WAC 182-503-0130 Authorized representative.

Effective August 17, 2015

1. ​Designating an authorized representative (AREP).
   1. A person may designate an AREP to act on his or her behalf in eligibility-related interactions with the medicaid agency by completing the agency's Authorized Representative Designation Form (DSHS 14-532), or through any of the methods described in 42 C.F.R. 435.907(a) and 42 C.F.R. 435.923. The Authorized Representative Designation Form is available online at https://www.dshs.wa.gov/fsa/forms.
   2. A court-appointed legal guardian with authority to make financial decisions on a person's behalf is that person's AREP.
   3. An agreement creating power of attorney (POA) that grants decision-making authority regarding the person's financial interactions with the agency establishes the POA as the AREP.
   4. If a person is unable to designate an AREP due to a medical condition, an individual may designate himself or herself as the AREP by signing the agency's Authorized Representative Designation Form (DSHS 14-532).
2. Serving as an AREP. To serve as an AREP, an individual or organization must:
   1. Have a good-faith belief that the information he or she provides to the agency is correct.
   2. Report any change in circumstance required under WAC 182-504-0105 unless doing so would exceed the scope of authorized representation or violate state or federal law.
   3. A provider, staff member, or volunteer of an organization must also comply with 42 C.F.R. 435.923(d-e).
3. Terminating authorized representation.
   1. The person or the AREP may terminate the authorized representation at any time for any reason by notifying the agency verbally or in writing.
   2. Authorized representation terminates automatically when the person dies.

WAC 182-503-0120 Washington apple health -- Equal access services.

Effective December 3, 2025.

1. When you have a mental, neurological, cognitive, physical or sensory impairment, or limitation that prevents you from receiving health care coverage, we provide services to help you apply for, maintain, and understand the health care coverage options available and eligibility decisions we make. These services are called equal access (EA) services.
2. We provide EA services on an ongoing basis to ensure that you are able to maintain health care coverage and access to services we provide. EA services include, but are not limited to:
   1. Helping you to:
      1. Apply for or renew coverage;
      2. Complete and submit forms;
      3. Give us information to determine or continue your eligibility;
      4. Ask for continued coverage;
      5. Ask for reinstated (restarted) coverage after your coverage ends; and
      6. Ask for and participate in a hearing.
   2. Giving you additional time, when needed, for you to give us information before we reduce or end your health care coverage;
   3. Explaining our decision to change, reduce, end, or deny your health care coverage;
   4. Working with your authorized representative, if you have one, and giving that person copies of notices and letters we send you; and
   5. Providing you the services of a sign language interpreter/transliterator who is certified by the Registry of Interpreters for the Deaf at the appropriate level of certification.
      1. These services may include in-person sign language interpreter services, relay interpreter services, and video interpreter services, as well as other services; we decide which services to offer you based on your communication needs and preferences.
      2. We offer these services as a reasonable accommodation, free of charge, if you are deaf, hard-of-hearing, or a deaf-blind person who uses sign language to communicate.
   6. Not taking adverse action in your case, or automatically reinstating your coverage for up to three months after the adverse action was taken, if we determine that your impairment or limitation was the cause of your failure to follow through on something you need to do to get or keep your Washington apple health coverage, such as:
      1. Applying for or renewing coverage;
      2. Completing and submitting forms;
      3. Giving us information to determine or continue your eligibility;
      4. Asking for continued or reinstated coverage; or
      5. Asking for and participating in a hearing.
3. We inform you of your right to EA services listed in subsection (2) of this section:
   1. On printed applications and notices, including the printed rights and responsibilities form;
   2. In the Washington healthplanfinder web site, including the electronic rights and responsibilities form; and
   3. During contact with us.
4. We provide you the EA services listed in subsection (2) of this section if you ask for EA services, you are receiving services through the home and community living administration, or we determine that you would benefit from EA services. We determine you would benefit from EA services if you:
   1. Appear to have or claim to have any impairment or limitation described in subsection (1) of this section;
   2. Have a developmental disability;
   3. Are disabled by alcohol or drug addiction;
   4. Are unable to read or write in any language;
   5. Appear to have limitations in your ability to communicate, understand, remember, process information, exercise judgment and make decisions, perform routine tasks, or relate appropriately with others (whether or not you have a disability) that may prevent you from understanding the nature of EA services or affect your ability to access our programs; or
   6. Are a minor not residing with your parents.
5. If we determine that you are eligible for EA services, we develop and document an EA plan appropriate to your needs. The plan may be updated or changed at any time based on your request or a change in your needs.
6. You may at any time refuse the EA services offered to you.
7. We reinstate your coverage when:
   1. We end coverage because we were unable to determine if you continue to qualify; and
   2. You provide proof that you are still qualified for coverage within 20 calendar days from when we ended your coverage. We restore your coverage retroactive to the first of the month so there is no break in your coverage.
8. If you believe that we have discriminated against you on the basis of a disability or another protected status, the person may file a complaint with the U.S. Department of Health and Human Services at https://www.hhs.gov/civil-rights/filing-a-complaint/complaint-process/ or Region Manager, Office for Civil Rights, U.S. Department of Health and Human Services, 2201 Sixth Ave. – M/S: RX-11, Seattle, WA 98121-1831 (voice phone 800-368-1019, fax 206-615-2297, TDD 800-537-7697).

