WAC 182-504-0120 Washington apple health -- Effective dates of changes.

Effective August 29, 2014.

1. We (the agency or its designee) determine the date a change affects your Washington apple health (WAH) coverage based on:
   1. The date you report the change to us;
   2. The date you give us the requested verification; and
   3. The type of WAH you or your family is receiving.
2. When you report a change after you submit your application, but before your application is processed, the change is considered when processing your application.
3. If another person, agency, or data source reports a change in circumstances, the information may be used in determining your eligibility. We will not rely on information received from a person, agency, or data source to terminate your WAH coverage without requesting additional information from you.
4. A change in income affects your ongoing eligibility only if it is expected to continue beyond the month when the change is reported, and only if it is expected to last more than two months.
5. A change that results in termination of your WAH coverage takes effect the first of the month following the advance notice period.
6. The advance notice period:
   1. Begins on the day we send the letter about the change to you; and
   2. Is determined according to the rules in WAC 182-518-0025.
7. A change that results in a decreased scope of care takes effect on the first of the month following the advance notice period. Examples of a decreased scope of care are:
   1. Termination of WAH categorically needy (CN) medical and approval for other WAH coverage with a lesser scope of care such as WAH medically needy (MN) medical;
   2. WAH-MN recipient with a change that increases the spenddown liability amount;
   3. WAH-MN recipient with no spenddown liability with a change that results in WAH-MN with a spenddown liability.
8. A change that results in an increased scope of care takes effect on the first of the month following the date the change was reported, when you provide the required verification:
   1. Within ten days of the date we requested the verification; or
   2. By the end of the month of your change report, whichever is later.

      If you are a WAH-MN applicant with a spenddown liability that has not yet been met and you report a change that results in your becoming eligible for WAH-CN medical or WAH for adults, your change report will be treated as a new application for purposes of retroactive WAH coverage as described in WAC 182-504-0005.

9. If you do not provide the required verification timely under subsection (8) of this section, we make the change effective the first of the month following the month in which you provide the verification. We may terminate your WAH coverage if you do not provide the required verification.
10. When a law or regulation requires a change in WAH, the date specified by the law or regulation is the effective date of the change.
11. When a change in income or allowable expenses is reported timely (within thirty days) and changes the amount you pay towards the cost of your care for institutional programs (residing in a medical institution), we calculate your new participation amount based on:
    1. Either actual income received in a month or allowable deductions incurred in a month, or both; or
    2. An estimate of your monthly or allowable expenses in a prospective period of six months or less, based on both actual income received in a preceding period of six months or less and income expected to be received during the prospective period. At the end of the prospective period or when any significant change occurs, we reconcile this estimate for the period with income received during the same period.
12. When a change in income, or allowable expenses, changes the amount you pay towards the cost of your care for a home and community-based waiver or service, we calculate your new participation amount effective the first of the month following the date the change was reported, except that the new participation amount will be effective the month the change occurs if the change is the loss of an income source that you report within thirty days of the change.
13. We use the following rules to determine the effective date of change for the health care for workers with disabilities (HWD) program:
    1. HWD coverage begins the month after coverage in another medical program ends and the premium amount has been approved by the eligible person; and
    2. If a change in income increases or decreases the monthly premium, the change is effective the first of the month after the change is reported. For more information on premium requirements for this program, see WAC 182-511-1250.

WAC 182-503-0060 Washington apple health -- Application processing times.

