Effective Date of Rule: February 13, 2012.

     Purpose: The health care authority (HCA) intends to reform, align, and clarify the Basic Health processes as a result of the federal requirements contained in the section 1115 federal waiver and to align rules and processes as a portion of the implementation of chapter 15, Laws of 2011 (2E2SHB 1738, section 53), for the transition of the single state medicaid agency to the HCA.

     Citation of Existing Rules Affected by this Order: Amending WAC 182-22-320.

     Statutory Authority for Adoption: RCW 70.47.050.

     Under RCW 34.05.350 the agency for good cause finds that immediate adoption, amendment, or repeal of a rule is necessary for the preservation of the public health, safety, or general welfare, and that observing the time requirements of notice and opportunity to comment upon adoption of a permanent rule would be contrary to the public interest.

     Reasons for this Finding: On January 18, 2012, the HCA received confirmation from the Center for Medicare and Medicaid Services that HCA's grievance process is out of compliance with federal law. Without the immediate adoption of this rule, no viable hearing process exists to address members' grievances, thus endangering members' ability to access medical care and services. The lack of a grievance process has immobilized subsidized Basic Health operations.

     Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 1, Repealed 0; Federal Rules or Standards: New 0, Amended 1, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 1, Repealed 0.

     Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0;      Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 1, Repealed 0.

     Date Adopted: February 10, 2012.

Kevin M. Sullivan

Rules Coordinator

OTS-4601.2

AMENDATORY SECTION(Amending Order 10-03, filed 11/30/10, effective 12/31/10)

WAC 182-22-320   How to appeal health care authority (HCA) decisions.   (1) HCA decisions regarding the following may be appealed under this section:

     (a) Eligibility;

     (b) Premiums;

     (c) Premium adjustments or penalties;

     (d) Enrollment;

     (e) Suspension;

     (f) Disenrollment; or

     (g) Selection of managed health care system (MHCS).

     (2) ((To appeal an HCA decision, enrollees)) The hearing process described in chapter 388-526 WAC applies to the subsidized basic health program (BHP) appeal process found in this subsection. Where conflict exists, the requirements in this chapter take precedence.

     (a) To appeal an HCA decision, enrollees or applicants must send a written request for a hearing to the HCA. The written hearing request should be signed by the appealing party and must be received by the HCA within ninety calendar days of the date of the agency action. The request must be sent to:

     Basic Health Appeals

     P.O. Box 42690

     Olympia, WA 98504-2690

     (b) The hearing request should include:

     (i) The name, mailing address, and BHP account number of the subscriber or applicant;

     (ii) The name and address of the enrollee or applicant affected by the decision, if that person is not the subscriber on the account;

     (iii) A copy of the HCA notice of the decision that is being appealed or, if the notice is not available, a statement of the decision being appealed;

     (iv) A statement explaining why the appealing party believes the decision was incorrect, outlining the facts surrounding the decision and including supporting documentation; and

     (v) If the appealing party is not an enrollee or the subscriber on the account, a signed agreement from the enrollee authorizing the appealing party to act on the enrollees behalf and authorizing the HCA to release otherwise confidential information to the appealing party's designated representative.

     (c) HCA provides at least ten days advanced notice of any change in enrollment or premiums. An enrollee may continue receiving the same benefits under the same terms and conditions as received before the change, if a hearing is requested before the effective date of the agency action. This is called continuation of benefits. Requests for continuation of benefits should be in writing. To qualify for continuation of benefits, the appealing party must continue to pay all premiums when due as required by law and request the hearing in writing before the effective date of the agency's action.

     (d) All active appeals filed for which no final agency decision has been rendered will be subject to the rules in this subsection. HCA reviews all appeals to determine whether the appeal can be resolved prior to sending the appeal to the office of administrative hearings (OAH) to schedule a hearing. If the appeal can be resolved to the satisfaction of the applicant or enrollee who requested the hearing, and they choose to withdraw the appeal, HCA will send a withdrawal confirmation notice and close the appeal. If the appeal cannot be resolved in favor of the applicant or enrollee that requested the hearing or if that party chooses not to withdraw the appeal, HCA will forward the appeal to OAH so a hearing can be scheduled. The provisions of chapter 388-526 WAC only apply if the appeal is sent to OAH for a hearing.

     (3) This subsection applies only to Washington health (WH) program appeals. Enrollees or applicants must send a letter of appeal to the HCA. The letter of appeal should be signed by the appealing party and must be received by the HCA within thirty calendar days of the date of the decision.

