WSR 12-22-046

PERMANENT RULES

HEALTH CARE AUTHORITY


(Medicaid Program)

[ Filed November 2, 2012, 4:22 p.m. , effective December 3, 2012 ]


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

Purpose: 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).

Citation of Existing Rules Affected by this Order: Amending WAC 182-534-0100.

Statutory Authority for Adoption: RCW 41.05.021.

Other Authority: Section 1115 (a)(2) of the Social Security Act.

Adopted under notice filed as WSR 12-18-037 on August 29, 2012.

Changes Other than Editing from Proposed to Adopted Version: The agency updated the incorrect cross-references under WAC 182-534-0100 (2)(b):

(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 WAC 182-545-200.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 1, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 1, Repealed 0.

Date Adopted: November 2, 2012.

Kevin M. Sullivan

Rules Coordinator

OTS-4981.2


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)) 182-545-200.

(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.]