reglab/statecodes huggingface dataset:
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-524 - COFA ISLANDER HEALTH CARE › Section 182-524-0100 - General

Current through Register Vol. 24-14, July 15, 2024
(1) Compact of Free
				Association (COFA) islander health care and COFA islander dental care are
				state-funded programs administered by the health care authority (the agency) to
				pay the monthly premiums and out-of-pocket expenses for silver level qualified
				health plans or qualified dental plans for eligible COFA islanders.
(2) For the purpose of this chapter, "our,"
				"us," and "we" refer to the agency or the agency's designee and "you" refers to
				the applicant for, or recipient of, COFA islander health care.
(3) You have the right to appeal any adverse
				agency action regarding COFA islander health care or COFA islander dental care
				as described in chapter 182-526 WAC. For coordinated appeals with the
				Washington health benefit exchange, as described under WAC
				182-526-0102,
				we treat appeals made to either the Washington health benefit exchange or us as
				filed on the same day. You will not have to submit any information that you
				have previously submitted to either the Washington health benefit exchange or
				us.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-524 - COFA ISLANDER HEALTH CARE › Section 182-524-0200 - Definitions

Current through Register Vol. 24-14, July 15, 2024
This section defines terms used in this chapter. See chapter
				  182-500 WAC for additional definitions.
"Advance premium tax credit (APTC)"
- A tax
				  credit taken in advance to lower a monthly health insurance payment (or
				  premium).
"COFA islander"
- A person who is a citizen of
				  the Federated States of Micronesia, the Republic of the Marshall Islands, or
				  the Republic of Palau.
"COFA islander dental care"
- An
				  agency-administered program that pays the premium and out-of-pocket costs for a
				  stand-alone dental plan for eligible COFA islanders.
"COFA islander health care"
- An
				  agency-administered program that pays the premium and out-of-pocket costs for a
				  silver level qualified health plan for eligible COFA islanders.
"Compact of Free Association (COFA)"
- A legal
				  agreement between the government of the United States and the governments of
				  the Federated States of Micronesia (U.S.
				  Pub.
				  L. 108-188 ); the Republic of the Marshall Islands
				  (U.S.
				  Pub.
				  L. 108-188 ); and the Republic of Palau (U.S. Pub.
				  L. 99-658 ).
"Cost-sharing funds"
- Agency-provided funds for
				  out-of-pocket costs.
"Out-of-pocket costs"
- Copayments, coinsurance,
				  deductibles, and other cost-sharing requirements imposed under a qualified
				  health plan for services, pharmaceuticals, devices, and other health benefits
				  covered by the plan and rendered as in-network. Excludes premiums, balance
				  billing amounts for out-of-network providers, and spending for non-covered
				  services.
"Premium cost"
- A person's premium for a
				  qualified health plan, minus the amount of the person's advanced premium tax
				  credit.
"Qualified dental plan (QDP)"
- A stand-alone
				  dental plan offered by the Washington health benefit exchange (HBE). For a
				  definition of stand-alone dental plan, see WAC
				  284-43-6020.
"Qualified dental plan - Noncovered services"
-
				  In-network services that are not covered by the QDP, and are consistent with
				  but do not exceed benefits covered under the agency's adult dental program
				  described in chapter 182-535 WAC.
"Silver level qualified health plan (QHP)"
-
				  Silver level indicates the category of a qualified health plan (QHP) offered by
				  the Washington health benefit exchange (HBE). For a definition of QHP, see WAC
				  182-500-0090.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-524 - COFA ISLANDER HEALTH CARE › Section 182-524-0250 - How to apply

Current through Register Vol. 24-14, July 15, 2024
(1) COFA islanders
				age nineteen and older may apply for a qualified health plan (QHP) by:
(a) Completing the application via the
				Washington Health plan finder web site at www.wahealthplanfinder.org;
(b) Calling the Washington health benefit
				exchange (HBE) customer support center and completing an application by
				telephone;
(c) Calling the COFA
				islander health care support line and completing an application by telephone;
				or
(d) Completing the application
				for health care coverage (HCA 18-001P), and mailing or faxing to the
				HBE.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-524 - COFA ISLANDER HEALTH CARE › Section 182-524-0275 - Eligibility-COFA islander dental care coverage

Current through Register Vol. 24-14, July 15, 2024
You apply for COFA islander dental care the same way you
				  would apply for COFA islander health care as described in WAC
				  182-524-0250.
(1) To be eligible for state-funded COFA
				islander dental care, you must enroll in a qualified dental plan (QDP) through
				the Washington health benefit exchange (HBE) during open enrollment or when you
				qualify for a special enrollment period as described in
				45 C.F.R.
				155.410 and 45 C.F.R. 420.
(2) You are eligible for COFA islander dental
				care administered by us no earlier than January 1, 2021, if you enroll in a QDP
				and:
(a) Meet the requirements of COFA
				islander health care as described in WAC
				182-524-0300(1)(a) through
				(f); or
(b) Are enrolled in medicare, meet the
				requirements as described in WAC
				182-524-0300(1)(a) and
				(c) and:
(i) Are a resident as described in WAC
				182-524-0400(1) through
				(3).
(ii) You can be temporarily out-of-state and
				remain on COFA islander dental care if you:
(A) Intend to return once the purpose of your
				absence concludes; and
(B) Meet the
				eligibility requirements described in this section.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-524 - COFA ISLANDER HEALTH CARE › Section 182-524-0300 - Eligibility

