and you meet eligibility requirements.
  5. Hearing rights. If you do not agree with agency action under
    this section, you may request an administrative hearing under chapter
    182-526 WAC, and you may be entitled to continued coverage under WAC
    182-504-0130.

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.

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.

Worker Responsibilities

See Apple Health - Verification Requirements 182-503-0050 regarding initial use of available data sources prior to written verification requests.
See Apple Health - Applications 182-503-0060 for application processing times.
See Apple Health - Equal access services 182-503-0120 when individuals request equal access services

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Third-party resources and LTC insurance

Revised date
Purpose statement

This section explains how long term care insurance and third party resources apply to long term care programs.

Long-term care insurance

Policies covering long-term care are considered a third party resource.

See rules regarding additional assets allowed under the Long-term care partnership program.

The agency does not count LTC insurance payments when determining income eligibility or participation in the cost of care. LTC insurance is considered a third party resource.

When LTC insurance payments exceed the private cost of care in a medical facility the amount refunded to the client is:

  • Not considered income
  • Considered a resource if any is left over on the first of the following month.

Consult HCS Management Bulletin H06-076 dated October 30, 2006 for additional information on Third Party Liability (TPL) and Nursing Facility Billing Policy Update. This MB includes Provider Q and A attachments regarding insurance billing. The provider is expected to bill the primary insurance first before medicaid.

Long-term care insurance and nursing facilities (NF)

The agency will continue to assign participation, which the nursing facility may collect until the TPL party begins making payments. If the TPL insurance payment is equal to or more than the Medicaid rate, the total participation must be refunded to the individual for the months paid by the TPL party. If the TPL insurance is less than the Medicaid rate, the NF can only collect up to the Medicaid rate as the total payment. The NF must refund any excess participation collected to the individual. The NF should report the amount of the individual's refund to the local HCS office at the time it is refunded.

The NF will be allowed to charge the TPL insurance companies the private rate and keep the amount paid by the TPL insurance, even if it is over the Medicaid rate. Individuals will not be reimbursed the difference between the Medicaid rate and the TPL insurance payment amount.

Effective October 16, 2006 the long-term care (LTC) ACES award letter has text advising individuals to let case managers, financial workers, facilities and providers know when they have LTC insurance.

Financial workers must inform new applicants with TPL insurance that pays for NF care that the NF must bill the insurance company directly and the state will not pay for services until the TPL insurance company has either paid or denied payment.

If the NF reports a refund of participation to the individual, review eligibility to ensure that the individual’s resources are not over the standard. The refund is considered a new resource and not income. Follow advance and adequate notice and reporting requirements criteria if making changes in participation or eligibility.

What happens if a resident has insurance but the NF is not a network provider for their insurance?

The NF should contact the insurance carrier to determine if they will pay a nonnetwork provider, or can decide to become a network provider if possible.

If neither of these options is possible, the NF needs to contact the HCS social worker to see if it is possible to relocate the resident to a network provider or if there is good cause not to relocate a resident.

The HCS social worker determines if there is good cause not to relocate a resident and notifies the Coordination of Benefits (COB) unit at Health Care Authority (HCA):

  • Once good cause is determined and HCA COB has been notified, DSHS can approve the NF claim.

Complete instructions for the HCS social worker can be found in the LTC manual - Nursing Facility Case Management & Relocation under Home & Community Services Private Health Insurance and Good Cause Determinations.

Private payments in the month of application

  • A private payment in the form of a deposit or as part of a contract has no impact on the individual's eligibility for institutional care.
  • When a friend or relative makes a private payment for institutional care on the individual's behalf:
    • Determine eligibility as if the payment had not been made.
    • Once you determine the individual is eligible for institutional care for that month, the NF is required to refund the payment to the person who made it, then bill DSHS at the facility's DSHS contracted rate. The NF must accept the DSHS payment as "payment in full".
  • When an individual prepays a private payment for institutional care from his/her:
    • Income, determine eligibility as if the payment had not been made.
    • Resources, add the payment back to the individual's other resources. If total resources are:
      • At or below the institutional resource standard, determine eligibility as if the payment had not been made.
      • Above the institutional resource standard, consider reduction of resources by medical expenses (WAC 182-513-1350).
  • When an eligible individual prepays a private payment to the NF and the payment exceeds the individual's participation in the cost of care, the NF must refund the balance to the individual.

Private payment for extras

Don't consider the value of extras purchased by relatives or others for NF individuals (such as telephone, television set, radio, private room) as income if the following criteria is met:

  • Funds for payment of the extras are:
    • From a source other than the individual,
    • Not under the control of the individual and
    • Paid directly to the NF or other provider, and
  • The extras purchased are not covered by the medical care or institutional care program , and
  • The extras aren't required (implied or otherwise) by the NF as a condition for the individual to receive services covered by the Medicare or institutional care program.