Effective August 8, 2021

1. We process applications for Washington apple health medicaid within forty-five calendar days, with the following exceptions:
   1. If you are pregnant, we process your application within fifteen calendar days;
   2. If you are applying for a program that requires a disability decision, we process your application within sixty calendar days; or
   3. The modified adjusted gross income (MAGI)-based apple health application process using Washington Healthplanfinder may provide faster or real-time determination of eligibility for medicaid.
2. For calculating time limits, "day one" is the day we get an application from you that includes at least the information described in WAC 182-503-0005(8). If you give us your paper application during business hours, "day one" is the day you give us your application. If you give us your paper application outside of business hours, "day one" is the next business day. If you experience technical difficulties while attempting to give us your application in Washington Healthplanfinder, "day one" is the day we are able to determine, based on the evidence available, that you first tried to submit an application that included at least the information described in WAC 182-503-0005(8).
3. We determine eligibility as quickly as possible and respond promptly to applications and information received. We do not delay a decision by using the time limits in this section as a waiting period.
4. If we need more information to decide if you can get apple health coverage, we will send you a letter within twenty calendar days of your initial application that:
   1. Follows the rules in chapter 182-518 WAC;
   2. States the additional information we need; and
   3. Allows at least ten calendar days to provide it. We will allow you more time if you ask for more time or need an accommodation due to disability or limited-English proficiency.
5. Good cause for a delay in processing the application exists when we acted as promptly as possible but:
   1. The delay was the result of an emergency beyond our control;
   2. The delay was the result of needing more information or documents that could not be readily obtained;
   3. You did not give us the information within the time frame specified in subsection (1) of this section.
6. Good cause for a delay in processing the application does NOT exist when:
   1. We caused the delay in processing by:
      1. Failing to ask you for information timely; or
      2. Failing to act promptly on requested information when you provided it timely; or
   2. We did not document the good cause reason before missing a time frame specified in subsection (1) of this section. 

WAC 182-526-0495 Equitable estoppel.

Effective March 16, 2017

1. Equitable estoppel is a legal doctrine that may be used only as
   1. an affirmative defense to prevent the health care authority (HCA) from collecting an overpayment. Equitable estoppel may not be used to require HCA to continue to provide something or to require HCA to take action contrary to a statute.
2. There are five elements of equitable estoppel. A party asserting the doctrine of equitable estoppel must prove all of the following five elements by clear and convincing evidence:
   1. HCA made a statement or took an action or failed to take an action, which is inconsistent with a later claim or position by HCA.
   2. The party reasonably relied on HCA's original statement, action or failure to act.
   3. The party will be injured to its detriment if HCA is allowed to contradict the original statement, action or failure to act.
   4. Equitable estoppel is needed to prevent a manifest injustice. Factors to be considered in determining whether a manifest injustice would occur include, but are not limited to, whether:
      1. The party cannot afford to repay the money to HCA;
      2. The party gave HCA timely and accurate information when required;
      3. The party did not know that HCA made a mistake;
      4. The party is free from fault; and
      5. The overpayment was caused solely by an HCA mistake.
   5. The exercise of government functions is not impaired.
3. If the administrative law judge (ALJ) concludes that the party has proven all of the elements of equitable estoppel by clear and convincing evidence, HCA is estopped or prevented from taking action or enforcing a claim of overpayment against that party.

WAC 182-526-0485 Standard of proof.

Effective February 1, 2013

Standard of proof refers to the amount of evidence needed to prove a party's position. Unless the rules or law states otherwise, the standard of proof in a hearing is a preponderance of the evidence. This standard means that it is more likely than not that something happened or exists.

WAC 182-526-0480 Burden of proof.

Effective February 1, 2013

1. Burden of proof is a party's responsibility to:
   1. Provide evidence regarding disputed facts; and
   2. Persuade the administrative law judge (ALJ) that a position is correct.
2. To persuade the ALJ, the party who has the burden of proof must provide the amount of evidence required by WAC 182-526-0485. The ALJ decides if a party has met the burden of proof.

WAC 182-526-0450 Witness.