Current through Register Vol. 24-14, July 15, 2024
In order to be eligible for state-funded COFA islander health
				  care, you must enroll in a silver level qualified health plan (QHP) through the
				  Washington health benefit exchange (HBE) during open enrollment or when you
				  qualify for a special enrollment period as described in
				  45
				  C.F.R. 155.410 and 45 C.F.R. 155.420.
(1) You are eligible for state-funded COFA
				islander health care administered by us no earlier than January 1, 2019, if
				you:
(a) Are a COFA islander;
(b) Meet the residency requirements as
				described under WAC 182-524-0400;
(c) Have household income, as defined under
				26 C.F.R.
				1.36B-1(e), under one
				hundred thirty-three percent of the federal poverty level (FPL);
(d) Do not qualify for another federal or
				state medical assistance programs under chapter 74.09 RCW, that provides
				minimum essential coverage;
(e)
				Qualify for, and accept, the maximum advance premium tax credit available under
				45 C.F.R.
				155.305(f); and
(f) Are enrolled in a silver level
				QHP.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-524 - COFA ISLANDER HEALTH CARE › Section 182-524-0400 - Residency requirements

Current through Register Vol. 24-14, July 15, 2024
(1) This section
				applies only to residency requirement for COFA islander health care.
(2) A resident is a person who currently
				lives in Washington and:
(a) Intends to
				reside here, including people without a fixed address; or
(b) Entered the state looking for a job;
				or
(c) Entered the state with a job
				commitment.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-524 - COFA ISLANDER HEALTH CARE › Section 182-524-0500 - Notice requirements

Current through Register Vol. 24-14, July 15, 2024
(1) The
				provisions in chapter 182-518 WAC apply to COFA islander health care, where
				applicable. This section applies only to notices and letters that we send
				regarding COFA islander health care.
(2) We send you written notices (letters)
				when we:
(a) Approve you for COFA islander
				health care;
(b) Deny you for COFA
				islander health care;
(c) Change or
				terminate your eligibility from COFA islander health care;
(d) Ask you for more information;
				and
(e) Reimburse you for premium
				costs, as determined by WAC 182-524-0600.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-524 - COFA ISLANDER HEALTH CARE › Section 182-524-0600 - Payments

Current through Register Vol. 24-14, July 15, 2024
(1) We pay your
				silver level qualified health plan (QHP) premium costs directly to the QHP
				carrier unless we determine good cause exists to reimburse you for the premium
				costs.
(2) We pay your mandatory
				out-of-pocket costs separate from your premium costs through cost-sharing
				funds.
(3) Cost-sharing funds are
				only for your out-of-pocket costs.
(4) We will not pay for, or reimburse you
				for, costs not considered as out-of-pocket costs or expenses incurred by people
				not covered under COFA islander health care.
(5) You are responsible for ensuring the
				services you receive are covered under your QHP and rendered as
				in-net-work.
(6) We may stop
				payments of your silver level QHP premium costs and your cost-sharing funds
				when you:
(a) Fail to provide verification of
				payments through us or an agency-contracted vendor;
(b) Fail to respond to a request for
				information from us or an agency-contracted vendor;
(c) Misuse your cost-sharing funds by:
(i) Purchasing anything not considered an
				out-of-pocket cost; or
(ii)
				Allowing another person access to your cost-sharing funds.
(d) Are no longer eligible for COFA islander
				health care as described under WAC 182-524-0300.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-526 - Administrative hearing rules for medical services programs › Section 182-526-0005 - Purpose and scope

Current through Register Vol. 24-14, July 15, 2024
(1) This chapter:
(a) Describes the general hearing rules and
				procedures that apply to:
(i) The resolution
				of disputes between an appellant and 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; and
(ii) The
				resolution of disputes between an appellant and the health care authority (HCA)
				arising from the prescription drug pricing transparency program in chapter
				182-51 WAC and the all payer health care claims data base rules in chapter
				182-70 WAC.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-526 - Administrative hearing rules for medical services programs › Section 182-526-0015 - Terms in the Administrative Procedure Act compared to this chapter