Example: Jane Doe, a NF resident is eligible for CN and institutional care. Her daughter pays the NF directly for a telephone in Jane's room. Don't consider this payment as income to Jane since neither the medical care nor institutional care cover this service and the daughter pays directly to the NF

Medicaid supplementation in long-term settings from Washington LawHelp

Long-term care insurance and residential or in-home services

Report long-term care insurance for those applying or receiving in-home or residential long term services and supports on the Home and Community Services (HCS) Financial Eligibility and Policy (FEP) SharePoint page under the Notify Us tab LTC insurance workarounds.
Report long-term care insurance for those applying or receiving nursing facility or hospice as a program care to Mark Benya, Health Care Authority (HCA), Coordination of Benefits. 

Third-party resources and Medicaid

WAC 182-501-0200 Third-party resources

WAC 182-502-0100 (2) General conditions of payment (Medicaid the payer of last resort).

Payments from the Veteran's administration for aid and attendant care or unusual medical expenses (UME) are considered a third party resource. This applies to long-term care services such as nursing home or personal care services. Payments from the VA for aid and attendance or UME are not considered as income in initial or post eligibility. These payments are excluded from SSI related Medicaid eligibility per WAC 182-512-0840. It is essential to code these payments correctly in ACES so the payments aren't used to determine eligibility but applied as a third party resource toward long term care services.

Worker Responsibilities

Any health, dental, long-term care insurance or some other type of third-party insurance must be reported to coordination of benefits (COB) at Health Care Authority (HCA). This can be done by providing a:

The COB will receive an automatic assignment of the medical coverage information form, health insurance card or insurance policy once the document is imaged into the electronic case record (ECR).

Monitor resource eligibility on cases where LTC insurance payments exceed the cost of care.

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State-funded long-term care for noncitizens

Revised date
Purpose statement

There are 2 state-funded LTSS programs:

  1. WAC 182-507-0125 describes the state-funded long-term services and supports program for those needing LTSS outside of a hospital
    1. A slot for this program requires a pre-approval by Emily Watts, Residential Program Manager at Home and Community Services (HCS) headquarters.
    2. This program has limited funding by the legislature and is only for those not eligible for the state-funded Medical Care Services (MCS) program.
    3. The ACES program for nursing facility coverage is L04. The case will trickle to a L95 if income is over the special income level (SIL).
    4. The ACES program LTSS at home or in an alternate living facility is L24.
  2. WAC 182-508-0005 State-funded medical care services (MCS) program for those eligible for ABD cash and HEN eligibility described in 388-400-0060.
    1. Most individuals on MCS are legally admitted and in their 5-year bar for federal medicaid.
    2. This program only covers state-funded residential and nursing facility services. MCS does not require pre-approval for nursing facility or ALF admissions. There is no in-home services without an approved ETR by HCS HQ.
    3. The ACES code is A01, A05 and A24.

WAC 182-507-0125 State-funded long-term care services.

WAC 182-507-0125 State-funded long-term care services.

Effective August 26, 2024

  1. Caseload limits.
    1. The state-funded long-term care services program is subject to caseload limits determined by legislative funding.
    2. The aging and long-term support administration (ALTSA) or the developmental disabilities administration (DDA) must preauthorize state-funded long-term care service before payments begin.
    3. ALTSA or DDA cannot authorize a service, under chapter 388-106 WAC or under chapter 388-825 WAC, if doing so would exceed statutory caseload limits.
  2. Location of services. State-funded long-term care services may be provided in:
    1. The person's own home, defined in WAC 388-106-0010;
    2. An adult family home, defined in WAC 182-513-1100;
    3. An assisted living facility, defined in WAC 182-513-1100;
    4. An enhanced adult residential care facility, defined in WAC 182-513-1100;
    5. An adult residential care facility, defined in WAC 182-513-1100; or
    6. A nursing facility, defined in WAC 182-500-0050, but only if nursing facility care is necessary to sustain life; or
    7. A residential habilitation center, defined in WAC 388-835-0010, that is an intermediate care facility for individuals with intellectual disabilities (ICF/IID), defined in WAC 182-500-0050.
  3. Client eligibility. To be eligible for the state-funded long-term care services program, a person must meet all of the following conditions:
    1. General eligibility requirements for medical programs under WAC 182-503-0505, except (c) and (d) of this subsection;
    2. Be age 19 or older;
    3. Reside in one of the locations under subsection (2) of this section;
    4. Attain institutional status under WAC 182-513-1320;
    5. Meet the functional eligibility requirements under WAC 388-106-0355 for nursing facility level of care or under WAC 388-845-0030 for ICF/IDD level of care;
    6. Not have a penalty period due to a transfer of assets under WAC 182-513-1363;
    7. Not have equity interest in a primary residence more than the amount under WAC 182-513-1350; and
    8. Meet the requirements under chapter 182-516 WAC for annuities owned by the person or the person's spouse.
  4. General limitations.
    1. If a person entered Washington only to obtain medical care, the person is ineligible for state-funded long-term care services.
    2. The certification period for state-funded long-term care services may not exceed 12 months.
    3. People who qualify for state-funded long-term care services receive categorically needy (CN) medical coverage under WAC 182-501-0060.
  5. Supplemental security income (SSI)-related program limitations.
    1. A person who is related to the SSI program under WAC 182-512-0050 (1), (2), and (3) must meet the financial requirements under WAC 182-513-1315 to be eligible for state-funded long-term care services.
    2. An SSI-related person who is not eligible for the state-funded long-term care services program under CN rules may qualify under medically needy (MN) rules under WAC 182-513-1395.
    3. The agency determines how much an SSI-related person is required to pay toward the cost of care, using:
      1. WAC 182-513-1380, if the person resides in a nursing facility or residential habilitation center.
      2. WAC 182-515-1505 or 182-515-1510, if the person resides in one of the locations listed in subsection (2)(a) through (e) of this section.
  6. Modified adjusted gross income (MAGI)-based program limitations.
    1. A person who is related to the MAGI-based program may be eligible for state-funded long-term care services under this section and chapter 182-514 WAC if the person resides in a nursing facility.
    2. A MAGI-related person is not eligible for residential or in-home care state-funded long-term care services unless the person also meets the SSI-related eligibility criteria under subsection (5)(a) of this section.
    3. A MAGI-based person does not pay toward the cost of care in a nursing facility.
  7. Current resource, income, PNA, and room and board standards are found at www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/program-standard-income-and-resources.

