WAC 182-526-0005 Purpose and scope

WAC 182-526-0005 Purpose and scope.

Effective February 7, 2025

  1. This chapter:
    1. Describes the general hearing rules and procedures that apply to the resolution of disputes between an appellant and the health care authority (HCA), an agency designee, or an HCA-contracted managed care organization (MCO) or health plan, or a dispute involving an assessed overpayment by HCA against an HCA-contracted MCO or health plan, involving:
    2. Medical services programs established under chapter 74.09 RCW including, but not limited to, Washington apple health fee-for service, integrated managed care (see chapters 182-538 and 182-538B WAC), and crisis and noncrisis services in (see chapters 182-538C);
    3. Washington apple health expansion (see chapters 182-525, 182-525A, and 182-525B WAC); and
    4. The prescription drug pricing transparency program in chapter 182-51 WAC and the all payer health care claims database rules in chapter 182-70 WAC.
    5. Supplements the Administrative Procedure Act (APA), chapter 34.05 RCW, and the model rules, chapter 10-08 WAC, adopted by the office of administrative hearings (OAH).
    6. Establishes rules encouraging informal dispute resolution between the health care authority (HCA), its authorized agents, or an HCA-contracted MCO or health plan, and people or entities who disagree with its actions.
  2. Unless specifically excluded by this chapter or program rules, this chapter regulates all hearings involving:
    1. Medical services programs established under chapter 74.09 RCW including, but not limited to, managed care in chapters 182-538, 182-538A, and 182-538B WAC, and crisis and noncrisis services in chapter 182-538C WAC;
    2. Apple health expansion eligibility or services as described in chapters 182-525, 182-525A, and 182-525B WAC; and
    3. Prescription drug pricing transparency program in chapter 182-51 WAC and the all payer health care claims database rules in chapter 182-70 WAC. 
  3. Nothing in this chapter is intended to affect the constitutional rights of any person or to limit or change additional requirements imposed by statute or other rule. Other laws or rules determine if a hearing right exists, including the APA and program rules or laws.
  4. If there is a conflict between this chapter and specific program rules, the specific program rules prevail. HCA's hearing rules and program rules prevail over the model hearing rules in chapter 10-08 WAC.
  5. The hearing rules in this chapter do not apply to the public employees benefits board program (see chapter 182-16 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.

WAC 182-523-0130 Medical extension--Redetermination

WAC 182-523-0130 Medical extension--Redetermination.

Effective August 24, 2014

  1. When the agency or its designee determines the family or an individual family member is ineligible during the medical extension period, the agency or its designee must determine if they are eligible for another medical program.
  2. Children are eligible for twelve month continuous eligibility beginning with the first month of the medical extension period.
  3. When a family reports a reduction of income, the family may be eligible for the Washington apple health for parents and caretaker relatives program (described in WAC 182-505-0240) instead of medical extension benefits.
  4. When a medical extension period is ending, the family is required to complete a renewal of eligibility as described in WAC 182-504-0035.
  5. Postpartum and family planning extensions are described in WAC 182-505-0115.

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 182-523-0100 Washington apple health--Medical extension

WAC 182-523-0100 Washington apple health--Medical extension.

Effective December 28, 2019

  1. A parent or caretaker relative who was eligible for and who received coverage under Washington apple health for parents and caretaker relatives, described in WAC 182-505-0240, in any three of the last six months is eligible, along with all dependent children living in the household, for twelve months' extended health care coverage if the person becomes ineligible for coverage due to increased earnings or hours of employment.
  2. A person remains eligible for apple health medical extension unless:
    1. The person:
      1. Moves out of state;
      2. Dies; or
      3. Leaves the household.
    2. The family:
      1. Moves out of state;
      2. Loses contact with the agency or its designee or the whereabouts of the family are unknown; or
      3. No longer includes an eligible dependent child as defined in WAC 182-503-0565(2).
  3. When a person or family is determined ineligible for apple health coverage under subsection (2)(a)(i) through (iii) or (b)(i) or (ii) of this section during the medical extension period, the agency or its designee redetermines eligibility for the remaining household members as described in WAC 182-504-0125 and sends written notice as described in chapter 182-518 WAC before apple health medical extension is terminated.

