Exception to Rule (ETR): DSHS Programs
Authored By: Northwest Justice Project - CLEAR Intake Line
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The Department of Social and Health Services (DSHS) can give you some benefits even if you do not meet all their requirements. This is an “exception to a rule” or “ETR.” #7101EN
- What is an ETR?
- What programs or benefits does DSHS consider for ETRs?
- Can I ask for an ETR about medical or dental services?
- Does DSHS grant many ETR requests?
- When should I ask for an ETR?
- Should I ask for an administrative hearing too?
- When should I ask for an administrative hearing?
- What if I miss my deadline?
- Which decision do I want first?
- Is an ETR right for me?
- How do I request an ETR?
- What paperwork should I send?
- Do you have a sample ETR request?
- When will I get the ETR decision?
- Do I get benefits while I wait for a decision?
- What if they denied my ETR?
- What if my ETR is for personal care hours?
The Department of Social and Health Services (DSHS) can give you some benefits even if you do not meet all their requirements. This is an “exception to rule” or ETR.
Temporary Assistance for Needy Families (TANF), including WorkFirst
Additional Requirements for Emergent Needs (AREN)
Long Term Care (LTC) services, including COPES
Medicare Savings Program (MSP)
Aged, Blind, or Disabled (ABD) or Housing and Essential Needs (HEN)
Those requests have different rules. Read Exception to Rule: Washington Apple Health.
DSHS considers ETR requests case-by-case. It grants only a few.
Act right away. Most ETR requests do not have deadlines. It takes time to get the request ready and get info to support your request.
Yes. If DSHS denies, cuts, or stops your benefits, you should usually request both.
DSHS and/or the Office of Administrative Hearings (OAH) must get your hearing request within 90 days of the written notice that DSHS denied, cut, or stopped your benefits.
If DSHS is stopping services or benefits, and you want to keep getting the benefit until you get a hearing decision, you must ask for an administrative hearing and “continued benefits” within ten days of their notice or before the date the benefit stops. DSHS can ask you to pay back up to 60 days’ worth of benefits only if you lose your appeal.
You can still appeal or ask for an ETR. You might have to show you had “good cause” for missing the deadline. Example: You were in the hospital.
You want to get the decision on your ETR before the hearing. If the administrative hearing date is before you think you will get a decision on the ETR, contact the assigned Administrative Hearing Coordinator and the OAH. Ask them to postpone (“continue”) your hearing. Explain that you are waiting for a decision on an ETR request on the same issue. Contact info for the FHC and OAH should be on the hearing notice. To contact your local OAH office, go to http://oah.wa.gov/Home/Index/3411.
When deciding your ETR request, DSHS considers if:
The exception would not go against the law.
Your situation is different from most others’.
The exception is in the interest of the economy and your welfare.
One of these is true:
The ETR makes it more likely for you to function effectively.
You have an impairment or limitation making it very hard to use the normal eligibility or payment process.
*See WAC 388-440-0001.
Example 1: The most you can usually get for emergency assistance for housing and utilities is $750. Your child is on a ventilator in your home. You are $1,000 behind on utility bills. You got a shut-off notice for the power. You can afford the monthly charges in the future. You cannot make up the back bills. Without electricity to run the ventilator, your child's safety is at risk. You can ask for an ETR for more emergency assistance to keep the power on.
Example 2: DSHS cuts your in-home care hours at your yearly CARE assessment. (Read Understanding Your CARE Tool Assessment.) You should ask for an ETR if you have:
Multiple, extreme, constant behaviors requiring more time or supervision. They also make it hard to provide care.
A medical condition DSHS does not list as clinically complex. It has the same impact on your ability to care for yourself as a listed condition. Example: You have a rare chromosomal disease. It has the same functional impact as Cerebral Palsy. You will not get the same number of in-home care hours as someone with Cerebral Palsy.
*ETR requests for CARE assessments have more rules. See “How do I request an ETR,” below.
Ask your case manager to do it. If they will not, you can do it yourself.
Send your case manager your ETR request and any paperwork helping your case. If you are asking for the ETR on your own, send it to the ETR Coordinator for your Community Services Office (CSO), Developmental Disabilities Administration (DDA) office, or Home and Community Services (HCS) Office.
*To get the ETR Coordinator’s name, contact your local office.
CARE Assessment ETRs: Make your ETR request to your case manager or local HCS, Area Agency on Aging (AAA) or DDA field office, verbally OR in writing. Requests approved at the field level go to the ETR committee in Olympia for a final decision.
Your ETR request should include:
A letter explaining why you need it and how you meet the requirements
Documents and evidence supporting your request
The number of the rule you want an exception to [example: WAC 388-106-0030]
Yes. See Appendix A at the end. You can change it to meet your needs.
You should get a written decision within ten days of
the decision to file your ETR request if you requested a case manager submit your ETR request, AND
DSHS's decision on your ETR request
If you request only an ETR, not an administrative hearing - No.
If they are going to stop a benefit and you ask for an administrative hearing within ten days of the date on the termination notice - Yes, until an Administrative Law Judge (ALJ) decides your case. If the tenth day happens before the end of the month, you have until the end of the month to ask for an administrative hearing and keep getting benefits.
*If you lose your hearing, DSHS can ask you to pay back up to 60 days of assistance.
In general, there is no administrative hearing for an ETR denial. You can file a complaint with DSHS. This is not an administrative hearing. You do not present your case to a judge.
You should first give your written complaint to a department supervisor, then the department administrator. DSHS must give you a decision within ten days. WAC 388-426-0005.
If you have been getting more in-home personal care hours than the CARE assessment would have given you and DSHS later cuts or ends the ETR for the extra hours, you have a right to a hearing. WAC 388-825-120 (DDD); WAC 388-106-1315 (all other clients getting in-home personal care services through DSHS).
If you have not been getting extra hours through an ETR, and they deny your initial ETR request, talk to a lawyer.
This publication provides general information concerning your rights and responsibilities. It is not intended as a substitute for specific legal advice.
This information is current as of September 2018.
© 2018 Northwest Justice Project — 1-888-201-1014.
(Permission for copying and distribution granted to the Alliance for Equal Justice and to individuals for non-commercial purposes only.)