Administrative Hearings

Purpose: 

This category will provide an explanation of the following elements regarding Administrative Hearings.

Overview

Revised October 29, 2015

DSHS Hearing Rules are found in chapter 388-02 WAC.  

Clients have the right to receive written notice of their administrative hearing rights at the time of application, denial, termination, suspension, grant reduction or notification of overpayment. [see RCW 74.08.080].

Clients have the right to be represented or to represent themselves at an administrative hearing.

The client who requests an administrative hearing is called the appellant.  However, in an Administrative Disqualification Hearing food assistance case the department requests the hearing and the client is called the respondent.


Clarifying Information:

The Community Service Office (CSO) Administrative Hearing Coordinator (AHC) is usually a Financial Service Specialist (FSS) who has the responsibility for administrative fair hearings in the CSO. The Aging and Disability Services Administration (ADSA) AHC has the responsibility for the administrative hearings related to ADSA clients. The CSO Administrator (CSOA) has the authority to resolve issues with the client prior to an administrative hearing.

Remember that not every complaint received about a department action is a request for an administrative hearing. Refer to information in WAC 388-426-0005  for complaints that are not appropriate for an administrative hearing.

Administrative hearings are conducted by Administrative Law Judges (ALJ), employed by the Office of Administrative Hearings (OAH) which is a separate agency from DSHS. The administrative hearing can be held in person or by teleconference call.  The Office of Administrative Hearings (OAH) is responsible for scheduling administrative hearings and sending a notice of the date and time for the administrative hearing to all participants.

The DSHS Board of Appeals (BOA) is responsible for reviewing the initial hearing decisions when reconsideration is requested by either the department or the appellant.

Exception: The department cannot request reconsideration on Basic Food decisions. See 7 CFR 273.15 (q)(2).   

The client has the right to request judicial review of a final DSHS hearing decision.

 

Administrative Hearing Coordinator's Role

Revised October 28, 2015

DSHS Hearing Rules are found in chapter 388-02 WAC.

The following is a summary of general duties assigned to an Administrative Hearing Coordinator (AHC).

To find out the name of the Administrative Hearing Coordinator (AHC) in Community Services Division (CSD) regions / offices, please contact:

Danielle LeMier, Administrative Hearings Program Coordinator
Operations, Community Services Division
360-338-5210
Email:  Danielle.LeMier@dshs.wa.gov


Clarifying Information: 

The Community Services Office (CSO) Administrative Hearing Coordinator (AHC) is usually a Financial Services Coordinator (FSS) who has responsibility for the Administrative Hearing operations in the CSO.

The AHC acts as the liaison, in cases involving Administrative Hearings, between the CSO and

  • The appellant
  • The appellant's representative
  • The Office of Administrative Hearings (OAH)
  • The DSHS Board of Appeals (BOA)
  • The Health Care Authority (HCA)
  • The Community Services Division (CSD)
  • The Office of the Assistant Attorney General (AAG)
  • Children's Administration (CA)
  • The Office of Fraud and Accountability (OFA)
  • Other agencies or individuals involved in specific hearings.

The AHC must maintain the appearance of fairness in the Administrative Hearing process. The following guidelines apply:

  1. Communication with Administrative Law Judge (ALJ), department witnesses, appellants their witnesses and representatives must be on a professional level.
  2. Any communication between the AHC and an ALJ regarding a specific hearing must include the appellant and/or their representative. Private conversations with an ALJ about an administrative hearing (ex-parte communications) are strictly prohibited, unless it involves a safety issue. See RCW 34.05.455.

Administrative Hearing Coordinator (AHC) Responsibilities: 

  1. Maintain in BarCode Administrative Hearing Control System (AHCS) the following specific information:
    1. Name and client ID of appellant;
    2. Date of request for hearing;
    3. Hearing Issue;
    4. Name of appellant representative, if any;
    5. Pre-Hearing meeting (PHM) activities, if any;
    6. Scheduled date of hearing;
    7. Continuances requested;
    8. Date and result of hearing decision; and
    9. Date of request for review and/ or reconsideration.
  2. Document hearing actions on ACES narrative;
  3. Determine eligibility for continued benefits under WAC 388-458-0040;
  4. Give notice to Office of Financial Recovery (OFR) to stop recovery when an administrative hearing about an overpayment has been requested;
  5. Represent the Department at the voluntary Pre-Hearing Meeting, Pre-Hearing Conference, and the Administrative Hearing;
  6. Contact the local Assistant Attorney General (AAG) when necessary to determine whether an AAG should be present at an administrative hearing.
  7. Contact the division program manager for Administrative Hearings when a local AAG is not available;
  8. Notify the OAH of any accommodation needed due to client Equal Access (EA) status;
  9. Notify the OAH if interpreter services are requested for Limited English Proficient (LEP) clients;
  10. Prepare the DSHS 09-354(X), Administrative Hearing Report or similar document as an attachment to exhibits (Administrative Hearing Packet);
  11. Provide copies of the Administrative Hearing Packet to all parties;
  12. Coordinate and conduct pre-hearing meeting or pre-hearing conference activities;
  13. Arrange for subpoenas to be issued by the AAG, when necessary;
  14. Distribute copies of hearing decisions as necessary to:

          a) Supervisor/Social Service Supervisor.

