PERMANENT RULES
SOCIAL AND HEALTH SERVICES
(Health and Recovery Services Administration)
(Medical Assistance)
Effective Date of Rule: January 1, 2007.
Purpose: Adoption of these rules will:
| • | Improve the quality of care received by DSHS clients by using a consistent, evidence-based approach to making benefit coverage decisions. |
| • | Make health and recovery services administration (HRSA) benefit coverage rules clearer, more transparent, and consistent. |
| • | Establish a clear, transparent process by which HRSA determines what services are included under its benefit coverage. |
| • | Maximize program resources through prudent use of cost-effective practices. |
Citation of Existing Rules Affected by this Order: Amending WAC 388-501-0050 Healthcare -- General coverage, 388-501-0160 Exception to rule -- Request for a noncovered healthcare service, 388-531-0100 Scope of coverage for physician-related services -- General and administrative, 388-416-0015 Certification periods for CN and SCHIP medical programs, 388-475-1000 Healthcare for workers with disabilities (HWD) -- Program description, 388-501-0180 Out-of-state medical care, 388-519-0100 Spenddown of excess income for the medically needy program, 388-530-1000 Drug program, 388-530-1150 Noncovered drugs and pharmaceutical supplies and reimbursement limitations, 388-531-1600 Bariatric surgery, 388-533-0340 Maternity support services -- Noncovered services, 388-533-0385 Infant case management -- Noncovered services, 388-535-1265 Dental-related services not covered -- Adults, 388-535A-0040 Covered and noncovered orthodontic services and limitations to coverage, 388-538-063 Mandatory enrollment in managed care for GAU clients, 388-538-095 Scope of care for managed care enrollees, 388-540-130 Covered services, 388-540-140 Noncovered services, 388-540-150 Reimbursement -- General, 388-543-1100 Scope of coverage and limitations for DME, 388-543-1150 Limits and limitation extensions, 388-544-0010 Vision care -- General, 388-544-0450 Vision care -- Prior authorization, 388-544-1100 Hearing aid services -- General, 388-544-1400 Hearing aid services -- Noncovered services, 388-545-900 Neurodevelopmental centers, 388-546-0200 Scope of coverage for ambulance transportation, 388-546-0250 Ambulance services the department does not cover, 388-550-2596 Services and equipment covered by the department but not included in LTAC fixed per diem rate, 388-551-2130 Noncovered home health services, 388-551-3000 Private duty nursing services for client seventeen and younger, 388-553-500 Home infusion therapy/parenteral nutrition program -- Coverage, 388-554-500 Orally administered enteral nutrition products -- Coverage, 388-554-600 Tube-delivered enteral nutrition products and related equipment and supplies -- Coverage, 388-556-0500 Medical care services under state-administered cash programs and 388-800-0045 What services are offered by ADATSA?; new WAC 388-501-0060 Healthcare coverage -- Scope of covered categories of service, 388-501-0065 Healthcare coverage -- Description of covered categories of service and 388-501-0169 Healthcare coverage -- Limitation extension; and repealing WAC 388-501-0300 Limits on scope of medical program services, 388-529-0100 Scope of covered medical services by program and 388-529-0200 Medical services available to eligible clients.
Statutory Authority for Adoption: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700.
Adopted under notice filed as WSR 06-19-098, 06-19-099, and 06-19-100 on September 19, 2006.
Changes Other than Editing from Proposed to Adopted Version: (New wording from what was originally proposed is underlined, deleted wording is lined through): WAC 388-501-0050 subsections (4) through new (7):
(4) The department's fee-for-service program pays only for services furnished by enrolled providers who meet the requirements of chapter 388-502 WAC.
(5) The department does not pay for any service, treatment, equipment, drug, or supply requiring prior authorization from the department, if prior authorization was not obtained before the service was provided.
(6) Covered services
(a) Covered services are either:
(i) "Federally-mandated" - means the State of Washington is required by federal regulation (42 CFR 440.210 and 220) to cover the service for Medicaid clients; or
(ii) "State-option" - means the State of Washington is not federally-mandated to cover the service but has chose to do so at its own discretion.
