WAC 182-526-0605 Reconsideration of a final order entered by a review judge.

Effective March 16, 2017

1. If a party does not agree with the final order and wants it reconsidered, the party may request the review judge to reconsider the decision.
2. The party must make the request in writing and clearly state why the party wants the final order reconsidered. The party must file the written reconsideration request with the BOA and it must be received by the deadline under WAC 182-526-0620.
3. The party should send a copy of the request to all other parties or their representatives.
4. After receiving a reconsideration request, BOA serves a copy to the other parties and representatives and gives them time to respond.
5. The final order or the reconsideration decision is the final HCA decision. If a party disagrees with that decision, the party must petition for judicial review to change it.
6. If a party asks for reconsideration of the final order, the reconsideration process must be completed before a party requests judicial review. However, the party does not need to request reconsideration of a final order before requesting judicial review.
7. The party may ask the court to stay or stop the HCA action after filing the petition for judicial review.

WAC 182-526-0600 Authority of the review judge.

Effective March 16, 2017

1. In some cases, review judges review initial orders and enter final orders. The review judge has the same decision-making authority as the administrative law judge (ALJ). The review judge considers the entire record and decides the case de novo (anew). In reviewing findings of fact, the review judge must give due regard to the ALJ's opportunity to observe witnesses.
2. Review judges may remand (return) cases to the office of administrative hearings for further action.
3. In cases where there is a consolidated hearing under WAC 182-526-0387, any party may request review of the initial order in accordance with the requirements contained in this chapter.
4. Review judges may not review an ALJ order after the order becomes final, except as provided in WAC 182-526-0580.
5. A review judge conducts the hearing and enters the final order in cases where a contractor for the delivery of nursing facility services requests an administrative hearing under WAC 388-96-904 (5).

WAC 182-501-0060 Health care coverage--Program benefit packages--Scope of service categories.

Effective April 22, 2023

1. This rule provides a table that lists:
   1. The following Washington apple health programs:
      1. The alternative benefits plan (ABP) medicaid;
      2. Categorically needy (CN) medicaid;
      3. Medically needy (MN) medicaid; and
      4. Medical care services (MCS) programs (includes incapacity based and aged, blind, and disabled medical care services), as described in WAC 182-508-0005; and
   2. The benefit packages showing what service categories are included for each program.
2. Within a service category included in a benefit package, some services may be covered and others noncovered.
3. Services covered within each service category included in a benefit package:
   1. Are determined in accordance with WAC 182-501-0050 and 182-501-0055 when applicable.
   2. May be subject to limitations, restrictions, and eligibility requirements contained in agency rules.
   3. May require prior authorization (see WAC 182-501-0165), or expedited prior authorization when allowed by the agency.
   4. Are paid for by the agency or the agency's designee and subject to review both before and after payment is made. The agency or the client's managed care organization may deny or recover payment for such services, equipment, and supplies based on these reviews.
4. The agency does not pay for covered services, equipment, or supplies that:
   1. Require prior authorization from the agency or the agency's designee, if prior authorization was not obtained before the service was provided;
   2. Are provided by providers who are not contracted with the agency as required under chapter 182-502 WAC;
   3. Are included in an agency or the agency's designee waiver program identified in chapter 182-515 WAC; or
   4. Are covered by a third-party payor (see WAC 182-501-0200), including medicare, if the third-party payor has not made a determination on the claim or has not been billed by the provider.
5. Programs not addressed in the table:
   1. Medical assistance programs for noncitizens (see chapter 182-507 WAC); and
   2. Family planning only programs (see WAC 182-532-500 through 182-532-570);
   3. Postpartum and family planning extension (see WAC 182-523-0130(4) and 182-505-0115(5));
   4. Eligibility for pregnant minors (see WAC 182-505-0117); and
   5. Kidney disease program (see chapter 182-540 WAC).
6. Scope of service categories. The following table lists the agency's categories of health care services.
   1. Under the ABP, CN, and MN headings, there are two columns. One addresses clients twenty years of age and younger, and the other addresses clients twenty-one years of age and older.
   2. The letter "Y" means a service category is included for that program. Services within each service category are subject to limitations and restrictions listed in the specific medical assistance program rules and agency issuances.
   3. The letter "N" means a service category is not included for that program.
   4. Refer to WAC 182-501-0065 for a description of each service category and for the specific program rules containing the limitations and restrictions to services.                  