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 182-520-0010 Washington apple health overpayments resulting from an administrative hearing

WAC 182-520-0010 Washington apple health overpayments resulting from an administrative hearing.

Effective July 14, 2016.

  1. If a person asks for Washington apple health coverage to continue during an appeal, he or she must pay the agency for the cost of that coverage if both (a) and (b) of this subsection occur:
    1. The administrative law judge, or review judge if applicable, enters an order:
      1. That the person was not eligible for apple health coverage during the appeal;
      2. Dismissing the hearing under WAC 182-526-0285(3) because the person defaulted (did not attend or refused to participate) and the agency's action that was appealed included a finding that the person was not eligible for apple health coverage; or
      3. Dismissing the hearing under WAC 182-526-0285(4) due to a written agreement between all the parties that the person will pay for an overpayment of the cost of apple health coverage.
    2. The agency decides to collect the overpayment.
  2. The overpayment amount is limited to payments for apple health coverage that were spent:
    1. During the sixty days following receipt of the hearing request; and
    2. For a person who was not eligible for apple health coverage.
  3. The agency will not attempt to recover an apple health overpayment from a nonneedy caretaker relative or guardian except in the case of fraud by the caretaker relative or guardian as described in WAC 182-520-0005.

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 182-520-0005 Washington apple health fraud referrals and overpayments

WAC 182-520-0005 Washington apple health fraud referrals and overpayments.

Effective July 14, 2016.

  1. The agency or the agency's designee may refer a case to the office of fraud and accountability for a fraud investigation when it has reliable information that the person purposely misrepresented their circumstances in order to qualify for Washington apple health.
  2. When a fraud investigation reveals substantial evidence to support a finding of fraud, the case is referred for prosecution. The prosecuting attorney's office decides which cases will be prosecuted.
  3. When a referral results in a conviction, an overpayment amount for the cost of the apple health coverage is established.
  4. The person is responsible to pay the agency for the amount of overpayment established as a result of a fraud conviction.

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 182-519-0110 Spenddown of excess income for the medically needy program

