WAC 182-532-123 Reproductive health - Other covered services for women

WAC 182-532-123 Reproductive health—Other covered services for women

Effective September 1, 2013

Other reproductive health services covered for women include:
  1. Office visits when medically necessary;
  2. Food and Drug Administration (FDA)-approved prescription and nonprescription contraceptive methods, as identified in chapter 182-530 WAC;
  3. Over-the-counter (OTC) family planning drugs, devices, and drug-related supplies, as described in chapter 182-530 WAC;
  4. Sterilization procedures that meet the requirements of WAC 182-531-1550 if requested by the client and performed in an appropriate setting for the procedures;
  5. Screening and treatment for sexually transmitted infections (STI), including lab tests and procedures;
  6. Education and supplies for FDA-approved contraceptives, natural family planning, and abstinence;
  7. Mammograms for clients forty years of age and older once per year, and for clients thirty-nine years of age and younger with prior authorization;
  8. Colposcopy and related medically necessary follow-up services;
  9. Maternity-related services as described in chapter 182-533 WAC; and
  10. Abortion.

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 182-532-120 Reproductive health - Covered yearly exams for women

WAC 182-532-120 Reproductive health—Covered yearly exams for women

Effective September 1, 2013

  1. Along with services listed in WAC 182-531-0100, the medicaid agency covers one of the following yearly exams per client per year:
    1. A cervical, vaginal, and breast cancer screening exam; or
    2. A comprehensive prevention visit for family planning. (Under a delayed pelvic protocol, the comprehensive prevention visit for family planning may be split into two visits, per client, per year.)
  2. The cervical, vaginal, and breast cancer screening examination:
    1. Must follow the guidelines of a nationally recognized protocol; and
    2. May be billed by a provider other than a TAKE CHARGE provider.
  3. The comprehensive prevention visit for family planning:
    1. Must be provided by one or more qualified TAKE CHARGE providers. (See WAC 182-532-730.)
    2. Must include:
      1. A clinical breast examination and pelvic examination that follows the guidelines of a nationally recognized protocol; and
      2. Client-centered counseling that incorporates risk factor reduction for unintended pregnancy and anticipatory guidance about the advantages and disadvantages of all contraceptive methods.
    3. May include a pap smear according to current, nationally recognized clinical guidelines.
    4. Must be documented in the client's chart with detailed information that allows for a well-informed follow-up visit.
    5. Must be billed by a TAKE CHARGE provider only.

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 182-532-100 Reproductive health services - Eligibility.

WAC 182-532-100 Reproductive health services -- Eligibility

Effective October 1, 2019

  1. The medicaid agency covers reproductive health services, as described under WAC 182-532-120, for clients covered by one of the Washington apple health programs listed in the table in WAC 182-501-0060.
  2. A client enrolled in an agency-contracted managed care organization (MCO) may self-refer outside their MCO for reproductive health care services including, but not limited to, family planning, abortion, and sexually transmitted infection (STI) services from any agency-approved provider.
  3. A client who is age twenty-one or older may not self-refer outside their MCO for sterilizations.

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 182-526-0300 Order of dismissal based on subject matter

WAC 182-526-0300 Order of dismissal based on subject matter

Effective March 16, 2017

  1. An order of dismissal issued based on lack of subject matter jurisdiction must be entered as an initial order subject to the requirements of WAC 182-526-0520.

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 182-526-0284 Orders of default

WAC 182-526-0284 Orders of default.

Effective August 18, 2018

  1. An order of default may be entered when the appellant fails to attend a scheduled prehearing conference or hearing. The order of default will include a notice of inquiry as to whether the appellant wants to petition to reinstate the hearing.
  2. The appellant may file a petition to vacate an order of default under WAC 182-526-0290.
  3. An order of default 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 does not file a petition to vacate within twenty-one calendar days of the order being served (mailed) on the parties under WAC 182-526-0290 (2) and (5)(b); or
    2. If 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 default becomes a final order.
  5. The appellant may seek judicial review of a final order of default 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 182-526-0102 Coordinated appeals process with the Washington health benefits exchange

WAC 182-526-0102 Coordinated appeals process with the Washington health benefits exchange.

