Appeal DSHS Care Hours Washington: ETR, Exception to Rule, and Administrative Hearings

Why Care Hours Fall Short

The DSHS CARE assessment places your parent into one of 17 classification sub-groups across five main groups (A through E), and each group has a fixed maximum number of monthly personal care hours. A Group A Low classification authorizes just 22 hours per month. A Group C Medium gets 115 hours. The gap between what the algorithm assigns and what your parent actually needs can be enormous.

The most common reasons for an inadequate allocation:

Under-reporting during the assessment. Many older adults minimize their difficulties during the CARE interview — they do not want to appear incapable, or they perform better in a structured interview setting than they do at home day-to-day. The assessor can only score what the client demonstrates and reports.

Cognitive and behavioral needs underweighted. The CARE tool measures ADL performance, cognitive performance, clinical complexity, and behavioral patterns. If a parent has significant cognitive decline but can still physically perform basic ADLs (dressing, eating) with prompting, they may score lower than their actual supervision needs warrant.

Changed circumstances since the last assessment. CARE assessments are reassessed annually or when a significant change in condition occurs. A parent who has declined substantially between assessments may be operating under an outdated allocation.

The Exception to Rule (ETR) Process

Before filing a formal appeal, start with an Exception to Rule (ETR) request under WAC 388-440-0001. This is an administrative mechanism that allows DSHS to authorize care hours above the standard allocation for your parent's classification group without requiring a hearing.

An ETR request goes through your parent's HCS case manager. The case manager submits the request to their supervisor and regional administrator, documenting why the standard allocation is insufficient. Supporting documentation should include:

• Physician statements describing care needs that exceed the classification group's hour allocation
• Caregiver logs showing time spent on ADL assistance, supervision for safety, and behavioral management
• Incident reports documenting falls, wandering episodes, medication errors, or emergency room visits that occurred because existing care hours were inadequate
• Therapy evaluations from physical, occupational, or speech therapists identifying functional deficits

The ETR process is handled through DSHS rather than an OAH hearing. DSHS will notify you in writing whether additional hours are approved or denied.

If the ETR is denied, you have not lost anything. You can still file a formal appeal to the Office of Administrative Hearings.

Filing an Administrative Hearing

Under WAC 388-106-1305, you have the right to contest the result of a CARE assessment. For a public-assistance case, WAC 388-02-0085 provides 90 days after receiving notice of an aggrieving decision to request a hearing with the Office of Administrative Hearings (OAH).

File the hearing request in writing. Include:

• Your parent's name and client ID
• The specific DSHS action you are appealing (the care hour allocation and the classification group assigned)
• The number of hours you believe should be authorized and why
• A brief description of your parent's care needs that the current allocation does not cover

If the appeal concerns a proposed reduction or termination and you request it within the deadline on the notice, you may be entitled to continued services while the hearing is pending. Confirm the continued-benefits rules in the notice.

Preparing for the Hearing

The Administrative Law Judge (ALJ) will review the CARE assessment scoring de novo, meaning they examine the evidence independently rather than deferring to the assessor's judgment. Bring:

A detailed ADL diary. For at least two weeks before the hearing, document every instance of ADL assistance: what task, how long it took, what level of help was needed (verbal prompting, hands-on, total assistance). Include nighttime needs — repositioning, toileting, behavioral episodes — which are frequently undercounted in the standard assessment.

Video documentation (with your parent's consent) showing the difference between their performance during a structured interview and their actual daily functioning. This is particularly powerful for cognitive and behavioral issues where a parent can appear more capable in a one-on-one setting than they are at home.

A physician's letter specifically addressing the CARE classification and explaining why the allocated hours are medically insufficient. Generic letters ("the patient needs more care") are less effective than letters that reference specific ADL deficits, the frequency of required interventions, and the safety risks of inadequate coverage.

Comparison data showing that your parent's needs are more consistent with a higher classification group. Reference the CARE group table: if your parent is scored Group B Medium (69 hours) but has behavioral patterns and ADL scores consistent with Group B High (129 hours), present the evidence that maps to the higher group's criteria.

What the ALJ Can Do

The ALJ can:

• Uphold the current allocation
• Order DSHS to rescore the CARE assessment based on the evidence presented
• Order DSHS to reclassify your parent into a higher care group
• Order additional hours through the ETR mechanism

If the ALJ rules in your favor, DSHS must implement the revised allocation. If the ruling goes against you, you can request a Board of Appeals review within 21 days.

Ongoing Monitoring

Care hours are not permanent. DSHS reassesses annually, and any change in your parent's condition — improvement or decline — can trigger a reassessment. After a successful appeal, continue documenting your parent's care needs so that the next reassessment accurately reflects their current situation.

If your parent's condition worsens significantly between scheduled reassessments, request an interim reassessment. Do not wait for the annual review — delays in adjusting care hours can lead to preventable hospitalizations that restart the entire discharge planning cycle.

For families navigating care hour allocations alongside hospital discharge planning, the Hospital-to-Home Washington guide includes a care assessment preparation workbook with ADL scoring guidance and a framework for documenting behavioral and cognitive needs in the terminology the CARE tool uses.

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