Exception to Rule (ETR): Washington Apple Health
The Health Care Authority (HCA) can approve Washington Apple Health (Medicaid) benefits even if you do not meet all financial requirements. They can also cover necessary medical/dental services that Medicaid normally does not cover. This is an “exception to a rule” or “ETR.” #5105EN
- What is an ETR?
- Does HCA grant all ETR requests?
- What is my deadline to ask for an ETR?
- Should I also ask for an Administrative Hearing?
- When should I ask for a hearing?
- What if I miss the deadline to appeal?
- 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 sample letters?
- How long will an ETR decision take?
- Do I get benefits while waiting for a decision?
- What if they denied my ETR?
What is an ETR?
The Health Care Authority (HCA) can approve Washington Apple Health (Medicaid) benefits even if you do not meet all financial requirements. They can also cover necessary medical and dental services that Medicaid normally does not cover. These are each an “exception to a rule” or ETR.
Does HCA grant all ETR requests?
No. It grants only a few.
What is my deadline to ask for an ETR?
You must make an ETR request for financial eligibility within 90 days of the written notice denying Washington Apple Health benefits.
You must make an ETR request regarding non-covered medical or dental services within 90 days of the notice denying the service.
*It takes time to get the request ready and get info to support your request. Act right away.
Should I also ask for an Administrative Hearing?
Yes. If HCA denies or stops your Washington Apple Health benefits OR HCA or your Apple Health Managed Care plan denies coverage of medically necessary services, you should usually ask for both.
When should I ask for a hearing?
HCA and/or the Office of Administrative Hearings (OAH) must get your administrative hearing request within 90 days of the written notice stating HCA denied, cut, or stopped your benefits.
If you get Apple Health through a managed care plan, such as Amerigroup, Community Health Plan of Washington United Healthcare Community Plan, or Molina Healthcare of Washington, Inc., you must use their appeal process first. The denial or termination notice should say how to appeal the decision. If not, call the plan’s customer service number.
If HCA is ending benefits, and you want to keep getting the service or 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 service or benefit stops. HCA can ask you to pay back up to 60 days’ worth of benefits if you lose your appeal.
What if I miss the deadline to appeal?
You can still appeal or ask for an ETR. You may need to show you had “good cause” for missing the deadline. Example: You were in the hospital.
Which decision do I want first?
You want the decision on your ETR first. If the administrative hearing date is before you think you will get a decision on the ETR, contact the assigned Administrative Hearing Coordinator and OAH. Ask them to postpone (“continue”) your hearing. Explain that you are waiting for a decision on an ETR request on the same issue. The hearing notice should have the FHC or OAH’s contact info. To contact your local OAH office, go to http://oah.wa.gov/Home/Index/3411.
Is an ETR right for me?
Washington Apple Health financial eligibility - When deciding on your ETR request, HCA 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 overall economy and your welfare.
One of these:
The ETR increases your chances to function effectively.
You have an impairment or limitation making it very hard to use the normal eligibility or payment process.
Coverage of non-covered medical or dental services through Washington Apple Health - HCA considers if
The exception would not go against the law.
The requested item or service is “good medical practice.”
The requested service is cost-effective.
Your condition is so different that no other cheaper Medicaid service or item would meet your needs as well.
The services HCA would pay for under their rules do not work for you.
*The financial eligibility ETR rule is WAC 182-503-0090.
*The non-covered service ETR rule is WAC 182-501-0160.
Example 1: Your dentist recommends a dental procedure to treat a calcium growth inside your mouth. HCA denies coverage. In most people, the growth is harmless. In your case, you cannot have dentures fitted. You ask for an ETR. You show your case is rare, removal is the only treatment available, and it will be cheaper in the end because it will prevent further medical problems.
Example 2: Your doctor recommends Botox injections to treat a rare medical condition affecting the use of your muscles. HCA denies coverage because your condition is rare or the medical treatment is experimental. You may ask for an ETR. You argue that no other, cheaper treatment works as well, and it will result in a lower overall cost of care by letting you live independently without a care provider’s aid.
How do I request an ETR?
Washington Apple Health financial eligibility - Mail your ETR request to:
Health Care Authority
PO Box 45531
Olympia WA 98504
Coverage of non-covered medical or dental services through Washington Apple Health - Have your provider fax your request and supporting paperwork to the Health Care Authority at 1-866-668-1214.
*For more info, contact the HCA Medical Assistance Customer Service Center: 1-800-562-3022.
NOTE: If you have an Apple Health managed care plan, such as Amerigroup, Community Health Plan of Washington United Healthcare Community Plan, or Molina Healthcare of Washington, Inc., you must submit your ETR request to that plan. Generally, your provider can fax or send the ETR request to the same contact info where they send prior authorization requests.
What paperwork should I send?
A letter to HCA or the managed care plan explaining why you need an ETR and how you meet the requirements
Evidence supporting your request, including a statement or records from your doctor, dentist, care providers, or other medical professionals
The number for the rule you want an exception to [example: WAC 182-501-0070]
*You must submit your written ETR request within 90 days of the date of the written notice denying authorization for the service.
Do you have sample letters?
Yes. You can change them to meet your needs:
Sample Letter A - Requesting an ETR for non-covered services
Sample Letter B - Request for a statement and documentation from your doctor or dentist
How long will an ETR decision take?
HCA or the managed care plan has fifteen working days to give its written decision. WAC 182-501-0160(5).
They may ask for more info. You must get them this info within 30 days of the request. They will then decide within five business days.
Do I get benefits while waiting for a decision?
If you request only an ETR, not an administrative hearing - No.
If they are going to end 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 administrative hearing, DSHS may ask you to pay back up to 60 days of assistance.
What if they denied my ETR?
In general, there is no hearing for a denial of an ETR. Talk to a lawyer.
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