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WAC 182-527-2746 Estate recovery-Asset-related limitations.
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WAC 182-527-2746 Estate recovery—Asset-related limitations.
Effective March 14, 2016
For the purposes of this section, the term "agency" includes the agency's designee.
- Before July 25, 1993. For services received before July 25, 1993, that are subject to recovery, the agency may exempt:
- The first fifty thousand dollars of the estate's value at the time of the client's death; and
- Sixty-five percent of the remaining value of the estate.
- July 24, 1993, through June 30, 1994. For services that are subject to recovery that were received on or after July 25, 1993, through June 30, 1994, the agency exempts two thousand dollars' worth of personal property.
- Life estate.
- The agency may file a lien against a client's life estate interest in real property.
- The agency's lien against the property may not exceed the value of the client's life estate. Under this subsection, value means the fair market value of the property multiplied by the life estate factor that corresponds to the client's age on the client's last birthday. For a list of life estate factors, see the life estate and remainder interest tables maintained by the Social Security Administration.
- The agency may not enforce a lien under this subsection against any property right that vested before July 1, 2005.
- Joint tenancy.
- The agency may file a lien against property in which a client was a joint tenant when the client died.
- The agency's lien against the property may not exceed the value of the client's interest in the property. Under this subsection, value means the fair market value of the property divided by the number of joint tenants on the day the client died.
- The agency may not enforce a lien under this subsection against any property right that vested before July 1, 2005.
- Qualified long-term care partnership.
- Assets designated as protected by a qualified long-term care partnership (QLTCP) policy issued after November 30, 2011, may be disregarded for estate recovery purposes if:
- The insured person's estate is the recipient of the estate recovery exemption; or
- The insured person holds title to property which is potentially subject to a predeath lien and that person asserts the property is protected under the QLTCP policy.
- A person must provide clear and convincing evidence to the office of financial recovery that the asset in question was designated as protected, including:
- Proof of a valid QLTCP policy;
- Verification from the LTC insurance company of the dollar amount paid out by the policy; and
- A current department of social and health services QLTCP asset designation form when the QLTCP policy paid out more than was previously designated.
- The insured person's estate must provide clear and convincing evidence proving an asset is protected before the final recovery settlement.
- Assets designated as protected by a qualified long-term care partnership (QLTCP) policy issued after November 30, 2011, may be disregarded for estate recovery purposes if:
- Rules specific to American Indians and Alaska natives.
- Certain properties belonging to American Indians/Alaska natives (AI/AN) are exempt from estate recovery if at the time of death:
- The deceased client was enrolled in a federally recognized tribe; and
- The estate or heir documents the deceased client's ownership interest in trust or nontrust real property and improvements located on a reservation, near a reservation as designated and approved by the Bureau of Indian Affairs of the U.S. Department of the Interior, or located:
- Within the most recent boundaries of a prior federal reservation; or
- Within the contract health service delivery area boundary for social services provided by the deceased client's tribe to its enrolled members.
- Protection of trust and nontrust property under subsection (4) of this section is limited to circumstances when the real property and improvements pass from an Indian (as defined in 25 U.S.C. Chapter 17, Sec. 1452(b)) to one or more relatives (by blood, adoption, or marriage), including Indians not enrolled as members of a tribe and non-Indians, such as spouses and stepchildren, that their tribe would nonetheless recognize as family members, to a tribe or tribal organization and/or to one or more Indians.
- Certain AI/AN income and resources (such as interests in and income derived from tribal land and other resources currently held in trust status and judgment funds from the Indian Claims Commission and the U.S. Claims Court) are exempt from estate recovery by other laws and regulations.
- Ownership interests in or usage rights to items that have unique religious, spiritual, traditional, and/or cultural significance or rights that support subsistence or a traditional life style according to applicable tribal law or custom.
- Government reparation payments specifically excluded by federal law in determining eligibility are exempt from estate recovery as long as such funds have been kept segregated and not commingled with other countable resources and remain identifiable.
