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.

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.

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.

WAC 182-501-0175 Medical care provided in bordering cities.

Effective July 1, 2011

1. An eligible Washington state resident may receive medical care in a recognized out-of-state bordering city on the same basis as in-state care.
2. The only recognized bordering cities are:
   1. Coeur d'Alene, Moscow, Sandpoint, Priest River, and Lewiston, Idaho; and
   2. Portland, The Dalles, Hermiston, Hood River, Rainier, Milton-Freewater, and Astoria, Oregon.

WAC 182-532-790 TAKE CHARGE program - Good cause exemption from billing third party insurance.

Effective September 1, 2013

1. Under the TAKE CHARGE program, two groups of clients may request an exemption from the medicaid requirement to bill third-party insurance due to "good cause." The two groups are:
   1. TAKE CHARGE applicants who:
      1. Are eighteen years of age or younger;
      2. Are covered under their parents' health insurance; and
      3. Do not want their parents to know that they are seeking and/or receiving family planning services.
   2. Individuals who are domestic violence victims and are covered under the perpetrator's health insurance.
2. "Good cause" means that the use of the third-party coverage would violate a client's confidentiality because the third party:
   1. Routinely sends verification of services to the third-party subscriber and that subscriber is someone other than the applicant; and/or
   2. Requires the applicant to use a primary care provider who is likely to report the applicant's request for family planning services to the subscriber.

WAC 182-501-0165 Medical and dental coverage—Fee-for-service (FFS) prior authorization—Determination process for payment.

Effective August 9, 2015

1. This section applies to fee-for-service (FFS) requests for medical or dental services and medical equipment that:
   1. Are identified as covered services or early and periodic screening, diagnosis, and treatment services; and
   2. Require prior authorization by the medicaid agency.
2. The following definitions and those found in chapter 182-500 WAC apply to this section:

           "Controlled studies" - Studies in which defined groups are compared with each other to reduce bias.

           "Credible evidence" - Type I-IV evidence or evidence-based information from any of the following sources:

           • Clinical guidelines

           • Government sources

          • Independent medical evaluation (IME)

          • Independent review organization (IRO)

          • Independent technology assessment organizations

          • Medical and hospital associations

         • Policies of other health plans

         • Regulating agencies (for example, the Federal Drug Administration or Department of Health)

         • Treating provider

          • Treatment pathways

        "Evidence-based" - The ordered and explicit use of the best evidence available (see "hierarchy of evidence" in subsection (6)(a) of this section) when making health care decisions.

        "Health outcome" - Changes in health status (mortality and morbidity) which result from the provision of health care services.

         "Institutional review board (IRB)" - A board or committee responsible for reviewing research protocols and determining whether:

         (1) The rights and welfare of human subjects are adequately protected;

         (2) The risks to people are minimized and are not unreasonable;

         (3)The risks to people are outweighed by the potential benefit to them or by the knowledge to be gained; and

         (4)The proposed study design and methods are adequate and appropriate in the light of stated study objectives.

"Independent review organization (IRO)" - A panel of medical and benefit experts intended to provide unbiased, independent, clinical, evidence-based reviews of adverse decisions.

"Independent medical evaluation (IME)" - An objective medical examination of the client to establish the medical facts.

"Provider" - The person who is responsible for diagnosing, prescribing, and providing medical, dental, or mental health services to agency clients.

(3) The agency authorizes, on a case-by-case basis, requests described in subsection (1) of this section when the agency determines the service or equipment is medically necessary as defined in WAC 182-500-070. The process the agency uses to assess medical necessity is based on:

(a) The evaluation of submitted and obtainable medical, dental, or mental health evidence as described in subsections (4) and (5) of this section; and

(b) The application of the evidence-based rating process described in subsection (6) of this section.

(4) The agency reviews available evidence relevant to a medical, dental, or mental health service or equipment to:

(a) Determine its efficacy, effectiveness, and safety;

(b) Determine its impact on health outcomes;

(c) Identify indications for use;

(d) Evaluate pertinent client information;

(e) Compare to alternative technologies; and

(f) Identify sources of credible evidence that use and report evidence-based information.

(5) The agency considers and evaluates all available clinical information and credible evidence relevant to the client's condition. The provider responsible for the client's diagnosis, or treatment, or both, must submit with the request credible evidence specifically related to the client's condition including, but not limited to:

(a) A physiological description of the client's disease, injury, impairment, or other ailment;

(b) Pertinent laboratory findings;

(c) Pertinent X-ray and/or imaging reports;

(d) Individual patient records pertinent to the case or request;

(e) Photographs, or videos, or both, if requested; and

(f) Objective medical/dental/mental health information such as medically/dentally acceptable clinical findings and diagnoses resulting from physical or mental examinations.

