WAC 182-526-0640  Judicial review of a final order.

Effective March 16, 2017

1. Judicial review is the process of appealing a final order to a court.
2. The party that requested the hearing may appeal a final order by filing a written petition for judicial review that meets the requirements of RCW 34.05.546. HCA may not request judicial review.
3. The party seeking judicial review must consult RCW 34.05.510 to 34.05.598 for further details of the judicial review process.

WAC 182-526-0635 Process after a party requests reconsideration.

Effective February 1, 2013

1. After the review judge receives a reconsideration request, the review judge has twenty calendar days to enter and serve a reconsideration decision unless the review judge serves notice allowing more time.
2. After BOA receives a reconsideration request, the review judge must either:
   1. Write a reconsideration decision; or
   2. Serve all parties an order denying the request.
3. If the review judge does not serve an order or notice granting more time within twenty days of receipt of the reconsideration request, the request is denied.

WAC 182-526-0630 Responding to a reconsideration request.

Effective February 1, 2013

1. A party does not have to respond to a request for reconsideration of a final order. A response is optional.
2. If a party responds, that party must file a response with the board of appeals (BOA) by or before the seventh business day after the date the review judge mailed the request to the party.
3. A party should send a copy of the response to any other party or representative.
4. If a party needs more time to respond, the review judge may extend its deadline if the party gives a good reason within the deadline in subsection (2) of this section.

WAC 182-526-0620 Deadline for requesting reconsideration.

Effective February 1, 2013

1. To request reconsideration of a final order entered by a review judge, the BOA must receive a written reconsideration request on or before the tenth calendar day after the final order was served.
2. The review judge may extend its deadline for filing a request for reconsideration if a party:
   1. Asks for more time before the deadline expires; and
   2. Gives a good reason for the extension. 
3. If a reconsideration request is filed after the deadline, the final order will not be reconsidered and the deadline to ask for judicial review of the final HCA decision continues to run.
4. If a party does not request reconsideration or fails to ask for an extension within the deadline, the final order may not be reconsidered and it becomes the final HCA decision.

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 June 11, 2025

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; 
      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
      5. Washington apple health expansion (AHE); 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 Washington apple health for kids and Washington apple health for kids with premium programs, which includes the children's health insurance program (CHIP), receive CN-scope of health care services.
* Medically necessary nursing facility services are covered when the enrollee's condition meets the criteria for rehabilitative or skilled care.
** Only for age 20 and younger.

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 June 23, 2024

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);
   4. Volunteer chore services; and
   5. Guardianship and conservatorship assistance program 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.