Effective March 16, 2017

  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:
    1. By telephone;
    2. By mail (which should be sent to Health Care Authority, P.O. Box 45504, Olympia, WA 98504-5504);
    3. In person;
    4. By facsimile transmission;
    5. By email; or
    6. By any other commonly available electronic means.
  3. When an applicant or recipient appeals an HBE determination of eligibility for health insurance premium tax credits (HIPTC) or cost-sharing reductions with HBE and also requests a hearing with HCA related to apple health eligibility, the ALJ will not require the applicant or recipient to submit information to the ALJ that the applicant or recipient previously submitted to HBE.
  4. If an applicant or recipient submits to HBE a request for a hearing related to apple health eligibility, the ALJ will accept the date HBE received the request for the hearing as the date filed for the purposes of timeliness standards and will treat it as a valid hearing request.
  5. If the applicant or recipient appeals only the determination related to apple health eligibility, subsection (3) of this section does not apply.

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 182-526-0100 Expedited administrative hearings for urgent health care needs

WAC 182-526-0100 Expedited administrative hearings for urgent health care needs.

Effective January 5, 2018

  1. Requesting an expedited hearing.
    1. An expedited hearing may be requested only in matters involving applicants or recipients.
    2. 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.
    3. 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.
    4. A recipient may be eligible for continued coverage according to WAC 182-504-0130.
  2. Exception to notice requirements. The notice requirements in this section prevail over notice requirements in WAC 182-526-0250.
  3. Standard for granting an expedited hearing request.
    1. For the purposes of this section, an urgent health care need means that waiting for an otherwise timely final order could jeopardize the applicant's or recipient's life, health or ability to attain, maintain, or regain maximum function.
    2. The administrative law judge (ALJ) grants a request for an expedited hearing only if the ALJ finds by a preponderance of the evidence submitted with the applicant's or recipient's expedited hearing request and the information listed below that the applicant or recipient has an urgent health care need.
    3. Information the ALJ may consider when determining whether the applicant or recipient has an urgent health care need and whether to subsequently grant or deny an expedited hearing request includes, but is not limited to:
      1. The documentation submitted with the expedited hearing request to show an urgent health care need;
      2. Whether the recipient is eligible for continued coverage of the benefits denied, reduced, or terminated by the agency or the agency's designee pending resolution of the appeal as an expedited hearing request may not be granted for individuals receiving continued coverage;
      3. The length of time between the applicant's or recipient's receipt of the agency's or the agency designee's adverse notice and the applicant's or recipient's request for an expedited hearing; and
      4. Whether the documentation submitted with the expedited hearing request shows that an appointment with a provider for a health care procedure or treatment to address the applicant's or recipient's stated urgent health care need:
        1. Is scheduled; or
        2. Cannot be scheduled due to a lack of coverage.
  4. Time frame and notice requirements for expedited hearing request determination. The ALJ must grant or deny the expedited hearing request and issue the determination within four business days of receipt of the request by OAH or as expeditiously as possible. OAH must immediately notify the parties orally and in writing of the ALJ's determination, unless the parties waive written notification. The oral and written notice must clearly state:
    1. Whether the expedited hearing request was approved or denied;
    2. That a hearing has been or will be scheduled; and
    3. The information listed in subsection (3)(c) of this section that the ALJ relied upon.
  5. Scheduling an expedited hearing. If the ALJ grants a request for an expedited hearing, OAH will schedule a hearing and provide notice as expeditiously as possible, allowing for a reasonable amount of notice and time for the parties to prepare for hearing. The notice rules in WAC 182-526-0250 do not apply.
  6. Denial of expedited hearing. If the ALJ denies an expedited hearing request, OAH will schedule the hearing based on standard scheduling practices and the notice rules in WAC 182-526-0250.
  7. Appeal right. There is no right to appeal an ALJ's determination to grant or deny an expedited hearing request.
  8. Expedited hearing initial order. If an expedited hearing request is granted and an expedited hearing is held, the ALJ must issue an initial order as expeditiously as possible.
  9. Expedited final order. Any party may request administrative review of the initial order with the health care authority board of appeals according to WAC 182-526-0560 through 182-526-0600. The board of appeals will issue a final order as expeditiously as possible.
  10. Delayed expedited hearing request determination or expedited hearing initial order. The ALJ has a duty to determine whether to grant or deny an expedited hearing request and, if granted, to issue an expedited hearing initial order as expeditiously as possible, except in unusual circumstances when:
    1. An ALJ is unable to reach a decision because the applicant or recipient requests a delay or does not take a required action; or
    2. There is an administrative or other emergency beyond OAH's or the agency's control.

