1738-S2.E AMH CODY BLAC 096

E2SHB 1738 - H AMD 706

By Representative Cody

ADOPTED 05/02/2011

    On page 50, beginning on line 22, after "(1)" strike all material through "section" on page 52, line 17 and insert "The following persons have the right to an adjudicative proceeding:

    (a) Any applicant or recipient who is aggrieved by a decision of the authority or an authorized agency of the authority; or

    (b) A current or former recipient who is aggrieved by the authority's claim that he or she owes a debt for overpayment of assistance.

    (2) For purposes of this section:

    (a) "Applicant" means any person who has made a request, or on behalf of whom a request as been made to the authority for any medical services program established under chapter 74.09 RCW.

    (b) "Recipient" means a person who is receiving benefits from the authority for any medical services program established in this chapter.

    (3) An applicant or recipient has no right to an adjudicative proceeding when the sole basis for the authority's decision is a federal or state law requiring an assistance adjustment for a class of applicants or recipients.

    (4) An applicant or recipient may file an application for an adjudicative proceeding with either the authority or the department and must do so within ninety calendar days after receiving notice of the aggrieving decision.  The authority shall determine which agency is responsible for representing the state of Washington in the hearing, in accordance with agreements entered pursuant to RCW 41.05.021.

    (5)(a) The adjudicative proceeding is governed by the administrative procedure act, chapter 34.05 RCW, and this subsection. The following requirements shall apply to adjudicative proceedings in which an appellant seeks review of decisions made by more than one agency.  When an appellant files a single application for an adjudicative proceeding seeking review of decisions by more than one agency, this review shall be conducted initially in one adjudicative proceeding.  The presiding officer may sever the proceeding into multiple proceedings on the motion of any of the parties, when:

    (i) All parties consent to the severance; or

    (ii) Either party requests severance without another party's consent, and the presiding officer finds there is good cause for severing the matter and that the proposed severance is not likely to prejudice the rights of an appellant who is a party to any of the severed proceedings.

    (b) If there are multiple adjudicative proceedings involving common issues or parties where there is one appellant and both the authority and the department are parties, upon motion of any party or upon his or her own motion, the presiding offer may consolidate the proceedings if he or she finds that the consolidation is not likely to prejudice the rights of the appellant who is a party to any of the consolidated proceedings.

    (c) The adjudicative proceeding shall be conducted at the local community services office or other location in Washington convenient to the applicant or recipient and, upon agreement by the applicant or recipient, may be conducted telephonically.

    (d) The applicant or recipient, or his or her representative, has the right to inspect his or her file from the authority and, upon request, to receive copies of authority documents relevant to the proceedings free of charge.

    (e) The applicant or recipient has the right to a copy of the audio recording of the adjudicative proceeding free of charge.

    (f) If a final adjudicative order is issued in favor of an applicant, medical services benefits must be provided from the date of earliest eligibility, the date of denial of the application for assistance, or forty-five days following the date of application, whichever is soonest.  If a final adjudicative order is issued in favor of a recipient, medical services benefits must be provided from the effective date of the authority's decision.

    (g) The authority is limited to recovering an overpayment arising from assistance being continued pending the adjudicative proceeding to the amount recoverable up to the sixtieth day after the director’s receipt of the application for an adjudicative proceeding.

    (6) If the director requires that a party seek administrative review of an initial order to an adjudicative proceeding governed by this section, in order for the party to exhaust administrative remedies pursuant to RCW 34.05.534, the director shall adopt and implement rules in accordance with this subsection.

    (a) The director, in consultation with the secretary, shall adopt rules to create a process for parties to seek administrative review of initial orders issued pursuant to RCW 34.05.461 in adjudicative proceedings governed by this subsection when multiple agencies are parties.

    (b) This process shall seek to minimize any procedural complexities imposed on appellants that result from multiple agencies being parties to the matter, without prejudicing the rights of parties who are public assistance applicants or recipients.

    (c) Nothing in this subsection shall impose or modify any legal requirement that a party seek administrative review of initial orders in order to exhaust administrative remedies pursuant to RCW 34.05.534.

    (7) This subsection only applies to an adjudicative proceeding in which the appellant is an applicant for or recipient of medical services programs established under this chapter and the issue is his or her eligibility or ineligibility due to the assignment or transfer of a resource.  The burden is on the authority or its authorized agency to prove by a preponderance of the evidence that the person knowingly and willingly assigned or transferred the resource at less than market value for the purpose of qualifying or continuing to qualify for medical services programs established under this chapter.  If the prevailing party in the adjudicative proceeding is the applicant or recipient, he or she is entitled to reasonable attorneys' fees.

    (8) When an applicant or recipient files a petition for judicial review as provided in RCW 34.05.514 of an adjudicative order entered with respect to the medical services program, no filing fee may be collected from the person and no bond may be required on any appeal.  In the event that the superior court, the court of appeals, or the supreme court renders a decision in favor of the applicant or recipient, the person is entitled to reasonable attorneys' fees and costs.  If a decision of the court is made in favor of an applicant, assistance shall be paid from the date of earliest eligibility, the date of the denial of the application for assistance, or forty-five days following the date of application, whichever is soonest. If a decision of the court is made in favor of a recipient, assistance shall be paid from the effective date of the authority's decision.

    (9) The provisions of RCW 74.08.080 do not apply to adjudicative proceedings requested or conducted with respect to the medical services program pursuant to this section.

    (10) The authority shall adopt any rules it deems necessary to implement this section."

EFFECT:   Eliminates the definition of an "action" as applicable to adjudicative proceedings for Medicaid applicants or recipients.  Allows applicants and recipients to file for an adjudicative proceeding with either the Department of Social and Health Services (DSHS) or the Health Care Authority (HCA) and requires the agencies to determine the responsible agency.

Establishes procedures for Medicaid applicants and recipients to receive review of decisions made by multiple agencies (DSHS and HCA) and standards for when it is appropriate to sever the review into multiple proceedings.

Requires the HCA to adopt rules, under specific circumstances, to establish a process for parties to seek administrative review of initial orders in cases involving multiple agencies.  Requires the rules to minimize procedural complexities that may arise for appellants as a result of having to seek review from multiple agencies.

Limits the authority of the HCA to recover overpayments pending an adjudicative proceeding from Medicaid recipients to the amount recoverable up to the 60th day after the Director receives the application for an adjudicative proceeding.

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