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.

ALTSA/HCS headquarters must track each case using the state funds to pay for long-term care services under this program.

The following must be reported to Residential Policy Program Manager, Emily Watts.

  • New admits. Include the date and facility.
  • Discharges. Include the date and circumstances.

Any closures. Include the date and circumstances.

Specialty hospital unit for AEM coverage

Most admissions into the state-funded long-term care program start out in a hospital. Hospital applications are completed by a specialty hospital unit at CSD for a determination of AEM for those 65 and older and not eligible for the MAGI AEM program.

The HBE determines the eligibility for individuals receiving Health Care Coverage under the Modified Adjusted Gross Income (MAGI) method.

This unit refers to HCA medical consultant for possible AEM coverage in the hospital.

Prior to admission into a NF, a prior approval by the HCS residential program manager is needed. Even if there is an approval of AEM in the hospital, AEM does not cover NF admissions.

Once an AEM Hospital case has been approved a NF slot by HCS HQ, HCS financial staff will transfer the case into HCS for maintenance and tracking.

Example #1: Joe Smith is approved through 10/31/2009 under the federal AEM program. The federal AEM program for nursing home ended on 10/31/2009. Effective 11/1/2009, this client was grandfathered into the state-funded nursing facility program as Mr. Smith is still in need of nursing home care. The medical coverage group in ACES is an L04.

Example #2: Jane Smith has been in a hospital for six months. All options for alternative settings has been explored by the hospital. She must either remain in the hospital indefinitely or be placed in a nursing home.

She is assessed by the HCS social worker and meets NFLOC. The HCS office handling the assessment contacts HCS headquarters for an available slot under the state-funded long-term care program. Once headquarters approves a slot and the client is financially and resource eligible, an L04 is opened in ACES. The nursing home will be able to admit Jane and bill under the state-funded nursing facility program.

Example #3: Jayna Smith is a legally admitted noncitizen in the 5-year bar.

Jayna is over 65, has been hospitalized, and needs nursing facility care due to a stroke. She has been assessed by the HCS SW and meets NFLOC.

Jayna can be opened on ABD cash and state funded MCS medical. There is no need to refer for the state-funded funded nursing facility program.

MCS placements do not need a preapproval by HCS HQ.

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Hospice index

Revised date
Purpose statement

To provide an overview of the Hospice program and explain how to correctly determine eligibility for hospice.

