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
3789.7(1) Covered services
(a) Covered services are:
(i) Medical and dental services, equipment, and supplies that are within the scope of the eligible client's medical assistance program (see chapter 388-529 WAC) and listed as covered in MAA rules; and
(ii) Determined to be medically necessary as defined in WAC 388-500-0005 or dentally necessary as defined in WAC 388-535-0150.
(b) Providers must obtain prior authorization (PA) or expedited prior authorization (EPA) when required by MAA.
(i) See WAC 388-501-0165 for the PA process.
(ii) The EPA process is designed to eliminate the need for written and telephonic requests for prior authorization for selected services and procedure codes. MAA requires a provider to create an authorization number for EPA for selected procedure codes, using the process explained in the billing instructions for the specific service or program.
(iii) See chapter 388-538 WAC for managed care requirements.
(c) Covered services are subject to the limitations specified by MAA. Providers must obtain PA or EPA before providing services that exceed the specified limit (quantity, frequency or duration). This is known as a limitation extension.
(i) See WAC 388-501-0165 for the PA process.
(ii) The EPA process is designed to eliminate the need for written and telephonic requests for prior authorization for selected services and procedure codes. MAA requires a provider to create an authorization number for EPA for selected procedure codes, using the process explained in the billing instructions for the specific service or program.
(iii) See chapter 388-538 WAC for managed care requirements.
(d) MAA does not reimburse for covered services, equipment or supplies:
(i) That are included in a DSHS waivered program; or
(ii) For a MAA client who is Medicare-eligible if:
(A) The services, equipment or supplies are covered under Medicare; and
(B) Medicare has not made a determination on the claim or has not been billed by the provider.
(2) Noncovered services
(a) MAA does not cover services, equipment or supplies to which any of the following apply:
(i) The service or equipment is not included as a covered service in the state plan;
(ii) Federal or state laws or regulations prohibit coverage;
(iii) The service or equipment is considered experimental or investigational by the Food and Drug Administration or the Health Care Financing Administration; or
(iv) MAA rules do not list the service or equipment as covered.
(b) MAA reviews all initial requests for noncovered services based on WAC 388-501-0165.
(c) If a noncovered service, equipment or supply is prescribed under the EPSDT program, it will be evaluated as a covered service and reviewed for medical necessity)) The following rules, WAC 388-501-0050 through WAC 388-501-0065, describe the healthcare services available to a client on a fee-for-service basis or as an enrollee in a managed care organization (MCO)(defined in WAC 388-538-050). Noncovered services are described in WAC 388-501-0070.
(1) Service categories listed in WAC 388-501-0060 do not represent a contract for services.
(2) The client must be eligible for the covered service on the date the service is performed or provided.
(3) The department pays only for medical or dental services, equipment, or supplies that are:
(a) Within the scope of the client's medical program;
(b) Covered - see subsection (5);
(c) Medically necessary;
(d) Ordered or prescribed by a healthcare provider meeting the requirements of chapter 388-502 WAC; and
(e) Furnished by a provider according to the requirements of chapter 388-502 WAC.
(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 chosen 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.
(7) Noncovered services
(a) The department does not pay for any service, equipment, or supply:
(i) That federal or state law or regulations prohibit the department from covering;
(ii) Listed as noncovered in WAC 388-501-0070 or in any other program rule. The department evaluates a request for a noncovered service only if an exception to rule is requested according to the provisions in WAC 388-501-0160.
(b) When Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) applies, a noncovered service, equipment, or supply will be evaluated according to the process in WAC 388-501-0165 to determine if it is medically necessary, safe, effective, and not experimental (see WAC 388-534-0100 for EPSDT rules).
[Statutory Authority: RCW 74.08.090. 01-12-070, § 388-501-0050, filed 6/4/01, effective 7/5/01. Statutory Authority: RCW 74.04.050 and 74.08.090. 00-01-088, § 388-501-0050, filed 12/14/99, effective 1/14/00.]
(2) Not all categories of service listed in this section are covered under every medical program, nor do they represent a contract for services. Services are subject to the exclusions, limitations, and eligibility requirements contained in department rules.
(3) Services covered under each listed category:
(a) Are determined by the department after considering available evidence relevant to the service or equipment to:
(i) Determine efficacy, effectiveness, and safety;
(ii) Determine impact on health outcomes;
(iii) Identify indications for use;
(iv) Compare alternative technologies; and
(v) Identify sources of credible evidence that use and report evidence-based information.
(b) May require prior authorization (see WAC 388-501-0165), or expedited authorization when allowed by the department.
(c) Are paid for by the department and subject to review both before and after payment is made. The department or the client's managed care organization may deny or recover payment for such services, equipment, and supplies based on these reviews.
(4) The department does not pay for covered services, equipment, or supplies that:
(a) Require prior authorization from the department, if prior authorization was not obtained before the service was provided;
(b) Are provided by providers who are not contracted with the department as required under chapter 388-502 WAC;
(c) Are included in a department waiver program identified in chapter 388-515 WAC; or
(d) Are covered by a third-party payer (see WAC 388-501-0200), including Medicare, if the third-party payer has not made a determination on the claim or has not been billed by the provider.
(5) Scope of covered service categories. The following table lists the department's covered categories of healthcare services.
• Under the four program columns (CN, MN, MCS, and AEM), the letter "C" means a service category is covered for that program, subject to any limitations listed in the specific medical assistance program WAC and department issuances.
• The letter "N" means a service category is not covered under that program.
• The letter "E" means the service category is available on ly if it is necessary to treat the client's emergency medical condition and may require prior authorization from the department.