Current through Register Vol. 24-14, July 15, 2024
To improve clarity and understanding, the rules in this
				  chapter may use different words than the Administrative Procedure Act (APA) or
				  the model rules. Following is a list of terms used in those laws and the terms
				  as used in these rules:
Chapter 34.05 RCW
Chapter 10-08 WAC
Chapter 182-526 WAC
Adjudicative proceeding.
Different terms are used to refer to different
								stages of the hearing process and may include prehearing meeting, prehearing
								conference, hearing, review, reconsideration, and the entire hearing
								process.
Application for adjudicative proceeding.
Request a hearing.
Presiding officer.
Administrative law judge, review judge, or
								designated HCA employee.
Reviewing officer.
Review judge.
Statutory Authority:
					 2011 1st sp.s. c
					 15§ 53, chapters 74.09,
					 34.05 RCW, and 10-08 WAC.
					 13-02-007, §
											182-526-0015, filed 12/19/12,
					 effective 2/1/13.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-526 - Administrative hearing rules for medical services programs › Section 182-526-0020 - Good cause

Current through Register Vol. 24-14, July 15, 2024
(1) Good cause is a
				substantial reason or legal justification allowing the administrative law judge
				(ALJ) to grant a party's request or to excuse their action or inaction,
				including granting a continuance or excusing a failure to appear at an
				administrative proceeding.
(2) To
				determine if there is good cause, the administrative law judge may consider the
				provisions of Superior Court Civil Rule 60 as a guideline. Good cause may
				include, but is not limited to, the following examples:
(a) The party who requested the hearing
				ignored a notice because he or she was in the hospital or was otherwise
				prevented from responding; or
(b)
				The party who requested the hearing could not respond to the notice because it
				was written in a language that he or she did not understand.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-526 - Administrative hearing rules for medical services programs › Section 182-526-0025 - Use and location of the office of administrative hearings

Current through Register Vol. 24-14, July 15, 2024
(1) The health care
				authority (HCA) may use administrative law judges employed by the office of
				administrative hearings (OAH) to conduct administrative hearings and issue
				initial orders in accordance with
				RCW
				34.05.425(1)(c).
(2) In some situations, HCA may use presiding
				officers employed by HCA to conduct administrative hearings and issue final
				orders in accordance with
				RCW
				34.05.425(1)(a) and (b).
				When HCA uses HCA-employed presiding officers to conduct administrative
				hearings, HCA's presiding officer has all the duties and responsibilities set
				forth in this chapter relating to administrative law judges and the office of
				administrative hearings. The notice of hearing will identify whether the case
				is to be heard by OAH or an HCA-employed presiding officer.
(3)
(a) OAH
				headquarters location is:
Office of Administrative Hearings
2420 Bristol Court S.W.
P.O. Box 42488
Olympia, WA 98504-2488
360-664-8717
fax: 360-664-8721
(b) The headquarters office is open from 8:00
				a.m. to 5:00 p.m. Monday through Friday, except legal holidays.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-526 - Administrative hearing rules for medical services programs › Section 182-526-0030 - Contacting the board of appeals

Current through Register Vol. 24-14, July 15, 2024
The information included in this section is current at the
				  time of rule adoption, but may change. Current information and additional
				  contact information are available on the health care authority's internet site,
				  in person at the board of appeals (BOA) office, or by a telephone call to the
				  BOA's main public number.
Board of Appeals
Location
626 8th Avenue S.E.
Olympia, Washington
Mailing address
P.O. Box 42700
Olympia, WA 98504-2700
Toll free telephone
1-844-728-5212
Fax
360-507-9018
Electronic service
HCABoardofAppeals@hca.wa.gov
Internet website
https://www.hca.wa.gov/about-hca/board-appeals
Statutory Authority:
					 2011 1st sp.s. c
					 15§ 53, chapters 74.09,
					 34.05 RCW, and 10-08 WAC.
					 13-02-007, §
											182-526-0030, filed 12/19/12,
					 effective 2/1/13.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-526 - Administrative hearing rules for medical services programs › Section 182-526-0035 - Calculating when a hearing deadline ends

Current through Register Vol. 24-14, July 15, 2024
(1) When counting days to calculate when a
				hearing deadline ends under program rules or statutes:
(a) Do not include the day of the action,
				notice, or order. For example, if a hearing decision is mailed on Tuesday and
				the party has twenty-one days to request a review, start counting the days with
				Wednesday.
(b) If the last day of
				the period is a Saturday, Sunday, or a designated holiday under WAC
				357-31-005, the deadline is the
				next business day.
(c) For periods
				of seven days or less, count only business days. For example, if the party has
				seven days to respond to a review request that was mailed on Friday, May 10th,
				the response period ends on Tuesday, May 21st.
(d) For periods over seven days, count every
				calendar day, including Saturdays, Sundays, and designated holidays under WAC
				357-31-005.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-526 - Administrative hearing rules for medical services programs › Section 182-526-0040 - Service of documents on another party

