Washington Administrative Code

(1) The manufacturer may informally dispute the authority's determination of a violation under this chapter.(2) The manufacturer must submit a request for an informal dispute resolution conference to the authority in writing, in a manner that provides proof of receipt by the auth…

A manufacturer has a right to an administrative hearing under chapters 34.05 RCW and 182-526 WAC, if the authority assesses a notice of violation and fine(s) against the manufacturer.[Statutory Authority: RCW 41.05.021, 41.05.160, chapter 70.405 RCW, and 2022 c 153. WSR 24-02-078…

The board must allow 30 calendar days for the submission of public comment before setting an upper payment limit. Prior to the 30-day comment period, the authority will notify the public of both the beginning and ending dates that written comment will be accepted.[Statutory Autho…

(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 fr…

(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:(a) The administrative law judge, or review judge if applicable, enters an order:(i) Th…

(1) General right to recover.(a) A long-term services and supports (LTSS) client overpayment is any payment for LTSS made by the agency or the agency's designee on a client's behalf in excess of that to which the client is legally entitled.(b) An LTSS client overpayment may be ca…

(1) This section describes certain types of income and resources received as a result of the COVID-19 public health emergency that the health care authority (agency) does not count as income or resources when determining apple health eligibility. This includes certain unemploymen…

(1) In response to the coronavirus (COVID-19) public health emergency (PHE) declared by the Secretary of the U.S. Department of Health and Human Services (HHS) and in response to Section 6008 of the Families First Coronavirus Response Act (Public Law 116-127), the medicaid agency…

(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 hou…

(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 contin…

(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 d…

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 Fede…

(1) COFA islanders age nineteen and older may apply for a qualified health plan (QHP) by:(a) Completing the application via the Washington Healthplanfinder website at www.wahealthplanfinder.org;(b) Calling the Washington health benefit exchange (HBE) customer support center and c…

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 benefi…

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…

(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…

(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 he…

(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 fund…

(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, a…

The following definitions and those found in RCW 34.05.010 apply to this chapter:"Administrative law judge (ALJ)" - 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…

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 RCWChapter 10-08 WACChapter 1…

(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 dete…

(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…

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 c…

(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 counti…

(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 administra…

(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 …

(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…

(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 infor…

(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 …

(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 n…

(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…

(1) After a hearing is requested, in accordance with WAC 182-526-0025, 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 h…

(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 la…

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, chapt…

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…

(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.(2) OAH may hire or contract with persons to interpret at hearings.(3) The fol…

(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…

(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 informati…

(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) OA…

(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 …

(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 ass…

(1) A prehearing 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 arr…

(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 th…

(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 pers…

(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 resol…

(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 …

(1) Appeal. A data supplier may request an appeal of a denial of its administrative review conducted in accordance with WAC 182-70-100.(a) Request for an appeal must be submitted in writing to the health care authority (HCA) within fifteen calendar days after receipt of written n…

(1) For penalties imposed under WAC 182-70-600, the Washington all payer health care claims database (WA-APCD) program director or the director's designee conducts a hearing and prepares a final order.(2) The hearing must be conducted in accordance with this chapter and the Admin…

The hearing process described in this section applies to requests for an appeal made by an intermediate care facility for individuals with intellectual disabilities (ICF/IID), as defined in WAC 388-825-020.(1) Right to hearing. An ICF/IID may request a hearing when it is dissatis…