          b) Coordinate implementation of hearing decisions;

          c) Prepare petition for review or request for Board of Appeals (BOA) reconsideration of initial decision or response to appellant petition as appropriate;

Exception: The department cannot request BOA reconsideration for Basic Food hearing decisions.  See 7 CFR (q)(2).

   17. Notify the Office of Fraud and Accountability (OFA) of any hearing requests on cases that have been referred for prosecution.

Continued Benefits

Revised October 28, 2015

Purpose:

If a client meets continued benefits eligibility requirements, the client receives the level of benefits they were receiving prior to the administrative hearing request until the hearing decision is issued.

If the hearing decision affirms the department action (i.e. reduction, suspension, or termination of benefits) the continued benefits paid to the client pending the administrative hearing may become an overpayment for the client.   See WAC 388-458-0040.

Clarifying Information:

  1. Continued benefits for clients are governed by WAC 388-458-0040.
  2. Continued benefits are authorized at the benefit level the client was receiving before the action was taken by the department which resulted in the hearing request.
  3. Clients must be notified in writing of their eligibility for continued benefits.

Administrative Hearing Coordinator (AHC) Responsibilities:

1. Review each administrative hearing request to determine eligibility for continued benefits.

Note: A client is eligible for continued benefits at the level of benefits they were receiving before the department took the action that reduced, suspended, or terminated their benefits, until the end of the month when the hearing decision was issued, unless:

  a) The client failed to request the administrative hearing within the 10 day period after the change letter was mailed by the department.

  b) The client’s Basic Food certification has ended.

  c) The client’s Medical Certification Period has ended.

  d) The client requested in writing that the department not give them continued benefits.

  e) The client withdrew their administrative hearing request.

2. When the AHC determines the client is eligible for continued benefits.

  a) Reinstate terminated benefits or make changes to the ACES record to cancel a reduction or suspension of benefits.

  b) Send notice of eligibility to client which includes the following information:

       i) Benefits have been continued based on your hearing request;

       ii) Some or all of the continued benefits may be considered an overpayment if the department action is affirmed; and

       iii) If you do not wish to receive continued benefits, you must make that request to the department in writing.

2. If the AHC determines that the client is not eligible for continued benefits send ACES letter D01C for cash or medical or D02C for Basic Food. The following information should be included:

  a) Why continued benefits cannot be authorized, citing the regulation; and

  b) The information regarding Administrative Hearing rights.

3. Call the Office of Administrative Hearings (OAH) to schedule an expedited administrative hearing when clients appeal the hearing decision regarding continued benefits.

4. Notify the Social Service Specialist /Case Manager when continued benefits terminate.

5. AHC will establish overpayments that result from the payment of continued benefits to clients, if appropriate.

Financial Services Specialist (FSS)/Case Manager Responsibilities:

1. Continue to process all case actions or changes that do not apply specifically to the administrative hearing issue. 

2. Notify the AHC of any case actions or changes that result in a reduction, suspension or termination of cash, food, or medical benefits.

Equitable Estoppel

Revised October 28, 2015

 


Clarifying Information: 

Equitable Estoppel is a legal principle which means that, in certain cases, the Administrative Law Judge (ALJ) can order the department to stop doing something because it is not fair to a client i.e. overpayment.  See WAC 388-02-0495.

In 2012, the department, in consultation with Legal Services, the Office of the Attorney General and the Office of Administrative Hearings, developed a stipulation and agreed order of dismissal to be used to take the place of a formal administrative hearing and written decision by an Administrative Law Judge (ALJ), in cases where the client raises the  equitable estoppel defense to eliminate an overpayment.

Appellants may raise the equitable estoppel as a defense in administrative hearings.

Exception:  The equitable estoppel defense cannot be applied for overpayments related to the Supplemental Nutrition Assistance Program (SNAP), Food Assistance Program (FAP) or the Washington Combined Application Program (WASHCAP) as the principle of equitable estoppel is considered contrary to federal law.  Because FAP and WASHCAP are required to mirror federal law it cannot be used for these programs. See WAC 388-410-0025.  

The Stipulation and Agreed Order of Dismissal should be considered for cases which meet all of the following conditions:

  1. The sole issue for the administrative hearing is the fairness of the collection of an overpayment, and
  2. Neither party (appellant or department) is disputing any fact affecting the outcome of the case. There is agreement about the amount and the facts of the overpayment; and
  3. The department is satisfied that all elements of estoppel have been established by the appellant with "clear, cogent, and convincing" evidence. This means that the fact is proven by the evidence to be highly probable.