Current through Register Vol. 24-14, July 15, 2024
(1) When the rules in this chapter or in
				other program rules or statutes require a party to serve copies of documents on
				other parties, the party must send copies of the documents to all other parties
				or their representatives.
(2) When
				sending documents to the office of administrative hearings (OAH) or the board
				of appeals (BOA), the party must file the documents at one of the locations
				listed in WAC
				182-526-0025(2)
				for OAH or in WAC
				182-526-0030
				for BOA.
(3) When sending documents
				to the assigned OAH field office, the parties should use the address of the
				assigned OAH listed on the notice of hearing. If a field office has not been
				assigned, all written communication about the hearing must be sent to the OAH
				Olympia field office, which sends the communication to the correct office.
				Documents may be sent only as described in this section to accomplish
				service.
(4) Unless otherwise
				stated in law, a party may serve someone by:
(a) Personal service (hand
				delivery);
(b) First class,
				registered, or certified mail;
(c)
				Fax;
(d) Electronic
				service;
(e) Commercial delivery
				service; or
(f) Legal messenger
				service.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-526 - Administrative hearing rules for medical services programs › Section 182-526-0040 - Service of documents on another party

Current through Register Vol. 24-14, July 15, 2024
(1) When the rules in this chapter or in
				other program rules or statutes require a party to serve copies of documents on
				other parties, the party must send copies of the documents to all other parties
				or their representatives.
(2) When
				sending documents to the office of administrative hearings (OAH) or the board
				of appeals (BOA), the party must file the documents at one of the locations
				listed in WAC
				182-526-0025(2)
				for OAH or in WAC
				182-526-0030 for BOA.
(3) When sending documents to the assigned
				OAH field office, the parties should use the address of the assigned OAH listed
				on the notice of hearing. If a field office has not been assigned, all written
				communication about the hearing must be sent to the OAH Olympia field office,
				which sends the communication to the correct office. Documents may be sent only
				as described in this section to accomplish service.
(4) Unless otherwise stated in law, a party
				may serve someone by:
(a) Personal service
				(hand delivery);
(b) First class,
				registered, or certified mail;
(c)
				Fax;
(d) Electronic
				service;
(e) Commercial delivery
				service;
(f) Legal messenger
				service; or
(g) Department of
				enterprise services consolidated mail services if the serving party is a state
				agency, including the agency and OAH. See
				RCW
				43.19.710.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-526 - Administrative hearing rules for medical services programs › Section 182-526-0045

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority:
					 2011 1st sp.s. c
					 15§ 53, chapters 74.09,
					 34.05 RCW, and 10-08 WAC.
					 13-02-007, §
											182-526-0045, filed 12/19/12,
					 effective 2/1/13.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-526 - Administrative hearing rules for medical services programs › Section 182-526-0070 - Filing documents

Current through Register Vol. 24-14, July 15, 2024
(1) Filing is the
				act of delivering documents to the office of administrative hearings (OAH) or
				the board of appeals (BOA).
(2) The
				date of filing is the date documents are received by OAH or BOA.
(3) Filing is complete when the documents are
				received by OAH or BOA during business days between 8:00 a.m. to 5:00 p.m. If
				the documents are received after 5:00 p.m. on a business day, the filing is
				effective the next business day.
(4) A party may file documents by delivering
				them to OAH or BOA by:
(a) Personal service
				(e.g., hand delivery);
(b) First
				class, registered, or certified mail;
(c) Fax transmission;
(d) Electronic service:
(e) Other secure electronic means established
				by the agency or OAH;
(f)
				Electronic cloud sharing service approved by the agency;
(g) Commercial delivery service; or (h) Legal
				messenger service.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-526 - Administrative hearing rules for medical services programs › Section 182-526-0080 - Resolving a dispute with the health care authority

Current through Register Vol. 24-14, July 15, 2024
(1) If a person or entity disagrees with a
				decision or action of the health care authority (HCA) or one of its authorized
				agents, the person or entity may request a hearing.
(2) A notice of an action or decision by HCA
				or its authorized agent sent to a person's or entity's correct address is
				presumed to be received by the person or entity on the fourth business day
				after it was sent by first class mail. This presumption does not apply to
				certified or registered mail.
(3) A
				hearing must be requested in the manner and within the deadlines established in
				statute or rule.
(4) After a person
				or entity requests a hearing the dispute may be resolved through:
(a) Any prehearing alternative or
				administrative process offered by the program, HCA's authorized agent, or the
				HCA hearing representative;
(b) A
				prehearing meeting;
(c) A
				prehearing conference; or
(d) A
				hearing.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-526 - Administrative hearing rules for medical services programs › Section 182-526-0085 - Determining if a hearing right exists