• Refer to WAC 388-501-0065 for a description of each service category and for the specific program WAC containing the limitations and exclusions to services.
| Service Categories | CN* | MN | MCS | AEM |
| (a) Adult day health | C | C | N | E |
| (b) Ambulance (ground and air) | C | C | C | E |
| (c) Blood processing/administration | C | C | C | E |
| (d) Dental services | C | C | C | E |
| (e) Detoxification | C | C | C | E |
| (f) Diagnostic services (lab & x-ray) | C | C | C | E |
| (g) Family planning services | C | C | C | E |
| (h) Healthcare professional services | C | C | C | E |
| (i) Hearing care (audiology/hearing exams/aids) | C | C | C | E |
| (j) Home health services | C | C | C | E |
| (k) Hospice services | C | C | N | E |
| (l) Hospital services -inpatient/outpatient | C | C | C | E |
| (m) Intermediate care facility/services for mentally retarded | C | C | C | E |
| (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 | E |
| (cc) Therapy -occupational/physical/speech | C | C | C | E |
| (dd) Vision care (exams/lenses) | C | C | C | E |
*Clients enrolled in the State Children's Health Insurance Program and the Children's Health Program receive CN scope of medical care.
[]
(1) For categorically needy (CN), medically needy (MN), and medical care services (MCS), refer to the WAC citations listed in the following descriptions for specific details regarding each service category. For Alien Emergency Medical (AEM) services, refer to WAC 388-438-0110.
(2) The following service categories are subject to the exclusions, limitations, and eligibility requirements contained in department rules:
(a) Adult day health - Skilled nursing services, counseling, therapy (physical, occupational, speech, or audiology), personal care services, social services, general therapeutic activities, health education, nutritional meals and snacks, supervision, and protection. [WAC 388-71-0702 through WAC 388-71-0776]
(b) Ambulance - Emergency medical transportation and ambulance transportation for nonemergency medical needs. [WAC 388-546-0001 through WAC 388-546-4000]
(c) Blood processing/administration - Blood and/or blood derivatives, including synthetic factors, plasma expanders, and their administration. [WAC 388-550-1400 and WAC 388-550-1500]
(d) Dental services - Diagnosis and treatment of dental problems including emergency treatment and preventive care. [Chapter 388-535 WAC and Chapter 388-535A WAC]
(e) Detoxification - Inpatient treatment performed by a certified detoxification center or in an inpatient hospital setting. [WAC 388-800-0020 through WAC 388-800-0035; and WAC 388-550-1100]
(f) Diagnostic services - Clinical testing and imaging services. [WAC 388-531-0100; WAC 388-550-1400 and WAC 388-550-1500]
(g) Family planning services - Gynecological exams; contraceptives, drugs, and supplies, including prescriptions; sterilization; screening and treatment of sexually transmitted diseases; and educational services. [WAC 388-532-530]
(h) Healthcare professional services - Office visits, emergency room, nursing facility, home-based, and hospital-based care; surgery, anesthesia, pathology, radiology, and laboratory services; obstetric services; kidney dialysis and renal disease services; osteopathic care, podiatry services, physiatry, and pulmonary/respiratory services; and allergen immunotherapy. [Chapter 388-531 WAC]
(i) Hearing care - Audiology; diagnostic evaluations; hearing exams and testing; and hearing aids. [WAC 388-544-1200 and WAC 388-544-1300; WAC 388-545-700; and WAC 388-531-0100]
(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 388-551-2220]
(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 388-551-1850]
(l) Hospital services - inpatient/outpatient - Emergency room; hospital room and board (includes nursing care); inpatient services, supplies, equipment, and prescription drugs; surgery, anesthesia; diagnostic testing, laboratory work, blood/blood derivatives; radiation and imaging treatment and diagnostic services; and outpatient or day surgery, and obstetrical services. [Chapter 388-550 WAC]
(m) Intermediate care facility/services for mentally retarded - Habilitative training, health-related care, supervision, and residential care. [Chapter 388-835 WAC]
(n) Maternity care and delivery services - Community health nurse visits, nutrition visits, behavioral health visits, midwife services, maternity and infant case management services, and community health worker visits. [WAC 388-533-0330]
(o) Medical equipment, durable (DME) - Wheelchairs, hospital beds, respiratory equipment; prosthetic and orthotic devices; casts, splints, crutches, trusses, and braces. [WAC 388-543-1100]
(p) Medical equipment, nondurable (MSE) - Antiseptics, germicides, bandages, dressings, tape, blood monitoring/testing supplies, braces, belts, supporting devices, decubitus care products, ostomy supplies, pregnancy test kits, syringes, needles, transcutaneous electrical nerve stimulators (TENS) supplies, and urological supplies. [WAC 388-543-2800]
(q) Medical nutrition services - Enteral and parenteral nutrition, including supplies. [Chapter 388-553 WAC and Chapter 388-554 WAC]
(r) Mental health services - Inpatient and outpatient psychiatric services and community mental health services. [Chapter 388-865 WAC]
(s) Nursing facility services - Nursing, therapies, dietary, and daily care services. [Chapter 388-97 WAC]
(t) Organ transplants - Solid organs, e.g., heart, kidney, liver, lung, pancreas, and small bowel; bone marrow and peripheral stem cell; skin grafts; and corneal transplants. [WAC 388-550-1900 and WAC 388-550-2000, and WAC 388-556-0400]
(u) Out-of-state services - Emergency services; prior authorized care. Services provided in bordering cities are treated as if they were provided in state. [WAC 388-501-0175 and WAC 388-501-0180; WAC 388-531-1100; and WAC 388-556-0500]
(v) Oxygen/respiratory services - Oxygen, oxygen equipment and supplies; oxygen and respiratory therapy, equipment, and supplies. [Chapter 388-552 WAC]
(w) Personal care services - Assistance with activities of daily living (e.g., bathing, dressing, eating, managing medications) and routine household chores (e.g., meal preparation, housework, essential shopping, transportation to medical services). [WAC 388-106-0010, 0300, 0400, 0500, 0600, 0700, 0720 and 0900]
(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 - Continuous 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.