- Certain properties belonging to American Indians/Alaska natives (AI/AN) are exempt from estate recovery if at the time of death:
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.
- Before July 25, 1993. For services received before July 25, 1993, that are subject to recovery, the agency may exempt:
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WAC 182-527-2738 Estate recovery - General right to recover.
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WAC 182-527-2738 Estate recovery—General right to recover.
Effective March 14, 2016
For the purposes of this section, the term "agency" includes the agency's designee.
- When the agency may file. After a Washington apple health client has died, the medicaid agency may file liens to recover the cost of services subject to recovery that were correctly paid on the client's behalf.
- Notice requirement.
- Before the agency may file a lien under this section, it sends notice via first class mail as follows:
- If the estate has a personal representative, the agency sends notification to:
- The personal representative; and
- Any known title holder.
- If the estate has known heirs but no personal representative, the agency sends notification to:
- Any known heir; and
- Any known title holder.
- If the estate has no personal representative and no known heirs, the agency sends notification to:
- The address listed on the title; and
- Any known title holder.
- If the estate has a personal representative, the agency sends notification to:
- The notice states:
- The agency's intent to file a lien against the deceased client's property;
- The amount the agency seeks to recover;
- The deceased client's name, identification number, date of birth, and date of death;
- The county in which the property is located; and
- How to request an administrative hearing.
- Before the agency may file a lien under this section, it sends notice via first class mail as follows:
- The agency may not recover from the client's estate so long as there remains:
- A surviving spouse; or
- A surviving child who:
- Is age twenty or younger; or
- Is blind or disabled as defined in WAC 182-512-0050.
- Interest assessed on past-due debt.
- Interest on a past-due debt accrues at a rate of one percent per month under RCW 43.17.240.
- A lien under this section becomes a past-due debt when the agency has recorded the lien in the county where the property is located and nine months have passed since the lien was recorded or a creditor's claim was filed, whichever is sooner.
- The agency may waive interest if reasonable efforts to sell the property have failed.
- Administrative hearing. An administrative hearing under this section is governed by WAC 182-527-2753.
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.
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WAC 182-514-0263 Non-SSI-related institutional medically needy coverage for pregnant people and people age 20 and younger.
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WAC 182-514-0263 Non-SSI-related institutional medically needy coverage for pregnant people and people age 20 and younger.
Effective June 26, 2022
- Medically needy (MN) coverage under this section is only available for people age 20 and younger or pregnant people. The medicaid agency determines a client who meets SSI-related criteria under WAC 182-512-0050 eligible for institutional MN coverage under WAC 182-513-1395. If a client meets requirements in both this section and WAC 182-513-1395, the client may choose which program to enroll in for coverage.
- A client whose income exceeds the categorically needy (CN) standards under WAC 182-514-0250 and 182-514-0260 is:
- Eligible for MN coverage with no spenddown if the client's countable income (CI) is equal to or less than the department-contracted daily rate times the number of days in the institution;
- Eligible for MN coverage after a spenddown under WAC 182-519-0110 is met if the client's CI is above the department-contracted daily rate times the number of days in the institution but less than the institution's private rate;
- Not eligible for payment of long-term care services provided by the institution if the person's CI exceeds the institution's private rate;
- Responsible for paying up to the monthly state rate for the facility as participation in the cost of care; and
- Allowed to keep a monthly personal needs allowance (PNA) under WAC 182-513-1105. Current PNA and long-term care standards can be found at the agency's program standard for income and resources webpage.
- If a client's CI exceeds the institution's private rate, the agency determines eligibility for medical coverage under chapter 182-519 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.
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WAC 182-543-5000 Covered—Prosthetics/orthotics.
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WAC 182-543-5000 Prosthetics/orthotics.