Current through Register Vol. 24-14, July 15, 2024
(1) A person or entity has a right to a
				hearing only if a law or program rule gives that right.
(2) Some programs may require a person or
				entity to go through an informal administrative process before requesting or
				having a hearing. The notice of the agency's action includes information about
				this requirement if it applies.
(3)
				Program rules and statutes may limit the time a person or entity has to request
				a hearing. The deadline for filing the request for hearing varies by the
				program involved. Hearing requests should be submitted right away to protect
				the right to a hearing, even if the parties are also trying to resolve the
				dispute informally. The notice of the agency's action contains information
				about this requirement.
(4) If the
				health care authority (HCA) hearing representative or the administrative law
				judge (ALJ) questions the person's or entity's right to a hearing, the ALJ or
				review judge (RJ) must address whether the hearing right exists.
(5) If on appeal of the initial order the HCA
				hearing representative or the review judge questions the right to a hearing,
				the review judge decides whether the hearing right exists.
(6) If the ALJ or RJ decides that the person
				or entity does not have a right to a hearing, the ALJ or RJ enters an order
				dismissing the hearing .
(7) If the
				ALJ or RJ decides that a person or entity has a right to a hearing, the hearing
				proceeds.
Statutory Authority:
					 2011 1st sp.s. c
					 15§ 53, chapters 74.09,
					 34.05 RCW, and 10-08 WAC.
					 13-02-007, §
											182-526-0085, filed 12/19/12,
					 effective 2/1/13.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-526 - Administrative hearing rules for medical services programs › Section 182-526-0090

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority:
					 2011 1st sp.s. c
					 15§ 53, chapters 74.09,
					 34.05 RCW, and 10-08 WAC.
					 13-02-007, §
											182-526-0090, filed 12/19/12,
					 effective 2/1/13.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-526 - Administrative hearing rules for medical services programs › Section 182-526-0095 - Requesting a hearing

Current through Register Vol. 24-14, July 15, 2024
(1) A hearing
				request may be made orally or in writing, unless a rule requires otherwise. If
				an oral request is allowed by rule, an oral request for hearing can be made to
				a health care authority (HCA) employee, HCA's authorized agent, or to the
				office of administrative hearings (OAH) employee in person, by telephone, or by
				voice mail.
(2) Program rules may
				require a specific method and location for sending a written request for
				hearing. A written request for hearing should be sent to the location specified
				in the notice.
(3) A hearing
				request should contain:
(a) The requestor's
				name;
(b) The requestor's
				address;
(c) The requestor's
				telephone number;
(d) The
				applicant's, recipient's, or provider's identification number;
(e) A description of each agency action being
				contested;
(f) A brief explanation
				of why the person or entity disagrees with HCA's action; and
(g) Any accommodation to help the requestor
				fully participate in the hearing, including a foreign or sign language
				interpreter or any other accommodation for an individual with a
				disability.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-526 - Administrative hearing rules for medical services programs › Section 182-526-0100 - Expedited administrative hearings for urgent health care needs

Current through Register Vol. 24-14, July 15, 2024
(1)
Requesting an expedited hearing.
(a) An expedited hearing may be requested
				only in matters involving applicants or recipients.
(b) An applicant or recipient may request an
				expedited administrative hearing when the applicant or recipient believes there
				is an urgent health care need as defined in subsection (3) of this
				section.
(c) The applicant or
				recipient bears the burden of proof to establish an urgent health care need and
				must submit evidence or arrange for evidence to be submitted to the office of
				administrative hearings (OAH) with the expedited hearing request to support the
				need for an expedited hearing. Agency staff may help an applicant or recipient
				who asks for assistance in obtaining information that the agency has pursuant
				to WAC 182-503-0120.
(d) A recipient may be eligible for continued
				coverage according to WAC
				182-504-0130.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-526 - Administrative hearing rules for medical services programs › Section 182-526-0102 - Coordinated appeals process with the Washington health benefits exchange

Current through Register Vol. 24-14, July 15, 2024
(1) The health care
				authority (HCA) coordinates with the Washington state health benefits exchange
				(HBE) to ensure a seamless appeal process for determinations related to
				eligibility for Washington apple health when the modified adjusted gross income
				(MAGI) methodology is used as described in WAC
				182-509-0305.
(2) An applicant, recipient, or an authorized
				representative of an applicant or recipient may request an apple health
				hearing:
(a) By telephone;
(b) By mail (which should be sent to Health
				Care Authority, P.O. Box 45504, Olympia, WA 98504-5504);
(c) In person;
(d) By facsimile transmission;
(e) By email; or
(f) By any other commonly available
				electronic means.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-526 - Administrative hearing rules for medical services programs › Section 182-526-0105

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority:
					 2011 1st sp.s. c
					 15§ 53, chapters 74.09,
					 34.05 RCW, and 10-08 WAC.
					 13-02-007, §
											182-526-0105, filed 12/19/12,
					 effective 2/1/13.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-526 - Administrative hearing rules for medical services programs › Section 182-526-0110 - Process after a hearing is requested