¹ Clients enrolled in the Apple Health for Kids programs (with and without premium) receive CN-scope of health care services. The Apple Health for Kids programs includes the children's health insurance program (CHIP).

WAC 182-527-2750 Estate recovery - Delay of recovery for undue hardship.

Effective March 14, 2016

For the purposes of this section, the term "agency" includes the agency's designee.

1. If an undue hardship exists at the time of the client's death, an heir may ask the agency to delay recovery.
   1. Undue hardship exists only when:
      1. The property subject to recovery is the sole income-producing asset of an heir;
      2. Recovery would deprive an heir of shelter and the heir cannot afford alternative shelter; or
      3. The client is survived by a state-registered domestic partner.
   2. Undue hardship does not exist if the client or the heir created circumstances to avoid estate recovery.
2. If the agency determines recovery would cause an undue hardship for an heir, the agency may delay recovery until the hardship no longer exists.
3. If the agency denies an heir's request to delay recovery, the agency notifies the heir in writing.  The notice includes instructions on how to request a hearing.
4. If the agency grants a delay of recovery under this section, the heir must:
   1. Timely comply with any agency request for information or records;
   2. Not sell, transfer, or encumber the property;
   3. Reside on the property;on the property;
   4. Timely pay property taxes and utilities;
   5. Ensure the property for its fair market  value;
   6. Name the state of Washington as the primary payee on the property insurance policy;
   7. Provide the agency with a copy of the property insurance policy upon request;
   8. Continue to satisfy the requirements in subsection (1) of this section.
5. If the heir dies, or violates any provision of subsection (4) of this section, the agency may begin recovery.
6. If the agency denies the request, the heir may request an administrative hearing under WAC 182-527-2753. 

WAC 182-527-2742  Estate recovery-Service-related limitations.

Effective July 1, 2017

For the purposes of this section, the term "agency" includes the agency's designee.

The agency's payment for the following services is subject to recovery:

1. State-only funded services, except:
   1. Adult protective services;
   2. Offender reentry community safety program services;
   3. Supplemental security payments (SSP) authorized by the developmental disabilities administration (DDA); and
   4. Volunteer chore services.
2. For dates of service on or after January 1, 2014:
   1. Basic Plus waiver services;
   2. Community first choice (CFC) services;
   3. Community option program entry system (COPES) services;
   4. Community protection waiver services;
   5. Core waiver services;
   6. Hospice services;
   7. Intermediate care facility for individuals with intellectual disabilities services provided in either a private community setting or in a rural health clinic;
   8. Individual and family services;
   9. Medicaid personal care services;
   10. New Freedom consumer directed services;
   11. Nursing facility services;
   12. Personal care services funded under Title XIX or XXI;
   13. Private duty nursing administered by aging and long-term support administration (ALTSA) or the DDA;
   14. Residential habilitation center services;
   15. Residential support waiver services;
   16. Roads to community living demonstration project services;
   17. The portion of the managed care premium used to pay for ALTSA-authorized long-term care services under the program of all-inclusive care for the elderly (PACE); and
   18.  The hospital and prescription drug services provided to a client while the client was receiving services listed in this subsection.
3. For dates of service beginning January 1, 2010, through December 31, 2013:
   1. Medicaid services;
   2. Premium payments to managed care organizations (MCOs); and
   3. The client's proportional share of the state's monthly contribution to the Centers for Medicare and Medicaid Services to defray the costs for outpatient prescription drug coverage provided to a person who is eligible for medicare Part D and medicaid.
4. For dates of service beginning June 1, 2004, through December 31, 2009:
   1. Medicaid services;
   2. Medicare premiums for individuals also receiving medicaid;
   3. Medicare savings programs (MSPs) services for people also receiving medicaid; and
   4.  Premium payments to MCOs. 
5. For dates of service beginning July 1, 1995, through May 31, 2004:
   1. Adult day health services;
   2. Home and community-based services;
   3. Medicaid personal care services;
   4. Nursing facility services;
   5. Private duty nursing services; and
   6. The hospital and prescription drug services provided to a client while the client was receiving services listed in this subsection. 
6. For dates of service beginning July 1, 1994, through June 30, 1995:
   1. Home and community-based services;
   2. Nursing facility services; and 
   3. Hospital and prescription drug services provided to a client while the client was receiving services listed in this subsection.
7. For dates of service beginning July 26, 1987, through June 30, 1994: Medicaid services.
8. For dates of service through December 31, 2009.  If a client was eligible for the MSP, but not otherwise medicaid eligible, the client's estate is liable only for any sum paid to cover medicare premiums and cost-sharing benefits.
9. For dates of service beginning January 1, 2010.  If a client was eligible for medicaid and the MSP, the client's estate is not liable for any sum paid to cover medical assistance cost-sharing benefits.
10. For dates of service beginning July 1, 2017, long-term services and supports authorized under the medicaid transformation project are exempt from estate recovery. Exempted services include those provided under:
    1. Medicaid alternative care under WAC 182-513-1600;
    2. Tailored supports for older adults under WAC 182-513-1610;
    3. Supportive housing under WAC 388-106-1700 through 388-106-1765; or
    4. Supported employment under WAC 388-106-1800 through 388-106-1865.