WAC 182-513-1240 The hospice program

WAC 182-513-1240 The hospice program

Effective February 25, 2023

  1. General information.
    1. The hospice program provides palliative care to people who elect to receive hospice services and are certified as terminally ill by their physician.
    2. Program rules governing election of hospice services are under chapter 182-551 WAC.
    3. A person may revoke an election to receive hospice services at any time by signing a revocation statement.
    4. Transfer of asset rules under WAC 182-513-1363 do not apply to the hospice program in any setting, regardless of which apple health program the person is eligible to receive.
  2. When hospice is a covered service.
    1. A person who receives coverage under a categorically needy (CN), medically needy (MN), or alternative benefits plan (ABP) program is eligible for hospice services as part of the program specific benefit package.
    2. A person who receives coverage under the alien emergency medical (AEM) program under WAC 182-507-0110 may be eligible for payment for hospice services if preapproved by the agency.
    3. A person who receives coverage under the medical care services (MCS) program is not eligible for coverage of hospice services.
  3. When HCB waiver rules are used to determine eligibility for hospice.
    1. A person who is not otherwise eligible for a CN, MN, or ABP noninstitutional program who does not reside in a medical institution, may be eligible for CN coverage under the hospice program by using home and community based (HCB) waiver rules under WAC 182-515-1505 to determine financial eligibility.
    2. When HCB waiver rules are used, the following exceptions apply:
      1. A person on the hospice program may reside in a medical institution, including a hospice care center, 30 days or longer and remain eligible for hospice services; and
      2. A person residing at home on the hospice program who has available income over the special income limit (SIL), defined under WAC 182-513-1100, is not eligible for CN coverage. If available income is over the SIL, the agency or its designee determines eligibility for medically needy coverage under WAC 182-519-0100.
    3. When HCB waiver rules are used, a person may be required to pay income and third-party resources (TPR) as defined under WAC 182-513-1100 toward the cost of hospice services. The cost of care calculation is described under WAC 182-515-1509.
    4. When a person already receives HCB waiver services and elects hospice, the person must pay any required cost of care towards the HCB waiver service provider first.
  4. Eligibility for hospice services in a medical institution:
    1. A person who elects to receive hospice services, resides in a medical institution for 30 days or longer, and has income:
      1. Equal to or less than the SIL is income eligible for CN coverage. Eligibility for institutional hospice is determined under WAC 182-513-1315; or
      2. Over the SIL may be eligible for MN coverage under WAC 182-513-1245.
    2. A person eligible for hospice services in a medical institution may have to pay toward the cost of nursing facility or hospice care center services. The cost of care calculation is under WAC 182-513-1380.
  5. Changes in coverage. The agency or its designee redetermines a person's eligibility under WAC 182-504-0125 if the person:
    1. Revokes the election of hospice services and is eligible for coverage using HCB waiver rules only, described in subsection (3) of this section; or
    2. Loses CN, MN, or ABP eligibility.
  6. Personal needs allowance and income and resource standards for hospice and home and community based (HCB) waiver programs are found at www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/program-standard-income-and-resources.

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.

WAC 182-513-1245 Medically needy hospice in a medical institution.

WAC 182-513-1245 Medically needy hospice in a medical institution.

Effective February 20, 2017

  1. General information.
    1. When living in a medical institution, a person may be eligible for medically needy coverage under the hospice program. A person must:
      1. Meet program requirements under WAC 182-513-1315;
      2. Have available income that exceeds the special income level (SIL), defined under WAC 182-513-1100, but is below the institution's monthly state-contracted rate;
      3. Meet the financial requirements of subsection (4) or (5) of this section; and
    2. Elect hospice services under chapter 182-551 WAC.
  2. Financial eligibility.
    1. The agency or its designee determines a person's resource eligibility, excess resources, and medical expense deductions using WAC 182-513-1350.
    2. The agency or its designee determines a person's countable income by:
      1. Excluding income under WAC 182-513-1340;
      2. Determining available income under WAC 182-513-1325 or 182-513-1330;
      3. Disregarding income under WAC 182-513-1345; and
      4. Deducting medical expenses that were not used to reduce excess resources under WAC 182-513-1350.
  3. Determining the state-contracted daily rate in an institution, and the institutional medically needy income level (MNIL).
    1. The agency or its designee determines the state-contracted daily rate in an institution and the institutional MNIL based on the living arrangement, and whether the person is entitled to receive hospice services under medicare.
    2. When the person resides in a hospice care center:
      1. If entitled to medicare, the state-contracted daily rate is the state-contracted daily hospice care center rate. The institutional MNIL is calculated by multiplying the state-contracted daily rate by 30.42.
      2. If not entitled to medicare, the state-contracted daily rate is the state-contracted daily hospice care center rate, plus the state-contracted daily hospice rate. To calculate the institutional MNIL, multiply the state-contracted daily rate by 30.42.
    3. When the person resides in a nursing facility:
      1. If entitled to medicare, the state-contracted daily rate is ninety-five percent of the nursing facility's state-contracted daily rate. The institutional MNIL is calculated by multiplying the state-contracted daily rate by 30.42.
      2. If not entitled to medicare, the state-contracted daily rate is ninety-five percent of the nursing facility's state-contracted daily rate, plus the state-contracted daily hospice rate. The institutional MNIL is calculated by multiplying the state-contracted daily rate by 30.42.
  4. Eligibility for agency payment to the facility for institutional hospice services and the MN program.
    1. If a person's countable income plus excess resources is less than or equal to the state-contracted daily rate under subsection (3) of this section times the number of days the person has resided in the medical institution, the person:
      1. Is eligible for agency payment to the facility for institutional hospice services;
      2. Is approved for MN coverage for a twelve-month certification period;
    2. Pays excess resources under WAC 182-513-1350; and
    3. Pays income towards the cost of care under WAC 182-513-1380.
  5. Eligibility for institutional MN spenddown.
    1. If a person's countable income is more than the state-contracted daily rate times the number of days the person has resided in the medical institution, but less than the institution's private rate for the same period, the person:
      1. Is not eligible for agency payment to the facility for institutional hospice services; and
      2. Is eligible for the MN spenddown program for a three-month or six-month base period when qualifying medical expenses meet a person's spenddown liability.
    2. Spenddown liability is calculated by subtracting the institutional MNIL from the person's countable income for each month in the base period. The values from each month are added together to determine the spenddown liability.
    3. Qualifying medical expenses used to meet the spenddown liability are described in WAC 182-519-0110, except that only costs for hospice services not included within the state-contracted daily rate are qualifying medical expenses.
  6. Eligibility for MN spenddown.
    1. If a person's countable income is more than the institution's private rate times the number of days the person has resided in the medical institution, the person is not eligible for agency payment to the facility for institutional hospice services and institutional MN spenddown; and
    2. The agency or its designee determines eligibility for MN spenddown under chapter 182-519 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.