(b) The department may limit the scope, amount, duration, and/or frequency of covered services. Limitation extensions are authorized according to WAC 388-501-0169.
(6) (7) Noncovered services
WAC 388-501-0060, in the table following subsection (5):
| Service Categories | CN* | MN | MCS | AEM |
| (m) Intermediate care facility/services for mentally retarded | C | C | C | |
| (n) Maternity care and delivery services | C | C | N | E |
| (o) Medical equipment, durable (DME) | C | C | C | E |
| (p) Medical equipment, nondurable (MSE) | C | C | C | E |
| (q) Medical nutrition services | C | C | C | E |
| (r) Mental health services | C | C | C | E |
| (s) Nursing facility services | C | C | C | E |
| (t) Organ transplants | C | C | C | N |
| (u) Out-of-state services | C | C | N | E |
| (v) Oxygen/respiratory services | C | C | C | E |
| (w) Personal care services | C | C | N | N |
| (x) Prescription drugs | C | C | C | E |
| (y) Private duty nursing | C | C | N | E |
| (z) Prosthetic/orthotic devices | C | C | C | E |
| (aa) School medical services | C | C | N | N |
| (bb) Substance abuse services | C | C | C | |
| (cc) Therapy - occupational/physical/speech | C | C | C | E |
| (dd) Vision care (exams/lenses) | C | C | C | E |
WAC 388-501-0065, subsections of subsection (2)
(d) Dental Services-Diagnosis and treatment of dental of dental problems including emergency treatment; and preventive care. [Chapter 388-535 WAC and Chapter 388-535A WAC]
(j) Home health services-Intermittent, short-term skilled
nursing care, physical therapy, speech therapy, home infusion
therapy, and health aide services, provided in the home. [WAC 388-551-2000 through WAC 388-551-3000 388-551-2220]
(k) Hospice services-Physician services, skilled nursing care, medical social services, counseling services for client and family, drugs, medications (including biologicals), medical equipment and supplies needed for palliative care, home health aide, homemaker, personal care services, medical transportation, respite care, and brief inpatient care. This benefit also includes services rendered in a hospice care center and pediatric palliative care services. [WAC 388-551-1210 through WAC 338-551-1850]
(x) Prescription drugs-Outpatient drugs (including in nursing facilities), both generic and brand name; drug devices and supplies; some over-the-counter drugs; oral, topical, injectable drugs; vaccines, immunizations, and biologicals; and family planning drugs, devices, and supplies. [WAC 388-530-1100] Additional coverage for medications and prescriptions is addressed in specific program WAC sections.
(y) Private duty nursing-Continues skilled nursing services provided in the home, including client assessment, administration of treatment, and monitoring of medical equipment and client care for clients seventeen years of age and under. [WAC 388-551-3000] For benefits for clients eighteen years of age and older, see WAC 388-106-1000 through WAC 388-106-1055.
dd) Vision care - Eye exams, refractions, frames, lenses,
ocular prosthetics, and nonelective surgery. [WAC 388-544-0250 through WAC 388-544-0550]
WAC 388-501-0169, subsection (4):
(4) In addition to subsection (3), both the department and MCO consider the following in evaluating a request for a limitation extension:
(a) The level of improvement the client has shown to date related to the requested service and the reasonably calculated probability of continued improvement if the requested service is extended; and
(b) The reasonably calculated probability the client's condition will worsen if the requested service is not extended.
A final cost-benefit analysis is available by contacting Kevin Sullivan, P.O. Box 45504, Olympia, WA 98504-5504, phone (360) 725-1344, fax (360) 586-9727, e-mail sullikm@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 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 3, Amended 36, Repealed 3.
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 0, Repealed 0.
Date Adopted: November 30, 2006.
Robin Arnold-Williams
Secretary
Reviser's note: The material contained in this filing exceeded the page-count limitations of WAC 1-21-040 for appearance in this issue of the Register. It will appear in the 07-01 issue of the Register.