WSR 12-18-037

PROPOSED RULES

HEALTH CARE AUTHORITY


(Medicaid Program)

[ Filed August 29, 2012, 9:54 a.m. ]

Original Notice.

Preproposal statement of inquiry was filed as WSR 12-14-029.

Title of Rule and Other Identifying Information: WAC 182-534-0100 EPSDT.

Hearing Location(s): Health Care Authority (HCA), Cherry Street Plaza Building, Sue Crystal Conference Room 106A, 626 8th Avenue, Olympia, WA 98504 (metered public parking is available street side around building. A map is available at http://maa.dshs.wa.gov/pdf/CherryStreetDirectionsNMap.pdf or directions can be obtained by calling (360) 725-1000), on October 9, 2012, at 10:00 a.m.

Date of Intended Adoption: Not sooner than October 10, 2012.

Submit Written Comments to: HCA Rules Coordinator, P.O. Box 45504, Olympia, WA 98504-5504, delivery 626 8th Avenue, Olympia, WA 98504, e-mail arc@hca.wa.gov, fax (360) 586-9727, by 5:00 p.m. on October 9, 2012.

Assistance for Persons with Disabilities: Contact Kelly Richters by October 1, 2012, TTY (800) 848-5429 or (360) 725-1307 or e-mail kelly.richters@hca.wa.gov.

Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: These rules are necessary to clarify that persons nineteen and twenty years of age who are eligible for any of the following programs that receive medicaid funding under the Transitional Bridge 1115 Demonstration Waiver allowed under section 1115 (a)(2) of the Social Security Act are not eligible for EPSDT services:

(a) Basic health;

(b) Medical care services; or

(c) Alcohol and Drug Addiction Treatment and Support Act (ADATSA).

Statutory Authority for Adoption: RCW 41.05.021, 1115 (a)(2) of the Social Security Act.

Statute Being Implemented: RCW 41.05.021.

Rule is not necessitated by federal law, federal or state court decision.

Name of Proponent: HCA - medicaid, governmental.

Name of Agency Personnel Responsible for Drafting: Wendy L. Boedigheimer, HCA, P.O. Box 45504, Olympia, WA 98504, (360) 725-1306; Implementation and Enforcement: Sharon Reddick, HCA, P.O. Box 45530, Olympia, WA 98504, (360) 725-1656.

No small business economic impact statement has been prepared under chapter 19.85 RCW. The agency has analyzed the proposed rules and concludes that they do not impose more than minor costs for affected small businesses.

A cost-benefit analysis is not required under RCW 34.05.328. RCW 34.05.328 does not apply to HCA rules unless requested by the joint administrative rules [review] committee or applied voluntarily.

August 29, 2012

Kevin M. Sullivan

Rules Coordinator

OTS-4981.1


AMENDATORY SECTION(Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)

WAC 182-534-0100   EPSDT.   (1) Persons who are eligible for medicaid, except those identified in subsection (4) of this section, are eligible for coverage through the early and periodic screening, diagnosis, and treatment (EPSDT) program up through the day before their twenty-first birthday.

(2) Access and services for EPSDT are governed by federal rules at 42 C.F.R., Part 441, Subpart B which were in effect as of January 1, 1998.

(a) The standard for coverage for EPSDT is that the services, treatment or other measures are:

(i) Medically necessary;

(ii) Safe and effective; and

(iii) Not experimental.

(b) EPSDT services are exempt from specific coverage or service limitations which are imposed on the rest of the CN and MN program. Examples of service limits which do not apply to the EPSDT program are the specific numerical limits in WAC 388-545-300, 388-545-500, and 388-545-700.

(c) Services not otherwise covered under the medicaid program are available to children under EPSDT. The services, treatments and other measures which are available include but are not limited to:

(i) Nutritional counseling;

(ii) Chiropractic care;

(iii) Orthodontics; and

(iv) Occupational therapy (not otherwise covered under the MN program).

(d) Prior authorization and referral requirements are imposed on medical service providers under EPSDT. Such requirements are designed as tools for determining that a service, treatment or other measure meets the standards in subsection (2)(a) of this section.

(3) Transportation requirements of 42 C.F.R. 441, Subpart B are met through a contract with transportation brokers throughout the state.

(4) Persons who are nineteen through twenty years of age who are eligible for any of the following programs that receive medicaid funding under the transitional bridge demonstration waiver allowed under section 1115 (a)(2) of the Social Security Act are not eligible for EPSDT services:

(a) Basic health;

(b) Medical care services; or

(c) Alcohol and Drug Addiction Treatment and Support Act (ADATSA).

[11-14-075, recodified as 182-534-0100, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.08.090, 42 C.F.R., Part 441, Subpart B. 02-07-016, 388-534-0100, filed 3/8/02, effective 4/8/02. Statutory Authority: RCW 74.08.090. 01-02-076, 388-534-0100, filed 12/29/00, effective 1/29/01. 00-11-183, recodified as 388-534-0100, filed 5/24/00, effective 5/24/00. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. 98-16-044, 388-86-027, filed 7/31/98, effective 9/1/98. Statutory Authority: RCW 74.08.090. 90-12-061 (Order 3019), 388-86-027, filed 5/31/90, effective 7/1/90; 82-01-001 (Order 1725), 388-86-027, filed 12/3/81; 81-10-015 (Order 1647), 388-86-027, filed 4/27/81; 80-15-034 (Order 1554), 388-86-027, filed 10/9/80; 79-12-047 (Order 1457), 388-86-027, filed 11/26/79; Order 1112, 388-86-027, filed 4/15/76; Order 738, 388-86-027, filed 11/22/72.]