WAC 182-503-0040 Washington apple health -- Interview requirements.

Effective July 25, 2013

1. An individual applying for Washington apple health (WAH) (as defined in WAC 182-500-0120) is not required to have an in-person interview to determine eligibility.
2. The agency or its designee may contact an individual by phone or in writing to gather any additional information that is needed to make an eligibility determination.
3. A phone or in-person interview is required to determine initial financial eligibility for WAH long-term care services.
4. The interview requirement described in subsection (3) of this section may be waived if the applicant is unable to comply:
   1. Due to his or her medical condition; or
   2. Because the applicant does not have a family member or another individual that is able to conduct the interview on his or her behalf.

WAC 182-503-0110 Washington apple health -- Limited-English proficient (LEP) services.

Effective March 31, 2014.

1. We provide interpreter and translation services (limited-English proficient or LEP services) free of charge to you if you have limited ability to read, write, and/or speak English. Interpreter services are those used for oral communication between two parties who do not speak the same language. Translation services are those used for written communication.
2. We provide LEP services in your primary language.
   1. A primary language is the language you tell us that you wish to use when communicating with us. You may designate at least one primary language for oral communications and at least one primary language for written communications, and you may designate a different primary language for oral and for written communications.
   2. We note your primary languages in a record available to the agency, its designee, and health benefit exchange employees.
3. We can provide LEP services through bilingual workers and/or contracted interpreters and translators who are expected to be competent. We consider a bilingual worker or a contracted interpreter or translator to be competent if he or she is:
   1. Certified for interpreting and/or translating in the language by the language testing and certification program of the department of social and health services;
   2. Certified or otherwise determined to be competent for interpreting and/or translating in the language by an association or organization with a regional or national reputation for certifying or determining the competence of interpreters and/or translators; or
   3. Determined competent for interpreting and/or translating in the language by us, taking into account his or her:
      1. Demonstrated proficiency in both English and the other language;
      2. Orientation and training that includes the skills and ethics of interpreting;
      3. Fundamental knowledge in both languages of any specialized terms or concepts peculiar to Washington apple health;
      4. Sensitivity to cultural differences; and
      5. Demonstrated ability to convey information accurately in both languages.
4. We provide notice of the availability of LEP services on printed applications and notices, in the Washington Healthplanfinder website, and during contact with persons who appear to need LEP services.
5. LEP services include:
   1. Spoken language interpreter (oral) services in person, over the telephone, or through other simultaneous audio or visual transmission (if available); and
   2. Translation of our forms, letters, and other text-based materials, whether printed in hard-copy or stored and presented by computer. These include, but are not limited to:
      1. Our pamphlets, brochures, and other informational material that describe our services and your health care rights and responsibilities;
      2. Our applications and other forms you need to complete and/or sign; and
      3. Notices of our actions affecting your eligibility for health care coverage.
   3. Direct provision of services by our bilingual employees.
6. We provide interpreter services and translated documents in a prompt manner that allows the timely processing of your eligibility for health care coverage within time frames defined in WAC 182-503-0060, 182-503-0035, and 182-504-0125.
7. If you believe that we have discriminated against you on the basis of race, color, national origin, birthplace, or another protected status, you may file a complaint with the U.S. Department of Health and Human Services or Regional Manager, Office of Civil Rights, U.S. Department of Health and Human Services, 2201 Sixth Ave. – M/S: RX-11, Seattle, WA 98121-1831 (voice phone 800-368-1019, fax 206-615-2297, TDD 800-537-7697).

