C.

The lack of medical-only care will decrease or discontinue the earning power of the wage earner or potential wage earner or result in the need for public assistance;

The applicant cannot obtain necessary emergent medical-only care from any other source.

12. Except in an emergency all requests for medical-only care shall be approved by the screening physician prior to date service is rendered. When a person with an acute or emergent condition is admitted to a hospital or is given emergency care by a physician prior to the date of application and he is later determined eligible for medical-only care, the date of certification shall be the date the emergency occurred, provided the MCFO is notified within 24 hours, or not later than the next working day if the emergency occurs when the office of the MCFO is closed. In such instances the Department shall assume responsibility for the costs of the care as of the date of certification, provided the screening physician approves the services.

When a person in a coma or unable to provide necessary information because of his medical condition is admitted to the hospital and no information is available regarding the patient, the date of application shall be the date the patient becomes rational, but certification shall be retroactive to date of emergency.

If the attending physician or hospital does not report the service provided to a medical-only applicant, otherwise financially eligible within the specified time, the Department shall pay only from the date of application.

The Department shall not be responsible for payment when a person with an acute or emergent condition is admitted by a hospital on the assumption that he can pay for his emergency care and is discharged from the hospital without paying for his care.

The Department shall not be responsible for payment when a person admitted by a hospital for an acute or emergent medical condition is later found to be a poor financial risk by the hospital.

If a relative, or responsible person, or the patient admitted to a hospital signifies his intention to pay for the cost of care by contract arrangement, the MCW shall consider this fact in determining financial eligibility.

13. Eligibility for medical-only care shall be for ONLY one ailment or one condition. Each MO shall be certified individually and for a specified time. Certification of the head of the family unit does not constitute certification of other dependent members of the family.

14. Financial eligibility of persons currently receiving medical-only care shall be reviewed monthly and recertified for continuing care. Recertification shall include a review of the financial resources of the patient and a review of the health condition by the attending physician.

III.

15. When a resident of another state, and specifically a resident of a state bordering Washington, while temporarily visiting or temporarily residing in Washington, suffers an accidental injury, or requires medical care and/or hospitalization for an emergent and acute condition within the boundaries of the State of Washington, eligibility shall be determined according to the criteria in Part II of these Rules except as provided:

The benefits of the MO program shall not be available to
residents of other states who enter Washington for the
purpose of obtaining care under the Washington MO program.

b. The benefits of the Washington MO program shall also not apply
to residents of other states whose accidental injuries or
emergent and acute conditions are manifest concurrently with
entrance to the State.

MEDICAL ONLY CARE FOR PRISONERS (Revised October 1, 1960)

Medical-only care shall be furnished by the Department for an inmate of a city or county jail who: (1) is a MO, and (2) requires hospital treatment of an acute or emergent medical condition in the opinion of the screening physician, and (3) is placed in a participating hospital by the confining authority.

IV. OTHER RULES APPLICABLE (Effective April 1, 1959)

V.

The Rules of the Department filed with the Secretary of State pursuant to Section 74.08.090 RCW not inconsistent with the foregoing Rules or Chapter 74.09 RCW shall also have full force and effect to the extent applicable to State Medical Care Program.

COMPLAINTS, FAIR HEARINGS AND APPEALS

A. REQUEST FOR A FAIR HEARING

(Effective April 1, 1959)

1. Any applicant for or recipient of medical care granted under the provisions of Chap. 74.09 RCW who feels aggrieved by the decision of the screening physician refusing him medical, dental, or related services, or the denial of such services by administrative decision of the MCW, or by other administrative decision of the Division of Medical Care, has a right to a fair hearing which shall be conducted by the duly appointed hearing examiner for the State Department of Public Assistance.

2. Any such applicant or recipient may file a notice of appeal for a
fair hearing within sixty (60) days from the date of oral or written
notification of the denial of medical, dental, or related services,
or within sixty (60) days after the last treatment by a participat-
ing physician. A fair hearing request which is filed more than
sixty (60) days after receiving notification of the decision appealed
may be dismissed by the supervising examiner on the grounds that it
is untimely.

3. The notice of appeal must be in writing and should show the approximate
date of said alleged refusal of medical, dental or related services
and the reasons for believing that said refusal was incorrect. The
written appeal should include the address of the applicant or recipient

76123 0-61—pt. 2– -30

4.

and must be dated and signed by the claimant, or his legal guardian.
If husband or wife are claimants, one spouse may sign on behalf of
the other. The request for a fair hearing shall be filed with any
local MCFO or with any MCW within the county where the complaint
originates, or with the Division of Medical Care, State Office.
Any MCFO or MCW receiving a request for a fair hearing shall in-
mediately forward such request to the supervising examiner of the
State Department of Public Assistance.

Any applicant or recipient may withdraw his request for a fair hearing at any time prior to the decision thereon. Such withdrawal shall be made in writing, in which case the previous determination or decision rendered shall be final. The supervising examiner of the State Department of Public Assistance shall be immediately furnished with a copy of the withdrawal notice.

B. PROCEDURE PRIOR TO HEARING (Effective April 1, 1959)

1.

2.

All pre-hearing review is the responsibility of the Division of
Medical Care.

The Medical Services Administrator (Legal) shall review all fair hearing requests of the appellant to determine:

a.