Hospice Clarifying Information

Worker Responsibilities

Hospice agency contacts

Hospice agencies FAX the HCA 13-746 Hospice notification form to the HCA DMS HUB at: 360-725-1965.

Hospice agency contacts
Address, phone numbers and provider numbers. This link lists the Hospice Care Centers. Hospice Care Centers are considered medical institutions.

Please report broken links or content problems.

Administrative hearing decision

Revised date
Purpose statement

To clarify the different types of orders and decisions that may be issued during an administrative hearing on eligibility for Apple Health programs.

WAC 182-526-0195 Prehearing conferences.

WAC 182-526-0195 Prehearing conferences.

Effective September 27, 2021

  1. Unlike a prehearing meeting, a prehearing conference is a formal proceeding conducted on the record by an administrative law judge (ALJ) to address issues and prepare for a hearing.
    1. The ALJ must make an audio record of the prehearing conference.
    2. An ALJ may conduct the prehearing conference in person, by telephone, or in any other manner acceptable to the parties.
  2. All parties must attend the prehearing conference. If the party who requested the hearing does not attend the prehearing conference, the ALJ may enter an order of default and an order dismissing the hearing.
  3. The ALJ may require a prehearing conference. Any party may request a prehearing conference.
  4. The ALJ must grant the appellant's, and may grant the managed care organization's or the agency representative's, first request for a prehearing conference if it is filed with the office of administrative hearings (OAH) at least seven business days before the scheduled hearing date.
  5. When the ALJ grants a party's request for a prehearing conference, the ALJ must continue the previously scheduled hearing when necessary to comply with notice requirements in this section.
  6. The ALJ may grant additional requests for prehearing conferences.
  7. The office of administrative hearings (OAH) must schedule prehearing conferences for all cases which concern:
    1. The department's division of residential care services under Title XIX of the federal Social Security Act.
    2. Provider and vendor overpayment hearings.
    3. Estate recovery and predeath liens.
  8. During a prehearing conference the parties and the ALJ may:
    1. Simplify or clarify the issues to be decided during the hearing;
    2. Agree to the date, time, and place of the hearing;
    3. Identify any accommodation or safety issues;
    4. Agree to postpone the hearing;
    5. Allow the parties to make changes in their own documents, including the notice or the hearing request;
    6. Agree to facts and documents to be entered during the hearing;
    7. Set a deadline to exchange names and phone numbers of witnesses and documents before the hearing;
    8. Schedule additional prehearing conferences;
    9. Resolve the dispute;
    10. Consider granting a stay if authorized by law or program rule; or
    11. Rule on any procedural issues and substantive motions raised by any party.
  9. After the prehearing conference, the ALJ must enter a written order describing:
    1. The actions taken at the prehearing conference;
    2. Any changes to the documents;
    3. A statement of the issue or issues identified for the hearing;
    4. Any agreements reached; and
    5. Any ruling of the ALJ.
  10. OAH must serve the prehearing order on the parties at least fourteen calendar days before the scheduled hearing.
  11. A party may object to the prehearing order by notifying OAH in writing within ten calendar days after the mailing date of the order. The ALJ must issue a ruling on the objection within five days from the date a party files an objection.
  12. If no objection is made to the prehearing order, the order determines how the hearing is conducted, including whether the hearing will be in person or held by telephone conference or other means, unless the ALJ changes the order for good cause.
  13. The ALJ may take further appropriate actions to address other concerns raised by the parties.

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.

WAC 182-526-0255 Notice of hearing or notice of prehearing conference.

WAC 182-526-0255 Notice of hearing or notice of prehearing conference.

Effective March 16, 2017

  1.  
    1. A notice of hearing or a notice of prehearing conference is a written notice issued by the office of administrative hearings (OAH) that must include the:
      1. Names of all parties to whom the notice is sent and, if known, the names and addresses of their representatives;
      2. Name, mailing address, and telephone number of the administrative law judge (ALJ), if known;
      3. Date, time, place, and nature of the hearing or prehearing conference;
      4. Legal authority and jurisdiction for the hearing; and
      5. Date of the hearing request.
    2. A notice of hearing or prehearing conference must include a statement that the appellant's failure to attend the prehearing conference or hearing may result in the loss of the right to a hearing.
    3. If the appellant fails to appear, the ALJ may enter an order of default.
  2. Limited-English proficiency. The notice must include a statement that, if the appellant needs a qualified interpreter because they or any of their witnesses are people with limited-English proficiency, OAH will provide an interpreter at no cost to that party.
  3. The notice must state whether the hearing or prehearing conference is to be held by telephone or in person, and how to request a change in the way it is held.
  4. The notice of hearing or prehearing conference informs the appellant:
    1. How to indicate any special needs for the appellant or their witnesses, including the need for an interpreter in a primary language or for sensory impairments;
    2. How to contact OAH if a party has a safety concern; and
    3. That the appellant may request a qualified interpreter if the appellant or any of the appellant's witnesses are people with limited-English proficiency, and that OAH provides such interpreters at no cost to the appellant.