     (a) The letter of appeal should include:

     (((a))) (i) The name, mailing address, and ((BHP or)) WHP account number of the subscriber or applicant;

     (((b))) (ii) The name and address of the WH enrollee or applicant affected by the decision, if that person is not the subscriber on the account;

     (((c))) (iii) A copy of the HCA notice of the decision that is being appealed or, if the notice is not available, a statement of the decision being appealed;

     (((d))) (iv) A statement explaining why the appealing party believes the decision was incorrect, outlining the facts surrounding the decision and including supporting documentation; and

     (((e))) (v) If the appealing party is not an enrollee or the subscriber on the account, a signed agreement from the enrollee, authorizing the appealing party to act on his/her behalf.

     (((3))) (b) When an appeal is received, the HCA will send a notice to the appealing party, confirming that the appeal has been received and indicating when a decision can be expected. If the appealing party is not an enrollee on the affected account, the notice will also be sent to the subscriber.

     (((4))) (c) Initial HCA decisions: The HCA will conduct WH appeals according to RCW 34.05.485. The HCA appeals committee or a single presiding officer designated by the HCA will review and decide the appeal. The appealing party may request an opportunity to be present in person or by telephone to explain his or her view. If the appealing party does not request an opportunity to be present to explain, the HCA appeals committee or presiding officer will review and decide the appeal based on the information and documentation submitted.

     (((5))) (i) The HCA will give priority handling to appeals regarding a loss of coverage for an enrollee with an urgent medical need that could seriously jeopardize the enrollee's life, health, or ability to regain maximum function, provided:

     (((a))) (A) The appeal is received within ten business days of the effective date of the loss of coverage; and

     (((b))) (B) The enrollee has clearly stated in the letter of appeal or has otherwise notified the HCA that he or she has an urgent medical need.

     (((6))) (ii) For all other appeals, the HCA will send the appealing party written notice of the initial HCA decision within sixty days of receiving the letter of appeal. If the appealing party is not an enrollee on the affected account, the notice will also be sent to the subscriber. The notice will include the reasons for the initial decision and instructions on further appeal rights.

     (((7))) (d) Review of initial HCA decision on WH appeal: The initial HCA decision becomes the final agency decision unless the HCA receives a valid request for a review from the appealing party.

     (((a))) (i) To be a valid request for review, the appealing party's request may be either verbal or in writing, but must:

     (((i))) (A) Be received within thirty days of the date of the initial HCA decision.

     (((ii))) (B) Include a summary of the initial HCA decision being appealed and state why the appealing party believes the decision was incorrect; and

     (((iii))) (C) Provide any additional information or documentation that the appealing party would like considered in the review.

     (((b))) (ii) Requests for review of an initial HCA decision regarding a disenrollment for nonpayment will be reviewed by the office of administrative hearings through a hearing conducted under chapter 34.12 RCW and RCW 34.05.488 through 34.05.494.

     (((c))) (iii) All other requests for review of an initial HCA decision will be reviewed by a presiding officer designated by the HCA according to the requirements of RCW 34.05.488 through 34.05.494, with the following exception: These review decisions will be based on the record and documentation submitted, unless the presiding officer decides that an in-person or telephone hearing is needed. If an in-person or telephone hearing is needed, the presiding officer will decide whether to conduct the hearing as an informal hearing or formal adjudicative proceeding.

     (((d))) (iv) The presiding officer will issue a written notice of the review decision, giving reasons for the decision, within twenty-one days of receiving the request for review, unless the presiding officer finds that additional time is needed for the decision.

     (((8))) (e) Enrollees who appeal a disenrollment decision that was based on eligibility issues and not related to premium payments may remain enrolled during the appeal process, provided:

     (((a))) (i) The appeal was submitted according to the requirements of this section; and

     (((b))) (ii) The enrollee:

     (((i))) (A) Remains otherwise eligible;

     (((ii))) (B) Continues to make all premium payments when due; and

     (((iii))) (C) Has not demonstrated a danger or threat to the safety or property of the MHCS or health care authority or their staff, providers, patients or visitors.

     (((9) Enrollees who appeal a disenrollment decision related to nonpayment of premium or any issue other than eligibility will remain disenrolled during the appeal process.

     (10) If the appealing party disagrees with a review decision under subsection (6) of this section, the appealing party may request judicial review of the decision, as provided for in RCW 34.05.542. Request for judicial review must be filed with the court within thirty days of service of the final agency decision.)) (4) For both WH and the BHP, enrollees who appeal a disenrollment decision related to nonpayment of premium or any issue other than eligibility will remain disenrolled during the appeal process.

[Statutory Authority: Chapter 70.47 RCW. 10-24-062 (Order 10-03), § 182-22-320, filed 11/30/10, effective 12/31/10.]

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