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 182-505-0300 Hospital Presumptive Eligibility

WAC 182-505-0300 Hospital Presumptive Eligibility

Effective 6/30/2017

  1. Purpose. The hospital presumptive eligibility (HPE) program provides temporary Washington apple health coverage to HPE-eligible persons who enroll through an HPE-qualified hospital.
  2. HPE-eligible persons. To be HPE-eligible:
    1. A person must:
      1. Be younger than age 65; and
      2. Meet the eligibility requirements for one or more of the following programs:
        1. Washington apple health for pregnant women (chapter 182-505 WAC);
        2. Washington apple health for kids (chapter 182-505 WAC);
        3. Washington apple health for foster care (chapter 182-505 WAC);
        4. Washington apple health for parents and caretaker relatives (chapter 182-505 WAC);
        5. Washington apple health for adults (chapter 182-505 WAC); or
        6. Family planning only services (chapter 182-532 WAC).
    2. A person must not:
      1. Be an apple health beneficiary;
      2. Be a supplemental security income beneficiary; or
      3. Have received HPE coverage within the preceding 24 months.
  3. HPE-qualified hospitals. To be HPE-qualified, a hospital must:
    1. Operate in Washington state;
    2. Submit a signed core provider agreement (CPA) to the agency;
    3. Submit a signed HPE agreement to the agency;
    4. Comply with the terms of the CPA and HPE agreements;
    5. Determine HPE eligibility using only those employees who have successfully completed the agency's HPE training;
    6. Agree to provide HPE-application assistance to anyone who requests it; and
    7. Agree to be listed on the agency's web site as an HPE-application assistance provider.
  4. Limitations.
    1. An HPE-qualified hospital must attempt to help the person complete a regular apple health application before filing an HPE application. If the person cannot indicate whether they expect to file a federal tax return or be claimed as a tax dependent, the HPE-qualified hospital may treat the person as a nonfiler under WAC 182-506-0010 (5)(c) for HPE purposes.
    2. HPE coverage begins on the earlier of:
      1. The day the HPE-qualified hospital determines the person is eligible; or
      2. The day the HPE-qualified hospital provides a covered medical service to the person, but only if the hospital determines the person is eligible and submits the decision to the agency no later than five calendar days after the date of service.
    3. HPE coverage ends on the earlier of:
      1. The last day of the month following the month in which HPE coverage began; or
      2. The day the agency determines the person is eligible for other apple health coverage.
    4. HPE coverage does not qualify a person for continuous eligibility under WAC 182-504-0015.
    5. If HPE coverage is based on pregnancy, the pregnant person is eligible for HPE coverage only once for that pregnancy.
    6. The HPE program covers only those services included in the programs listed in subsection (2)(e) of this section, except that pregnancy-related services are limited to ambulatory prenatal care.
    7. A child born to a person with HPE coverage is ineligible for apple health under WAC 182-505-0210(2). An HPE-qualified hospital must complete a separate HPE determination for the newborn child.

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.

Trauma-informed approach

Imagine a world where we interact with every life we meet as if we knew their story of hardship and trial—and engaged with them from that knowledge. Welcome to trauma-informed approach (TIA). 