(6) The agency uses the following processes to determine whether a requested service described in subsection (1) is medically necessary:

(a) Hierarchy of evidence - How defined. The agency uses a hierarchy of evidence to determine the weight given to available data. The weight of medical evidence depends on objective indicators of its validity and reliability including the nature and source of the evidence, the empirical characteristics of the studies or trials upon which the evidence is based, and the consistency of the outcome with comparable studies. The hierarchy (in descending order with Type I given the greatest weight) is:

(i) Type I: Meta-analysis done with multiple, well-designed controlled studies;

(ii) Type II: One or more well-designed experimental studies;

(iii) Type III: Well-designed, quasi-experimental studies such as nonrandomized controlled, single group pre-post, cohort, time series, or matched case-controlled studies;

(iv) Type IV: Well-designed, nonexperimental studies, such as comparative and correlation descriptive, and case studies (uncontrolled); and

(v) Type V: Credible evidence submitted by the provider.

(b) Hierarchy of evidence - How classified. Based on the quality of available evidence, the agency determines if the requested service is effective and safe for the client by classifying it as an "A,""B,""C," or "D" level of evidence:

(i) "A" level evidence: Shows the requested service or equipment is a proven benefit to the client's condition by strong scientific literature and well-designed clinical trials such as Type I evidence or multiple Type II evidence or combinations of Type II, III or IV evidence with consistent results (An "A" rating cannot be based on Type III or Type IV evidence alone).

(ii) "B" level evidence: Shows the requested service or equipment has some proven benefit supported by:

(A) Multiple Type II or III evidence or combinations of Type II, III or IV evidence with generally consistent findings of effectiveness and safety (A "B" rating cannot be based on Type IV evidence alone); or

(B) Singular Type II, III, or IV evidence in combination with agency-recognized:

(I) Clinical guidelines;

(II) Treatment pathways; or

(III) Other guidelines that use the hierarchy of evidence in establishing the rationale for existing standards.

(iii) "C" level evidence: Shows only weak and inconclusive evidence regarding safety, or efficacy, or both. For example:

(A) Type II, III, or IV evidence with inconsistent findings; or

(B) Only Type V evidence is available.

(iv) "D" level evidence: Is not supported by any evidence regarding its safety and efficacy, for example that which is considered investigational or experimental.

(c) Hierarchy of evidence - How applied. After classifying the available evidence, the agency:

(i) Approves "A" and "B" rated requests if the service or equipment:

(A) Does not place the client at a greater risk of mortality or morbidity than an equally effective alternative treatment; and

(B) Is not more costly than an equally effective alternative treatment.

(ii) Approves a "C" rated request only if the provider shows the requested service is the optimal intervention for meeting the client's specific condition or treatment needs, and:

(A) Does not place the client at a greater risk of mortality or morbidity than an equally effective alternative treatment;

(B) Is less costly to the agency than an equally effective alternative treatment; and

(C) Is the next reasonable step for the client in a well-documented tried-and-failed attempt at evidence-based care.

(iii) Denies "D" rated requests unless:

(A) The requested service or equipment has a humanitarian device exemption from the Food and Drug Administration (FDA); or

(B) There is a local institutional review board (IRB) protocol addressing issues of efficacy and safety of the requested service that satisfies both the agency and the requesting provider.

(7) Within fifteen days of receiving the request from the client's provider, the agency reviews all evidence submitted and:

(a) Approves the request;

(b) Denies the request if the requested service is not medically necessary; or

(c) Requests the provider submit additional justifying information. The agency sends a copy of the request to the client at the same time.

(i) The provider must submit the additional information within thirty days of the agency's request.

(ii) The agency approves or denies the request within five business days of the receipt of the additional information.

(iii) If the provider fails to provide the additional information, the agency will deny the requested service.

(8) When the agency denies all or part of a request for a covered service or equipment, the agency sends the client and the provider written notice, within ten business days of the date the information is received, that:

(a) Includes a statement of the action the agency intends to take;

(b) Includes the specific factual basis for the intended action;

(c) Includes reference to the specific WAC provision upon which the denial is based;

(d) Is in sufficient detail to enable the recipient to:

(i) Learn why the agency's action was taken; and

(ii) Prepare an appropriate response.

(e) Is in sufficient detail to determine what additional or different information might be provided to challenge the agency's determination;

(f) Includes the client's administrative hearing rights;

(g) Includes an explanation of the circumstances under which the denied service is continued or reinstated if a hearing is requested; and

(h) Includes examples(s) of "lesser cost alternatives" that permit the affected party to prepare an appropriate response.

(9) If an administrative hearing is requested, the agency or the client may request an independent review organization (IRO) or independent medical examination (IME) to provide an opinion regarding whether the requested service or equipment is medically necessary. The agency pays for the independent assessment if the agency agrees that it is necessary, or an administrative law judge orders the assessment.