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.

WAC 182-526-0280 Continuing a hearing when an appellant is an applicant or recipient.

WAC 182-526-0280 Continuing a hearing when an appellant is an applicant or recipient.

Effective January 5, 2018

  1. Any party may request a continuance under this section either orally or in writing.
  2. Before contacting the office of administrative hearings (OAH) to request a continuance, the party seeking the continuance must make a good faith effort to contact the other parties to find out if they agree to a continuance. The party making the request for a continuance must let OAH know whether the other parties agreed to the continuance.
  3. Standard when less than sixty days. When a continuance request is made less than sixty days from the date OAH received the hearing request:
    1. If all parties agree to the continuance, the ALJ must grant the request unless the ALJ holds a prehearing conference and finds that good cause for a continuance does not exist under WAC 182-526-0020.
    2. If the parties do not agree to the continuance, the ALJ must schedule a prehearing conference and determine if good cause for a continuance exists under WAC 182-526-0020 and under the following factors:
      1. Why the party is requesting a continuance;
      2. Why the other party or parties are objecting to the request;
      3. Whether a continuance in the case has previously been granted at the request of the same party who is now requesting the continuance and, if so, whether it was for the same reason;
      4. The extent to which the requesting or objecting parties could have prevented the need for delay;
      5. The number and duration of previous continuances in the case and who requested them;
      6. The legal or factual complexity of the case;
      7. The relative harm to the parties if the continuance is granted or denied, including the risk of harm to the appellant if he or she is not receiving continued benefits;
      8. The impact of a continuance on the parties' ability to adequately prepare and present their cases;
      9. Any need to provide accommodation, translation, or interpreter services; and
      10. The impact of a continuance on the ability of OAH to issue a timely initial decision; or
      11. Other relevant factors.
  4. Standard when sixty days or greater. When a continuance request is made sixty days or more from the date OAH received the hearing request:
    1. The ALJ must not only consider whether there is good cause to continue the hearing but also must find a compelling reason for the continuance.
    2. Compelling reasons include:
      1. Medical evidence is required;
      2. Extraordinary circumstances exist, such as the sudden unforeseen onset of an illness or adverse event that was beyond the party's ability to prevent;
      3. The hearing format changes or the ALJ finds a compelling reason to change the way a witness appears at the hearing according to WAC 182-526-0360;
      4. The appellant needs more time to prepare or present evidence or argument because the agency issued an amended notice under WAC 182-526-0260;
      5. The need for more time was caused by another party's action or inaction, considering the relative capacity and resources of the parties;
      6. The need to provide accommodation, translation, or interpreter services;
      7. A party received notice of the date or deadline thirty days or more after OAH received the hearing request;
      8. Whether the continuance is needed to allow for effective assistance of counsel of record; or
      9. Other compelling reasons.
  5. The ALJ must notify all parties whether a continuance was granted or denied orally on the record, or must do so in writing within five business days of the prehearing conference.
  6. If the ALJ grants a continuance, OAH must serve a new notice of hearing on the parties at least fourteen calendar days before the new hearing date, unless the parties agree to a shorter time period.

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.

WAC 182-526-0285 Orders of dismissal.

WAC 182-526-0285 Orders of dismissal.

Effective August 18, 2018

  1. An order of dismissal may be entered when the appellant withdraws the request for hearing under WAC 182-526-0115.
  2. An appellant may file a petition (request) to vacate an order of dismissal under WAC 182-526-0290.
  3. An order of dismissal becomes a final order by operation of law, disposing of the appellant's request for a hearing under RCW 34.05.440 if:
    1. The appellant fails to appear at a prehearing conference scheduled to address the petition to vacate under WAC 182-526-0290 (3) and (4) (a).
  4. The health care authority or managed care organization action stands after an order of dismissal becomes a final order.
  5. The appellant may seek judicial review of a final order of dismissal to the superior court under WAC 182-526-0640.

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.

WAC 182-526-0520 Information which must be included in the ALJ's initial order.

WAC 182-526-0520 Information which must be included in the ALJ's initial order.

Effective March 16, 2017

In an initial order, the administrative law judge (ALJ) must:

  1. Identify the matter as a health care authority appeal;
  2. List the name and docket number of the case and the names of all parties and representatives;
  3. Make findings concerning the facts used to resolve the dispute based on the hearing record;
  4. Explain how the ALJ determined that evidence is credible or not credible when the facts or conduct of a witness is questioned;
  5. State the law that applies to the dispute;
  6. Apply the law to the facts of the case in the conclusions of law;
  7. Discuss the reasons for the decision based on the facts and the law;
  8. State the result and remedy ordered;
  9. Explain how to request corrections to the initial order or petition for review by the board of appeals (BOA) and provide the deadlines for such requests;
  10. State the date the initial order becomes final according to WAC 182-526-0525; and
  11. Include any other information required by law or program rules.