(z) Prosthetic/orthotic devices - Artificial limbs and other external body parts; devices that prevent, support, or correct a physical deformity or malfunction. [WAC 388-543-1100]
(aa) School medical services - Medical services provided in schools to children with disabilities under the Individuals with Disabilities Education Act (IDEA). [Chapter 388-537 WAC]
(bb) Substance abuse services - Chemical dependency assessment, case management services, and treatment services. [WAC 388-533-0701 through WAC 388-533-0730; WAC 388-556-0100 and WAC 388-556-0400; and WAC 388-800-0020]
(cc) Therapy - occupational/physical/speech - Evaluations, assessments, and treatment. [WAC 388-545-300, WAC 388-545-500, and WAC 388-545-700]
(dd) Vision care - Eye exams, refractions, frames, lenses, ocular prosthetics, and surgery. [WAC 388-544-0250 through WAC 388-544-0550]
[]
Reviser's note: The brackets and enclosed material in the text of the above section occurred in the copy filed by the agency and appear in the Register pursuant to the requirements of RCW 34.08.040.
AMENDATORY SECTION(Amending WSR 00-03-035, filed 1/12/00,
effective 2/12/00)
WAC 388-501-0160
Exception to rule -- Request for a
noncovered ((medical or dental)) healthcare service((, or
related equipment)).
A client and/or ((their)) the client's
provider may request ((prior authorization for MAA)) the
department to pay for a noncovered ((medical or dental))
healthcare service((, or related equipment)). This is called
an exception to rule.
(1) ((MAA)) The department cannot approve an exception to
rule if the ((exception violates)) requested service is
excluded under state ((or federal law or federal regulation))
statute.
(2) The item or service(s) for which an exception is requested must be of a type and nature which falls within accepted standards and precepts of good medical practice;
(3) All exception requests must represent cost-effective utilization of medical assistance program funds as determined by the department;
(4) A request for an exception to rule must be submitted
to the department in writing within ninety days of the date of
the written notification denying authorization for the
noncovered service. For ((MAA)) the department to consider
the exception to rule request((,)):
(a) The client and/or the client's healthcare provider
must submit sufficient client-specific information and
documentation ((must be submitted for the MAA)) to Health and
Recovery Services Administration's medical director or
designee ((to determine if:
(a))) which demonstrate the client's clinical condition
is so different from the majority that there is no equally
effective, less costly covered service or equipment that meets
the client's need(s)((; and))
(b) ((The requested service or equipment will result in
lower overall costs of care for the client)) The client's
healthcare professional must certify that medical treatment or
items of service which are covered under the client's medical
assistance program and which, under accepted standards of
medical practice, are indicated as appropriate for the
treatment of the illness or condition, have been found to be:
(i) Medically ineffective in the treatment of the client's condition; or
(ii) Inappropriate for that specific client.
(((3) The MAA medical director or designee evaluates and
considers requests on a case-by-case basis according to the
information and documentation submitted from the provider.
(4) Within fifteen working days of MAA's receipt of the request, MAA notifies the provider and the client, in writing, of MAA's decision to grant or deny the exception to rule)) (5) Within fifteen business days of receiving the request, the department sends written notification to the provider and the client:
(a) Approving the exception to rule request;
(b) Denying the exception to rule request; or
(c) Requesting additional information.
(i) The additional information must be received by the department within thirty days of the date the information was requested.
(ii) The department approves or denies the exception to rule request within five business days of receiving the additional information.
(iii) If the requested information is insufficient or not provided within thirty days, the department denies the exception to rule request.
(6) The HRSA medical director or designee evaluates and considers requests on a case-by-case basis. The HRSA medical director has final authority or approve or deny a request for exception to rule.
(((5))) (7) Clients do not have a right to a fair hearing
on exception to rule decisions.
[Statutory Authority: RCW 74.08.090, 74.04.050, 74.09.035. 00-03-035, § 388-501-0160, filed 1/12/00, effective 2/12/00. Statutory Authority: RCW 74.08.090. 94-10-065 (Order 3732), § 388-501-0160, filed 5/3/94, effective 6/3/94. Formerly WAC 388-81-030.]
(1) No extension of covered services will be authorized when prohibited by specific program rules.
(2) When an extension is not prohibited by specific program rules, a client or the client's provider may request a limitation extension.
(3) Under fee-for-service (FFS), the department evaluates requests for limitation extensions using the process described in WAC 388-501-0165. For a managed care enrollee, the client's managed care organization (MCO) evaluates requests for limitation extensions according to the MCO's prior authorization process.
(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) Within the scope of an eligible client's medical
((care)) assistance program. Refer to ((chapter 388-529)) WAC
388-501-0060 and WAC 388-501-0065; and
(b) Medically necessary as defined in 388-500-0005.
(2) ((MAA evaluates a request for any service that is
listed as noncovered in WAC 388-531-0150 under the provisions
of WAC 388-501-0165.
(3) MAA)) The department evaluates a request for a
service that is in a covered category((, but has been
determined to be experimental or investigational under WAC 388-531-0550,)) under the provisions of WAC 388-501-0165
((which related to medical necessity)).
(((4) MAA)) (3) The department evaluates requests for
covered services that are subject to limitations or other
restrictions and approves such services beyond those
limitations or restrictions ((when medically necessary, under
the standards for covered services in WAC 388-501-0165)) as
described in WAC 388-501-0169.
(((5) MAA)) (4) The department covers the following
physician-related services, subject to the conditions in
subsections (1), (2), and (3)((, and (4))) of this section:
(a) Allergen immunotherapy services;
(b) Anesthesia services;
(c) Dialysis and end stage renal disease services (refer to chapter 388-540 WAC);
(d) Emergency physician services;
(e) ENT (ear, nose, and throat) related services;
(f) Early and periodic screening, diagnosis, and treatment (EPSDT) services (refer to WAC 388-534-0100);
(g) ((Gender dysphoria surgery and related procedures,
treatment, prosthetics, or supplies when recommended after a
multidisciplinary evaluation including at least urology,
endocrinology, and psychiatry;
(h))) Family planning services (refer to chapter 388-532 WAC);
(((i))) (h) Hospital inpatient services (refer to chapter 388-550 WAC);
(((j))) (i) Maternity care, delivery, and newborn care
services (refer to chapter 388-533 WAC);
(((k))) (j) Office visits;
(((l))) (k) Vision-related services, ((per)) refer to
chapter 388-544 WAC;
(((m))) (l) Osteopathic treatment services;
(((n))) (m) Pathology and laboratory services;
(((o))) (n) Physiatry and other rehabilitation services
(refer to chapter 388-550 WAC);
(((p))) (o) Podiatry services;
(((q))) (p) Primary care services;
(((r))) (q) Psychiatric services, provided by a
psychiatrist;
(((s))) (r) Pulmonary and respiratory services;
(((t))) (s) Radiology services;
(((u))) (t) Surgical services;
(((v) Surgery)) (u) Cosmetic, reconstructive, or plastic
surgery, and related services and supplies to correct
physiological defects from birth, illness, or physical trauma,
or for mastectomy reconstruction for post cancer treatment;
and
(((w))) (v) Other outpatient physician services.