Current through Register Vol. 24-14, July 15, 2024
(1) After a hearing is requested, the office
				of administrative hearings (OAH) must send a copy of the hearing request to the
				health care authority (HCA) or HCA's authorized agent who made the decision on
				HCA's behalf, unless OAH received the hearing request from HCA or HCA's
				authorized agent.
(2) OAH sends
				the hearing request to HCA or HCA's authorized agent within four business days
				of OAH receiving the request.
(3)
				OAH must serve all parties with a notice of hearing, which advises the parties
				of the hearing date, time, and location. This document is called the notice of
				hearing. In appropriate cases, OAH also serves a written notice of a prehearing
				conference .
(4) Before the hearing
				or prehearing conference is held:
(a) The HCA
				hearing representative may contact any other party to try to resolve the
				dispute or gather information; and
(b) The party who requested the hearing may
				contact the HCA hearing representative to try to resolve the dispute or gather
				information.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-526 - Administrative hearing rules for medical services programs › Section 182-526-0112

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority:
					 2011 1st sp.s. c
					 15§ 53, chapters 74.09,
					 34.05 RCW, and 10-08 WAC.
					 13-02-007, §
											182-526-0112, filed 12/19/12,
					 effective 2/1/13.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-526 - Administrative hearing rules for medical services programs › Section 182-526-0115 - Withdrawing a request for hearing

Current through Register Vol. 24-14, July 15, 2024
(1)
				The appellant may withdraw the hearing request for any reason and at any time
				by contacting the health care authority hearing representative or the office of
				administrative hearings (OAH). The request for withdrawal must be made orally
				on the record with the administrative law judge or in writing.
(2) After the request for withdrawal is
				received, the hearing is canceled and the administrative law judge (ALJ) enters
				an order dismissing the hearing. If a hearing request is withdrawn, the
				appellant may not be able to request another hearing on the same
				action.
(3) If an appellant
				withdraws the hearing request, the order of dismissal may only be set aside
				according to WAC
				182-526-0290.
Statutory Authority:
					 2011 1st sp.s. c
					 15§ 53, chapters 74.09,
					 34.05 RCW, and 10-08 WAC.
					 13-02-007, §
											182-526-0115, filed 12/19/12,
					 effective 2/1/13.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-526 - Administrative hearing rules for medical services programs › Section 182-526-0120 - Interpreter services for hearings

Current through Register Vol. 24-14, July 15, 2024
If the party requesting the hearing needs an interpreter
				  because the party or its witness is a person with limited-English-proficiency,
				  the office of administrative hearings will provide an interpreter at no cost to
				  that party.
Statutory Authority:
					 2011 1st sp.s. c
					 15§ 53, chapters 74.09,
					 34.05 RCW, and 10-08 WAC.
					 13-02-007, §
											182-526-0120, filed 12/19/12,
					 effective 2/1/13.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-526 - Administrative hearing rules for medical services programs › Section 182-526-0130 - Limited-English-proficient parties - Notice requirements

Current through Register Vol. 24-14, July 15, 2024
If the office of administrative hearings is notified that the
				  party who has requested the hearing is a limited-English-proficient (LEP)
				  person, all hearing notices, decisions and orders must:
(1) Be written in that party's primary
				language; or
(2) Include a
				statement in the party's primary language:
(a) Indicating the importance of the notice;
				and
(b) Providing information about
				how to get help in understanding the notice and responding to it.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-526 - Administrative hearing rules for medical services programs › Section 182-526-0135 - Interpreters

Current through Register Vol. 24-14, July 15, 2024
(1) The office of
				administrative hearings (OAH) must provide a qualified interpreter to assist
				any person at no charge who:
(a) Has
				limited-English-proficiency; and
(b) Is a party or witness in a
				hearing.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-526 - Administrative hearing rules for medical services programs › Section 182-526-0140 - Waiving interpreter services

Current through Register Vol. 24-14, July 15, 2024
(1)
				If one of the parties is limited-English-proficient (LEP), that party may ask
				to waive interpreter services.
(2)
				The request must be in writing or through a qualified interpreter on the
				record.
(3) The administrative law
				judge must determine if the waiver has been knowingly and voluntarily
				made.
(4) The party may withdraw
				their waiver at any time before or during the hearing.
Statutory Authority:
					 2011 1st sp.s. c
					 15§ 53, chapters 74.09,
					 34.05 RCW, and 10-08 WAC.
					 13-02-007, §
											182-526-0140, filed 12/19/12,
					 effective 2/1/13.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-526 - Administrative hearing rules for medical services programs › Section 182-526-0145 - Interpreter requirements

Current through Register Vol. 24-14, July 15, 2024
(1) Interpreters
				must:
(a) Use the interpretive mode that the
				parties, the person with hearing loss, the interpreter, and the administrative
				law judge (ALJ) consider the most accurate and effective;
(b) Interpret statements made by the parties
				and the ALJ;
(c) Not disclose
				information about the hearing without the written consent of the parties;
				and
(d) Not comment on the hearing
				or give legal advice.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-526 - Administrative hearing rules for medical services programs › Section 182-526-0150 - Hearing decisions involving limited-English-proficient parties