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.

WAC 182-526-0525 When initial orders become final.

WAC 182-526-0525  When initial orders become final.

Effective March 16, 2017

An initial order becomes a final order at 5:00 p.m. on the twenty-first calendar day after the office of administrative hearings (OAH) serves the initial order, unless:

  1. Any party files a request for review of the initial order within twenty-one calendar days of the serving (mailing) of the initial order in accordance with WAC 182-526-0580(1);
  2. Any party files a request for extension of the deadline for filing a request for review which is granted by the review judge under WAC 182-526-0580(2); or
  3. Any party files a late request for review which is accepted by a review judge in accordance with WAC 182-526-0580(3);
  4. A managed care enrollee requests review by an independent review (IR) organization in accordance with RCW 48.43.535 prior to the initial order becoming final or a final order being entered by a review judge. See WAC 182-526-0200 for enrollee appeals.

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.

WAC 182-526-0530 How to correct or appeal an initial order

WAC 182-526-0530 How to correct or appeal an initial order.

Effective February 1, 2013

  1. If a party disagrees with an administrative law judge's (ALJ) initial order because of a clerical error, the party may ask for a corrected initial order from the ALJ as provided in WAC 182-526-0540 through 182-526-0555.
  2. If a party disagrees with an initial order for a reason other than a clerical error and wants the initial order changed, the party must request review by a review judge as provided in WAC 182-526-0560 through 182-526-0595.

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.

WAC 182-526-0605 Reconsideration of a final order entered by a review judge.

WAC 182-526-0605 Reconsideration of a final order entered by a review judge.

Effective March 16, 2017

  1. If a party does not agree with the final order and wants it reconsidered, the party may request the review judge to reconsider the decision.
  2. The party must make the request in writing and clearly state why the party wants the final order reconsidered. The party must file the written reconsideration request with the BOA and it must be received by the deadline under WAC 182-526-0620.
  3. The party should send a copy of the request to all other parties or their representatives.
  4. After receiving a reconsideration request, BOA serves a copy to the other parties and representatives and gives them time to respond.
  5. The final order or the reconsideration decision is the final HCA decision. If a party disagrees with that decision, the party must petition for judicial review to change it.
  6. If a party asks for reconsideration of the final order, the reconsideration process must be completed before a party requests judicial review. However, the party does not need to request reconsideration of a final order before requesting judicial review.
  7. The party may ask the court to stay or stop the HCA action after filing the petition for judicial review.

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

The clarifying information on this page applies to eligibility decisions for Apple Health programs.

Acronyms and definitions

An administrative law judge (ALJ) is an impartial decision-maker who is an attorney and presides at an administrative hearing. ALJs are employed by the office of administrative hearings (OAH), which is a separate state agency, as defined in RCW 34.05.010. ALJs are not Department of Social and Health Services or Health Care Authority (HCA) employees or representatives.

An appellant is a person or entity who requests a hearing about an action of HCA or its designee.

The hearing record is the official documentation of the hearing process. The record includes recordings or transcripts, admitted exhibits, decisions, briefs, notices, orders, and other filed documents.

Find out what the Office of Administrative Hearings (OAH) does in the appeals process.

Types of orders

  1. Prehearing meeting (WAC 182-526-0175): This is an informal meeting between HCA and the appellant and does not involve the ALJ. It can take place by phone, email, or in-person. The purpose is to:
    1. Clarify the issue(s).
    2. Exchange information.
    3. Resolve any issues through an agreement or withdrawal.
    4. Explain any rules or laws and answer questions.
  2. Notice of hearing (182-526-0255): This is a formal notice of the date, time, and location of the administrative hearing. This notice is sent to all parties, including the appellant and all agencies involved, such as HCA, DSHS (if the hearing is about a Classic Medicaid case), and OAH. It includes:
    1. A copy of the request for an administrative hearing
    2. Contact information for the parties
    3. The docket numbers,
    4. A summary of the appellant's legal rights
    5. A referral to potentially free legal resources that are available.
  3. Prehearing conference (WAC 182-526-0195): This is a formal notice of a meeting mailed to all parties and includes HCA, the appellant, and an ALJ. This can be used to:
    1. Clarify any issues
    2. Set deadlines,
    3. Agree to a continuance,
    4. Resolve the dispute,
    5. Determine eligibility for continued coverage,
    6. Address other issues.

      If the appellant fails to show, the ALJ may issue an order of default and dismiss the hearing.

  4. Order of dismissal (WAC 182-526-0285): This is an order issued by an ALJ when an appellant withdraws the hearing request or does not appear for the hearing. The most common reasons for an order of dismissal are:
    1. Default/no show: The appellant fails to appear.
    2. Withdrawal: The appellant withdrew their request for hearing.

