WSR 16-13-059 PERMANENT RULES HEALTH CARE AUTHORITY (Washington Apple Health) [Filed June 13, 2016, 9:08 a.m., effective July 14, 2016] Effective Date of Rule: Thirty-one days after filing.
Purpose: The agency amended this chapter and added new WAC 182-520-0015 to support agency and agency designee action in establishing and recovering long-term services and supports client overpayments. Housekeeping changes were also made in WAC 182-520-0005 and 182-520-0010 to remove the abbreviation "WAH" and make language about the agency's designee parallel with the new section in the chapter.
Citation of Existing Rules Affected by this Order: Amending 182-520-0005 and 182-520-0010.
Adopted under notice filed as WSR 16-09-013 on April 8, 2016.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 3, Repealed 0.
Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 3, Repealed 0.
Date Adopted: June 13, 2016.
Wendy Barcus
Rules Coordinator
AMENDATORY SECTION (Amending WSR 14-01-021, filed 12/9/13, effective 1/9/14)
WAC 182-520-0005 Washington apple health fraud referrals and overpayments.
(1) The agency or ((its)) the agency's designee may refer a case to the office of fraud and accountability for a fraud investigation when it has reliable information that the person purposely misrepresented their circumstances in order to qualify for Washington apple health (((WAH))).
(2) When a fraud investigation reveals substantial evidence to support a finding of fraud, the case is referred for prosecution. The prosecuting attorney's office decides which cases will be prosecuted.
(3) When a referral results in a conviction, an overpayment amount for the cost of the ((WAH)) apple health coverage is established.
(4) The person is responsible to pay the agency for the amount of overpayment established as a result of a fraud conviction.
AMENDATORY SECTION (Amending WSR 14-01-021, filed 12/9/13, effective 1/9/14)
WAC 182-520-0010 Washington apple health overpayments resulting from an administrative hearing.
(1) If a person asks for Washington apple health (((WAH))) coverage to continue during an appeal, he or she must pay the agency for the cost of that coverage if both (a) and (b) of this subsection occur:
(a) The administrative law judge, or review judge if applicable, enters an order:
(i) That the person was not eligible for ((WAH)) apple health coverage during the appeal;
(ii) Dismissing the hearing under WAC 182-526-0285(3) because the person defaulted (did not attend or refused to participate) and the agency's action that was appealed included a finding that the person was not eligible for ((WAH)) apple health coverage; or
(iii) Dismissing the hearing under WAC 182-526-0285(4) due to a written agreement between all the parties that the person will pay for an overpayment of the cost of ((WAH)) apple health coverage.
(b) The agency decides to collect the overpayment.
(2) The overpayment amount is limited to payments for ((WAH)) apple health coverage that were spent:
(a) During the sixty days following receipt of the hearing request; and
(b) For a person who was not eligible for ((WAH)) apple health coverage.
(3) The agency will not attempt to recover ((a WAH)) an apple health overpayment from a nonneedy caretaker relative or guardian except in the case of fraud by the caretaker relative or guardian as described in WAC 182-520-0005.
NEW SECTION
WAC 182-520-0015 Long-term services and supports client overpayments.
(1) General right to recover.
(a) A long-term services and supports (LTSS) client overpayment is any payment for LTSS made by the agency or the agency's designee on a client's behalf in excess of that to which the client is legally entitled.
(b) An LTSS client overpayment may be caused by:
(i) A client or a client's authorized representative misstating or failing to reveal a fact affecting eligibility under WAC 182-503-0505;
(ii) A client or a client's authorized representative failing to timely report a change required under WAC 182-504-0105; or
(iii) The agency or the agency's designee's error.
(c) The agency or the agency's designee may recoup an LTSS client overpayment:
(i) Up to six years after the date of the notice in subsection (2) of this section; and
(ii) Regardless of whether the program is state-funded, federally funded, or both.
(d) The amount of the LTSS client overpayment equals the amount the agency or the agency's designee paid on the client's behalf minus the amount to which the client was legally entitled.
(2) Notice.
(a) The agency notifies the client or the client's authorized representative by:
(i) Personal service under RCW 4.28.080; or
(ii) Certified mail, return receipt requested.
(b) The agency or the agency's designee may prove that it notified the client by providing:
(i) A sworn statement;
(ii) An affidavit or certificate of mailing; or
(iii) The certified mail receipt signed by the client or the client's authorized representative.
(c) The notice states:
(i) The client's name;
(ii) The client's address;
(iii) The date the agency or the agency's designee issued the notice;
(iv) The amount of the LTSS client overpayment;
(v) How the agency calculated the LTSS client overpayment;
(vi) How the client may request an administrative hearing; and
(vii) How the client may make a payment.
(3) Response.
(a) The client must respond to the notice within ninety days of the date the agency or the agency's designee served the client with the notice of the LTSS client overpayment by:
(i) Paying the agency or the agency's designee;
(ii) Establishing a payment plan with the agency or the agency's designee; or
(iii) Requesting an administrative hearing.
(b) If the client does not respond to the notice within ninety days of the date the agency or the agency's designee served the client with the notice, the agency or the agency's designee may initiate collection action.
(4) Hearings. A person who disagrees with agency or the agency's designee's action under this section may request an administrative hearing under chapter 182-526 WAC.
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