Cases must be determined individually based on each unique set of facts. The purpose of the stipulation is to avoid unnecessary administrative hearings. An administrative hearing is unnecessary only when the department agrees that the appellant has established the case for equitable estoppel and the appellant agrees to the facts of the overpayment. If either party, the AHC (or other department representative) or the appellant, disputes any fact affecting the outcome of the case, an administrative hearing should be held and a formal decision made by the ALJ.

Administrative Hearing Coordinator (AHC) Responsibilities:

Review each hearing request, consulting with supervisors as appropriate, to determine if equitable estoppel is a factor. If yes, apply the following guidelines to determine if the case is appropriate for use of the stipulation and agreed order.

Guidelines for Establishment of Equitable Estoppel:

Element #1:

An admission, statement, or act by the department, which is inconsistent with a later claim. The department makes a statement, takes an action, or fails to act and later finds that they were incorrect. The client is informed after the fact that the error was made.

Factors which may be used as evidence of element #1:

  1. The department had all the information available to correctly determine eligibility
  2. The client received the benefits
  3. The department has assessed an overpayment.

Element #2:

An action by the client on the faith of the department's admission, statement or act. The client must have taken some action that was reasonable given the circumstances; e.g. cashed the check and spent the money.

Factors which may be used as evidence of element #2:

  • The client's belief in the department's action was reasonable.

EXAMPLE:

 Client receives a letter informing him that his check will be $400. Client has reported income correctly and has no reason to suspect that the amount might be an error. 

The benefit is no longer available. Document the facts using the best verification obtainable, including the client's statements when necessary. 

Element #3:

An injury to the client arising from permitting the department to contradict or repudiate such admission, statement or act.The client experiences either a loss or a detrimental change in their position because the department reverses a decision regarding eligibility. Depending on the specific circumstances of the case, the imposition of a debt that could not be anticipated or avoided by the client may establish injury.

Factors which may be used as evidence of injury:

The client made financial decisions or plans based on a reasonable belief that the benefits they received were correct:

  1. Spent the money on items they would not have otherwise bought and which are not an available resource.

  2. Paid outstanding debts they would not otherwise have paid

  3. Failed to use an available family or community resource due to the receipt of the benefits. Food Banks, help from relatives, the Salvation Army.

    EXAMPLE:

    The client receives TANF medical benefits for several months before the department discovers the family is ineligible. The client acted in good faith and is without fault. The family used private medical providers during the period in question based on a reasonable belief that they were entitled to medical assistance. The family did not use the free medical clinic in their town that was available and could have met their medical needs. Injury can be established based on the failure to use an available community resource.
     

    When determining injury, the effects of non-cash benefits, such as training and childcare can and should be considered.

    The appellant and the department must be in agreement regarding the establishment of injury. If the appellant and the department cannot agree on the nature or extent of the injury, the case should go to hearing.

Element #4:

Equitable estoppel is necessary to prevent a manifest injustice.The overpayment is clearly unfair to the client based on the way that it occurred and repayment would compromise the client's ability to meet basic needs.

Factors which can be used as evidence of element #4:

  1. The client cannot repay the overpayment without drawing on funds needed for basic requirements. Document income and expenditures. Verify only questionable amounts.

  2. It is clear that the client acted in good faith by following the rules required to maintain eligibility for public assistance.

    a) The client reported income timely and accurately

          b) The overpayment was solely due to department error; and

          c) The client has "clean hands". That is, without fault. The client fulfilled all their responsibility to inform the department of changes in their circumstances.

Element #5: 

Applying equitable estoppel will not impair the exercise of governmental powers. Element #5 will be considered to be met unless there is an extraordinary circumstance. This element must be considered on a case by case basis. The cumulative effect of equitable estoppel applied to many cases is not permitted. 

Administrative Hearing Coordinator (AHC) Procedures:

When the appellant and the department (AHC and their supervisor) agree that equitable estoppel should be applied, the AHC:

  1. Completes and signs The Agreed Order and Stipulation, DSHS-EE ORDER 1/98 (currently available from CSD headquarters) and,
  2. Contacts the appellant to review and sign the stipulation, and
  3. Submits the stipulation to the ALJ for review and signature at least 3 days prior to the administrative hearing.

Although it is best to obtain agreement for the stipulation before the administrative hearing, it is not always be possible. The order can be done either in pre-hearing meeting with the appellant (and representative) on the day of the administrative hearing or on the record with the ALJ presiding. It still saves time required for administrative hearing and written decision.

When the signed order is received from the ALJ, the AHC must forward a copy to the Office of Financial Recovery (OFR).