Effective January 1, 2019
- The medicaid agency pays for, without prior authorization (PA), the following prosthetics and orthotics. Items that meet the definition of medical equipment may be covered under the requirements for medical equipment. Prosthetics and orthotics that do not meet those definitions are covered, with stated limitations:
- Thoracic-hip-knee-ankle orthosis (THKAO) standing frame - One every five years.
- Preparatory, above knee "PTB" type socket, nonalignable system, pylon, no cover, SACH foot plaster socket, molded to model - One per lifetime, per limb.
- Preparatory, below knee "PTB" type socket, nonalignable system, pylon, no cover, SACH foot thermoplastic or equal, direct formed - One per lifetime, per limb.
- Socket replacement, below the knee, molded to patient model - One per twelve-month period, per limb.
- Socket replacement, above the knee/knee disarticulation, including attachment plate, molded to patient model - One per twelve-month period, per limb.
- All other prosthetics and orthotics are limited to one per twelve-month period per limb.
- Prosthetics and orthotics beyond these limits may be prior authorized when medically necessary, as defined in WAC 182-500-0070.
- The agency pays only licensed prosthetic and orthotic providers to supply prosthetics and orthotics. This licensure requirement does not apply to the following:
- Providers who are not required to have specialized skills to provide select orthotics, but meet medical equipment and pharmacy provider licensure requirements;
- Occupational therapists providing orthotics who are licensed by the Washington state department of health in occupational therapy; and
- Out-of-state providers, who must meet the licensure requirements of that state.
- The agency pays only for prosthetics or orthotics that are listed as such by the Centers for Medicare and Medicaid Services (CMS), that meet the definition of prosthetic or orthotic in WAC 182-543-1000 and are prescribed under WAC 182-543-1100.
- The agency pays for repair or modification of a client's current prosthesis. To receive payment, all of the following must be met:
- All warranties are expired;
- The cost of the repair or modification is less than fifty percent of the cost of a new
prosthesis and the provider has submitted supporting documentation; and - The repair must have a warranty for a minimum of ninety days.
- Clients are responsible for routine maintenance of their prosthetic or orthotic. If a client
does not have the physical or mental ability to perform this task, the client's caregiver is
responsible for routine maintenance of the prosthetic or orthotic. The agency requires PA for extensive maintenance to a prosthetic or orthotic.
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.
- The medicaid agency pays for, without prior authorization (PA), the following prosthetics and orthotics. Items that meet the definition of medical equipment may be covered under the requirements for medical equipment. Prosthetics and orthotics that do not meet those definitions are covered, with stated limitations:
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WAC 182-543-2000 Eligible providers and provider requirements.
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WAC 182-543-2000 Eligible providers and provider requirements.
Effective May 1, 2025
- The medicaid agency pays on a fee-for-service basis, providers (including providers who supply medical equipment and supplies in an outpatient clinical setting), pharmacies, and suppliers, for medical equipment, medical supplies, complex rehabilitation technology (CRT), and related repair services.
- Providers pharmacies, and suppliers (including out-of-state providers, pharmacies, and suppliers) must:
- Be enrolled with medicare as a pharmacy, supplier of medical equipment, medical supplies, and related repair services, or as a CRT supplier (CRT suppliers must also comply with the requirements in WAC 182-543-4400); and
- Possess a national provider identifier (NPI) for a pharmacy, supplier of medical equipment, medical supplies, and related repair services, or CRT supplier.
- Prosthetics and orthotics providers, and occupational therapists providing orthotics, must meet the licensing regulations of the state in which they practice.
