Washington Medicaid Appeals and Fair Hearings

If your Washington Apple Health (Medicaid) coverage is denied, cut, or ended, you have the right to appeal and request a fair hearing, and you can often keep your benefits during the appeal.1,2 You have 90 days from the date printed at the top of your notice to request a hearing, but the window to keep your benefits flowing is much shorter.1

In This Guide

• What a Washington Medicaid Appeal Covers
• The Deadlines That Decide Your Washington Medicaid Appeal
• How to Keep Your Benefits During the Appeal
• Managed Care (MCO) Appeals: Exhaust Your Plan First
• How to Request a Washington Medicaid Fair Hearing
• Frequently Asked Questions
• Learn More

What a Washington Medicaid Appeal Covers

Federal law gives Medicaid applicants and recipients the right to a fair hearing before the state agency. Section 1902(a)(3) of the Social Security Act requires each state plan to provide a hearing to anyone whose claim for medical assistance is denied or is not acted on with reasonable promptness. The implementing regulation at 42 CFR 431.220 extends that right to anyone who believes the agency acted erroneously, denied a claim for eligibility or for covered services, or failed to act with reasonable promptness, and also to managed care enrollees and to nursing facility residents who believe a transfer or discharge decision is wrong.2 In Washington, that right runs through an administrative hearing that you request when you disagree with a coverage or eligibility decision on your Apple Health.1

In practice, that covers decisions like these:2

• A denial of your application, or a later decision about your eligibility
• A termination or reduction of coverage you already have
• A change in the amount or type of services you receive, such as a cut in authorized hours
• A prior authorization denial
• The spend-down amount the agency says you must incur in medical expenses to qualify
• A managed care plan's denial, reduction, suspension, or termination of a service

The right reaches across the program, from the first eligibility decision to a mid-year cut in services. It has one stated exception. Federal rules do not require a hearing when the only issue is a federal or state law that requires an automatic change adversely affecting some or all beneficiaries.2 HCA says the same: you may not have a right to a hearing if your coverage is denied, ends, or changes because a state or federal law changed and the change affects everyone in the program the same way (RCW 74.09.741(3)).1

One narrower protection sits alongside the hearing right. If your coverage ended only because you did not return your renewal form on time, you do not always have to appeal or reapply: under 42 CFR 435.916(a)(3)(iii), if you submit the renewal form within 90 days after the termination date, the agency must reconsider your eligibility without a new application. That duty covers eligibility based on modified adjusted gross income (MAGI). If you qualify through SSI, age, disability, long-term care, a Medicare Savings Program, or the medically needy pathway, Washington may offer the same window but is not required to, so ask HCA.4

The Deadlines That Decide Your Washington Medicaid Appeal

Two deadlines matter in a Washington Medicaid appeal, and they are different numbers.

The request window is 90 days. You have 90 days from the date at the top of the notice HCA mailed you to request a hearing. Federal law at 42 CFR 431.221(d) caps this window at 90 days from the date the notice is mailed, and Washington uses the full federal 90 days rather than a shorter state window.1,3 The clock runs from the mailing date printed on the notice, not the day it reached your mailbox.

The continued-coverage window is much shorter: 10 days, or the end of the month, whichever is later. That is the deadline that keeps your benefits flowing while the case is decided.1

The managed care windows are different again: a denial from a plan starts with a 60-day window to file the plan's appeal, then a separate window to request a state fair hearing after the plan decides.5

How to Keep Your Benefits During the Appeal

This protection is called continued coverage, or aid paid pending. Keeping your benefits during the appeal is not automatic. It depends on asking for a hearing in time.

If HCA ended or reduced coverage you already have, you can keep that coverage during the hearing process only if you ask for a hearing within 10 days of receiving the notice or by the end of the month, whichever is later.1 This is a much shorter window than the 90 days you have to request the hearing itself, so a reader who waits the full 90 days can win the right to a hearing yet lose coverage in the meantime.

The federal rule behind this protection is 42 CFR 431.230(a): when the agency sends the required advance notice and you request the hearing before the date the action takes effect, the agency may not terminate or reduce your services until a decision is rendered after the hearing, unless both halves of a narrow exception are met: the hearing determines that the sole issue is one of federal or state law or policy, and the agency promptly tells you in writing that services will be terminated or reduced pending the decision.6 The trigger is the date of action on your notice.