WAC 182-527-2740 Estate recovery - Age-related limitations.

Effective March 14, 2016

For the purposes of this section, the term "agency" includes the agency's designee.

1. Liability for medicaid services.
   1. Beginning July 26, 1987, a client's estate is liable for medicaid services subject to recovery that were provided on or after the client's sixty-fifth birthday.
   2. Beginning July 1, 1994, a client's estate is liable for medicaid services subject to recovery that were provided on or after the client's fifty-fifth birthday.
2. Liability for state-only-funded long-term care services.
   1. A client's estate is liable for all state-only-funded long-term care services provided by the home and community services division of the department of social and health services (DSHS) on or after July 1, 1995.
   2. A client's estate is liable for all state-only-funded long-term care services provided by the developmental disabilities administration of DSHS on or after June 1, 2004.

WAC 182-527-2730 Definitions

Effective March 16, 2016

The following definitions apply to this chapter:

"Contract health service delivery area (CHSDA)" means the geographic area within which contract health services will be made available by the Indian health service to members of an identified Indian community who reside in the area as identified in 42 C.F.R. Sec. 136.21(d) and 136.22.

"Estate" means all property and any other assets that pass upon the client's death under the client's will or by intestate succession under chapter 11.04 or 11.62 RCW. The value of the estate will be reduced by any valid liability against the client's property when the client died. An estate also includes:

1. For a client who died after June 30, 1995, and before July 27, 1997, nonprobate assets as defined by RCW 11.02.005, except property passing through a community property agreement; or
2. For a client who died after July 26, 1997, and before September 14, 2006, nonprobate assets as defined by RCW 11.02.005.
3. For a client who died on or after September 14, 2006, nonprobate assets as defined by RCW 11.02.005 and any life estate interest held by the client immediately before death.

"Heir" means a person entitled to inherit a deceased client's property under a valid will accepted by the court, or a person entitled to inherit under the Washington state intestacy statute, RCW 11.04.015. 

Life estate" means an ownership interest in a property only during the lifetime of the person owning the life estate. 

"Lis pendens" means a notice filed in public records warning that title to certain real property is in litigation and the outcome of the litigation may affect the title.

"Long-term care services (LTC)" means, for the purposes of this chapter only, the services administered directly or through contract by the department of social and health services (DSHS) for clients of the home and community services division of DSHS and the developmental disabilities administration of DSHS including, but not limited to, nursing facility care and home and community services.

"Property" means everything a person owns, whether in whole or in part.

1. "Personal property" means any movable or intangible thing a person owns, whether in whole or in part; 
2. "Real property" means land and anything growing on, attached to, or built on it, excluding anything that may be removed without injury to the land;
3. "Trust property" means any type of property held in trust for the benefit of another.

"Qualified long-term care insurance partnership" means an agreement between the Centers for Medicare and Medicaid services (CMS) and the Washington state insurance commission which allows for the disregard of any assets or resources in an amount equal to the insurance benefit payments that are made to or on behalf of a person who is a beneficiary under a long-term care insurance policy that has been determined by the Washington state insurance commission to meet the requirements of section 1917 (b)(1)(C)(iii) of the act.

"Recover" or "recovery" means the agency or the agency's designee's receipt of funds to satisfy the client's debt.