What is trauma-informed approach?

Dr. Isaiah Pickens, Ph.D., an expert on cultivating trauma-informed approaches, explains:

For more information

Learn how to implement a trauma-informed approach in your agency

In 2019, HCA awarded nearly 1.4 million dollars in grants to organizations across the state to build on the trauma-informed work already happening across the state, and to support interest that had been previously unfunded.

To hear more from providers that participated in this initiative and what they learned, watch our webinar on trauma-informed approaches.

Expand your trauma-informed footprint

Use the following list of self-evaluation tools to explore how you can increase trauma-informed approach across your agency.

Events

Online training

The following online courses on trauma-informed approach (TIA) are available in English and Spanish:

  • TIA overview for everyone
  • TIA for agency leaders
  • TIA for staff
  • TIA for supervisors

How do I sign up? 

You will use the Bridge app to sign up for training. You must have a Bridge account before you can register for a course. 

  1. Go to the TIA Washington Training Center.
  2. Scroll down the page to register for Bridge.
  3. Once you have created a Bridge account, log into Bridge to register for a training. 
  4. You will receive a welcome invitation from TIA Washington to access the courses.

Promissory notes and loans

Revised date
Purpose statement

Describe and clarify rules on how promissory notes and loans affect Medicaid eligibility.

WAC 182-516-0400 Promissory notes and loans.

WAC 182-516-0400 Promissory notes and loans.

Effective March 2, 2018

  1. General.
    1. In this section, note includes promissory note, loan or other obligation to pay.
    2. The medicaid agency or the agency's designee determines the value of outstanding principal and interest payments using amortization schedules, unless otherwise stated in this section.
  2. A note as a resource.
    1. A note is a resource. The value of the note is the fair market value (FMV).
    2. The FMV of a note is the outstanding principal of the note, unless convincing evidence to the contrary is provided to the agency or the agency's designee.
    3. If the note owner provides convincing evidence to the agency or the agency's designee of a legal bar to the sale of the note, the note's FMV is zero.
  3. A note as income.
    1. Interest on a note is unearned income.
    2. If the FMV of the note under subsection (2)(c) of this section is zero, the principal portion of recurring payments is unearned income.
    3. The agency or the agency's designee may budget the unearned income in equal monthly amounts at the request of the note owner, or at the agency's or the agency's designee's discretion. The budgeting period will be the note owner's certification period under chapter 182-504 WAC.
  4. A note as an asset transfer under WAC 182-513-1363.
    1. Subject to (b) of this subsection:
      1. The agency or the agency's designee evaluates the purchase of a note as an asset transfer if the purchase price of the note exceeds the FMV of the note;
      2. The value of the asset transfer is the difference between the purchase price of the note and the FMV of the note at the time of purchase; and
      3. The agency or the agency's designee determines the FMV of the note at the time of purchase using subsection (2) of this section, but can also determine the FMV of the note at a time after purchase if the agency or the agency's designee determines FMV of the note has changed since the time it was purchased.
    2. The assets used to purchase a note are an uncompensated asset transfer under WAC 182-513-1363, unless the note:
      1. Prohibits the cancellation of the balance of the note upon death of the note owner; and
      2. Is paid out, in equal periodic amounts with no deferral and no balloon payments, over a term not greater than the actuarial life expectancy of that note owner.
    3. The value of the uncompensated asset transfer under (b) of this subsection is the outstanding balance of the note due as of the date of the client's application for medical assistance for institutional or home and community-based waiver services.
    4. If the purchase of a note results in a period of ineligibili­ty under both (a) and (b) of this subsection, then the period of in­ eligibility under WAC 182-513-1363 will be the period that is longer.

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

General

When a person loans something of value (almost always cash), the promise to repay that loan is worth something. Generally, the value of the promise is the amount remaining to be paid on the loan.