Effective March 16, 2017

1. The following persons may be witnesses in a hearing:
   1. The appellant or the health care authority (HCA) hearing representative; or
   2. Anyone the parties or the administrative law judge (ALJ) asks to be a witness.
2. The ALJ decides who may testify as a witness.
3. An expert witness may not be a former HCA employee, a former HCA authorized agent, or a former employee of the department in the proceeding against HCA or the department if that employee was actively involved in the HCA action while working for HCA or the department, unless the HCA hearing representative agrees.
4. All witnesses:
   1. Must affirm or take an oath to testify truthfully during the hearing.
   2. May testify in person or by telephone.
   3. May request interpreters from the office of administrative hearings (OAH) at no cost to the party offering the witness.
   4. May be subpoenaed and ordered to appear according to WAC 182-526-0320.
5. Cross-examining a witness.
   1. Each party has the right to cross-examine (question) each witness.
   2. If a party has a representative, only the representative, and not the party, may question the witness.
   3. The ALJ may also question witnesses.
6. Witnesses may refuse to answer questions. However, if a witness refuses to answer a question, the ALJ may reject all of the related testimony of that witness.

WAC 182-526-0440 Judicial notice.

Effective February 1, 2013

1. The administrative law judge (ALJ) may consider and admit evidence by taking judicial notice.
2. Judicial notice is evidence that includes facts or standards that are generally recognized and accepted by judges, government agencies, or national associations. For example, an administrative law judge may take judicial notice of a calendar, a building code, or a standard or practice.
3. If a party requests judicial notice, or if the ALJ intends to take judicial notice, the ALJ may ask the party to provide a copy of the document that contains the information.
4. If judicial notice has been requested, or if the ALJ intends to take judicial notice, the ALJ must tell the parties before or during the hearing.
5. The ALJ must give the parties time to object to judicial notice evidence.

WAC 182-526-0415  Exhibits.

Effective March 16, 2017

1. Proposed exhibits.
   1. Proposed exhibits are documents or other objects that a party wants the administrative law judge (ALJ) to consider when reaching a decision.
   2. After the document or object is accepted by the ALJ, it is admitted and becomes an exhibit.
2. Marking and numbering proposed exhibits and providing copies.
   1. All parties should mark and number their proposed exhibits before the hearing.
   2. All parties should send their proposed exhibits to the office of administrative hearings (OAH) and to all other parties in advance of the hearing.
   3. Parties should bring to the hearing enough copies of their proposed exhibits for all parties if those exhibits were not provided prior to the hearing.
   4. If the party who requested the hearing cannot afford to provide copies of its exhibits for all parties, the requesting party must make its proposed exhibits available for copying. The ALJ may require proof that the requesting party is unable to afford copies.
3. Admitting proposed exhibits into the record.
   1. The ALJ decides whether to admit a proposed exhibit into the record and also determines the importance of the evidence.
   2. The ALJ admits proposed exhibits into the record by marking, listing, identifying, and admitting the proposed exhibits.
   3. The ALJ must make rulings on the record to admit or exclude exhibits.
4. Disagreeing with an exhibit proposed by another party.
   1. A party may object to the authenticity or admissibility of any exhibit, or offer argument about how much importance the ALJ should give the exhibit.
   2. Even if a party agrees that a proposed exhibit is a true and authentic copy of a document, the agreement does not mean that a party agrees with:
      1. Everything in the exhibit or agrees that it should apply to the hearing;
      2. What the exhibit says; or
      3. How the ALJ should use the exhibit to make a decision.
   3. The ALJ may also exclude proposed exhibits from the record.
5. The following rules apply to filing proposed exhibits with OAH and serving them on the other parties for a telephonic hearing:
   1. Parties should file their proposed exhibits with OAH and serve them on the other parties at least five days before the telephonic hearing. In some cases, the ALJ may require that the parties file and serve them earlier.
   2. The health care authority hearing representative may help the appellant file copies of proposed exhibits with OAH and serve the other parties if the appellant cannot afford to do so. The ALJ may require the appellant to provide proof that they are unable to afford to do so.

WAC 182-526-0390 Evidence.