WAC 182-519-0110 Spenddown of excess income for the medically needy program

Effective January 27, 2019

  1. A person who applies for Washington apple health (WAH) and is eligible for medically needy (MN) coverage with a spenddown may choose a three-month or a six-month base period. A base period is a time period used to compute the spenddown liability amount. The months must be consecutive calendar months, unless a condition in subsection (4) of this section applies.
  2. A base period begins on the first day of the month a person applies for WAH, unless a condition in subsection (4) of this section applies.
  3. A person may request a separate base period to cover up to three calendar months immediately before the month of application. This is called a retroactive base period.
  4. A base period may vary from the terms in subsections (1), (2), or (3) of this section if:
    1. A three-month base period would overlap a previous eligibility period;
    2. The person has countable resources over the applicable standard for any part of the required base period;
    3. The person is not or will not be able to meet the temporary assistance to needy families (TANF)-related or supplemental security income (SSI)-related requirement for the required base period;
    4. The person is eligible for categorically needy (CN) coverage for part of the required base period; or
    5. The person was not otherwise eligible for MN coverage for each month of the retroactive base period.
  5. The medicaid agency or its designee calculates a person's spenddown liability. The MN countable income from each month of the base period is compared to the effective medically needy income level (MNIL) under WAC 182-519-0050. Income over the effective MNIL standard (based on the person's household size) in each month in the base period is added together to determine the total spenddown amount.
  6. If household income varies and a person's MN countable income falls below the effective MNIL for one or more months, the difference offsets the excess income in other months of the base period. See WAC 182-519-0100(7) if a spenddown amount results in zero dollars and cents.
  7. If a person's income decreases, the agency or its designee approves CN coverage for each month in the base period when the person's countable income and resources are equal to or below the applicable CN standards. Children age eighteen and younger and pregnant women who become CN eligible in any month of the base period are continuously eligible for CN coverage for the remainder of the certification, even if there is a subsequent increase in income.
  8. Once a person's spenddown amount is determined, qualifying medical expenses are deducted. A qualifying medical expense must:
    1. Be an expense for which the person is financially liable;
    2. Not have been used to meet another spenddown;
    3. Not be the confirmed responsibility of a third party. The agency or its designee allows the entire expense if a third party has not confirmed its coverage of the expense within:
      1. Forty-five days of the date of service; or
      2. Thirty days after the base period ends.
    4. Be an incurred expense for the person:
      1. The person's spouse;
      2. A family member residing in the person's home for whom the person is financially responsible; or
      3. A relative residing in the person's home who is financially responsible for the person.
    5. Meet one of the following conditions:
      1. Be an unpaid liability at the beginning of the base period;
      2. Be for paid or unpaid medical services incurred during the base period;
      3. Be for medical services incurred and paid during the three-month retroactive base period if eligibility for WAH was not established in that base period. Paid expenses that meet this requirement may be applied towards the current base period; or
      4. Be for medical services incurred during a previous base period, either unpaid or paid, if it was necessary for the person to make a payment due to delays in the certification for that base period.
  9. An exception to subsection (8) of this section exists for qualifying medical expenses paid on the person's behalf by a publicly administered program during the current or the retroactive base period. The agency or its designee uses the qualifying medical expenses to meet the spenddown liability. To qualify for this exception, the program must:
    1. Not be federally funded or make payments from federally matched funds;
    2. Not pay the expenses before the first day of the retroactive base period; and
    3. Provide proof of the expenses paid on the person's behalf.
  10. Once the agency or its designee determines the expenses are a qualified medical expense under subsection (8) or (9) of this section, the expenses are subtracted from the spenddown liability to determine the date the person's eligibility for medical coverage begins. Qualifying medical expenses are deducted in the following order:
    1. First, medicare and other health insurance deductibles, coinsurance charges, enrollment fees, copayments, and premiums that are the person's responsibility under medicare Part A through Part D. (Health insurance premiums are income deductions under WAC 182-519-0100(5));
    2. Second, medical expenses incurred and paid by the person during the three-month retroactive base period if eligibility for WAH was not established in that base period;
    3. Third, current payments on, or unpaid balance of, medical expenses incurred before the current base period that were not used to establish eligibility for medical coverage in another base period. The agency or its designee sets no limit on the age of an unpaid expense; however, the expense must be a current liability and be unpaid at the beginning of the base period;
    4. Fourth, other medical expenses that are not covered by the agency's or its designee's medical programs, minus any third-party payments that apply to the charges. A licensed health care provider must provide or prescribe the items or services allowed as a medical expense;
    5. Fifth, other medical expenses incurred by the person during the base period that are potentially payable by the MN program (minus any confirmed third-party payments that apply to the charges). This deduction is allowed even if payment is denied for these services because they exceed the agency's or its designee's limits on amount, duration, or scope of care. Scope of care is described in WAC 182-501-0060 and 182-501-0065; and
    6. Sixth, other medical expenses incurred by the person during the base period that are potentially payable by the MN program (minus any confirmed third-party payments that apply to the charges) and that are within the agency's or its designee's limits on amount, duration, or scope of care.
  11. If a person submits verification of qualifying medical expenses with his or her application that meet or exceed the spenddown liability, the person is eligible for MN medical coverage for the remainder of the base period unless their circumstances change. See WAC 182-504-0105 to determine which changes must be reported to the agency or its designee. The beginning of eligibility is determined under WAC 182-504-0020.
  12. If a person cannot meet the spenddown amount when the application is submitted, the person is not eligible until he or she provides proof of additional qualifying expenses that meet the spenddown liability.
  13. Each dollar of a qualifying medical expense may count once against a spenddown period that leads to eligibility for MN coverage. However, medical expenses may be used more than once if:
    1. The person did not meet his or her total spenddown liability and become eligible in a previous base period and the bill remains unpaid; or
    2. The medical expense was incurred and paid within three months of the current application, and the agency or its designee could not establish WAH eligibility for the person in the retroactive base period.
  14. The person must provide the proof of qualifying medical expense information to the agency or its designee within thirty days after the base period ends, unless there is a good reason for delay.
  15. Once a person meets the spenddown requirement and the certification begin date is established, newly identified expenses are not considered toward that spenddown unless:
    1. There is a good reason for the delay in submitting the expense; or
    2. The agency or its designee made an error when determining the correct begin date.
  16. Good reasons for delay in providing medical expense information to the agency or its designee include, but are not limited to:
    1. The person did not receive a timely bill from his or her medical provider or insurance company;
    2. The person has medical issues that prevent him or her from submitting proof on time; or
    3. The person meets the criteria for needing equal access under chapter WAC 182-503-0120.
  17. The agency or its designee does not pay for any expense or portion of an expense used to meet a person's spenddown liability.
  18. If an expense is potentially payable under the MN program, and only a portion of the medical expense is assigned to meet spenddown, the medical provider must not:
    1. Bill the person for more than the amount assigned to the remaining spenddown liability; or
    2. Accept or retain any additional amount for the covered service from the person. Any additional amount may be billed to the agency or its designee. See WAC 182-502-0160, Billing a client.
  19. The agency or its designee determines whether any payment is due to the medical provider on medical expenses partially assigned to meet a spenddown liability under WAC 182-502-0100.
  20. If the medical expense assigned to spenddown was incurred outside of a period of MN eligibility, or if the expense is not covered by WAH, the agency or its designee does not pay any portion of the bill.