Whether or not appellant has filed request in accord with Rules and Regulations of the State Department of Public Assistance.

b. Whether or not decisions of the screening physician, screening dentist or MCW have been made upon complete and accurate evaluation of the appellant's medical or financial situation in relation to existing standards, regulations and policies.

3. All records and information necessary to determine the validity of the appellant's complaint, fair hearing request or appeal shall be furnished by the MCFO. All such required data or information requested by the Medical Services Administrator (Legal) must be forwarded to the State Office of the Department of Public Assistance not later than 10 days of such request.

4. Upon receipt of the necessary material, evidence or reports the reviewing Medical Services Administrator shall evaluate the appellant's request in accord with existing rules, regulations and policies of the Department of Public Assistance.

8. May reverse the decision of the screening physician or dentist, or MCW when such adverse decision has been made contrary to rules and regulations and policies of the Division of Medical Care.

b. May resolve a situation resulting in the fair hearing request by compromise.

C.

When a situation cannot be resolved under paragraphs "a" and
"b" immediately preceding, the Medical Services Administrator

VI.

d.

will forward all records of the case to the office of the fair hearing examiner.

Included in this report shall be the names of all witnesses including the attending physician who shall be subject to call for attendance at a fair hearing procedure. Failure to attend the hearing without reasonable excuse shall constitute grounds for dismissal of a witness vendor from participating in the Medical Care Program.

When the Medical Services Administrator of the State Office of the Division of Medical Care transmits all pertinent review records to the fair hearing examiner, a fair hearing will be processed in accord with State Department of Public Assistance Regulations: Provided that, references to the County Office responsibilities contained in Regulations, shall be deemed responsibilities of the Division of Medical Care for the purpose of conducting fair hearing appeals from decisions of the Division of Medical Care.

PAYMENT FOR SERVICES RENDERED OR GOODS FURNISHED

a. LEGAL BASIS (Revised effective April 1, 1959)

B.

In accordance with Chapter 26, Laws of 1959, (Section 74.09.160 RCW)
the Department establishes a medical prepayment revolving fund (here-
after referred to as the "Pooled Fund") for the payment of obligations
incurred under the Medical Care Program.

The purpose of the Pooled Fund shall be (1) to pay for medical care and
allied services furnished to recipients of public assistance enumerated
in Paragraph "C" below, and (2) to secure such Federal matching funds
for medical care costs as may be available to the State under Federal
Law and the regulations of the U.S. Department of Health, Education, and
Welfare.

PAYMENT TO POOLED FUND (Revised effective April 1, 1959)

Payment shall be made into the Pooled Fund at a monthly rate of "premium"
as determined from time to time according to the Department's medical
care cost experience based on the number of persons assisted in the various
categories of public assistance.

C.

PERSONS COVERED BY POOLED FUND

(Revised effective October 1, 1960)

The Medical Pooled Fund covers all persons authorized to receive assistance (including those in suspended status) in the following programs:

D. PAYMENT FROM THE POOLED FUND (Revised effective April 1, 1959)

E.

All services or goods authorized and approved by the Division of Medical Care for and received by persons in the above categories may be paid from the Pooled Fund.

The monthly premium or payment to the fund shall be a monthly public assistance expenditure and recorded as assistance provided in behalf of the recipient.

Payment from the Pooled Fund shall be made for only medical and allied services rendered to the person in the month for which a payment was paid in his behalf into the fund. Payment to the vendor of the goods or services may be made subsequent to the month for which the premium was paid in behalf of the recipient.

Where payments are made from the Pooled Fund for the costs of medical care for persons not covered by a premium payment into the fund for the month in which the service was rendered, the Pooled Fund shall be reimbursed for the amount so paid out.

RESTITUTION (Revised effective October 1, 1960)

The

1. If a recipient of CA or NCA is found to have been ineligible for assistance received, the Public Assistance caseworker will request the MCFO to determine the recipient's eligibility for MO care. MCFO shall make a determination of the eligibility of the person and notify the CO. If the person was ineligible for medical care as a MO the MCFO shall report to the CO all vendor payments for medical care for the person during the period of over-payment.

2. If a person receives MD or MAA care for which he is not eligible or comes into possession of resources which he fails to disclose to the MCFO or conceals resources, such as cash on hand, bank accounts, saving accounts or any kind of resource, the total amount of such medical care payment made by the Department on his behalf shall be a debt due the Department.

3. If it is determined that a recipient of MAA has received medical care for which he was ineligible, the facts and circumstances upon which the determination of ineligibility was based shall be forwarded to the Division of Medical Care for further review and action. If the State Office Division of Medical Care concurs with the determination, the individual shall be so advised and repayment demanded. The due and owing amount will be the actual amounts paid by this Department to medical vendors on the recipient's behalf. If repayment is not obtained, the case and the files relative thereto shall be forwarded to the Attorney General for such further action as deemed necessary. In no event shall a lien be filed while the ineligible recipient of MAA or his dependent spouse is still living unless the claim has been reduced to judgment in a Superior Court of the State of Washington.

4. Any person who by means of a wilfully false statement or representation, or by impersonation, or other fraudulent device, or failure to reveal resources as required, obtains or attempts to obtain or aids cr abets any person to obtain medical care to which he is not

entitled shall be guilty of larcency.