      An appellant can request in writing that an Order of Dismissal be vacated (i.e., canceled) or set aside (see WAC 182-526-0290). A prehearing conference is scheduled. The ALJ issues a written order which will explain whether the appellant has established good cause (see WAC 182-526-0020) to have the hearing reinstated. If the ALJ determines good cause exists to vacate the dismissal order, the ALJ schedules a hearing.

  5. Order of Continuance (WAC 182-526-0280): A continuance is a rescheduling of a hearing to a later time or date. If a party would like a continuance, the party must see if the other parties agree. If so, an order of continuance is issued by OAH. If any of the other parties disagrees with the continuance, a prehearing conference is held. The ALJ either approves or denies the continuance request after the conference.
  6. Initial decision (WACs 182-526-0520 to 182-526-0595): The decision issued by the ALJ who presided at the hearing. The initial decision becomes the final decision if it is not appealed by either party within 21 calendar days after OAH mails the order. The ALJ who conducted the hearing is responsible for writing the initial decision and mail a copy to all parties. The order will:
    1. List all parties, witnesses, and exhibits (evidence).
    2. Determine the facts of the case.
    3. Explain why evidence or a witness is or is not credible.
    4. State the applicable laws and rules that apply to the issue.
    5. Discuss the reasons for the decision and how the laws apply to it.
    6. State the result and remedy being ordered and
    7. Explain the appeals process.
  7. Request for Reconsideration (WAC 182-526-0560 to 182-526-0635): When the ALJ issues an initial order, any party may request the ALJ to reconsider the decision. The request for reconsideration must be received by OAH on or before the 10th calendar day after the initial order was mailed. The ALJ can only consider evidence that was presented in the hearing unless the ALJ reopens the hearing record (see WAC 182-526-0500). The ALJ will issue a written order in response to the request for reconsideration.
  8. Judicial Review (WACs 182-526-0640 to 182-526-0650): Only the appellant has the right to request a judicial review of the final agency decision in superior court. Instructions regarding requesting judicial review are attached to the initial decision.

Worker responsibilities

When a decision is received, document in the ACES narrative the docket number, the type of decision, and the date of mailing. Include any other information necessary, including the outcome of the hearing.

  1. Order of Dismissal:
    1. Default/no show: If the hearing notice was sent to the appellant's reported address and the appellant failed to appear:
      1. document the ACES narrative, and
      2. file the decision with any related documents in the case record.

Note: If the hearing notice was sent to an address other than the appellant's reported address or there is some other reason that the notice of hearing was not properly delivered, contact the OAH and provide the correct address or other information needed to deliver the notice.

  1. Withdrawal: Document the ACES narrative and send the decision, with the request for withdrawal and any other related documents, to be imaged into Barcode.
  2. Reversed decisions: When the agency's decision is reversed, immediately:
    1. Review the decision to determine if a request for reconsideration is needed. If so:
      1. Document in ACES the reason for the request for reconsideration.
      2. Send the request to OAH with a copy to the appellant.
    2. If no request for reconsideration is needed:
      1. Reopen or approve coverage back to the date the action took place.
      2. Document the actions and decision and
      3. Send a letter to the household advising them of the hearing outcome and action taken to approve coverage.
  3. Affirmed decisions: When the agency's decision is affirmed, immediately:
    1. Terminate continued coverage. Adequate notice must be provided to the appellant, but advance notice is not required.
    2. Review the period of continued coverage, and establish overpayments as appropriate.
    3. Document in ACES the decision.
  4. Petition for review of initial decision:
    1. After implementing the initial decision, determine if a review is appropriate:
      1. Consult with a supervisor, administrator, or program manager, as appropriate.
      2. Consult with training or program management staff (i.e., Office of Medicaid Eligibility and Policy), if necessary.
    2. If the decision is made to petition for a review of the initial decision, prepare a memorandum for the Board of Appeals. Include:
      1. Appellant's name and docket number.
      2. All areas in which the agency believes the ALJ erred. See WAC 182-526-0575 for the review standard. The review judge usually only addresses areas that have been raised in the petition. Refer to findings of fact and conclusions of law by the number assigned in the decision.
      3. Cite WACs, findings of fact, or evidence in the record that support the agency's argument.
      4. New evidence which affects the decision and was not available for the initial hearing (even after reasonable diligence) can be brought up in the review.
      5. A request for the review judge to find in the agency's favor.
    3. Ensure the review is sent to the Board of Appeals and all other parties within the stated deadlines.
  5. Appellant petition for review:
    1. Do not reinstate continued coverage pending a review of the initial decision requested by the appellant.
    2. Review the appellant's petition to determine an appropriate response.
    3. If a response is required, prepare a memorandum to the Board of Appeals and include:
      1. The appellant's name and the docket number.
      2. A response which speaks only to the issues raised by the appellant.
      3. Argument which supports the finding in the initial decision.
    4. Ensure the response is sent to the Board of Appeals and all other parties within the stated deadlines.
  6. Receipt of review decision:
    1. Implement the review decision immediately.
    2. See WAC 182-526-0605 to determine if a request for reconsideration is appropriate.
    3. If a reconsideration is appropriate, prepare a memorandum to the Board of Appeals including the specific reason why the department does not agree with the review decision.

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