Two limits apply. Continued coverage is not available to challenge the denial of a new Apple Health application. And if you receive continued coverage but lose your hearing, you may have to pay back up to 60 days of that coverage.1

Managed Care (MCO) Appeals: Exhaust Your Plan First

Many Apple Health members get their care through a managed care organization (MCO). HCA lists Washington's Apple Health managed care plans as including Wellpoint (formerly Amerigroup), Community Health Plan of Washington, Coordinated Care, Molina Healthcare, and United Healthcare.1 When a plan denies care, you appeal to the plan before you can reach a state administrative hearing.

You must exhaust the plan's appeal first. If you are appealing a decision from an MCO, you must exhaust all levels of resolution and appeal within the plan's grievance system, under WAC 182-526-0200, before requesting an administrative hearing.1

Under 42 CFR 438.404, when a plan issues an adverse benefit determination it must give you timely written notice, and that notice must tell you how to appeal, how to ask for an expedited appeal, and how to request that your benefits continue.7

The plan appeal window is 60 days. Under 42 CFR 438.402, you have 60 calendar days from the date on the adverse benefit determination notice to file the plan's appeal, which can be requested orally or in writing. Each plan may have only one level of appeal, and a provider or authorized representative can file it for you with your written consent if state law permits.5 One exception matters if you have both Medicare and Medicaid: if you are enrolled in what federal rules call an applicable integrated plan, this 60-day rule does not govern the plan-level appeal, and a separate federal rule (42 CFR 422.629 through 422.634) applies instead, so follow the deadline on your plan's notice.5

Under 42 CFR 438.408, the plan must resolve your appeal as quickly as your health condition requires, within a deadline the state sets that can be no longer than 30 calendar days for a standard appeal and 72 hours for an expedited appeal, counted from when the plan receives it. Either appeal timeframe can be extended by up to 14 calendar days if you request the extension or the plan shows the state that it needs more information and how the delay is in your interest. If the plan extends the deadline without your asking, it must give you written notice of the reason within 2 calendar days and tell you that you can file a grievance if you disagree.8 If waiting could harm your health, ask the plan for an expedited appeal; its notice of the adverse benefit determination must explain when an appeal can be expedited and how to request it.7

Once the plan resolves the appeal against you, under 42 CFR 438.408(f) the state must give you no less than 90 and no more than 120 calendar days from the date of the plan's notice of resolution to request a state fair hearing; the exact number within that band is set by the state.8 If the plan fails to meet 42 CFR 438.408's notice and timing requirements for resolving your appeal, the appeal is deemed exhausted and you may go straight to a hearing.8 Keeping services during a plan appeal runs on a much shorter clock. If the plan is cutting services you already have, you must ask for continued benefits within 10 calendar days after the plan sends its notice, or by the date the cut takes effect if that is later. After a losing plan appeal, those benefits stop unless you request the state fair hearing and continued benefits within 10 calendar days after the plan sends its resolution notice.8 Whatever happens next, the first step is the same: file the plan's appeal within 60 calendar days of the date on the determination notice.5

How to Request a Washington Medicaid Fair Hearing

Washington's administrative hearings are conducted by the Office of Administrative Hearings (OAH), a separate state agency. An administrative law judge (ALJ) holds the hearing by telephone or in person and issues an initial order, and the Health Care Authority (HCA) Board of Appeals issues the final order.1

Your request does not need to be on any particular form and can be made orally or in writing. You can use any form or directions included with your decision letter, submit OAH's online hearing-request form, or contact OAH by phone at 1-800-583-8271.1

The office you file with depends on your case type. For classic cases (aged, Medicare-related, or long-term-care coverage), you can also request a hearing through the Department of Social and Health Services (DSHS) at 1-877-501-2233. For Modified Adjusted Gross Income (MAGI)-based cases, you can request through Washington Healthplanfinder at 1-855-923-4633 or through HCA at 1-800-562-3022.1 If you are appealing a managed care denial, exhaust the plan's internal appeal first, then request the OAH hearing.

After the ALJ issues the initial order, you may ask the HCA Board of Appeals to review it, and the Board issues the final order in your case.1

Learn More

Find personalized help navigating a Washington Medicaid appeal at brevy.com.

The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.