(1) For the purposes of this chapter, "we" refers to the agency or its designee and "you" refers to the applicant for, or recipient of, health care coverage.

(2) This section applies only to notices and letters that we send about eligibility for Washington apple health (WAH) programs. WAC 182-501-0165 applies to notices and letters regarding prior authorization or other action on requests to cover specific fee-for-service health care services.

(3) We send you written notices (letters) when we:

(a) Approve you for health care coverage for any program;

(b) Reconsider your application for other types of health care coverage based on new information;

(c) Deny you health care coverage (including because you withdrew your application) for any program (according to rules in WAC 182-503-0080);

(d) Ask you for more information to decide if you can start or renew health care coverage;

(e) Renew your health care coverage; or

(f) Change or terminate your health care coverage, even if we approve you for another kind of coverage.

(4) We send notices to you in your primary language if you ask us to and in English according to the rules in WAC 182-503-0110. If you need help to apply for or access your health care coverage due to a disability, we follow the equal access rules in WAC 182-503-0120.

(5) All WAH notices we send you include the following information:

(a) The date of the notice;

(b) Specific contact information for you if you have questions or need help with the notice;

(c) Your appeal rights, if an appeal is available, and the availability of potentially free legal assistance; and

(d) Other information required by state or federal law.

(1) We send written notice when we approve, reopen, reinstate, or deny coverage for any Washington apple health (WAH) program. The notice includes the information described in WAC 182-518-0005(4) and all of the following:

(a) The WAH coverage for each person approved, reopened or reinstated;

(b) The date that each person's coverage begins (the effective date); and

(c) The dates for which we approved each person's coverage (certification period).

(2) Denial and withdrawal notices include:

(a) The date of denial;

(b) Specific facts and reason(s) supporting the decision;

(c) Specific rules or statutes that support or require the decision; and

(d) Information to get help applying for nonmodified adjusted gross income (MAGI)-based WAH.

(3) If we deny your request for health care coverage or consider it withdrawn because you failed to give us requested information, the denial notice also includes:

(a) A list of the information you did not give us;

(b) The date we asked you for the information and the date it was due;

(c) Notice that we will reconsider your eligibility if we receive any information related to determining your eligibility, including any changes to information we have, within thirty days of the date of the notice;

(d) Information described in subsection (1) of this section; and

(e) Notice of administrative hearing rights.

(1) We send you written notice when we need more information as described in WAC 182-503-0050 to decide if you are eligible to receive or continue receiving Washington apple health (WAH) coverage. The notice includes:

(a) A description or list of the information that we need;

(b) When we must have the information (see WAC 182-503-0060 for applications and WAC 182-504-0035 for renewals);

(c) What action we will take and on what date, if we do not receive the information; and

(d) Information required in WAC 182-518-0005(4).

(2) If we have received conflicting information about facts we need to determine your coverage, the notice will also include:

(a) The information we received that does not match what you gave us and the source; and

(b) A request that you send us a statement explaining the difference(s) between the information from you and the information from the other source.

(3) We allow you at least ten days to return the information. If you ask, we may allow you more time to get us the information. If the tenth day falls on a weekend or holiday, the due date is the next business day.

(4) If the information we ask for costs money, we will pay for it or help you get the information in another way.

(1) We send you written notice before we stop your WAH coverage at the end of your certification period as described in WAC 182-504-0035.

(2) When we can administratively renew your coverage (as defined in WAC 182-500-0010), the notice includes:

(a) Your new certification period;

(b) The information we used to renew your coverage; and

(c) A request for you to give us updated information, if any of the information we used is inaccurate.

(3) When we cannot administratively renew your coverage, the notice includes:

(a) Information we currently have on record;

(b) How to complete the renewal using any of the methods described in WAC 182-504-0035 (1)(b);

(c) What action we will take on what date if we do not receive your completed renewal application on time; and

(d) That we follow the rules in WAC 182-518-0015.

(4) We send your renewal notice following the timeline in:

(a) WAC 182-504-0035(2) for programs based on modified adjusted gross income (MAGI); or

(b) WAC 182-504-0035(3) for non-MAGI based programs.

(1) General rule.

(a) We send written notice to you at least ten days before taking adverse action to terminate, suspend, or reduce your:

(i) Medicaid eligibility; or

(ii) Authorization for a covered service.

(b) The ten-day notice period starts on the day we sent the notice.

(2) Exceptions to ten-day notice period. We may send a notice fewer than ten days before the date of the action in the following circumstances.

(a) We send written notice to you at least five days before taking action to terminate, suspend, or reduce your medicaid eligibility or authorization for a covered service if:

(i) We have facts indicating fraud by you or on your behalf; and

(ii) We have verified the facts, if possible, through secondary sources.

(b) We send written notice to you no later than the date we took action to terminate, suspend, or reduce your medicaid eligibility or authorization for a covered service if:

(i) You requested the action;

(ii) A change in statute, federal regulation or administrative rule is the sole cause of the action;

(iii) You are incarcerated and expected to remain incarcerated at least thirty days;

(iv) Mail sent to you has been returned without a forwarding address, and we do not have a more current address for you; or

(v) We are terminating your eligibility because you:

(A) Died; or

(B) Began receiving medicaid from a jurisdiction other than Washington state.

(3) Notice contents. Written notice under this section states:

(a) The nature of the action;

(b) The effective date of the action;

(c) The facts and reason(s) for the action;

(d) The specific regulation on which the action is based;

(e) Your appeal rights, if any;

(f) Your right to continued coverage, if any; and

(g) Information found in WAC 182-518-0005(4).

(4) Reinstated coverage.

(a) If we do not meet the advance notice requirements under this section, we reinstate your coverage back to the date of the action. We may still take action once we meet notice requirements under this section.

(b) If you are receiving medically needy coverage, you cannot receive reinstated coverage past the end of the certification period described in WAC 182-504-0020.

(c) We may end your coverage if a notice we mailed to you is returned with no forwarding address. We reinstate your coverage if we learn your new address and you meet eligibility requirements.

(5) Hearing rights. If you do not agree with agency action under this section, you may request an administrative hearing under chapter 182-526 WAC, and you may be entitled to continued coverage under WAC 182-504-0130.

(1) For programs based on modified adjusted gross income (MAGI), you may choose to get notices by regular mail or in an electronic format through Washington Healthplanfinder.

(2) We send you letters (notices) about your eligibility for Washington apple health programs as described in WAC 182-518-0005 through 182-518-0025.

(3) When you select electronic notifications, also referred to as "paperless," we:

(a) Confirm your selection by regular mail;

(b) Notify you by email when a new notice has posted to your account; and

(c) Consider the notice received by you as of the date on the notice as described in WAC 182-518-0005.

(4) To read the notice, you must log in to your Washington Healthplanfinder account, as email messages do not include the content of the notice or other confidential information.

(5) If an email message is returned as undeliverable, we send the message to you by regular mail no later than three business days after the date of the undeliverable email response.

(6) You may ask at any time to stop receiving electronic notices from us.