The person who receives the loan and promises to repay is the grantor/payor of the promissory note. The grantee/payee of the loan is the person who owns the promissory note. Generally, the Medicaid client is the grantee/payee and the client owning the promissory note may have resource implications if resources are a part of Medicaid eligibility.

Example: Sam loans his daughter Erin $10,000. Erin creates and signs a promissory note to repay the $10,000 over 5 years. Erin is the grantor and Sam is the grantee. Sam no longer has the $10,000, but owns the note Erin created. After three years, Erin owes Sam $6,000. At this time, the value of Sam’s note is $6,000.

Sales contracts

Certain promissory notes exchanged for real property that was the client's (or spouse's) home are named "sales contracts" in WAC 182-512-0350. Before continuing here, review the promissory note to determine if it falls under any sales contract rules under WAC 182-512-0350 (3) through (10).

Resource

The assumed fair market value (FMV) of a note is the amount owing (the "principal"). If a note cannot be sold because of a legal barrier, the FMV is $0 (as opposed to being an excluded resource). However, under WAC 182-512-0250 (8), the value of a note (or any resource) is its FMV, less any encumbrances. Accept and consider evidence for the FMV of the note. Certain factors can value a note at less than the owed principal.

Examples: A few examples of where the FMV of a note may be less than the principal owed: The note is unsecured (the owner of the note does not have the ability to seize property to satisfy the note if the grantor defaults. The note bears no interest (a $10,000 note with $10,000 outstanding principal is worth much less than $10,000 if it is paid off over many years with no interest). No contract (there is no written agreement to pay, only an oral promise or an implied promise).

Income

When a note has a FMV greater than $0, the periodic payment consists of interest 

and principal (though sometimes it may only be principal if the note is interest free). Because the note is a resource, the principal portion of a periodic payment is a resource conversion, and not income (i.e., a portion of the note is turned into cash). The interest portion, if any, is unearned income.

If the FMV of a note is $0, the entire periodic payment is unearned income.

Asset transfer

There are two tests for an asset transfer related to notes.

  • First, as with any resource, if the assets used to purchase the note (i.e., in most circumstances, the money loaned) exceed the FMV of the note, there is uncompensated value. The date of the purchase of the note is the transfer date. Factors that affect the present FMV of the note also affect the FMV of the note when it was created.
  • Second, there are objective tests that, if failed, make the entire note uncompensated. The transfer date for these tests is the date of application for long-term care (LTC); and the uncompensated value is the outstanding principal on the date of application for long-term care (LTC).
    • The note must explicitly prohibit note cancellation upon the death of the note owner. Mere silence on the ability to cancel is not enough, the note must state it cannot be cancelled on death. A note can be amended to conform with this.
    • The note must be paid out, in equal periodic amounts with no deferral and no balloon payments, over a term not greater than the actuarial life expectancy of that note owner. A note payment schedule can be restructured to conform with this.

Example: Sara loaned her sister Jamie $30,000 one year ago. The note is unsecured and bears no interest. The note has equal payments, no deferral or balloon payments, is paid off within Sara's life expectancy and is not cancellable on death. Today the outstanding principal is $29,000. Sara has tried to sell the note, but many potential buyers feel the note isn't worth much. One buyer valued the note at $1,000 and another valued it at $2,000. A reasonable FMV would be $1,500. Because Sara gave Jamie $29,000 (originally $30,000, but $1,000 has been paid back) in exchange for a note worth $1,500, Sara has an uncompensated transfer of $27,500.

Example: Same example as above, except the note is paid off beyond Sara's life expectancy. Sara applied for LTC today. The uncompensated value is $29,000.

If a note is a transfer under both tests (the FMV test and the objective test), then the uncompensated value is the greater of the two.

Worker Responsibilities

Review any notes that the client or their financially responsible AU member owns. Accept and consider evidence as to the FMV of the note. Document the FMV of the note and how you determined the FMV. Calculate and document any unearned income on a note. 

Related links

WAC 182-512-0350

WAC 182-513-1363

Please report broken links or content problems.

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