Current through Register Vol. 24-14, July 15, 2024
(1) When an
				interpreter is used at a hearing, the administrative law judge must explain
				that the decision is written in English and that the office of administrative
				hearings (OAH) will provide an interpreter for a sight translation of the
				decision at no cost to that party.
(2) OAH must provide the party needing sight
				translation services information about how to obtain those services.
				Information about how to access sight translation must be attached to the
				decision or order.
(3) OAH or the
				board of appeals must send a copy of a decision or order to an interpreter for
				use in sight translation.
Statutory Authority:
					 2011 1st sp.s. c
					 15§ 53, chapters 74.09,
					 34.05 RCW, and 10-08 WAC.
					 13-02-007, §
											182-526-0150, filed 12/19/12,
					 effective 2/1/13.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-526 - Administrative hearing rules for medical services programs › Section 182-526-0155 - Appellant's representation in the hearing

Current through Register Vol. 24-14, July 15, 2024
(1) Appellants may act as their own
				representative or may choose to have someone represent them including, but not
				limited to, a friend, relative, community advocate, attorney or
				paralegal.
(2) All parties,
				including the health care authority (HCA) and their representatives, must
				provide their name, address, and telephone number to the office of
				administrative hearings (OAH) and all other parties prior to the
				hearing.
(3) The administrative law
				judge (ALJ) may require an appellant's representative to file a written notice
				of appearance, limited notice of appearance, or other documentation authorizing
				the representative to appear on behalf of the appellant.
(4) In cases involving confidential
				information, the representative must file a legally sufficient signed written
				consent or release of information document with HCA or HCA's authorized
				agent.
(5) If an appellant is
				represented by an attorney admitted to practice law in Washington state, the
				attorney must file a notice of appearance or limited notice of appearance and a
				notice of withdrawal if the attorney stops representing the appellant before
				the hearing process ends.
(6) HCA
				allows an exception to the requirement to file a notice of appearance in
				subsection (5) of this section when an appellant is represented by an attorney
				admitted to practice law in Washington state, and that attorney originally
				requested the appellant's hearing under WAC
				182-526-0095.
				If the attorney stops representing the appellant before the hearing process
				ends, the requirement to file a notice of withdrawal still applies.
(7) The following restrictions apply to an
				appellant's representative:
(a) HCA and HCA's
				authorized agents do not pay for an appellant's representation.
(b) OAH does not pay for an appellant's
				representation.
(c) The following
				people may not act as an appellant's representative in a hearing under this
				chapter:
(i) An employee of HCA;
(ii) HCA's authorized agent;
(iii) An employee of the department of social
				and health services (DSHS);
(iv) An
				employee of the department of children, youth, and families (DCYF);
(v) An employee of OAH; or
(vi) Anyone under eighteen years of
				age.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-526 - Administrative hearing rules for medical services programs › Section 182-526-0156 - Legal assistance in the hearing process

Current through Register Vol. 24-14, July 15, 2024
(1) The health care authority (HCA), HCA's
				authorized agents, and the office of administrative hearings (OAH) will not pay
				for an attorney for another party.
(2) If a party wants an attorney to represent
				him or her and cannot afford one, community resources may be available to
				assist that party. These legal services may be free or available at a reduced
				cost. HCA, HCA's authorized agent, or OAH can provide information about who to
				contact for legal assistance.
(3)
				Information about legal assistance can also be found at
www.oah.wa.gov
.
Statutory Authority:
					 2011 1st sp.s. c
					 15§ 53, chapters 74.09,
					 34.05 RCW, and 10-08 WAC.
					 13-02-007, §
											182-526-0156, filed 12/19/12,
					 effective 2/1/13.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-526 - Administrative hearing rules for medical services programs › Section 182-526-0157

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority:
					 2011 1st sp.s. c
					 15§ 53, chapters 74.09,
					 34.05 RCW, and 10-08 WAC.
					 13-02-007, §
											182-526-0157, filed 12/19/12,
					 effective 2/1/13.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-526 - Administrative hearing rules for medical services programs › Section 182-526-0170

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority:
					 2011 1st sp.s. c
					 15§ 53, chapters 74.09,
					 34.05 RCW, and 10-08 WAC.
					 13-02-007, §
											182-526-0170, filed 12/19/12,
					 effective 2/1/13.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-526 - Administrative hearing rules for medical services programs › Section 182-526-0175 - Prehearing meetings