 

Hearing Requests

Revised November 13, 2015

DSHS Hearing Rules are found in chapter 388-02 WAC


Clarifying Information:

  1. Either the client or their representative may request an administrative hearing.  The request must be made within in 90 days of the date of the notice of the department decision.
  2. The Administrative Law Judge (ALJ) is responsible for determining whether hearing requests are filed timely.
  3. Hearing requests must be forwarded to the Office of Administrative Hearings (OAH) for scheduling regardless of the date of the hearing request. See RCW 74.08.080
  4. The hearing request does not need to be in any particular form and can be made verbally or in writing to the department or in writing to OAH.   Note: Provider hearing requests must be made in writing and submitted to the Office of Financial Recovery (OFR).
  5. The hearing request can be made to any department employee.
  6. The hearing request should include the department decision being appealed, the date the client was notified of the department decision, and why the client is dissatisfied with the department decision.
  7. Any communication with the department indicating dissatisfaction with a department decision should be treated as a hearing request.
  8. Hearing requests can be sent to the OAH by DSHS staff through interoffice mail to MS 42489. 
  9.  Hearing requests can be mailed directly by the client/representative to OAH at PO Box 42489, Olympia, WA 98504-2489.

Financial Service Specialist (FSS)/Case Manager Responsibilities:

  1. Respond to the client and document in the ACES narrative when a client contacts the department regarding an adverse department decision.
  2. Explain the reasons for the department decision.
  3. Describe what rules apply to the department decision.
  4. Try to resolve the issue(s) with the client, but, if unable to resolve the issue(s) offer the client a supervisor conference, if appropriate.
  5. Inform the client of their right to an administrative hearing.
  6. Give or mail the client the pamphlet, How to Request a Hearing, DSHS 22-092(X) and a Request for Hearing, DSHS 5-013(X).
  7. Offer to complete an electronic Fair Hearing Request form through BarCode for the customer or provide the paper Request for Hearing form DSHS 5-013(X), if the the client prefers. Document the client's decision in ACES. 
  8. Forward the paper hearing request via Hotmail to the Document Management System (DMS).

Administrative Hearing Coordinator (AHC) Responsibilities:

  1. Maintain record of all hearing requests until scheduled.
  2. Contact client to clarify the hearing request, if necessary.
  3. Forward all hearing requests to the OAH for scheduling. 
    • If the client is Equal Access, include a copy of Accommodation plan with the hearing request.
    • If the client is Limited English Proficiency, include primary language information with the hearing request.
  4.  Document the receipt of a hearing request in ACES narrative.
  5. Follow up with the OAH if the hearing date is not received from OAH within 10 days.
 

Pre-Hearing Conference With An Administrative Law Judge

Created on: 
Sep 16 2015

Purpose:

A Pre-Hearing Conference is a formal proceeding conducted on the record by an Administrative Law Judge (ALJ) to prepare for an administrative hearing.

Clarifying Information: 

1.      The pre-hearing conference (PHC) may be required by an ALJ or requested by any party.  It is an essential step in the administrative hearing process.  See WAC 388-02-0200 – What Happens During a Pre-Hearing Conference.

2.      Attendance at the pre-hearing conference is mandatory for the parties.  If clients do not attend the pre-hearing conference, the ALJ may dismiss the hearing request or enter a default order against the client.

3.      An ALJ may conduct the pre-hearing conference in person, by telephone conference call, or in any other manner acceptable to the parties.

Note:  Mandatory Pre-Hearing Conferences do not apply to Basic Food cases.  See 7 CFR 273.15(d).  

Administrative Hearings Coordinator Responsibilities:

Notify all staff who are scheduled to participate in the pre-hearing conference of the date and time of the PHC.

Administrative Hearings Coordinator Procedures:

When participating in a pre-hearing conference: 

1.    Explain the facts on which the decision is based.

2.    Discuss the rules, which the department relied on when making the decision the client is appealing. Make copies of the cited rules available on request.

3.   Review the evidence that the department relied on and how it relates to the client's situation. 

 

Post Pre-Hearing Conference:

The Administrative Law Judge enters a written pre-hearing conference order describes actions taken, changes to documents, any agreements reached, and any ruling of ALJ.  The pre-hearing order determines if and how the administrative hearing is conducted, whether it will be in person, by telephone conference, or other means.

 

 

Pre-Hearing Meeting With the DSHS Representative

Created on: 
Sep 16 2015

Revised October 29, 2015

Pre-Hearing Meeting With the DSHS Representative

Purpose: 

The Pre-Hearing Meeting is an informal, voluntary meeting conducted by the DSHS Representative and the Client and/or Representative prior to an Administrative Hearing to attempt to resolve the issues at the lowest possible level. 

See WAC 388-02-0175 - What is a Pre-Hearing Meeting? 