- Providers pharmacies, and suppliers (including out-of-state providers, pharmacies, and suppliers) must:
- Providers and suppliers of medical equipment and supplies must:
- Meet the general provider requirements in chapter 182-502 WAC, except when the client is dual-eligible, medicare is the primary payer, and the agency is being billed only for one or more of the co-pay, coinsurance, or deductible;
- Have the proper business license and be certified, licensed and bonded if required, to perform the services billed to the agency;
- Have a valid prescription, which is referred to as a standard written order (SWO), for the medical equipment or supplies. A SWO is a written order communicated by the treating provider to the supplier that:
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- Is written by an authorized practitioner as defined in WAC 182-551-2010 and meets the face-to-face encounter requirements described in WAC 182-551-2040;
- Client's full name;
- Order date, which is the date the order was written or electronically signed by the treating practitioner;
- General item description, which may be either a general description (for example, wheelchair or hospital bed), a HCPCS code, a HCPCS code narrative, or a brand name or model number;
- For equipment, in addition to the base item description, the SWO may include all concurrently ordered options, accessories, or additional features that are separately billed or require an upgraded code (list each separately);
- For supplies, in addition to the base item description, the order/prescription may include all concurrently ordered supplies that are separately billed (list each separately);
- If applicable, the length of time the item is required; and
- The name, NPI, and signature of the treating practitioner, practitioner credentials, and the signature date.
- Is written by an authorized practitioner as defined in WAC 182-551-2010 and meets the face-to-face encounter requirements described in WAC 182-551-2040;
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- Provide instructions for use of equipment;
- Provide only new equipment to clients, which include full manufacturer and dealer warranties. See WAC 182-543-2250(3);
- Provide documentation of proof of delivery, upon agency request (see WAC 182-543-2200); and
- Bill the agency using only the allowed procedure codes listed in the agency's published billing guides.
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.
- The medicaid agency pays on a fee-for-service basis, providers (including providers who supply medical equipment and supplies in an outpatient clinical setting), pharmacies, and suppliers, for medical equipment, medical supplies, complex rehabilitation technology (CRT), and related repair services.
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WAC 182-560-100 Achieving a Better Life Experience (ABLE) Act.
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WAC 182-560-100 Achieving a Better Life Experience (ABLE) Act.
Effective September 8, 2018
This rule describes a qualified achieving a better life experience (ABLE) account and its effect on the determination of eligibility for Washington apple health coverage.
- A qualified ABLE account:
- Is established and maintained by a state, or its designated agency or entity;
- Meets federal requirements under 26 U.S.C. Sec. 529A; and
- Is used to save funds for the disability related expenses of the account's designated beneficiary.
- This section applies to ABLE account beneficiaries who:
- Are entitled to benefits based on blindness or disability under Title II or XVI of the Social Security Act; or
- Meet the blindness or disability requirements under WAC 182-512-0050 (1)(b) and (c).
- The disability or blindness described in subsection (2)(a) or (b) of this section must have occurred before age twenty-six.
- This section does not apply if the total combined annual contributions to an ABLE account exceed the limit under 26 U.S.C Sec. 529A.
- When determining countable income for apple health programs for the account's designated beneficiary, the medicaid agency or the agency's designee does not:
- Count contributions made by a person other then the designated beneficiary to the ABLE account;
- Count funds distributed from the account;
- Count earnings generated by the account, such as accrued interest or dividends; or
- Reduce income used to determine eligibility by the amount of contributions made to the account, including any funds the designated beneficiary may contribute to it.
- When determining eligibility for apple health programs, the agency or the agency's designee excludes as resources:
- The value of an ABLE account, including any earnings generated by the account; and
- Subject to subsection (8) of this section, distributions from the account for qualified disability expenses as long as the beneficiary:
- Maintains an ABLE account;
- Contributes to an ABLE account; or
- Receives distributions from such ABLE account.
- "Qualified disability expense (QDE)" means any expense related to the beneficiary's blindness or disability that is made for the benefit of the beneficiary, including the following expenses:
- Education;
- Housing;
- Transportation;
- Employment training and support;
- Assistive technology and personal support services;
- Health;
- Prevention and wellness;
- Financial management;
- Legal fees;
- Expenses for oversight and monitoring; and
- Funeral and burial expenses.