(((6) MAA)) (5) The department covers physical
examinations for ((MAA)) medical assistance clients only when
the physical examination is one or more of the following:
(a) A screening exam covered by the EPSDT program (see WAC 388-534-0100);
(b) An annual exam for clients of the division of developmental disabilities; or
(c) A screening pap smear, mammogram, or prostate exam.
(((7))) (6) By providing covered services to a client
eligible for a medical ((care)) assistance program, a provider
who has signed an agreement with ((MAA)) the department
accepts ((MAA's)) the department's rules and fees as outlined
in the agreement, which includes federal and state law and
regulations, billing instructions, and ((MAA)) department
issuances.
[Statutory Authority: RCW 74.08.090, 74.09.520. 01-01-012, § 388-531-0100, filed 12/6/00, effective 1/6/01.]
3794.4(2) For a child eligible for the newborn medical program, the certification period begins on the child's date of birth and continues through the end of the month of the child's first birthday.
(3) For a woman eligible for a medical program based on pregnancy, the certification period ends the last day of the month that includes the sixtieth day from the day the pregnancy ends.
(4) For families the certification period is twelve months with a six-month report required as a condition of eligibility as described in WAC 388-418-0011.
(5) For children, the certification period is twelve months. Eligibility is continuous without regard to changes in circumstances other than aging out of the program, moving out of state or death. When the medical assistance unit is also receiving benefits under a cash or food assistance program, the medical certification period is updated to begin anew at each:
(a) Approved application for cash or food assistance; or
(b) Completed eligibility review.
(6) For an SSI-related person the certification period is twelve months.
(7) When the child turns nineteen the certification period ends even if the twelve-month period is not over. The certification period may be extended past the end of the month the child turns nineteen when:
(a) The child is receiving inpatient services on the last day of the month the child turns nineteen;
(b) The inpatient stay continues into the following month or months; and
(c) The child remains eligible except for exceeding age nineteen.
(8) A retroactive certification period can begin up to three months immediately before the month of application when:
(a) The client would have been eligible for medical assistance if the client had applied; and
(b) The client received covered medical services as
described in WAC ((388-529-0100)) 388-501-0060 and WAC 388-501-0065.
(9) If the client is eligible only during the three-month retroactive period, that period is the only period of certification.
(10) Any months of a retroactive certification period are added to the designated certification periods described in this section.
(11) For a child determined eligible for SCHIP medical benefits as described in chapter 388-542 WAC:
(a) The certification periods are described in subsections (1), (5), and (7) of this section;
(b) There is not a retroactive eligibility period as described in subsections (8), (9), and (10); and
(c) For a child who has creditable coverage at the time of application, the certification period begins on the first of the month after the child's creditable coverage is no longer in effect, if:
(i) All other SCHIP eligibility factors are met; and
(ii) An eligibility decision is made per WAC 388-406-0035.
[Statutory Authority: RCW 74.08.090, 74.09.530, and 74.09.415. 05-19-031, § 388-416-0015, filed 9/12/05, effective 10/13/05. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.04.510, and 2004 c 54. 04-21-064, § 388-416-0015, filed 10/18/04, effective 11/18/04. Statutory Authority: RCW 74.08.090, 74.09.530, and 2003 c 10. 04-03-019, § 388-416-0015, filed 1/12/04, effective 2/12/04. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.08.090 and 74.09.450. 00-08-002, § 388-416-0015, filed 3/22/00, effective 5/1/00. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. 98-16-044, § 388-416-0015, filed 7/31/98, effective 9/1/98. Formerly 388-509-0970, 388-521-2105, 388-522-2210 and 388-522-2230.]
(1) The HWD program provides categorically needy (CN)
((Medicaid services)) scope of care as described in WAC
((388-529-0200)) 388-501-0060.
(2) The department approves HWD coverage for twelve months effective the first of the month in which a person applies and meets program requirements. See WAC 388-475-1100 for "retroactive" coverage for months before the month of application.
(3) A person who is eligible for another Medicaid program may choose not to participate in the HWD program.
(4) A person is not eligible for HWD coverage for a month in which the person received Medicaid benefits under the medically needy (MN) program.
(5) The HWD program does not provide long-term care (LTC) services described in chapters 388-513 and 388-515 WAC. LTC services include institutional, waivered, and hospice services. To receive LTC services, a person must qualify and participate in the cost of care according to the rules of those programs.
[Statutory Authority: RCW 74.08.090, Section 1902 (a)(10)(A)(ii) of the Social Security Act, and 2001 c 7 § 209(5), Part II. 02-01-073, § 388-475-1000, filed 12/14/01, effective 1/14/02.]
(a) Medical care coverage under all medical programs
administered by the ((medical assistance administration
(MAA))) department; 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); or
(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)) in WAC 388-501-0060;
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)) or
(((c))) (b) 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 (see
also WAC 388-501-0169).
(6) The department evaluates a request for a noncovered service if an exception to rule is requested according to the provisions in WAC 388-501-0160.
(7) The department determines out-of-state coverage for transportation services, including ambulance services, according to chapter 388-546 WAC.
(((7))) (8) 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 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.]
(2) A person's base period begins on the first day of the month of application, subject to the exceptions in subsection (4) of this section.