Clarifying Information: 

1.    The pre-hearing  meeting (PHM) ensures that hearings are held only in cases that cannot be resolved under current policy.
2.    The (PHM) is not designed to take the place of an administrative hearing. It is an opportunity for the client and/or their representative and the  Administrative Hearing Coordinator (AHC) to clarify the issue for hearing, correct errors and make agreements.
3.    The  PHM is not mandatory and does not need to be lengthy or formal. 
4.    The PHC can be held by telephone or in person. 
5.    The client has a right to decline a PHM.

Administrative Hearings Coordinator Responsibilities: 

1.    Attempt telephone contact immediately with the client for a  PHM as soon as possible after receiving the request for an administrative hearing; or  
2.    Use the DSHS 02-527(x) Pre-hearing Meeting Letter, ACES letter FHC2 Pre-hearing Meeting Notification or local CSO letter to schedule pre-hearing meeting when the telephone attempt is unsuccessful.
3.    Arrange for interpreter services or other accommodation as required. 
4.    Document on the ACES narrative when a client declines a PHM.

 

Administrative Hearings Coordinator Procedures: 

The AHC should be prepared to meet at least once, either in person or by telephone, with the client and/or the representative before the administrative hearing. Additional contacts should be scheduled as needed.
1.    When conducting a pre-hearing meeting: 

       a.    Attempt to identify and define the issues.
       b.    Explain the facts on which the decision is based.
       c.    Discuss the result the client expects from the administrative hearing.
       d.    Explain the client's right to representation and the local contact for free legal services.
       e.    Discuss the rules, which the department relied on when making the decision the client is appealing. Make copies of the cited rules available on    request.
       f.    Review the evidence that the department relied on and how it relates to the client's situation.
       g.    Attempt to resolve areas of factual dispute by reviewing the case record, ACES record or other documentation.
       h.    Allow the client an opportunity to provide additional information and/or documents that were not considered in the original decision.
       i.    Correct any CSO errors that are identified.
       j.    Coordinate with Regional staff for clarification of regulations, policies or procedures as needed.
       k.    Review alternative methods for helping the client, including community resources and the possibility of an Exception to Rule.
       l.    Review the hearing procedures, including testimony, swearing of witnesses and presentation of evidence.
       m.    Answer any general questions the client has regarding the hearing process.
       n.    Submit new or additional evidence provided by the appellant to the original decision maker or their supervisor for an amended decision, if appropriate. (See WAC 388-406-0060 (3) for application denials.)

2.    If a resolution is reached and the client wishes to withdraw the hearing request: 
       a.    Have the client complete a DSHS 02-528(X) Withdrawal of  Administrative Hearing which specifies the reason for the withdrawal and any agreements made by the  AHC or other CSO staff which resulted in the withdrawal:
       b.    For verbal withdrawals: 
              1)    Have the client complete a DSHS 02-528(X) as in (a) above or send the form to the client with instructions to complete as in (a) above.

              2)    Notify the Office of Administrative Hearings (OAH) immediately if the written withdrawal will not be received by OAH before the hearing is scheduled.

3.    Forward the original copy of the withdrawal to the OAH. Give one copy to the client and put one copy in the CSO hearing file.

Preparation

Revised October 28, 2015

DSHS Hearing Rules are found in chapter 388-02 WAC.

Clarifying Information:

Effective preparation for an administrative hearing includes a complete review of the department record. Documents are identified for their potential use as exhibits at the administrative hearing. Witnesses should be interviewed and prepared for their testimony. Errors in the record should be corrected. Client notices that are incomplete or do not meet advance or adequate requirements must be corrected and reissued before the administrative hearing.

The administrative hearing preparation is the responsibility of the Administrative Hearing Coordinator (AHC).

The Administrative Hearing report and proposed exhibits (Administrative Hearing Packet) should be made available to the client and their representative as soon as possible before the administrative hearing. The client may have seen the documents. However, the documents will be in a different format and may not look familiar to the client.

If an interpreter is involved, the Administrative Hearing Packet should be given to the interpreter in advance of the administrative hearing, if possible.

Evidence:

  1. Evidence can be in the form of documents or testimony.
  2. Documentary evidence can come from different sources. Documents which can be used as evidence in an administrative hearing include, but are not limited to:

a) Letters/notes provided by the client or others.

b) Applications, MSR, or other forms signed by the client.

c) Medical reports, employer statements, collateral statements or other documents provided by a third party and used by the department in the eligibility decision.

d) Financial computations, ACES screen prints including CAFI, MAFI and FSFI, Progressive Evaluation Process worksheets

e) Notices or letters sent by the department to the client either through ACES or manual notes.

f) Verification documents provided by the client (landlord statement, wage stubs).

     3. Testimony is provided by witnesses who have direct knowledge of facts related to the issue for hearing. It is appropriate to use a witness when the witness can testify:

a) That a document is authentic because the witness either prepared the document or observed the preparation;

b) About the source of a document because the witness either received the document or observed its receipt;

c) About his or her own actions;

d) About the actions of others; or

e) About statements made by the appellant to the witness.

