WSR 13-14-089

PROPOSED RULES

HEALTH CARE AUTHORITY

(Medicaid Program)

[Filed July 1, 2013, 2:22 p.m.]

Original Notice.

Preproposal statement of inquiry was filed as WSR 12-19-092.

Title of Rule and Other Identifying Information: WAC 182-526-0100 Expedited hearings, 182-526-0102 Coordinated appeals process with the Washington health benefits exchange, and 182-526-0218 The authority of a review judge when conducting a hearing as a presiding officer.

Hearing Location(s): Health Care Authority (HCA), Cherry Street Plaza Building, Sue Crystal Conference Room 106A, 626 8th Avenue, Olympia, WA 98504 (metered public parking is available street side around building. A map is available at http://maa.dshs.wa.gov/pdf/CherryStreetDirectionsNMap.pdf or directions can be obtained by calling (360) 725-1000), on August 6, 2013, at 10:00 a.m.

Date of Intended Adoption: Not sooner than August 7, 2013.

Submit Written Comments to: HCA Rules Coordinator, P.O. Box 45504, Olympia, WA 98504-5504, delivery 626 8th Avenue, Olympia, WA 98504, e-mail arc@hca.wa.gov, fax (360) 586-9727, by 5:00 p.m. on August 6, 2013.

Assistance for Persons with Disabilities: Contact Kelly Richters by July 29, 2013, TTY (800) 848-5429 or (360) 725-1307 or e-mail kelly.richters@hca.wa.gov.

Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: These rule amendments are necessary for implementation of the Affordable Care Act on January 1, 2014. HCA is amending WAC 182-526-0218 to support the new modified adjusted gross income (MAGI) methodology and adding new sections about expedited appeals and coordinating appeals with the Washington health benefits exchange (HBE).

Statutory Authority for Adoption: RCW 41.05.021; 42 C.F.R. § 431, 435, and 457; 45 C.F.R. § 155.

Statute Being Implemented: Patient Protection and Affordable Care Act (Public Law 111-148).

Rule is necessary because of federal law, Patient Protection and Affordable Care Act (Public Law 111-148).

Name of Proponent: HCA, governmental.

Name of Agency Personnel Responsible for Drafting: Kevin Sullivan, P.O. Box 42716, Olympia, WA 98504-2716, (360) 725-1344; Implementation and Enforcement: Annette Schuffenhauer, P.O. Box 45504, Olympia, WA 98504-5504, (360) 725-1254.

No small business economic impact statement has been prepared under chapter 19.85 RCW. The agency has analyzed the proposed rules and concludes they do not impose more than minor costs for affected small businesses.

A cost-benefit analysis is not required under RCW 34.05.328. RCW 34.05.328 does not apply to HCA rules unless requested by the joint administrative rules [review] committee or applied voluntarily.

July 1, 2013

Kevin M. Sullivan

Rules Coordinator

NEW SECTION

WAC 182-526-0100 Expedited hearings. (1) The expedited hearing process in this section applies to cases where an applicant or recipient requests an expedited hearing. For expedited hearings related to an enrollee appeal of a managed care organization, see WAC 182-526-0200.

(2) If an applicant or recipient has questions about how, when, and where to request an expedited hearing, the applicant or recipient should:

(a) Contact the HCA hearing representative or the office of administrative hearings (OAH); or

(b) Review the applicable statutes and rules.

(3) An applicant or recipient may request an expedited hearing by any method described in WAC 182-526-0095 or 182-526-0102.

(4) The administrative law judge (ALJ) or review judge will grant a request for an expedited hearing if the ALJ or review judge determines, based on credible medical evidence submitted by or on behalf of the applicant or recipient, that the time otherwise permitted for a hearing could jeopardize the person's life or health or ability to attain, maintain, or regain maximum function. The ALJ or the review judge must allow the HCA hearing representative, or designee if the HCA hearing representative is not available, an opportunity to respond to the request for an expedited hearing before granting or denying the request.

(5) When an expedited hearing is granted, the ALJ or review judge schedules the hearing and issues a decision as expeditiously as the person's health condition requires.

