PERMANENT RULES
SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)
Date of Adoption: December 6, 2000.
Purpose: Avoids duplicative rules by repealing WAC 388-86-115 Medical care provided out-of-state and incorporating language into WAC 388-501-0180. It clarifies department policy on coverage of medical services provided out-of-state to eligible medical assistance clients, and states that MAA requires out-of-state providers meet the same requirements as in-state providers in order to be reimbursed for medical services provided to eligible clients. It also updates program requirements and complies with the Governor's Executive Order 97-02.
Citation of Existing Rules Affected by this Order: Repealing WAC 388-86-115; and amending WAC 388-501-0180.
Statutory Authority for Adoption: RCW 74.08.090 and 74.09.035.
Adopted under notice filed as WSR 00-17-055 on August 9, 2000.
Changes Other than Editing from Proposed to Adopted Version: WAC 388-501-0180:
(1) For medical services coverage and reimbursement
purposes, the medical assistance administration (MAA) The
department of social and health services (DSHS) considers cities
bordering Washington state and listed in WAC 388-501-0175 the
same as in-state cities for:
(a) Medical care coverage under all medical programs administered by the medical assistance administration (MAA); and
(b) Reimbursement purposes.
(2) MAA covers emergent medical services provided
out-of-state to an eligible client if the medical services are
within the scope of the client's medial care program as specified
under chapter 388-529 WAC. The department does not cover
out-of-state medical care for clients under the following
state-administered (Washington state medical care only) medical
programs: (a) General assistance-unemployable (GA-U); (b)
Alcoholism and Drug Addiction Treatment and Support Act (ADATSA);
or (c) Medically indigent program (MIP). (This is now numbered
as (2), and was previously numbered as (4).)
(3) Subject to the exceptions and limitations in this
section, the department MAA covers out-of-state medical care
provided to eligible clients when the services are: nonemergent
medical services provided out-of-state to an eligible client only
if the medical services: (a) Are not readily available within
the state of Washington; (b) (a) Are Within the scope of the
client's medical care program as specified under chapter 388-529 WAC; and
(b) Medically necessary as defined in WAC 388-500-0005.
(c) Have prior authorization through MAA's process described
in WAC 388-501-0165. ((3)(c) is now part of (4).)
(4) MAA does not cover out-of-state medical services for
clients under state-administered (Washington state medical care
only) medical programs. See WAC 388-556-0500. If the client
travels out-of-state expressly to obtain medical care, the
medical services must have prior authorization through the
department's determination process described in WAC 388-501-0165.
(This is numbered as (4), and was previously part of (3)(c).)
(5) (new)
See WAC 388-501-0165 for the department's determination process for requests for:
(a) Any service that is listed in any Washington Administrative Code section as noncovered;
(b) A service that is in a covered category, but has been determined to be experimental or investigational under WAC 388-531-0550; and
(c) A covered service that is subject to the department's limitations or other restrictions and the request for the service exceeds those limitations or restrictions.
(5) (6) MAA The department determines out-of-state coverage
for transportation... (This is numbered as (6), and was previously
numbered as (5).)
(6) (7) MAA The department reimburses an out-of-state
provider for medical care provided to an eligible client if the
provider: (a) Meets the licensing requirements of the state in
which care is provided; (b) Contracts with MAA the department to
be an enrolled provider; and... (This is numbered as (7), and was
previously numbered as (6).)
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 1, Repealed 1.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 1, Repealed 1.
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 1. Effective Date of Rule: Thirty-one days after filing.
December 6, 2000
Marie Myerchin-Redifer, Manager
Rules and Policies Assistance Unit
2779.4(a) Residency requirements in WAC 388-505-0510 must be met.
(b) Medical assistance may be provided only in areas of Canada that border on the United States when no other resource is available.
(2) Persons eligible for the medically needy program may be provided medical care within the scope of that program.
(3) When an eligible person goes to another state, excluding bordering cities, expressly to obtain medical care that is available within the state of Washington, medical assistance will only be provided on an emergency basis.
(4) Medicaid will be provided to persons who enter the state and are determined to be financially eligible, provided the residency requirements in WAC 388-505-0510 are met.
(5) The department shall not provide medical care services out-of-state except in designated bordering cities under WAC 388-501-0175)) The department of social and health services (DSHS) considers cities bordering Washington state and listed in WAC 388-501-0175 the same as in-state cities for:
(a) Medical care coverage under all medical programs administered by the medical assistance administration (MAA); and
(b) Reimbursement purposes.
(2) The department does not cover out-of-state medical care for clients under the following state-administered (Washington state medical care only) medical programs:
(a) General assistance-unemployable (GA-U);
(b) Alcohol and Drug Addiction Treatment and Support Act (ADATSA); or
(c) Medically indigent program (MIP).
(3) Subject to the exceptions and limitations in this section, the department covers out-of-state medical care provided to eligible clients when the services are:
(a) Within the scope of the client's medical care program as specified under chapter 388-529 WAC; and
(b) Medically necessary as defined in WAC 388-500-0005.
(4) If the client travels out-of-state expressly to obtain medical care, the medical services must have prior authorization through the department's determination process described in WAC 388-501-0165.
(5) See WAC 388-501-0165 for the department's determination process for requests for:
(a) Any service that is listed in any Washington Administrative Code section as noncovered;
(b) A service that is in a covered category, but has been determined to be experimental or investigational under WAC 388-531-0550; and
(c) A covered service that is subject to the department's limitations or other restrictions and the request for the service exceeds those limitations or restrictions.
(6) The department determines out-of-state coverage for transportation services, including ambulance services, according to chapter 388-546 WAC.
(7) The department reimburses an out-of-state provider for medical care provided to an eligible client if the provider:
(a) Meets the licensing requirements of the state in which care is provided;
(b) Contracts with the department to be an enrolled provider; and
(c) Meets the same criteria for payment as in-state providers.
[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.]
2741.1 The following section of the Washington Administrative Code is repealed:
| WAC 388-86-115 | Medical care provided out-of-state. |