(3) A separate base period may be made for a retroactive period. The retroactive base period is made up of the three calendar months immediately prior to the month of application.
(4) A base period may vary from the terms in subsections (1), (2), or (3) of this section if:
(a) A three month base period would overlap a previous eligibility period; or
(b) A client is not or will not be resource eligible for the required base period; or
(c) The client is not or will not be able to meet the TANF-related or SSI-related requirement for the required base period; or
(d) The client is or will be eligible for categorically needy (CN) coverage for part of the required base period; or
(e) The client was not otherwise eligible for MN coverage for each of the months of the retroactive base period.
(5) The amount of a person's "spenddown" is calculated by the department. The MN countable income from each month of the base period is compared to the MNIL. The excess income from each of the months in the base period is added together to determine the "spenddown" for the base period.
(6) If income varies and a person's MN countable income falls below the MNIL for one or more months, the difference is used to offset the excess income in other months of the base period. If this results in a spenddown amount of zero dollars and cents, see WAC 388-519-0100(5).
(7) Once a person's spenddown amount is known, their qualifying medical expenses are subtracted from that spenddown amount to determine the date of eligibility. The following medical expenses are used to meet spenddown:
(a) First, Medicare and other health insurance deductibles, coinsurance charges, enrollment fees, or copayments;
(b) Second, medical expenses which would not be covered by the MN program;
(c) Third, hospital expenses paid by the person during the base period;
(d) Fourth, hospital expenses, regardless of age, owed by the applying person;
(e) Fifth, other medical expenses, potentially payable by the MN program, which have been paid by the applying person during the base period; and
(f) Sixth, other medical expenses, potentially payable by the MN program which are owed by the applying person.
(8) If a person meets the spenddown obligation at the time of application, they are eligible for MN medical coverage for the remainder of the base period. The beginning date of eligibility would be determined as described in WAC 388-416-0020.
(9) If a person's spenddown amount is not met at the time of application, they are not eligible until they present evidence of additional expenses which meets the spenddown amount.
(10) To be counted toward spenddown, medical expenses must:
(a) Not have been used to meet a previous spenddown; and
(b) Not be the confirmed responsibility of a third party. The entire expense will be counted unless the third party confirms its coverage within:
(i) Forty-five days of the date of the service; or
(ii) Thirty days after the base period ends; and
(c) Meet one of the following conditions:
(i) Be an unpaid liability at the beginning of the base period and be for services for:
(A) The applying person; or
(B) A family member legally or blood-related and living in the same household as the applying person.
(ii) Be for medical services either paid or unpaid and incurred during the base period; or
(iii) Be for medical services paid and incurred during a previous base period if that client payment was made necessary due to delays in the certification for that base period.
(11) An exception to the provisions in subsection (10) of this section exists. Medical expenses the person owes are applied to spenddown even if they were paid by or are subject to payment by a publicly administered program during the base period. To qualify, the program cannot be federally funded or make the payments of a person's medical expenses from federally matched funds. The expenses do not qualify if they were paid by the program before the first day of the base period.
(12) The following medical expenses which the person owes are applied to spenddown. Each dollar of an expense or obligation may count once against a spenddown cycle that leads to eligibility for MN coverage:
(a) Charges for services which would have been covered by
the department's medical programs as described in ((chapter
388-529)) WAC 388-501-0060 and WAC 388-501-0065, less any
confirmed third party payments which apply to the charges; and
(b) Charges for some items or services not typically covered by the department's medical programs, less any third party payments which apply to the charges. The allowable items or services must have been provided or prescribed by a licensed health care provider; and
(c) Medical insurance and Medicare copayments or coinsurance (premiums are income deductions under WAC 388-519-0100(4)); and
(d) Medical insurance deductibles including those Medicare deductibles for a first hospitalization in sixty days.
(13) Medical expenses may be used more than once if:
(a) The person did not meet their total spenddown amount and did not become eligible in that previous base period; and
(b) The medical expense was applied to that unsuccessful spenddown and remains an unpaid bill.
(14) To be considered toward spenddown, written proof of medical expenses for services rendered to the client must be presented to the department. The deadline for presenting medical expense information is thirty days after the base period ends unless good cause for delay can be documented.
(15) The medical expenses applied to the spenddown amount are the client's financial obligation and are not reimbursed by the department (see WAC 388-502-0100).
(16) Once a person meets their spenddown and they are issued a medical identification card for MN coverage, newly identified expenses cannot be considered toward that spenddown. Once the application is approved and coverage begins the beginning date of the certification period cannot be changed due to a clients failure to identify or list medical expenses.
[Statutory Authority: RCW 71.05.560, 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530. 06-13-042, § 388-519-0110, filed 6/15/06, effective 7/16/06. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, and 74.08.090. 05-08-093, § 388-519-0110, filed 4/1/05, effective 5/2/05; 98-16-044, § 388-519-0110, filed 7/31/98, effective 9/1/98. Formerly WAC 388-518-1830, 388-518-1840, 388-519-1905, 388-519-1910, 388-519-1930 and 388-522-2230.]
(2) ((MAA)) The department reimburses only pharmacies
that:
(a) Are ((MAA-enrolled)) department-enrolled providers;
and
(b) Meet the general requirements for providers described under WAC 388-502-0020.
(3) To be both covered and reimbursed under this chapter, prescription drugs must be:
(a) Medically necessary as defined in WAC 388-500-0005;
(b) Within the scope of coverage of an eligible client's
medical assistance program. Refer to ((chapter 388-529)) WAC
388-501-0060 and WAC 388-501-0065 for scope of coverage
information;
(c) For a medically accepted indication appropriate to the client's condition;
(d) Billed according to the conditions under WAC 388-502-0150 and 388-502-0160; and
(e) Billed according to the conditions and requirements of this chapter.
(4) Acceptance and filling of a prescription for a client
eligible for a medical care program constitutes acceptance of
((MAA's)) the department's rules and fees. See WAC 388-502-0100 for general conditions of payment.