WAC 182-501-0050 Health care general coverage.

Effective August 11, 2013

WAC 182-501-0050 through 182-501-0065 describe the health care services available to a client on a fee-for-service basis or to a client enrolled in a managed care organization (MCO) (defined in WAC 182-538-050). For the purposes of this section, health care services includes treatment, equipment, related supplies, and drugs. WAC 182-501-0070 describes noncovered services.

1. Health care service categories listed in WAC 182-501-0060 do not represent a contract for health care services.
2. For the provider to receive payment, the client must be eligible for the covered health care service on the date the health care service is performed or provided.
3. Under the agency's fee-for-service programs, providers must be enrolled with the agency or its designee and meet the requirements of chapter 182-502 WAC to be paid for furnishing health care services to clients.
4. The agency or its designee pays only for the health care services that are:
   1. Included in the client's health care benefits package as described in WAC 182-501-0060;
   2. Covered - See subsection (9) of this section;
   3. Ordered or prescribed by a health care provider who meets the requirements of chapter 182-502 WAC;
   4. Medically necessary as defined in WAC 182-500-0070;
   5. Submitted for authorization, when required, in accordance with WAC 182-501-0163;
   6. Approved, when required, in accordance with WAC 182-501-0165;
   7. Furnished by a provider according to chapter 182-502 WAC; and
   8. Billed in accordance with agency or its designee program rules and the agency's current published billing instructions.
5. The agency does not pay for any health care service requiring prior authorization from the agency or its designee, if prior authorization was not obtained before the health care service was provided; unless:
   1. The client is determined to be retroactively eligible for medical assistance; and
   2. The request meets the requirements of subsection (4) of this section.
6. The agency does not reimburse clients for health care services purchased out-of-pocket.
7. The agency does not pay for the replacement of agency-purchased equipment, devices, or supplies which have been sold, gifted, lost, broken, destroyed, or stolen as a result of the client's carelessness, negligence, recklessness, deliberate intent, or misuse unless:
   1. Extenuating circumstances exist that result in a loss or destruction of agency-purchased equipment, devices, or supplies, through no fault of the client that occurred while the client was exercising reasonable care under the circumstances; or
   2. Otherwise allowed under specific agency program rules.
8. The agency's refusal to pay for replacement of equipment, device, or supplies will not extend beyond the limitations stated in specific agency program rules.
9. Covered health care services.
   1. Covered health care services are either:
      1. "Federally mandated" - Means the state of Washington is required by federal regulation (42 C.F.R. 440.210 and 220) to cover the health care service for medicaid clients; or
      2. "State-option" - Means the state of Washington is not federally mandated to cover the health care service but has chosen to do so at its own discretion.
   2. The agency may limit the scope, amount, duration, and/or frequency of covered health care services. Limitation extensions are authorized according to WAC 182-501-0169.
10. Noncovered health care services.
    1. The agency does not pay for any health care service listed as noncovered in WAC 182-501-0070 or in any other agency program rule, unless the agency grants a request for an exception to rule allowing payment for the noncovered service. The agency evaluates a request for a noncovered health care service only if an exception to rule is requested according to the provisions in WAC 182-501-0160.
    2. When a noncovered health care service is recommended during the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) exam and then ordered by a provider, the agency evaluates the health care service according to the process in WAC 182-501-0165 to determine if it is medically necessary, safe, effective, and not experimental (see WAC 182-534-0100 for EPSDT rules).

WAC 182-500-0120 Medical assistance definitions -- W.

Effective July 25, 2013

"Washington apple health" means the public health insurance programs for eligible Washington residents. Washington apple health is the name used in Washington state for medicaid, the children's health insurance program (CHIP), and state-only funded health care programs.

"Washington Healthplanfinder" is a marketplace for individuals, families, and small businesses in Washington state to compare and enroll in health insurance coverage and gain access to premium tax credits, reduced cost sharing, and public programs such as Washington apple health. Washington Healthplanfinder is administered by the Washington health benefit exchange.

WAC 182-500-0110 Medical assistance definitions -- U.

Effective July 30, 2011

"Urgent care" means an unplanned appointment for a covered medical service with verification from an attending physician or facility that the client must be seen that day or the following day.

"Usual and customary charge" means the amount a provider typically charges to fifty percent or more of patients who are not medical assistance clients.