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 182-519-0100 Eligibility for the medically needy program

WAC 182-519-0100 Eligibility for the medically needy program

Effective January 27, 2019

  1. A person who meets the following conditions may be eligible for medically needy (MN) coverage under the special rules in chapters 182-513 and 182-515 WAC:
    1. Meets the institutional status requirements of WAC 182-513-1320;
    2. Resides in a medical institution as described in WAC 182-513-1395.
  2. A supplemental security income (SSI)-related person who lives in a medicaid agency-contracted alternate living facility may be eligible for MN coverage under WAC 182-513-1205.
  3. A person may be eligible for MN coverage under this chapter when he or she is:
    1. Not covered under subsection (1) and (2) of this section; and
    2. Eligible for categorically needy (CN) medical coverage in all other respects, except that his or her CN countable income is above the CN income standard.
  4. MN coverage may be available if the person is:
    1. A child;
    2. A pregnant woman;
    3. A refugee;
    4. An SSI-related person, including an aged, blind, or disabled person, with countable income under the CN income standard, who is an ineligible spouse of an SSI recipient; or
    5. A hospice client with countable income above the special income level (SIL).
  5. A person who is not eligible for CN medical who applies for MN coverage has the right to income deductions in addition to, or instead of, those used to calculate CN countable income. These deductions to income are applied to each month of the base period to calculate MN countable income:
    1. The agency disregards the difference between the medically needy income level (MNIL) described in WAC 182-519-0050 and the federal benefit rate (FBR) established by the Social Security Administration each year. The FBR is the one-person SSI payment standard;
    2. All health insurance premiums, except for medicare Part A through Part D premiums, expected to be paid by the person or family member during the base period or periods;
    3. Any allocations to a spouse or to dependents for an SSI-related person who is married or who has dependent children. Rules for allocating income are described in WAC 182-512-0900 through 182-512-0960;
    4. For an SSI-related person who is married and lives in the same home as his or her spouse who receives home and community-based waiver services under chapter 182-515 WAC, an income deduction equal to the MNIL, minus the nonapplying spouse's income; and
    5. A child or pregnant woman applying for MN coverage is eligible for income deductions allowed under temporary assistance for needy families (TANF) and state family assistance (SFA) rules and not under the rules for CN programs based on the federal poverty level. See WAC 182-509-0001(4) for exceptions to the TANF and SFA rules that apply to medical programs and not to the cash assistance program.
  6. The MNIL for a person who qualifies for MN coverage under subsection (1) of this section is based on rules in chapters 182-513 and 182-515 WAC.
  7. The MNIL for all other people is described in WAC 182-519-0050. If a person has countable income at or below the MNIL, the person is certified as eligible for up to 12 months of MN medical coverage.
  8. If a person has countable income over the MNIL, the countable income that exceeds the agency's MNIL standards is called "excess income."
  9. A person with "excess income" is not eligible for MN coverage until the person gives the agency or its designee evidence of medical expenses incurred by that person, their spouse, or family members living in the home for whom they are financially responsible. See WAC 182-519-0110(8). An expense is incurred when:
    1. The person receives medical treatment or medical supplies, is financially liable for the medical expense, and has not paid the bill; or
    2. The person pays for the expense within the current or retroactive base period under WAC 182-519-0110.
  10. Incurred medical expenses or obligations may be used to offset any portion of countable income that is over the MNIL. This is the process of meeting "spenddown."
  11. The agency or its designee calculates the amount of a person's spenddown by multiplying the monthly excess income amount by the number of months in the certification period under WAC 182-519-0110. The qualifying medical expenses must be greater than or equal to the total calculated spenddown amount.
  12. A person who is considered for MN coverage under this chapter may not spenddown excess resources to become eligible for the MN program. Under this chapter, a person is ineligible for MN coverage if the person's resources exceed the program standard in WAC 182-519-0050. A person who is considered for MN coverage under WAC 182-513-1395, 182-514-0250 or 182-514-0263 is allowed to spenddown excess resources.
  13. There is no automatic redetermination process for MN coverage. A person must apply for each eligibility period under the MN program.
  14. A person who requests a timely administrative hearing under WAC 182-518-0025 is not eligible for continued benefits beyond the end of the original certification date under the MN program.