(6) When an expedited hearing is denied, the ALJ or review judge should notify the parties orally but must serve a written notice denying the expedited hearing.

(7) The notice requirements in WAC 182-526-0250 do not apply to the expedited hearing process.

NEW SECTION

WAC 182-526-0102 Coordinated appeals process with the Washington health benefits exchange. (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 (WAH) when the modified adjusted gross income (MAGI) methodology is used as described in WAC 182-509-0305. The process in WAC 182-526-0218 (2)(b) applies to these appeals.

(2) An applicant, recipient, or an authorized representative of an applicant or recipient may request a hearing:

(a) By telephone;

(b) By mail (which should be sent to Health Care Authority, P.O. Box 15504, Olympia, WA 98504-5504);

(d) By facsimile transmission;

(e) By e-mail; or

(f) By any other commonly available electronic means.

(3) If the applicant or recipient appeals a determination of eligibility for health insurance premium tax credits (HIPTC) or cost-sharing reductions, HCA also treats this appeal as a request for a hearing related to WAH eligibility. The hearings are conducted as follows:

(a) HBE conducts a hearing related to the eligibility decision of HIPTC or cost-sharing reductions using its published hearings and appeals procedures.

(b) The hearing related to WAH eligibility is conducted either by:

(i) A review judge according to WAC 182-526-0218 (2)(b) after HBE issues a written decision from the hearing described under (a) of this subsection; or

(ii) An ALJ when the conditions described in WAC 182-526-0025(l) and 182-526-0218(5) are met. When an ALJ conducts the hearing related to WAH eligibility, the hearing may occur before or after HBE conducts the hearing described under (a) of this subsection related to HIPTC or cost-sharing reductions.

(c) If the applicant or recipient who requested a hearing related to HIPTC or cost-sharing reductions does not wish to have a hearing related to WAH eligibility, the applicant or recipient may withdraw the request for a hearing in accordance with WAC 182-526-0115.

(d) When conducting the hearing related to WAH eligibility, neither the ALJ nor the review judge will require the applicant or recipient to submit information to the ALJ or review judge that the applicant or recipient previously submitted to HBE.

(4) If the applicant or recipient appeals only the determination related to WAH eligibility, the process in subsection (3) of this section does not apply.

AMENDATORY SECTION (Amending WSR 13-02-007, filed 12/19/12, effective 2/1/13)

WAC 182-526-0218 The authority of a review judge when conducting a hearing as a presiding officer. (1) A review judge has the same authority and responsibilities as an administrative law judge (ALJ), as described in WAC 182-526-0215, when conducting a hearing.

(2) A review judge conducts the hearing and enters the final order in cases where:

(a) A contractor for the delivery of nursing facility services requests an administrative hearing under WAC 388-96-904(5);

(b) An applicant or recipient appeals an eligibility decision related to Washington apple health (WAH) described in WAC 182-526-0102, unless:

(i) The applicant or recipient requests an in-person hearing in accordance with WAC 182-526-0360;

(ii) The applicant or recipient files a single request for hearing contesting the actions made by both the department of social and health services (DSHS) and the health care authority (HCA) in accordance with WAC 182-526-0387; or

(iii) The chief review judge of the board of appeals determines that HCA does not have the resources to conduct the hearing.

(3) The review judge enters final HCA decisions on all cases in the form of a final order.

(4) Following a review judge's final order:

(a) Any party may request reconsideration of the final order as provided in this chapter and WAC 388-96-904(12), if applicable; and

(b) The party who requested the hearing, but not ((the health care authority)) HCA or any of its authorized agents, may file a petition for judicial review as provided in this chapter.

(5) If subsection (2)(b) of this section applies, the ALJ from the office of administrative hearings (OAH) conducts the hearing and issues an initial order appealable to the review judge according to the rules in this chapter. The ALJ conducts the hearing related to subsection (2)(b) of this section only when OAH receives a specific referral from HCA or its authorized agent that cites an exemption listed in subsection (2)(b) of this section.