Presenting the Case

Revised October 28, 2015

Clarifying Information:

  1. See WAC 388-02-0215  through WAC 388-02-0245 for the responsibilities of the Administrative Law Judge.
  2. The case is presented to the ALJ and generally consists of the following sections:

          a) Opening statement

          b) Presentation of the evidence

          c) Closing statement

    3. The ALJ's decision can only consider documents that have been formally entered into the record of the hearing.

    4. Either the client or the department may object to the admission of any document into the record. The ALJ will usually rule immediately regarding an objection.

   5. An objection should be raised if a document:

      a) Has been altered, or

      b) Is not what it is purported to be, or

      c) Is not relevant to the issue for hearing e.g. a medical report, which is not current.

Administrative Hearing Coordinator (AHC) Responsibilities: 

  1. Prepare the opening statement:

         a) Identify the action or department decision being contested;

         b) Explain the circumstances which led to the action or  department decision;

         c) Cite the specific regulation or statute which was applied in the department decision; and

        d) Explain how the documents and the witnesses if any will provide evidence to support the departments' position.

    2. Present the evidence:

       a) Introduce documentary evidence; explain how it relates to the facts of the case.

       b) Introduce and question witnesses. Ask questions that allow the witness to explain what he or she knows about the case.

      c) Present material in an orderly, logical manner. Consider if it is best to present the case in chronological sequence.

     d) Explain how the department came to know the facts of the case.

     e) Explain the reasons for the department decision and the regulations and/or statutes which support the decision.

     f) Show the steps taken to comply with regulations and notice requirements.

    g) Explain the actions taken by the department after the administrative hearing was requested, including whether or not a pre-hearing meeting was held. If a pre-hearing meeting was not held, be prepared to tell and document to the ALJ the number times the department attempted to contact the client before the administrative hearing.

     3. Closing statement:

        a) Briefly summarize the department's view of the case and review the regulations/statutes which support the department actions

      b) Explain why the ALJ should rule in favor of the department.

Note: If new information is raised by the client during the administrative hearing, it is appropriate for the AHC to respond to the new information. In addition, the AHC may ask that the department be allowed additional time to respond to the new evidence if it is extensive or it raises issues which were not presented in the original client hearing request.

Special Procedures on Non-Grant Medical Assistance and Health Care Authority hearings

Revised October 28, 2015

Clarifying Information:

Effective July 1, 2011, the Health Care Authority (HCA) became the single state Medicaid agency responsible for all medical assistance programs (Title XIX of the federal Social Security Act), State Children’s Health Insurance (S-CHIP) program (Title XXI of the federal Social Security Act), and Medical Care Services (MCS) programs. These programs are collectively known as the “Medical Services Programs.” Through an interagency agreement between HCA and DSHS, DSHS continues to provide all the services it previously provided in managing these cases. However, the legal jurisdiction for the Medical Services Programs moved from RCW 74.08.080 to RCW 74.09.741.  The AHC who previously represented the Department in these cases now represents the Health Care Authority as the HCA Hearing Representative. The Office of Administrative Hearings schedules these hearings as an HCA Hearing and will send a notice of the hearing to the DSHS AHC. If you have questions, please call the HCA Appeals Administrator at (360) 725-1254.

There are some hearings that are scheduled on the CSO docket but involve decisions made by other divisions, agencies or administrations, including:

  • Non Grant Medical Assistance decisions made by Division of Disability Determination Services (DDDS).
  • Medical Assistance decisions made by the Health Care Authority regarding:
  1. Creation of a single state Medicaid agency:

    a) Medical equipment and services, or

         b) Managed care eligibility or services, or

         c) Restricted use of medical care, or

        d) Coordination of Benefits or Third Party Liability issues.

In some cases, someone may represent the department from the agency or office that made the decision (e.g. issue related to denial of a medical service or choice of a managed care plan).

In some cases, the AHC will act as the agency representative, and the other office or agency will provide a witness to testify regarding the decision.

2. Transfer of administrative hearing rules for medical services programs from WAC 388-02 to WAC 182-526:

HCA now has its own hearing rules separate from DSHS hearing rules. Any hearing involving a medical services program will fall under the hearing rules listed in WAC 182-526. These rules are effective February 1, 2013. This means any hearing held on or after that date is subject to the rules listed in WAC 182-526.

Other important changes to the WACs include the following:

  • Definition updates for Limited English Proficiency clients and interpreters (WAC 182-526-0010, 182-526-0120 through 182-526-0150);
  • Clarification of the terms send (182-526-0040), serve (182-526-0045) and file (182-526-0070) in relation to documents for a hearing;
  • Pre-hearing conferences must still be granted if requested at least 7 business days before the scheduled hearing. The rule changed so the pre-hearing conference order must be served at least fourteen calendar days before the hearing, which may prevent OAH from having the pre-hearing conference on the same day as the hearing, unless parties voluntarily waive the timeliness requirements.