[Statutory Authority: RCW 74.09.080, 74.04.050 and 42 C.F.R. Subpart K, subsection 162.1102. 02-17-023, § 388-530-1000, filed 8/9/02, effective 9/9/02. Statutory Authority: RCW 74.08.090, 74.04.050. 01-01-028, § 388-530-1000, filed 12/7/00, effective 1/7/01. Statutory Authority: RCW 74.08.090. 96-21-031, § 388-530-1000, filed 10/9/96, effective 11/9/96.]
(a) Brand or generic drugs, when the manufacturer has not signed a rebate agreement with the federal Department of Health and Human Services. Refer to WAC 388-530-1125 for information on the drug rebate program.
(b) A drug prescribed:
(i) For weight loss or gain;
(ii) For infertility, frigidity, impotency, or sexual dysfunction;
(iii) For cosmetic purposes or hair growth; or
(iv) To promote tobacco cessation, except as described in WAC 388-533-0345 (3)(d) tobacco cessation for pregnant women.
(c) Over-the-counter (OTC) drugs and supplies, except as described under WAC 388-530-1100.
(d) Prescription vitamins and mineral products, except:
(i) When prescribed for clinically documented deficiencies;
(ii) Prenatal vitamins, only when prescribed and dispensed to pregnant women; or
(iii) Fluoride preparations for children under the early and periodic screening, diagnosis, and treatment (EPSDT) program.
(e) A drug prescribed for an indication or dosing that is not evidence based as determined by:
(i) ((MAA)) The department in consultation with federal
guidelines; or
(ii) The drug use review (DUR) board; and
(iii) ((MAA)) The department's medical consultants and
((MAA)) the department's pharmacist(s).
(f) Drugs listed in the federal register as "less-than-effective" ("DESI" drugs) or which are identical, similar, or related to such drugs.
(g) Drugs that are:
(i) Not approved by the Food and Drug Administration (FDA); or
(ii) Prescribed for non-FDA approved indications or dosing, unless prior authorized; or
(iii) Unproven for efficacy or safety.
(h) Outpatient drugs for which the manufacturer requires as a condition of sale that associated tests or monitoring services be purchased exclusively from the manufacturer or manufacturer's designee.
(i) Drugs requiring prior authorization for which ((MAA))
department authorization has been denied.
(j) Preservatives, flavoring and/or coloring agents.
(k) Less than a one-month supply of drugs for long-term therapy.
(l) A drug with an obsolete national drug code (NDC) more than two years from the date the NDC is designated obsolete by the manufacturer.
(m) Products or items that do not have an eleven-digit NDC.
(n) Nonpreferred drugs when a therapeutic equivalent is on the preferred drug list(s) (PDL), according to WAC 388-530-1100, and subject to the dispense as written (DAW) provisions of WAC 388-530-1280, and 388-530-1290.
(o) Less than a three-month supply of contraceptive patches, contraceptive rings, or oral contraceptives (excluding emergency contraceptive pills), unless otherwise directed by the prescriber.
(2) ((MAA)) The department does not reimburse enrolled
providers for:
(a) Outpatient drugs, biological products, insulin, supplies, appliances, and equipment included in other reimbursement methods including, but not limited to:
(i) Diagnosis-related group (DRG);
(ii) Ratio of costs-to-charges (RCC);
(iii) Nursing facility ((per diem)) daily rate;
(iv) Managed care capitation rates;
(v) Block grants; or
(vi) Drugs prescribed for clients who are on the ((MAA))
department's hospice program when the drugs are related to the
client's terminal illness and related condition(s).
(b) Any drug regularly supplied as an integral part of program activity by other public agencies (e.g., immunization vaccines for children).
(c) Prescriptions written on pre-signed prescription
blanks filled out by nursing facility operators or
pharmacists. ((MAA)) The department may terminate the core
provider agreement of pharmacies involved in this practice.
(d) Drugs used to replace those taken from nursing facility emergency kits.
(e) Drugs used to replace a physician's stock supply.
(f) Free pharmaceutical samples.
(g) A drug product after the product's national drug code (NDC) termination date.
(h) A drug product whose shelf life has expired.
(3) ((MAA)) The department evaluates each request for
authorization of a noncovered drug ((under WAC 388-530-1100(5)
and under the provisions of WAC 388-501-0165)), device, or
pharmaceutical supply as an exception to rule according to WAC 388-501-0160.
[Statutory Authority: RCW 74.08.090, 70.14.050, 69.41.150, 69.41.190, chapter 41.05 RCW. 05-02-044, § 388-530-1150, filed 12/30/04, effective 1/30/05. Statutory Authority: RCW 74.09.080, 74.04.050 and 42 C.F.R. Subpart K, subsection 162.1102. 02-17-023, § 388-530-1150, filed 8/9/02, effective 9/9/02. Statutory Authority: RCW 74.08.090, 74.04.050. 01-01-028, § 388-530-1150, filed 12/7/00, effective 1/7/01. Statutory Authority: RCW 74.08.090. 96-21-031, § 388-530-1150, filed 10/9/96, effective 11/9/96.]
(2) Bariatric surgery must be performed in a hospital with a bariatric surgery program, and the hospital must be:
(a) Located in the state of Washington or approved border cities (see WAC 388-501-0175); and
(b) Meet the requirements of WAC 388-550-2301.
(3) If bariatric surgery is requested or prescribed under
the EPSDT program, ((MAA)) the department evaluates it as a
covered service under EPSDT's standard of coverage that
requires the service to be:
(a) Medically necessary;
(b) Safe and effective; and
(c) Not experimental.
(4) ((MAA)) The department authorizes payment for
bariatric surgery and bariatric surgery-related services in
three stages:
(a) Stage one -- Initial assessment of client;
(b) Stage two -- Evaluations for bariatric surgery and successful completion of a weight loss regimen; and
(c) Stage three -- Bariatric surgery.
Stage one -- Initial assessment
(5) Any ((MAA)) department-enrolled provider who is
licensed to practice medicine in the state of Washington may
examine a client requesting bariatric surgery to ascertain if
the client meets the criteria listed in subsection (6) of this
section.
