General eligibility requirements that apply to all Apple Health programs

Administrative Hearing decision

Revised Date: 
July 25, 2014

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

WAC 182-526-0195 Prehearing conferences.

Effective March 16, 2017

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

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

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

Effective March 16, 2017

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

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

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

Effective January 5, 2018

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

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

WAC 182-526-0285 Orders of dismissal.

Effective August 18, 2018

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

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

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

Effective March 16, 2017

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

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

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

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

Effective March 16, 2017

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

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

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

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

Effective February 1, 2013

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

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

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

Effective March 16, 2017

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

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

Clarifying Information

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

Acronyms & Definitions

Administrative Law Judge (ALJ)

Appellant

Hearing Record

Office of Administrative Hearings (OAH)

Types of Orders

  1. Prehearing meeting (WAC 182-526-0175): This is an informal meeting between HCA and the appellant and does not involve the ALJ. It can take place by phone, email or in-person. The purpose is to clarify the issue(s), exchange information, resolve any issues through an agreement or withdrawal, and explain any rules or laws and answer questions.
  2. Notice of hearing (182-526-0255): This is a formal notice of the date, time, and location of the administrative hearing. It includes a copy of the request for an administrative hearing, contact information for the parties, the docket number, a summary of the appellant's legal rights, and a referral to potentially free legal resources that are available. This notice is sent to all parties, including the appellant and all agencies involved, such as HCA, DSHS (if the hearing is about a Classic Medicaid case), and OAH.
  3. Prehearing conference (WAC 182-526-0195): This is a formal meeting between HCA, the appellant, and an ALJ. This can be used to clarify any issues, set deadlines, agree to a continuance, resolve the dispute, and determine eligibility for continued coverage, among other issues. A formal notice is mailed to all parties. If the appellant fails to show, the ALJ may issue an order of default and dismiss the hearing.
  4. Order of dismissal (WAC 182-526-0285): This is an order issued by an administrative law judge (ALJ) when an appellant withdraws the hearing request or does not appear at the scheduled time for the hearing. The most common reasons for an order of dismissal are:
    1. Default/no show: If the hearing notice was sent to the appellant's reported address and the appellant failed to appear, document the ACES narrative and file the decision with any related documents in the case record. If the hearing notice was sent to an address other than the appellant's reported address or there is some other reason that the notice of hearing was not properly delivered, contact the OAH and provide that office with the correct address or other information needed to deliver the notice.
    2. Withdrawal: Document the ACES narrative and file the decision, with the request for withdrawal and any other related documents attached in the case record. An appellant can request in writing that an Order of Dismissal be vacated (i.e., canceled) or set aside (see WAC 182-526-0290). A prehearing conference will be scheduled. The ALJ will issue a written order which will explain whether the appellant has established good cause (see WAC 182-526-0020) to have the hearing reinstated. If the ALJ determines good cause exists to vacate the dismissal order, the ALJ will schedule a hearing.
  5. Order of Continuance (WAC 182-526-0280): A continuance is a rescheduling of a hearing to a later time or date. If a party would like a continuance, the party must see if the other parties will agree. If so, an order of continuance will be issued by OAH. If any of the other parties disagrees with the continuance, a prehearing conference will be held. The ALJ will either approve or deny the continuance request after that conference.
  6. Initial decision (WACs 182-526-0520 to 182-526-0595): The decision issued by the ALJ who presided at the hearing. The initial decision becomes the final decision if it is not appealed by either party within 21 calendar days after OAH mails the order. The ALJ who conducted the hearing is responsible to write the initial decision and mail a copy to all parties. The order will:
    1. List all parties, witness and exhibits (evidence);
    2. Determine the facts of the case;
    3. Explain why evidence or a witness is or is not credible;
    4. State the applicable laws and rules that apply to the issue;
    5. Discuss the reasons for the decision and how the laws apply to it;
    6. State the result and remedy being ordered; and
    7. Explain the appeals process.
  7. Request for Reconsideration (WAC 182-526-0560 to 182-526-0635): When the ALJ issues an initial order, any party may request the ALJ to reconsider the decision. The request for reconsideration must be received by OAH on or before the 10th calendar day after the initial order was mailed. The ALJ can only consider evidence that was presented in the hearing unless the ALJ reopens the hearing record (see WAC 182-526-0500). The ALJ will issue a written order in response to the request for reconsideration.
  8. Judicial Review (WACs 182-526-0640 to 182-526-0650): Only the appellant has the right to request a judicial review of the final agency decision in superior court. Instructions regarding requesting judicial review are attached to the initial decision.

Worker Responsibilities

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

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