Current through Register Vol. 24-14, July 15, 2024
(1) A pre-hearing
				meeting is an informal meeting with a health care authority (HCA) hearing
				representative that may be held before any prehearing conference or
				hearing.
(2) The HCA hearing
				representative may contact the party who requested the hearing before the
				hearing date to arrange a prehearing meeting. Any party may also contact the
				HCA hearing representative to request a pre-hearing meeting.
(3) A prehearing meeting is voluntary, but
				strongly encouraged. A party is not required to request a pre-hearing meeting
				and is not required to participate in one. A party's refusal to participate in
				a prehearing meeting does not affect the party's right to a hearing.
(4) The prehearing meeting may include all or
				some of the parties, but does not include an administrative law judge
				(ALJ).
(5) The prehearing meeting
				gives the parties an opportunity to:
(a)
				Clarify issues;
(b) Exchange
				documents and witness statements;
(c) Resolve issues through agreement or
				withdrawal; and
(d) Ask questions
				about the hearing process and the laws and rules that apply.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-526 - Administrative hearing rules for medical services programs › Section 182-526-0185 - Settlement agreements

Current through Register Vol. 24-14, July 15, 2024
(1) If the
				parties resolve the dispute during the prehearing meeting and put it in writing
				or present the agreement to an administrative law judge (ALJ), the agreement
				may be legally enforceable.
(2) If
				the parties want the ALJ to consider any agreements or stipulations made at the
				prehearing meeting, the parties must present them to the ALJ either before or
				during the hearing.
(3) If all the
				issues are not resolved in the prehear-ing meeting, the parties may request a
				prehearing conference before an ALJ or go to the scheduled hearing. The ALJ may
				also order a prehearing conference.
(4) If all the issues are resolved and the
				settlement agreement is in writing and signed by both parties, or presented
				orally by both parties to the ALJ, the ALJ enters the settlement agreement into
				the record and the agreement constitutes a withdrawal of the appellant's
				hearing request.
Statutory Authority:
					 2011 1st sp.s. c
					 15§ 53, chapters 74.09,
					 34.05 RCW, and 10-08 WAC.
					 13-02-007, §
											182-526-0185, filed 12/19/12,
					 effective 2/1/13.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-526 - Administrative hearing rules for medical services programs › Section 182-526-0195 - Prehearing conferences

Current through Register Vol. 24-14, July 15, 2024
(1) 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.
(a) The ALJ must make an audio record of the
				prehearing conference.
(b) An ALJ
				may conduct the prehearing conference in person, by telephone, or in any other
				manner acceptable to the parties.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-526 - Administrative hearing rules for medical services programs › Section 182-526-0200 - Enrollee appeals of a managed care organization action

Current through Register Vol. 24-14, July 15, 2024
(1) The hearing process described in this
				chapter applies to enrollee appeals of a health care authority (HCA)-contracted
				managed care organization (MCO) action. Where a conflict exists, the
				requirements in this section prevail.
(2) An MCO enrollee must exhaust all levels
				of resolution and appeal within the MCO's grievance system prior to requesting
				a hearing with HCA. See WAC
				182-538-110.
(3) If an MCO enrollee does not agree with
				the MCO's resolution of the enrollee's appeal, the enrollee may request a
				hearing orally or in writing to the contact information on the written notice.
				The enrollee must request the hearing within one hundred twenty calendar days
				of the date of receipt of the MCO's notice of resolution of the MCO's appeal
				process.
(a) An enrollee may request
				continuation of services pending the outcome of a hearing related to the
				termination, suspension, or reduction of a previously authorized
				service.
(b) To receive
				continuation of services pending the outcome of the hearing, the enrollee must
				request a hearing and request to continue services within ten days of the date
				of the MCO's notice of the resolution of the appeal. See WAC
				182-538-110 for additional
				requirements related to continuation of services.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-526 - Administrative hearing rules for medical services programs › Section 182-526-0203 - Administrative reviews requested by a reporting entity to the prescription drug pricing transparency program

Current through Register Vol. 24-14, July 15, 2024
(1)
(a) A reporting entity as defined in WAC
				182-51-0100, seeking
				administrative review of a fine or other appealable action of the authority
				taken under chapter 182-51 WAC or chapter 43.71C RCW, must file a written
				request for administrative review at the address provided in the authority's
				notice within twenty-eight calendar days after receiving the notice.
(b) When the authority has sent written
				notice by United States mail, it considers the reporting entity to have
				received the notice five calendar days after the date of the notification
				letter, unless actual proof of the date of receipt of the authority's
				notification letter exists. If such proof exists, the authority uses the actual
				date of receipt to determine timeliness of the reporting entity's request for
				administrative review. When the authority has electronically mailed (email)
				written notice, the date the authority's notification email was sent is
				considered to be the date of receipt by the reporting entity, irrespective of
				when the reporting entity reads the email.
(c) The reporting entity's request for
				administrative review must:
(i) Be signed by a
				partner, officer, or authorized employee of the reporting entity;
(ii) State the particular issues raised;
				and
(iii) Include supporting
				documentation or other information.