(6) The client meets the preliminary conditions of stage one when:
(a) The client is between twenty-one and fifty-nine years of age;
(b) The client has a body mass index (BMI) of thirty-five or greater;
(c) The client is not pregnant. (Pregnancy within the
first two years following bariatric surgery is not
recommended. When applicable, a family planning consultation
is highly recommended prior to bariatric surgery((.)));
(d) The client is diagnosed with one of the following:
(i) Diabetes mellitus;
(ii) Degenerative joint disease of a major weight bearing joint(s) (the client must be a candidate for joint replacement surgery if weight loss is achieved); or
(iii) Other rare comorbid conditions (such as pseudo tumor cerebri) in which there is medical evidence that bariatric surgery is medically necessary and that the benefits of bariatric surgery outweigh the risk of surgical mortality; and
(e) The client has an absence of other medical conditions such as multiple sclerosis (MS) that would increase the client's risk of surgical mortality or morbidity from bariatric surgery.
(7) If a client meets the criteria in subsection (6) of
this section, the provider must request prior authorization
from ((MAA)) the department before referring the client to
stage two of the bariatric surgery authorization process. The
provider must attach a medical report to the request for prior
authorization with supporting documentation that the client
meets the stage one criteria in subsections (5) and (6) of
this section.
(8) ((MAA)) The department evaluates requests for covered
services that are subject to limitations or other restrictions
and approves such services beyond those limitations or
restrictions when medically necessary, under the ((standards
for covered services in)) provisions of WAC 388-501-0165 and
WAC 388-501-0169.
Stage two -- Evaluations for bariatric surgery and successful completion of a weight loss regimen
(9) After receiving prior authorization from ((MAA)) the
department to begin stage two of the bariatric surgery
authorization process, the client must:
(a) Undergo a comprehensive psychosocial evaluation
performed by a psychiatrist, licensed psychiatric ARNP, or
licensed independent social worker with a minimum of two years
postmasters' experience in a mental health setting. Upon
completion, the results of the evaluation must be forwarded to
((MAA)) the department. The comprehensive psychosocial
evaluation must include:
(i) An assessment of the client's mental status or illness to:
(A) Evaluate the client for the presence of substance abuse problems or psychiatric illness which would preclude the client from participating in presurgical dietary requirements or postsurgical lifestyle changes; and
(B) If applicable, document that the client has been successfully treated for psychiatric illness and has been stabilized for at least six months and/or has been rehabilitated and is free from any drug and/or alcohol abuse and has been drug and/or alcohol free for a period of at least one year.
(ii) An assessment and certification of the client's ability to comply with the postoperative requirements such as lifelong required dietary changes and regular follow-up.
(b) Undergo an internal medicine evaluation performed by
an internist to assess the client's preoperative condition and
mortality risk. Upon completion, the internist must forward
the results of the evaluation to ((MAA)) the department.
(c) Undergo a surgical evaluation by the surgeon who will
perform the bariatric surgery (see subsection (13) of this
section for surgeon requirements). Upon completion, the
surgeon must forward the results of the surgical evaluation to
((MAA)) the department and to the licensed medical provider
who is supervising the client's weight loss regimen (refer to
WAC 388-531-1600 (9)(d)(ii)).
(d) Under the supervision of a licensed medical provider,
the client must participate in a weight loss regimen prior to
surgery. The client must, within one hundred and eighty days
from the date of ((MAA's)) the department's stage one
authorization, lose at least five percent of his or her
initial body weight. If the client does not meet this weight
loss requirement within one hundred and eighty days from the
date of ((MAA's)) the department's initial authorization,
((MAA)) the department will cancel the authorization. The
client or the client's provider must reapply for prior
authorization from ((MAA)) the department to restart stage
two. For the purpose of this section, "initial body weight"
means the client's weight at the first evaluation appointment.
(i) The purpose of the weight loss regimen is to help the client achieve the required five percent loss of initial body weight prior to surgery and to demonstrate the client's ability to adhere to the radical and lifelong behavior changes and strict diet that are required after bariatric surgery.
(ii) The weight loss regimen must:
(A) Be supervised by a licensed medical provider who has
a core provider agreement with ((MAA)) the department;
(B) Include monthly visits to the medical provider;
(C) Include counseling twice a month by a registered dietician referred to by the treating provider or surgeon; and
(D) Be at least six months in duration.
(iii) Documentation of the following requirements must be
retained in the client's medical file. Copies of the
documentation must be forwarded to ((MAA)) the department upon
completion of stage two. ((MAA)) The department will evaluate
the documentation and authorize the client for bariatric
surgery if the stage two requirements were successfully
completed.
(A) The provider must document the client's compliance in keeping scheduled appointments and the client's progress toward weight loss by serial weight recordings. Clients must lose at least five percent loss of initial body weight and must maintain the five percent weight loss until surgery;
(B) For diabetic clients, the provider must document the efforts in diabetic control or stabilization;
(C) The registered dietician must document the client's compliance (or noncompliance) in keeping scheduled appointments, and the client's weight loss progress;
(D) The client must keep a journal of active participation in the medically structured weight loss regimen including the activities under (d)(iii)(A), (d)(iii)(B) if appropriate, and (d)(iii)(C) of this subsection.
(10) If the client fails to complete all of the
requirements of subsection (9) of this section, ((MAA)) the
department will not authorize stage three -- Bariatric surgery.
(11) If the client is unable to meet all of the stage two
criteria, the client or the client's provider must reapply for
prior authorization from ((MAA)) the department to re-enter
stage two.
Stage three -- Bariatric surgery
(12) ((MAA)) The department may withdraw authorization of
payment for bariatric surgery at any time up to the actual
surgery if ((MAA)) the department determines that the client
is not complying with the requirements of this section.
(13) A surgeon who performs bariatric surgery for medical assistance clients must:
(a) Have a signed core provider agreement with ((MAA))
the department;
(b) Have a valid medical license in the state of Washington; and
(c) Be affiliated with a bariatric surgery program that meets the requirements of WAC 388-550-2301.