Effective March 16, 2017

1. Evidence includes documents, objects, and testimony of witnesses that parties offer during the hearing to help prove their positions.
2. Evidence may be all or parts of original documents and may be copies of the originals.
3. Parties may offer statements signed by a witness under oath or affirmation as evidence, if the witness cannot appear.
4. Testimony subject to cross examination by the other parties may be given more importance by the administrative law judge (ALJ).
5. The parties may bring evidence to any prehearing meeting, prehearing conference, or hearing, or may file evidence before these events with the office of administrative hearings (OAH).
6. The ALJ may set a deadline before the hearing for the parties to file proposed exhibits and the names of witnesses. If a party misses the deadline, the ALJ may refuse to admit the evidence unless:
   1. The ALJ finds that the offering party has good cause.
   2. The other parties agree that party has good cause for missing the deadline; or
   3. The other parties agree the ALJ may consider the evidence.
7.  Parties may bring any documents and witnesses to the hearing to support their position. However, the other parties may object to any evidence that is offered and may cross-examine witnesses
8. The ALJ determines whether the evidence is admitted and what importance to give it
   1. If the ALJ does not admit the evidence, the parties may make an offer of proof to show why the ALJ should admit it
   2. To make an offer of proof, a party presents evidence and argument on the record to show why the ALJ should consider the evidence
   3. The offer of proof preserves the argument for appeal.
9. The ALJ may only consider admitted evidence and matters officially noticed in the proceeding (judicial notice) to decide the case.
10. Admission of evidence is based upon the reasonable person standard. This standard means evidence that a reasonable person would rely on in making a decision.
11. The ALJ may admit and consider hearsay evidence in accordance with RCW 34.05.452.
12. The ALJ may reject evidence using the Washington rules of evidence as guidelines.
13. The ALJ must reject evidence if required by law.
14. The ALJ decides:
    1. What evidence is more credible if evidence conflicts; and
    2. The importance given to the evidence.
15. The ALJ uses the Washington rules of evidence as guidelines when those rules do not conflict with the rules of this chapter or the Washington Administrative Procedure Act, chapter 34.05 RCW.
16. The ALJ may permit a party or parties to submit additional evidence after the date of the hearing. The ALJ also may allow an appropriate amount of time for the other parties to respond and object to any evidence submitted after the hearing.

WAC 182-526-0387 Requesting that a hearing be consolidated or severed when multiple agencies are parties to the proceeding.

Effective February 23, 2025

1. The following requirements apply only to hearings in which an applicant or recipient of medical services programs administered by the agency, seeks review of decisions made by more than one agency, as defined in RCW 34.05.010. For example: A medical services program recipient appeals a termination of medical assistance by the health care authority and in the same request for hearing the recipient appeals a termination of cash assistance issued by the department of social and health services.
2. When the applicant or recipient of a medical services program files a single request for hearing objecting to decisions made by more than one agency, as defined in RCW 34.05.010, the office of administrative hearings (OAH) schedules one hearing. The administrative law judge (ALJ) may sever the proceeding into multiple hearings on the motion of any of the parties, when:
   1. All parties consent to the severance; or
   2. Any party requests severance without another party's consent, and the ALJ finds there is good cause for severing the hearing and that the proposed severance is not likely to prejudice the rights of the applicant or recipient in accordance with RCW 74.09.741(5).
3. If there are multiple hearings involving common issues or parties where there is one appellant and both the health care authority and the department are parties, upon motion of any party or upon the ALJ's motion, the ALJ may consolidate the hearings if the ALJ finds that the consolidation is not likely to prejudice the rights of the applicant or recipient who is a party to any of the consolidated hearings in accordance with RCW 74.09.741(5).
4. If the ALJ grants the motion to sever the hearing into multiple hearings or consolidate multiple hearings into a single hearing, the ALJ enters an order and OAH sends a new notice of hearing to the appropriate parties in accordance with WAC 182-526-0250, unless service of notice is waived by the parties.
5. Petitions for judicial review must be served on all agencies involved in the hearing.