WSR 11-14-054

PERMANENT RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Medicaid Purchasing Administration)

[ Filed June 29, 2011, 12:22 p.m. , effective July 30, 2011 ]


Effective Date of Rule: Thirty-one days after filing.

Purpose: Inform providers and other stakeholders of the change(s) in federal law. These policy changes are final. The department has to implement them or risk loss of federal matching funds. Implementation requires the department to submit a state plan amendment (SPA) and make necessary changes to WAC.

Citation of Existing Rules Affected by this Order: Amending WAC 388-501-0180 and 388-501-0184.

Statutory Authority for Adoption: RCW 74.08.090.

Other Authority: RCW 74.04.057 and 74.09.510.

Adopted under notice filed as WSR 11-11-085 on May 18, 2011.

A final cost-benefit analysis is available by contacting Carolyn Adams, Special Assistant for Healthcare Reform Implementation, DSHS, Division of Rates and Finance, P.O. Box 45510, phone (360) 725-1854, e-mail Carolyn.Adams@dshs.wa.gov.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 2, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 2, Repealed 0.

Date Adopted: June 28, 2011.

Susan N. Dreyfus

Secretary

4300.1
AMENDATORY SECTION(Amending WSR 08-08-064, filed 3/31/08, effective 5/1/08)

WAC 388-501-0180   Healthcare services provided outside the state of Washington -- General provisions.   WAC 388-501-0180 through 388-501-0184 apply only to services payable on a fee-for-service basis for Washington state medical assistance clients.

(1) Subject to the exceptions and limitations in this section, WAC 388-501-0182 and 388-501-0184, the department covers emergency and nonemergency out-of-state healthcare services provided to eligible Washington state medical assistance clients when the services are:

(a) Within the scope of the client's healthcare program as specified under chapter 388-501 WAC;

(b) Allowed to be provided outside the state of Washington by specific program WAC; and

(c) Medically necessary as defined in WAC 388-500-0005.

(2) The department does not cover services provided outside the state of Washington under the Involuntary Treatment Act (chapter 71.05 RCW and chapter 388-865 WAC), including designated bordering cities.

(3) When the department pays for covered healthcare services furnished to an eligible Washington state medical assistance client outside the state of Washington, its payment is payment in full according to 42 CFR 447.15. ((The department does not pay when the provider refuses to accept the department's payment as payment in full.))

(4) The department determines coverage for transportation services provided out of state, including ambulance services, according to chapter 388-546 WAC.

(5) With the exception of designated bordering cities (see WAC 388-501-0175), if the client travels out of state expressly to obtain healthcare, the service(s) must be prior authorized by the department. See WAC 388-501-0182 for requirements related to out-of-state nonemergency treatment and WAC 388-501-0165 for the department's medical necessity determination process.

(6) The department does not cover healthcare services provided outside the United States and U.S. territories, with the exception of British Columbia, Canada. See WAC 388-501-0184 for limitations on coverage of, and payment for, healthcare provided to medical assistance clients in British Columbia, Canada.

(7) See WAC 388-502-0120 for provider requirements for payment of healthcare provided outside the state of Washington.

[Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 74.09.035. 08-08-064, 388-501-0180, filed 3/31/08, effective 5/1/08. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. 06-24-036, 388-501-0180, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090 and 74.09.035. 01-01-011, 388-501-0180, filed 12/6/00, effective 1/6/01. Statutory Authority: RCW 74.08.090. 94-10-065 (Order 3732), 388-501-0180, filed 5/3/94, effective 6/3/94. Formerly parts of WAC 388-82-135 and 388-92-015.]


AMENDATORY SECTION(Amending WSR 08-08-064, filed 3/31/08, effective 5/1/08)

WAC 388-501-0184   Healthcare services provided outside of the United States and U.S. territories or in a foreign country.   For the purposes of this section the term "healthcare services" does not include the diagnosis and treatment for alcohol and/or substance abuse and mental health services.

(1) The provisions of WAC 388-501-0182 apply to this section.

(2) The department does not pay for healthcare services furnished in a foreign country, except for medical services furnished in the province of British Columbia, Canada, under the conditions specified in this section. The department pays for medical services furnished in British Columbia, Canada to the following Washington state medical assistance clients only:

(a) Those who reside in Point Roberts, Washington;

(b) Those who reside in Washington communities along the border with British Columbia, Canada (see subsection (3) of this section for further clarification); and

(c) Members of the Canadian First Nations who live in Washington state.

(3) For those medical assistance clients identified in subsection (((1))) (2) of this section, the department covers emergency and nonemergency medical services provided in British Columbia, Canada, when the services are:

(a) Within the scope of the client's healthcare program as specified in chapter 388-501 WAC;

(b) Allowed to be provided outside the United States and U.S. territories by specific program WAC; and

(c) Medically necessary as defined in WAC 388-500-0005.

(4) For those medical assistance clients identified in subsection (((1))) (2) of this section, the department covers nonemergency medical services in British Columbia, Canada, only when:

(a) It is general practice for Washington state medical assistance clients residing in these particular localities to use medically necessary resources across the Canadian border; or

(b) The medical services in British Columbia, Canada are closer or more readily accessible to the client's Washington state residence. As applied to nonemergency medical services, the phrase "closer or more readily accessible to the client's Washington state residence" means:

(i) There is not a United States provider for the same service within twenty-five miles of the client's Washington state residence; and

(ii) The closest Canadian provider of service is closer than the closest U.S. provider of the service.

(5) The department does not cover services provided ((outside of the United States)) in British Columbia, Canada under the Involuntary Treatment Act (chapter 71.05 RCW and chapter 388-865 WAC).

(6) When the department pays for covered medical services furnished to a Washington state medical assistance client in British Columbia, Canada, its payment is payment in full according to 42 CFR 447.15. ((The department does not pay when the provider refuses to accept the department's payment as payment in full.))

(7) A British Columbia, Canada provider who furnished healthcare services and/or covered items to a medical assistance client will receive payment from the department only when:

(a) Such reimbursement is made to a financial institution or entity located within the United States in U.S. dollars; and

(b) The participating British Columbia, Canada provider:

(i) Has signed a core provider agreement with the department;

(ii) Satisfies all medicaid conditions of participation;

(iii) Meets functionally equivalent licensing requirements; and

(iv) Complies with the same utilization control standards as in-state providers.

[Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 74.09.035. 08-08-064, 388-501-0184, filed 3/31/08, effective 5/1/08.]

Washington State Code Reviser's Office