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 182-519-0050 Monthly income and countable resource standards for medically needy (MN)

WAC 182-519-0050 Monthly income and countable resource standards for medically needy (MN).

Effective February 10, 2023

  1. Changes to the Medically Needy Income Level (MNIL) occur on January 1st of each calendar year when the Social Security Administration (SSA) issues a cost-of-living adjustment.
  2. Medically Needy (MN) standards for people who meet institutional status requirements are in WAC 182-513-1395. The standard for a client who lives in an alternate living facility is in WAC 182-513-1205.
  3. The resource standards for institutional programs are in WAC 182-513-1350. The institutional standard chart is found at Long Term Care Standards.
  4. Countable resource standards for the noninstitutional MN program are:
    1. One person $2,000.
    2. A legally married couple $3,000.
    3. For each additional family member add $50.
  5. People who do not meet institutional status requirements use the "effective" MNIL income standard to determine eligibility for the MN program. The "effective" MNIL is the one-person federal benefit rate (FBR) established by SSA each year, or the MNIL listed in the chart below, whichever amount is higher. The FBR is the supplemental security income (SSI) payment standard. For example, in 2023 the FBR is $914.
1 2 3 4 5 6 7 8 9 10
914 914 914 914 914 975 1125 1242 1358 1483

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 182-518-0030 Washington apple health -- Notice requirements -- Electronic notices

WAC 182-518-0030 Washington apple health -- Notice requirements -- Electronic notices.

Effective May 20, 2017.

  1. For programs based on modified adjusted gross income (MAGI), you may choose to get notices by regular mail or in an electronic format through Washington Healthplanfinder.
  2. We send you letters (notices) about your eligibility for Washington apple health programs as described in WAC 182-518-0005 through 182-518-0025.
  3. When you select electronic notifications, also referred to as "paperless," we:
    1. Confirm your selection by regular mail;
    2. Notify you by email when a new notice has posted to your account; and 
    3. Consider the notice received by you as of the date on the notice as described in WAC 182-518-0005.
  4. To read the notice, you must log in to your Washington Healthplanfinder account, as email messages do not include the content of the notice or other confidential information.
  5. If an email message is returned as undeliverable, we send the message to you by regular mail no later than three business days after the date of the undeliverable email response.
  6. You may ask at any time to stop receiving electronic notices from us.

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.

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