WAC 182-503-0100 Washington apple health -- Rights and responsibilities.

Effective June 3, 2025.

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.

1. If you are applying for or receiving health care coverage, you have the right to:
   1. Have your rights and responsibilities explained to you and given in writing;
   2. Be treated politely and fairly without regard to your race, color, political beliefs, national origin, religion, age, gender (including gender identity and sex stereotyping), sexual orientation, disability, honorably discharged veteran or military status, or birthplace;
   3. Ask for health care coverage using any method listed under WAC 182-503-0005 (if you ask us for a receipt or confirmation, we will provide one to you);
   4. Get help completing your application if you ask for it;
   5. Have an application processed promptly and no later than the timelines described in WAC 182-503-0060;
   6. Have at least ten calendar days to give the agency or its designee information needed to determine eligibility and be given more time if asked for;
   7. Have personal information kept confidential; we may share information with other state and federal agencies for purposes of eligibility and enrollment in Washington apple health;
   8. Get written notice, in most cases, at least ten calendar days before the agency or its designee denies, terminates, or changes coverage;
   9. Ask for an appeal if you disagree with a decision we make. You can also ask a supervisor or administrator to review our decision or action without affecting your right to a fair hearing;
   10. Ask for and get interpreter or translator services at no cost and without delay;
   11. Ask for voter registration assistance;
   12. Refuse to speak to an investigator if we audit your case. You do not have to let an investigator into your home. You may ask the investigator to come back at another time. Such a request will not affect your eligibility for health care coverage;
   13. Get equal access services under WAC 182-503-0120 if you are eligible;
   14. Ask for support enforcement services through the division of child support; and
   15. Refuse to cooperate with us in identifying, using, or collecting third-party benefits (such as medical support) if you fear, and can verify, that your cooperating with us could result in serious physical or emotional harm to you, your children, or a child in your care. Verification may include one of the following:
       1. A statement you sign, outlining your fears and concerns;
       2. Civil or criminal court orders (such as domestic violence protection orders, restraining orders, and no-contact orders);
       3. Medical, police, or court reports; or
       4. Written statement from clergy, friends, relatives, neighbors, or co-workers.
2. You are responsible to:
   1. Report changes in your household or family circumstances as required under WAC 182-504-0105 and 182-504-0110;
   2. Give us any information or proof needed to determine eligibility. If you have trouble getting proof, we help you get the proof or contact other persons or agencies for it;
   3. Assign the right to medical support as described in WAC 182-503-0540, unless you can submit verification (which may include one of the items listed in subsection (1)(o) of this section) that your cooperating with us could result in serious physical or emotional harm to you, your children, or a child in your care;
   4. Complete renewals when asked;
   5. Give medical providers information needed to bill us for health care services; and
   6. Cooperate with quality assurance or post enrollment review staff when asked.

WAC 182-503-0090 Washington apple health -- Exceptions to rule.

Effective December 3, 2025.

1. A client or client's representative may request an exception to a Washington apple health financial eligibility rule in Title 182 WAC. The request for an exception to rule (ETR) may be submitted orally or in writing. The request must:
   1. Be received within 90 calendar days of the agency action with which the client disagrees or wants waived;
   2. Identify the rule for which an exception is being requested;
   3. State what the client is requesting; and
   4. Describe how the request meets subsection (2) of this section.
2. The agency director or designee has the discretion to grant an ETR if they determine that the client's circumstances satisfy the conditions below:
   1. The exception would not contradict a specific provision of federal or state law; and
   2. The client's situation differs from the majority; and
   3. It is in the interest of the overall economy and the client's welfare, and:
      1. It increases opportunity for the client to function effectively; or
      2. The client has an impairment or limitation that significantly interferes with the usual procedures required to determine eligibility and payment.
3. A client does not have a right to an administrative hearing on ETR decisions under chapter 182-526 WAC.
4. A client is mailed a decision in writing within 10 calendar days when agency staff:
   1. Approve or deny an ETR request; or
   2. Request more information.
5. If the ETR is approved, the notice includes information on what is improved and for what time frame.
6. The agency designates staff at the home and community living administration (HCLA) to process all ETRs specifically relating to long-term services and supports programs described in Title 182 WAC.
7. This section does not apply to requests that the agency pay for noncovered medical or dental services or related equipment. WAC 182-501-0160 applies to such requests.

