Medicaid appeals in Washington: hearing deadline and keeping benefits

Medicaid (Washington Apple Health (Medicaid)) denials in Washington

Medicaid agency

Washington State Health Care Authority (HCA), with the Department of Social and Health Services (DSHS) for some eligibility

Who holds the hearing

Washington State Office of Administrative Hearings (OAH); HCA Board of Appeals reviews initial orders

Hearing deadline

90 days

The date you receive the notice of the decision

If you are late

A late request can be accepted for good cause, such as military deployment, medical reasons, housing instability, language barriers or domestic violence, but not if it is filed more than one year after the decision.

How to ask for a hearing

• Form: Use any form or directions that came with your decision letter
• Online: OAH online request for hearing form (HCA)
• Phone: Office of Administrative Hearings 1-800-583-8271
• Fax: OAH Olympia 360-586-6563
• Mail: Health Care Authority, P.O. Box 45504, Olympia, WA 98504-5504
• In person: Requests can be made in person

oah.wa.gov · 1-800-583-8271

Mail address

Health Care Authority, P.O. Box 45504, Olympia, WA 98504-5504

What to include

Your name, address and phone, your Apple Health client ID, a description of each action you disagree with, a short explanation of why, and any accommodation you need, such as an interpreter.

Keeping your benefits during the appeal

To keep your Apple Health coverage while you appeal a decision to end, suspend or reduce your eligibility or an authorized service, request a hearing by the tenth day after the notice was sent or by the last day of the month before the change takes effect. If that day is a weekend or holiday, you have until 5:00 p.m. the next business day. If you lose, HCA can recover only up to the first 60 days after it received your hearing request.

Law: WAC 182-504-0130; RCW 74.09.741(5)(g); RCW 74.09.741(4); WAC 182-526-0095, 182-526-0102

When the hearing is held

An OAH administrative law judge holds the hearing by phone or in person and issues an initial order; you can ask the HCA Board of Appeals to review it.

Law: WAC 182-526-0560 to 182-526-0600; RCW 74.09.741(4); WAC 182-526-0095, 182-526-0102

Faster (expedited) hearing

Ask OAH for an expedited hearing if waiting could jeopardize your life, health or ability to attain, maintain or regain maximum function, and send evidence of the urgent need with the request. The judge must decide whether to grant it within 4 business days. People who are getting continued coverage may not get an expedited hearing.

Law: RCW 74.09.741(4); WAC 182-526-0095, 182-526-0102

Medicaid health plan (managed care) in Washington

Appeal to the plan first

Appeal to your Apple Health managed care plan (such as Wellpoint, Community Health Plan of Washington, Coordinated Care, Molina or United Healthcare) within 60 calendar days of the notice. To keep a service the plan is cutting or stopping, appeal within 10 calendar days of the notice. The plan must decide within 30 days, or 72 hours for an expedited appeal. If it says no, request a hearing within 120 days; to keep services during the hearing, request it within 10 days of the plan's decision. The whole plan appeal and hearing process should be finished within 90 days of your plan appeal.

Then a state hearing

120 days

The date of the plan's written notice of resolution of your appeal

If the plan is late

If the plan does not follow the notice or timing rules, you can ask for a hearing without finishing the plan appeal.

Law: WAC 182-538-110; WAC 182-526-0200

Optional outside medical review

If you disagree with the judge's initial order, you can ask for an independent review by an IRO within 21 calendar days of the date the initial order was mailed, instead of or before review by an HCA review judge.

Law: under RCW 48.43.535; WAC 182-538-110; WAC 182-526-0200

Write my appeal: free letters

Letter: Medicaid fair hearing request