WSR 15-15-143
PERMANENT RULES
HEALTH CARE AUTHORITY
(Washington Apple Health)
[Filed July 17, 2015, 4:07 p.m., effective August 17, 2015]
Effective Date of Rule: Thirty-one days after filing.
Purpose: The agency has created a new rule regarding client authorized representatives, specifically how to designate, serve as, and terminate an authorized representative.
Citation of Existing Rules Affected by this Order: Amending WAC 182-500-0010.
Statutory Authority for Adoption: RCW 41.05.021, 41.05.160.
Adopted under notice filed as WSR 15-09-136 on April 22, 2015.
Changes Other than Editing from Proposed to Adopted Version:
•
In subsection (1)(a), "modalities" was changed to "methods." This change was made to improve comprehension with simpler language.
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The form number "(DSHS 14-532)" was placed after "Authorized Representative Designation Form" in subsections (1)(a) and (d). The sentence "The Authorized Representative Designation Form is available online at https://www.dshs/wa/gov/fsa/forms [https://www.dshs.wa.gov/fsa/forms]" was also added to subsection (1)(a). These changes were made so that the forms in the WAC could be easily located.
•
In subsection (1)(d), "someone" was changed to "a person." In subsections (1)(d) and (2), "a person" was changed to "an individual." These changes were made to clarify whether or not the WAC was referring to the client or the AREP.
•
In subsection (3), "Terminating an AREP" was changed to "Terminating authorized representation."
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 1, Amended 1, Repealed 0.
Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 0, Repealed 0.
Date Adopted: July 17, 2015.
Wendy Barcus
Rules Coordinator
AMENDATORY SECTION (Amending WSR 14-01-021, filed 12/9/13, effective 1/9/14)
WAC 182-500-0010 Medical assistance definition—A.
"Administrative renewal" means the agency uses verification from electronically available income data sources to verify and recertify a person's Washington apple health benefits for a subsequent certification period. A case is administratively renewed when the person's self-attested income is reasonably compatible (as defined in WAC 182-500-0095) with the information available to the agency from the electronic data sources and the person meets citizenship, immigration, Social Security number, and age requirements.
"Agency" means the Washington state health care authority (HCA), created ((pursuant to)) under chapter 41.05 RCW.
"Agency's designee" means the Washington state department of social and health services (DSHS), created ((pursuant to)) under chapter 43.20A RCW.
"Allowable costs" are the documented costs as reported after any cost adjustment, cost disallowances, reclassifications, or reclassifications to nonallowable costs which are necessary, ordinary and related to the outpatient care of medical care clients ((are)) or not expressly declared nonallowable by applicable statutes or regulations. Costs are ordinary if they are of the nature and magnitude which prudent and cost-conscious management would pay.
"Alternative benefits plan" means the range of health care services included within the scope of service categories described in WAC 182-501-0060 available to persons eligible to receive health care coverage under the Washington apple health modified adjusted gross income (MAGI)-based adult coverage described in WAC 182-505-0250.
"Ancillary services" means additional services ordered by the provider to support the core treatment provided to the patient. These services may include, but are not limited to, laboratory services, radiology services, drugs, physical therapy, occupational therapy, and speech therapy.
"Apple health for kids" is the umbrella term for health care coverage for certain groups of children that is funded by the state and federal governments under Title XIX medicaid programs or Title XXI Children's Health Insurance Program, or solely through state funds (including the program formerly known as the children's health program). Funding for any given child depends on the program for which the child is determined to be eligible. Apple health for kids programs are included in the array of health care programs available through Washington apple health (WAH).
"Attested income" means a self-declared statement of a person's income made under penalty of perjury to be true. (See also "self-attested income.")
"Authorization" means the agency's or the agency's designee's determination that criteria are met, as one of the preconditions to the agency's or the agency's designee's decision to provide payment for a specific service or device. (See also "expedited prior authorization" and "prior authorization.")
"Authorized representative" ((means a family member, friend, organization or someone acting responsibly on behalf of a person who is designated by the person to act on his or her behalf in all matters relating to an application or renewal of Washington apple health or other ongoing communications with agency or its designee. The authorization must be made in writing and signed by the person unless the person's medical condition prevents such written authorization. Authority to act on behalf of an applicant or beneficiary under state law can substitute for the person's authorization. The power to act as an authorized representative ends when the person or a court-appointed guardian of the person informs the agency or its designee that the representative is no longer authorized to act on his or her behalf, or when the agency learns of a change in the legal authority upon which the authorization is based)) is defined under WAC 182-503-0130.
NEW SECTION
WAC 182-503-0130 Authorized representative.
(1) Designating an authorized representative (AREP).
(a) A person may designate an AREP to act on his or her behalf in eligibility-related interactions with the medicaid agency by completing the agency's Authorized Representative Designation Form (DSHS 14-532), or through any of the methods described in 42 C.F.R. 435.907(a) and 42 C.F.R. 435.923. The Authorized Representative Designation Form is available online at https://www.dshs.wa.gov/fsa/forms.
(b) A court-appointed legal guardian with authority to make financial decisions on a person's behalf is that person's AREP.
(c) An agreement creating power of attorney (POA) that grants decision-making authority regarding the person's financial interactions with the agency establishes the POA as the AREP.
(d) If a person is unable to designate an AREP due to a medical condition, an individual may designate himself or herself as the AREP by signing the agency's Authorized Representative Designation Form (DSHS 14-532).
(2) Serving as an AREP. To serve as an AREP, an individual or organization must:
(a) Have a good-faith belief that the information he or she provides to the agency is correct.
(b) Report any change in circumstance required under WAC 182-504-0105 unless doing so would exceed the scope of authorized representation or violate state or federal law.
(c) A provider, staff member, or volunteer of an organization must also comply with 42 C.F.R. 435.923(d-e).
(3) Terminating authorized representation.
(a) The person or the AREP may terminate the authorized representation at any time for any reason by notifying the agency verbally or in writing.
(b) Authorized representation terminates automatically when the person dies.