Exception to Rule (ETR): DSHS Programs

Yes, you should read this if you live in Washington State and you are applying for or getting benefits from DSHS.

You will learn about how and when DSHS will make an exception to its rules (an ETR) to give or keep giving you benefits. You will also learn which benefits programs you might be able to get an ETR for and how and when to ask for an ETR.

Usually, you can only get benefits from the Department of Social and Health Services (DSHS) if you meet all their requirements to do so. But sometimes DSHS will make an exception. In those cases, DSHS can give you some benefits even though you do not meet the requirements. This is an "exception to rule" or ETR.

No. Here are the programs where you can get an ETR:

• Temporary Assistance for Needy Families (TANF), including WorkFirst     
• Additional Requirements for Emergent Needs (AREN)
• Childcare (WCCC)
• Long Term Care (LTC) services, including COPES
• Medicare Savings Program (MSP)
• Aged, Blind, or Disabled (ABD) or Housing and Essential Needs (HEN)

Yes, but the rules are different. Read Exception to Rule: Washington Apple Health to learn more.

DSHS considers these requests case-by-case. It grants only a few. But there are no downsides to asking for an ETR. You could be one of the cases that gets an ETR.

There is no deadline to do so, but the sooner you ask for one, the sooner DSHS will decide on your request, and the sooner you can get the ETR.  

It depends. If DSHS turns down (denies), cuts (reduces), or stops (terminates) your benefits because they say you haven't followed a program requirement (a rule), you should usually ask for both an ETR and a hearing.

Generally, DSHS and/or the Office of Administrative Hearings (OAH) must get your hearing request within 90 days of the date on DSHS' written notice that denied, reduced, or terminated your benefits. But if circumstances beyond your control, such as medical issues, housing instability, language barriers, or domestic violence, keep you from meeting that deadline, you should still ask for a hearing as soon as you can.

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 10 days of their notice or before the date the benefit stops. If you lose the hearing, DSHS can ask you to pay back up to 60 days of benefits.

*If you are going to be representing yourself at an administrative hearing, read Representing yourself at an administrative hearing for tips on how to prepare and how to give evidence and testify at your hearing.

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.

Yes. If the 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 (to 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.

It depends. When deciding your ETR request, DSHS considers whether:

• The exception goes against the law.

• Your situation is different from most other people's situations.

• 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.

*You can read the state regulation about this at 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 power 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:  You get in-home personal care hours. After your yearly assessment to decide how many of these hours of personal care you will get, DSHS decides you don't need as many. But you believe that DSHS doesn't understand your medical condition, that you do in fact still need the same number of hours. If DSHS' rules don't list your condition as clinically complex, but your condition has the same impact on your ability to care for yourself as a DSHS-listed condition, you can ask for an ETR to keep getting the same number of in-home care hours.

Ask your case manager to do it for you.  If your case manager disagrees that you qualify for an ETR, you can do ask for an ETR yourself.

If you are asking for the ETR yourself, send your case manager your ETR request and any paperwork that helps prove 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 appropriate ETR Coordinator's name, contact your local CSO. They will have the names for all the different ETR coordinators.  

CARE Assessment ETRs: Make your ETR request to your case manager or local HCS, Area Agency on Aging (AAA) or DDA field office. You can make your request verbally or in writing. We recommend you try to do it in writing, so you have a record of your request. 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 that help your request

• The number of the rule you want DSHS to make an exception to [example: WAC 388-106-0030]  

Yes. See below. You can change it to meet your needs, or you can create your own. 

• If you asked your case manager to make the ETR request for you, the case manager must let you know within 10 days from your asking if the case manager has decided not to make the request for you.

• If you made the ETR request on your own, you will get a decision within 10 days after making your ETR request.

It depends.

If you request only an ETR, and not an administrative hearing you will not get benefits while you wait for a decision.

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 you will receive benefits 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 benefits.

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 take 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 10 days. 

If you have been getting more in-home personal care hours than the CARE assessment would have given you and DSHS later reduces or ends the ETR for the extra hours, you have a right to a hearing. The state regulations that say this are at WAC 388-825-120 (DDD) and 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.