- Distributions under subsection (6)(b) of this section, which are retained into a subsequent calendar month:
- Remain excluded as resources as long as the distributions are identifiable and the beneficiary still intends to use the distribution for a QDE;
- Are available resources on the first day of a subsequent calendar month if the intent of the beneficiary changes such that the beneficiary will not use the distribution for a QDE; and
- Are available resources on the first day of any subsequent month when the distribution is actually used for a non-QDE.
- The agency or the agency's designee counts as a resource on the first day of the following month any funds distributed for purposes other than paying a QDE expense described in subsection (7) of this section.
- If the beneficiary has multiple ABLE accounts, the agency or the agency's designee applies this section to the first ABLE account established.
- Funds remaining in the ABLE account when the beneficiary dies are subject to estate recovery under chapter 182-527 WAC, less any:
- Outstanding QDE debts; and
- Premium payments made from the ABLE account on behalf of the beneficiary to obtain coverage under the apple health care for workers with disabilities described in WAC 182-511-1000.
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.
- A qualified ABLE account:
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WAC 182-505-0100 Monthly income standards for MAGI-based programs.
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WAC 182-505-0100 Monthly income standards for MAGI -based programs.
Effective November 1, 2024.
- Each year, the federal government publishes new federal poverty level (FPL) income standards in the Federal Register found at https://aspe.hhs.gov/poverty-guidelines.
- The income standards for the following Washington apple health programs change on the first day of April every year based on the new FPL, except for subsections (2) and (3) of this section.
- The agency determines income eligibility by comparing countable income as determined of the person's medical assistance unit (MAU), under WAC 182-506-0010 and 182-506-0012, to the applicable income standard. Rules for determining countable income are in chapter 182-509 WAC.
- Parents and caretaker relatives under WAC 182-505-0240 must have countable income equal to or below the following standards:
Medical Assistance Unit Size 1 2 3 4 5 6 7 8 9 10 11+ Medical Assistance Unit Size $511 $658 $820 $972 $1,127 $1,284 $1,471 $1,631 $1,792 $1,951 $1,951 - Parents and caretaker relatives with earned income above the limits in subsection (2) of this section are the only people who may be eligible for the transitional medical program described in WAC 182-523-0100.
- Adults described in WAC 182-505-0250 who are not eligible under subsection (2) or (3) of this section must have countable income equal to or below 133 percent of the FPL.
- Pregnant people described in WAC 182-505-0115 must have countable income equal to or below 210 percent of the FPL.
- Children with countable income:
- Equal to or below 210 percent of the FPL as described in WAC 182-505-0210 (3)(a)(i) receive coverage at no cost.
- Greater than 210 percent but equal to or less than 312 percent as described in WAC 182-505-0210 receive premium-based coverage. Premium amounts are described in WAC 182-505-0225.
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.
- Each year, the federal government publishes new federal poverty level (FPL) income standards in the Federal Register found at https://aspe.hhs.gov/poverty-guidelines.
This issue is not specific to ProviderOne. Please refer to the Adobe website for assistance. ProviderOne related issue: When creating barcode coversheets using come internet browsers, the barcode is not generating/displaying.
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WAC 182-513-1660 Medicaid Alternative Care (MAC) and Tailored Supports for Older Adults (TSOA) - Spousal Impoverishment
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WAC 182-513-1660 Medicaid alternative care (MAC) and tailored supports for older adults (TSOA)—Spousal impoverishment.
Effective February 25, 2023
- The medicaid agency or the agency's designee determines financial eligibility for medicaid alternative care (MAC) or tailored supports for older adults (TSOA) using spousal impoverishment protections under this section, when an applicant or recipient:
- Is married to, or marries a person not in a medical institution; and
- Is ineligible for a noninstitutional categorically needy (CN) SSI-related program or the TSOA program due to:
- Spousal deeming rules under WAC 182-512-0920 for MAC;
- Exceeding the resource limit in WAC 182-512-0010 for MAC, or the limit under WAC 182-513-1640 for TSOA; or
- Both (b)(i) and (ii) of this subsection.