WAC 182-503-0080 Washington apple health -- Application denials and withdrawals.

Effective November 3, 2019. 

1. We follow the rules about notices and letters in chapter 182-518 WAC. We follow the rules about timelines in WAC 182-503-0060.
2. We deny your application for apple health coverage when:
   1. You tell us either orally or in writing to withdraw your request for coverage; or
   2. Based on all information we have received from you and other sources within the time frames stated in WAC 182-503-0060, including any extra time given at your request or to accommodate a disability or limited-English proficiency:
      1. We are unable to determine that you are eligible; or
      2. We determine that you are not eligible.
   3. You are subject to asset verification and do not provide authorization as described in WAC 182-503-0055.
3. We send you a written notice explaining why we denied your application (per chapter 182-518 WAC).
4. We reconsider our decision to deny your apple health coverage without a new application from you when:
   1. We receive the information that we need to decide if you are eligible within thirty days of the date on the denial notice;
   2. You give us authorization to verify your assets as described in WAC 182-503-0055 within thirty days of the date on the denial notice;
   3. You request a hearing within ninety days of the date on the denial letter and an administrative law judge (ALJ) or HCA review judge decides our denial was wrong (per chapter 182-526 WAC).
5. If you disagree with our decision, you can ask for a hearing. If we denied your application because we do not have enough information, the ALJ will consider the information we already have and any more information you give us. The ALJ does not consider the previous absence of information or failure to respond in determining if you are eligible. 

WAC 182-503-0070 Washington apple health (WAH)-- When coverage begins.

Effective August 29, 2014.

1. Your Washington apple health (WAH) coverage starts on the first day of the month you applied for and we decided you are eligible to receive coverage, unless one of the exceptions in subsection (4) of this section applies to you.
2. Sometimes we can start your coverage up to three months before the month you applied (see WAC 182-504-0005).
3. If you are confined or incarcerated as described in WAC 182-503-0010, your coverage cannot start before the day you are discharged, except when:
   1. You are hospitalized during your confinement; and
   2. The hospital requires you to stay overnight.
4. Your WAH coverage may not begin on the first day of the month if:
   1. Subsection (3) of this section applies to you. In that case, your coverage would start on the first day of your hospital stay;
   2. You must meet a medically needy spenddown liability (see WAC 182-519-0110). In that case, your coverage would start on the day your spenddown is met; or
   3. You are eligible under the WAH alien emergency medical program (see WAC 182-507-0115). In that case, your coverage would start on the day your emergent hospital stay begins.
5. For long-term care, the date your services start is described in WAC 388-106-0045.

WAC 182-503-0050 Verification of eligibility factors.

