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182-518-0020  <<  182-518-0025 >>   182-518-0030

PDFWAC 182-518-0025

Washington apple healthNotice requirementsActions to terminate, suspend, or reduce eligibility or authorization for a covered service.

(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.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-22-060, § 182-518-0025, filed 10/31/16, effective 12/1/16. Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-052, § 182-518-0025, filed 7/29/14, effective 8/29/14.]
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