- When a resource test applies, the agency or the agency's designee determines countable resources using the SSI-related resource rules under chapter 182-512 WAC, except pension funds owned by the spousal impoverishment protections community (SIPC) spouse are not excluded as described under WAC 182-512-0550:
- Resource standards:
- For MAC, the resource standard is $2,000; or
- For TSOA, the resource standard is $53,100.
- Before determining countable resources used to establish eligibility for the applicant, the agency or the agency's designee allocates the state spousal resource standard to the SIPC spouse.
- The resources of the SIPC spouse are unavailable to the spousal impoverishment protections institutionalized (SIPI) spouse the month after eligibility for MAC or TSOA services is established.
- Resource standards:
- The SIPI spouse has until the end of the month of the first regularly scheduled eligibility review to transfer countable resources in excess of $2,000 (for MAC) or $53,100 (for TSOA) to the SIPC spouse.
- Income eligibility:
- For MAC:
- The agency or the agency's designee determines countable income using the SSI-related income rules under chapter 182-512 WAC, but uses only the applicant or recipient's income;
- If the applicant's or recipient's countable income is at or below the SSI categorically needy income level (CNIL), the applicant or recipient is considered a SIPI spouse and is income eligible for noninstitutional CN coverage and MAC services;
- For TSOA, see WAC 182-513-1635.
- For MAC:
- Once a person no longer receives MAC services, eligibility is redetermined without using spousal impoverishment protections under WAC 182-504-0125.
- If the applicant's separate countable income is above the standards described in subsection (4) of this section, the applicant is not income eligible for MAC or TSOA services.
- The spousal impoverishment protections described in this section are time-limited for MAC clients and expire on September 30, 2027.
- Standards described in this chapter are located at www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/program-standard-income-and-resources.
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.
- The medicaid agency or the agency's designee determines financial eligibility for medicaid alternative care (MAC) or tailored supports for older adults (TSOA) using spousal impoverishment protections under this section, when an applicant or recipient:
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WAC 182-513-1655 Tailored Supports for Older Adults (TSOA) - Renewals.
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WAC 182-513-1655 Tailored supports for older adults (TSOA) — Renewals.
Effective July 1, 2017
- A person who receives tailored supports for older adults (TSOA) services must complete a renewal of all eligibility factors for the program at least every twelve months.
- Forty-five days prior to the end of the certification period, notice is sent with the HCA 18-008 application for TSOA form. Complete the TSOA renewal in any of the following ways:
- Complete the TSOA application form, sign it, and mail it to P.O. Box 45826, Olympia, WA 98605 by the due date on the letter;
- Complete the TSOA application form, sign it, and fax it to 1-855-635-8305 by the due date on the letter;
- Renew online at Washington connection at https://www.washingtonconnection.org by the due date on the letter; or
- Call your local home and community services office at the telephone number on the letter by the due date on the letter.
- During the renewal process, the medicaid agency or the agency's designee reviews all eligibility factors to determine ongoing eligibility for TSOA, and may request additional verification of eligibility factors under WAC 182-503-0050 if unable to verify information through existing data sources. If additional information is needed, the agency or the agency's designee sends written notice under WAC 182-518-0015.
- If the agency or the agency's designee is unable to complete the renewal or determine eligibility for TSOA beyond the certification period, prior to ending eligibility for TSOA, the agency or the agency's designee sends a written termination notice as described in WAC 182-518-0025.
- A person who is terminated from TSOA for failure to renew has thirty days from the termination date to submit a completed renewal. If still eligible, TSOA is reopened without a break in eligibility.
- Equal access services as described in WAC 182-503-0120 are provided for anyone who needs help meeting the requirements of this section.
- Anyone who disagrees with an action regarding TSOA eligibility may ask for a hearing under chapter 182-526 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.