Effective November 3, 2019

1. General rules.
   1. We may verify the information we use to determine, redetermine, or terminate your apple health eligibility.
   2. We verify the eligibility factors listed in WAC 182-503-0505(3).
   3. Before we ask you to provide records to verify an eligibility factor, we use information available from state databases, including data from the department of social and health services and the department of employment security, federal databases, or commercially available databases to verify the eligibility factor.
   4. We may require information from third parties, such as employers, landlords, and insurance companies, to verify an eligibility factor if the information we received:
      1. Cannot be verified through available data sources;
      2. Did not verify an eligibility factor; or
      3. Is contradictory, confusing, or outdated.
   5. We do not require you to submit a record unless it is necessary to determine or redetermine your eligibility.
   6. If you can obtain verification within three business days and we determine the verification is sufficient to confirm an eligibility factor, we base our initial eligibility decision upon that record.
   7. If we are unable to verify eligibility as described in (f) of this subsection, then we may consider third-party sources.
   8. If a fee is required to obtain a necessary record, we pay the fee directly to the holder of the record.
   9. We do not deny or delay your application if you failed to provide information to verify an eligibility factor in a particular type or form.
   10. Except for eligibility factors listed in WAC 182-503-0505 (3)(c) and (d), we accept alternative forms of verification. If you give us a reasonable explanation that confirms your eligibility, we may not require additional documentation.
   11. Once we verify an eligibility factor that will not change, we may not require additional verification. Examples include:
       1. U.S. citizenship;
       2. Family relationships by birth;
       3. Social Security numbers; and
       4. Dates of birth, death, marriage, dissolution of marriage, or legal separation.
   12. If we cannot verify your immigration status and you are otherwise eligible for Washington apple health, we approve coverage and give additional time as needed to verify your immigration status.
2. Submission timelines.
   1. We allow at least ten calendar days for you to submit requested information.
   2. If you request more time to provide information, we allow the time requested.
   3. If the tenth day falls on a weekend or a legal holiday as described in RCW 1.16.050, the due date is the next business day.
   4. We do not deny or terminate your eligibility when we give you more time to provide information.
   5. If we do not receive your information by the due date, we make a determination based on all the information available.
3. Notice requirements.
   1. When we need more information from you to determine your eligibility for apple health coverage, we send all notices according to the requirements of WAC 182-518-0015.
   2. If we cannot determine you are eligible, we send you a denial or termination notice including information on when we reconsider a denied application under WAC 182-503-0080.
4. Equal access and limited-English proficiency services. If you are eligible for equal access services under WAC 182-503-0120 or limited-English proficiency services under WAC 182-503-0110, we provide legally sufficient support services.
5. Eligibility factors for nonmodified adjusted gross income (MAGI)-based programs. If you apply for a non-MAGI program under WAC 182-503-0510(3), we verify the factors in WAC 182-503-0505(3). In addition, we verify:
   1. Household composition, if spousal or dependent deeming under chapter 182-512 WAC or spousal or dependent allowance under chapters 182-513 and 182-515 WAC applies;
   2. Income and income deductions;
   3. Resources, including:
      1. Trusts, annuities, life estates and promissory notes under chapter 182-516 WAC;
      2. Real property transactions; and
      3. Financial records, as defined in WAC 182-503-0055, held by financial institutions.
   4. Medical expenses required to meet any spenddown liability under WAC 182-519-0110;
   5. All post-eligibility deductions used to determine cost of care for clients eligible for long-term services and supports under chapters 182-513 and 182-515 WAC;
   6. Transfers of assets under chapter 182-513 WAC and WAC 182-503-0055 when the program is subject to transfer of assets limitations;
   7. Shelter costs for long-term care cases where spousal and dependent allowances apply;
   8. Blindness or disability, if you claim either; and
   9. Social Security number for a community spouse if needed when you apply for long-term care.
6. Verification for MAGI-based programs.
   1. After we approve your coverage based on your self-attestation, we may conduct a post-eligibility review to verify your self-attested information.
   2. When conducting a post-eligibility review, we attempt to verify eligibility factors using your self-attested information available to us through state, federal, and commercially available data sources, or other third parties, before requiring you to provide information.
   3. You may be required to provide additional information if:
      1. We cannot verify an eligibility factor through other data sources listed in subsection (b) of this section; or
      2. The information received from the data source is not reasonably compatible with your self-attestation.
7. Reapplication following post-eligibility review. If your eligibility for MAGI-based apple health terminates because of a post-eligibility review and you reapply, we may request verification of eligibility factors prior to determining eligibility.

WAC 182-503-0010 Washington apple health -- Who may apply.

Effective January 16, 2020.

1. You may apply for Washington apple health for yourself.
2. You may apply for apple health for another person if you are:
   1. A legal guardian;
   2. An authorized representative (as described in WAC 182-503-0130);
   3. A parent or caretaker relative of a child age eighteen or younger;
   4. A tax filer applying for a tax dependent;
   5. A spouse; or
   6. A person applying for someone who is unable to apply on their own due to a medical condition and who is in need of long-term care services.
3. If you reside in an institution of mental diseases (as defined in WAC 182-500-0050(1)) or a public institution (as defined in WAC 182-500-0050(4)), including a Washington state department of corrections facility, city, tribal, or county jail, or secure community transition facility or total confinement facility (as defined in RCW 71.09.020), you, your representative, or the facility may apply for you to get the apple health coverage for which you are determined eligible.
4. You are automatically enrolled in apple health and do not need to submit an application if you are a:
   1. Supplemental security income (SSI) recipient;
   2. Person deemed to be an SSI recipient under 1619(b) of the SSA;
   3. Newborn as described in WAC 182-505-0210; or
   4. Child in foster care placement as described in WAC 182-505-0211.
5. You are the primary applicant on an application if you complete and sign the application on behalf of your household.
6. If you are an SSI recipient, then you, your authorized representative as defined in WAC 182-500-0010, or another person applying on your behalf as described in subsection (2) of this section, must turn in a signed application to apply for long-term care services as described in WAC 182-513-1315.