Client notices overview

Revised Date: 
December 8, 2014

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

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

Effective August 29, 2014.

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

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

Clarifying Information

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

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

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

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

Effective August 29, 2014.

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

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

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

Effective August 29, 2014.

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

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

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

Effective December 1, 2016.

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

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

WAC 182-504-0130 Washington apple health -- Continued coverage pending an appeal.

Effective December 1, 2016

  1. Continued coverage is when you continue to receive Washington apple health benefits while appealing a medicaid agency adverse action to terminate, suspend, or reduce your:
    1. Medicaid eligibility; or
    2. Authorization for a covered service.
  2. To qualify for continued coverage, you must request a hearing on the adverse action no later than:
    1. The tenth day after we (the medicaid agency or its designee) sent a notice of the action to you; or
    2. The last day of the month before the action takes effect.
  3. If your last day to request a hearing and still qualify for continued coverage falls on a Saturday, Sunday, or a designated holiday under WAC 357-31-005, you have until 5:00 p.m. on the next business day to request the hearing.
  4. Continued coverage ends when:
    1. You state in writing you no longer wish to receive continued coverage;
    2. You withdraw the appeal;
    3. You default and an order of dismissal is entered;
    4. An administrative law judge or a review judge issues an adverse ruling or written decision:
      1. Terminating your continued coverage; or
      2. Ruling you do not qualify for benefits.
  5. You cannot receive continued coverage if the adverse action was solely to a change in statute, federal regulation, or administrative rule, unless there is a question about whether you are in the class of people affected by the change.
  6. If you are receiving medically needy coverage, you cannot receive continued coverage past the end of the certification period described in WAC 182-504-0020.
  7. If you are receiving coverage under an alien medical program, you cannot receive continued coverage past the end of the certification period described in chapter 182-507 WAC.

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

Worker Responsibilities

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