Administrative Hearing Coordinator Responsibilities:

There are several offices within the Health Care Authority (HCA) that make decisions that are subject to administrative hearings. It is important to contact the appropriate office as soon as a notice of hearing is received to coordinate representation

A. Medical assistance hearings:

  1. For hearings involving medical services, equipment, transportation, managed care enrollment, and Patient Review and Coordination (PRC) program, contact the HCA’s Office of Hearings and Appeals at: MS 45504, 360-725-1254 or 1-800-351-6827.
  2. The HCA staff may act as the agency’s representative for these cases, coordinate testimony of medical consultants, help you obtain additional medical information, and arrange medical examinations, if necessary.
  3. The HCA Appeals Administrator will coordinate review and implementation of hearing decisions as required by HCA.
  4. The DSHS AHC acts as liaison between HCA’s staff and the Appellant and their representative if required. For example, if the Appellant requests an in-person hearing and it is scheduled at the local CSO, the DSHS AHC may assist the ALJ and the Appellant during the hearing because HCA staff participates in the hearing telephonically from Olympia, WA.
  5. For insurance issues, contact HCA’s Revenue, Recovery and Premium Payment Section or HCA’s Coordination of Benefits (COB) Section, as appropriate:
    • COB Health Units: 1-800-562-3022 ext # 16134
    • COB Casualty Unit: 1-800-562-3022 ext # 15462
    • RRPS Premium Payment: 1-800-562-3022 ext # 15473
  6. For eligibility and policy issues, when clarification is required, contact the regional eligibility representative in the Office of Medicaid, Medicare, Eligibility & Policy (OMMEP), Eligibility Policy and Service Delivery (EPSD) - MS 45534.
  7. For hearings involving SCHIP (F07), Take Charge (P06), BCCTP (S30) or other cases assigned to CSO 76 contact Susie Bahr 360-725-1724  MS 45531
  8. For hearings involving a cash AND medical program, such as TANF or ABD, the AHC will need to cite the correct hearing rules when necessary, which may mean citing both the HCA hearing rules and the DSHS hearing rules. The administrative law judge will also need to use the correct rules when entering and serving an order. All ALJ decisions on HCA cases must be "initial orders", not "final orders."

B. Non-grant medical assistance (NGMA) hearings: 

The AHC acts as the agency representative, and a DDDS employee provides testimony to support the decision. Clients have up to 90 days to request a hearing on a NGMA decision. As soon as the hearing request is received:

  1. If the original denial is affirmed in the DDDS review process, consult with the DDDS hearing supervisor who will assign someone to testify in support of the denial.
  2. Notify the appellant if the original DDDS decision is reversed in the DDDS review process.
  3. Coordinate requested continuances from either the appellant or DDDS with the local OAH office. Continuances are often necessary in these cases to obtain additional medical information. It is important that the AHC keep all parties informed of the status of the case prior to the hearing.
  4. Notify DDDS of the scheduled date and time of the hearing.
  5. Forward the DSHS 14-144 and the DDDS original decision packet in hard copy to the appropriate DDDS office. Attach any new medical documentation and release of information authorizations, if appropriate.  (Do not use the automated BarCode referral process for administrative hearing reviews.)
  6. Initiate reconsideration of the original decision by completing in hard copy a DSHS 14-144, Transmittal Summary, and check the box for the Administrative Hearing Review. The reconsideration is a required step in the DDDS process prior to hearing. Request continuances as appropriate to allow sufficient time for the reconsideration.

NOTE: A hearing request is not always needed for the Department to review a NGMA decision.  Clients may ask for a review within 30 days of the initial denial if medical evidence exists that was not used to make the original decision.  Please follow the above steps and note on the referral that it is a reconsideration of denial.

DDDS Hearings Contact:

Pauline Douglas
Hearings Manager
(360) 664-7416

MS 45550

The Decision

Revised October 28, 2015

DSHS Hearing Rules are found in chapter 388-02 WAC.

Clarifying Information:

Once a hearing request has been scheduled, a decision must be issued by the ALJ. 

Administrative Hearing Coordinator (AHC) Responsibilities: 

When a hearing decision is received by the department:

  1. Document the AHCS with the docket number, the type of decision, and the date of mailing.

  2. Include any other information necessary for a complete record.

  3. Summarize the hearing decision in the ACES narrative.

1. Order of dismissal: Issued when an appellant withdraws the hearing request or does not appear at the scheduled time for the administrative hearing.  An appellant can request that an Order of Dismissal be vacated or canceled. If the Order of Dismissal is vacated, the administrative hearing will be reinstated. Document the circumstances that led to the dismissal so that the department can respond in those cases.

a.  Default/no show: If the administrative hearing notice was correctly addressed and the appellant failed to appear, document the AHCS and ACES narrative and file the hearing decision with any related documents in the case record.  

