This category will provide an explanation of the following elements regarding Administrative Hearings.
Revised April 6, 2023
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.
Administrative Hearing Coordinators (AHCs) with the Community Services Division (CSD), Home and Community Services Division (HCS), and Developmental Disabilities Administration (DDA) manage hearing requests related to their programs. CSO Administrators (CSOAs) have the authority to resolve issues with clients prior to an administrative hearing.
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 aren’t appropriate for an administrative hearing.
Administrative Law Judges (ALJs), employed by the Office of Administrative Hearings (OAH), conduct Administrative hearings. OAH is a separate agency from DSHS. Administrative hearings are held in person or by teleconference call. 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 can’t request reconsideration on Basic Food decisions.
The client has the right to request judicial review of a final DSHS hearing decision.
Revised May 22, 2023
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
360-338-2721
Email: Danielle.LeMier@dshs.wa.gov
The AHC acts as the liaison, in cases involving Administrative Hearings, between the CSO and:
The AHC must maintain the appearance of fairness in the Administrative Hearing process. The following guidelines apply:
Exception: The department cannot request BOA reconsideration for Basic Food hearing decisions. See 7 CFR 273.15(q)(2).
Revised October 28, 2015
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.
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 an ACES letter general correspondence letter (0050-01). 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.
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.
Revised October 28, 2015
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:
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.
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:
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:
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:
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.
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:
Spent the money on items they would not have otherwise bought and which are not an available resource.
Paid outstanding debts they would not otherwise have paid
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.
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:
The client cannot repay the overpayment without drawing on funds needed for basic requirements. Document income and expenditures. Verify only questionable amounts.
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.
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.
When the appellant and the department (AHC and their supervisor) agree that equitable estoppel should be applied, the AHC:
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).
Revised May 22, 2023
A Pre-Hearing Conference is a formal proceeding conducted on the record by an Administrative Law Judge (ALJ) to prepare for an administrative hearing.
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).
Notify all staff who are scheduled to participate in the pre-hearing conference of the date and time of the PHC.
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.
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.
Revised October 29, 2015
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.
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.
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.
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.
Revised October 28, 2015
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.
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.
Revised October 28, 2015
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.
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.
Revised October 28, 2015
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:
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:
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:
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:
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.
Michael Magill
Disability Hearings Manager
(360) 664-7394
MS 45550
Revised October 28, 2015
Once a hearing request has been scheduled, a decision must be issued by the ALJ.
When a hearing decision is received by the department:
Document the AHCS with the docket number, the type of decision, and the date of mailing.
Include any other information necessary for a complete record.
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:
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:
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:
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.