If the notice of hearing was not correctly addressed or there is some other reason that the notice of hearing was not properly delivered, contact the Office of Administrative Hearings (OAH) and provide them with the correct address or other information needed to deliver the notice of hearing.

b.  Withdrawal: Document the AHCS, ACES narrative and file the hearing decision, with the request for withdrawal and any other related documents attached in the case record.

​2.  Initial decision: The initial decision is issued by the Administrative Law Judge (ALJ) who presided at the administrative hearing. The initial hearing decision becomes the final hearing decision if it is not appealed by either party within 21 days of the date that it is mailed.

The ALJ who conducted the administrative hearing is responsible for writing the initial hearing decision and mailing a copy to all parties. It is appropriate to follow up with the ALJ if the decision is delayed. No details of the case can be discussed before the hearing decision is issued.

The Health Care Authority (HCA) is responsible for administrative hearings involving medical equipment or medical services. Refer questions about these hearing decisions to the HCA Appeals Manager, MS 45503. (See Special Procedures in this category.)

HCA shall not implement hearing decisions concerning medical procedures, medical equipment, or dental services until a final order is issued. The HCA Appeals Manager will coordinate these cases

3.  Reversed decisions: When the department decision is reversed, immediately:

a. Authorize benefits for an applicant effective with the date of eligibility determined in the hearing decision.

b. Reinstate benefits for a recipient at the level paid prior to the hearing request, if the benefits are not already being continued, or at the level determined correct by the initial hearing decision.

c. Adjust overpayments or take any other action addressed in the initial hearing decision.

4.   Stay: When the department disagrees with the initial hearing decision, request a stay of the action per the initial hearing decision.

5.  Affirmed decisions:  When the department decision is affirmed, immediately:

a. Terminate the continued benefits. Adequate notice must be provided to the appellant. Advance notice is not required.

b. Review the period of continued benefits, and establish an overpayment, as appropriate.

c. Distribute the hearing decision to other offices or divisions (OFR, WorkFirst Division, etc.), as appropriate.

6.  Petition for review of initial decision: The AHC is responsible for filing a petition to review in cases involving public assistance cash and eligibility for medical assistance.

The Health Care Authority (HCA) is responsible for filing petitions for review in cases involving medical equipment, medical services, or MAGI medical cases. The HCA Appeals Manager at: MS 45503 coordinates the cases.

6.  AHC petitions for review to the DSHS Board of Appeals (BOA):

     a.  After implementing the initial hearing decision, determine if a review is appropriate:

  1. Consult with CSO supervisors or administrator, as appropriate
  2. Consult with regional trainers or program staff, if necessary
  3. See chapter 388-02 WAC, which gives a full explanation of the BOA review judge's authority.

     b.  If the department decides to petition the BOA fir a review of the initial hearing decision, prepare a memorandum for the BOA Board of Appeals, MS  45803 which includes:

  1. Appellant's name and docket number,
  2. All areas in which the department believes the ALJ erred. See chapter 388-02 WAC for the review standard. The review judge usually only addresses areas that have been raised in the petition for review. Refer to findings of fact and conclusions of law by the number assigned in the hearing decision.
  3. Cite WAC's, findings of fact or evidence in the record that support the department argument.
  4. New evidence which affects the hearing decision, and could not have been provided by the AHC at the hearing with reasonable diligence.
  5. A request asking the review judge to find in the department's favor.
  6. Refer to chapter 388-02 WAC for complete instructions regarding distribution and time frames for a petition for reconsideration.

7.  Appellant petition for review:

a. Do not reinstate continued benefits pending a review of the initial hearing decision requested by the appellant.

b. Review the appellant's petition to determine if a response is appropriate. A response may not be required if the appellant raises issues which are irrelevant or which are outside the authority of the ALJ, e.g., issues relating to the behavior of department workers.

c. If a response is required, prepare a memorandum to the Board of Appeals, MS 45803, which includes:

  1. The appellant's name and the docket number,
  2. A response which speaks only to the issues raised by the appellant,
  3. Argument(s) which supports the finding in the initial hearing decision.

d. Refer to chapter 388-02 WAC  for complete instructions regarding distribution and time frames for a response to a petition for review.

8. Receipt of review decision from BOA:

a. Implement the BOA review decision immediately.

b. See chapter 388-02 WAC to determine if a request for reconsideration is appropriate.

c. If a request for reconsideration is appropriate, prepare a memorandum to the Board of Appeals, MS 45803 including the specific reason why the department does not agree with the BOA review decision.

9. Judicial Review: The appellant has the right to request judicial review of the final agency decision in superior court. Instructions regarding requesting judicial review are attached to the BOA review decision. If an appellant asks about  judicial review, they should be advised to seek legal counsel and referred to the local legal services office.