(14) For hospital requirements for stage three -- Bariatric surgery, see WAC 388-530-2301.
[Statutory Authority: RCW 74.08.090, 74.09.520. 05-12-022, § 388-531-1600, filed 5/20/05, effective 6/20/05; 01-01-012, § 388-531-1600, filed 12/6/00, effective 1/6/01.]
(a) Not within the scope of the program;
(b) Not listed in WAC 388-533-0330; or
(c) Any service provided by staff not qualified to deliver the service.
(2) ((MAA)) The department evaluates requests for
services listed as noncovered under the provisions of WAC
((388-501-0165)) 388-501-0160.
[Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910. 04-13-049, § 388-533-0340, filed 6/10/04, effective 7/11/04.]
(a) Any direct delivery of services other than case management activities listed in WAC 388-533-0380(2); and
(b) Any service provided by staff not qualified to deliver the service.
(2) ((MAA)) The department evaluates requests for
services listed as noncovered under the provisions of WAC
((388-501-0165)) 388-501-0160.
[Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910. 04-13-049, § 388-533-0385, filed 6/10/04, effective 7/11/04.]
(2) ((MAA)) The department does not cover the following
dental-related services for adults:
(a) Any service specifically excluded by statute.
(b) More costly services when less costly, equally effective services as determined by the department are available.
(c) Services, procedures, treatment, devices, drugs, or application of associated services which the department or the Centers for Medicare and Medicaid Services (CMS) consider investigative or experimental on the date the services were provided.
(d) Coronal polishing.
(e) Fluoride treatments (gel or varnish) for adults, unless the clients are:
(i) Clients of the division of developmental disabilities;
(ii) Diagnosed with xerostomia, in which case the provider must request prior authorization; or
(iii) High-risk adults sixty-five and older. High-risk means the client has at least one of the following:
(A) Rampant root surface decay; or
(B) Xerostomia.
(f) Restorations for wear on any surface of any tooth without evidence of decay through the enamel or on the root surface.
(g) Flowable composites for interproximal or incisal restorations.
(h) Any permanent crowns, temporary crowns, or crown post and cores.
(i) Bridges, including abutment teeth and pontics.
(j) Root canal services for primary teeth.
(k) Root canal services for permanent teeth other than teeth six, seven, eight, nine, ten, eleven, twenty-two, twenty-three, twenty-four, twenty-five, twenty-six, and twenty-seven.
(l) Pulpotomy services for permanent teeth.
(m) Transitional or treatment dentures.
(n) Overdentures.
(o) Replacements for:
(i) Immediate maxillary or mandibular dentures;
(ii) Maxillary or mandibular partial dentures (resin); or
(iii) Complete maxillary or mandibular dentures in excess of one replacement in a ten-year period; or
(iv) Cast metal framework maxillary or mandibular partial dentures in excess of one replacement in a ten-year period.
(p) Rebasing of complete and immediate dentures and partial dentures.
(q) Adjustments of complete and immediate dentures and partial dentures.
(r) Tooth implants, including insertion, postinsertion, maintenance, and implant removal.
(s) Periodontal bone grafts or oral soft tissue grafts.
(t) Gingivectomy, gingivoplasty, or frenectomy, frenoplasty and other periodontal surgical procedures.
(u) Crown lengthening procedures.
(v) Orthotic appliances, including but not limited to, night guards, tempormandibular joint dysfunction (TMJ/TMD) appliances, and all other mouth guards.
(w) Any treatment of TMJ/TMD.
(x) Extraction of:
(i) Asymptomatic teeth;
(ii) Asymptomatic wisdom teeth; and
(iii) Surgical extraction of anterior teeth seven, eight, nine, ten, twenty-three, twenty-four, twenty-five, or twenty-six, which are considered simple extractions and paid as such.
(y) Alveoloplasty, alveoloectomy or tori, exostosis removal.
(z) Debridement of granuloma or cyst associated with tooth extraction.
(aa) Cosmetic treatment or surgery, except as prior authorized by the department for medically necessary reconstructive surgery to correct defects attributable to an accident, birth defect, or illness.
(bb) Nonemergent oral surgery for adults performed in an inpatient hospital setting, except:
(i) Nonemergent oral surgery is covered in an inpatient hospital setting for clients of the division of developmental disabilities when written prior authorization is obtained for the inpatient hospitalization; or
(ii) As provided in WAC 388-535-1080(4).
(cc) Dental supplies such as toothbrushes (manual, automatic, or electric), toothpaste, floss, or whiteners.
(dd) Dentist's time writing and calling in prescriptions or prescription refills.
(ee) Educational supplies.
(ff) Missed or canceled appointments.
(gg) Nonmedical equipment, supplies, personal or comfort items or services.
(hh) Provider mileage or travel costs.
(ii) Service charges or delinquent payment fees.
(jj) Supplies used in conjunction with an office visit.
(kk) Take-home drugs.
(ll) Teeth whitening.
(3) ((MAA)) The department evaluates a request for any
dental-related service((s)) that ((are not)) is listed as
noncovered ((or are in excess of the dental services program's
limitations or restrictions, according to WAC 388-501-0165))
under the provisions of WAC 388-501-0160.
(4) The department evaluates a request for a covered service in excess of the dental program's service limitations or restrictions according to the provisions of WAC 388-501-0169.
[Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, 2003 1st sp.s. c 25, P.L. 104-191. 03-19-079, § 388-535-1265, filed 9/12/03, effective 10/13/03.]
(a) Cleft lip, cleft palate, or other craniofacial anomalies when the client is treated by and receives follow-up care from a department-recognized craniofacial team for:
(i) Cleft lip and palate, cleft palate, or cleft lip with alveolar process involvement;
(ii) Craniofacial anomalies, including but not limited to:
(A) Hemifacial microsomia;
(B) Craniosynostosis syndromes;
(C) Cleidocranial dental dysplasia;
(D) Arthrogryposis; or
(E) Marfan syndrome.
(iii) Other medical conditions with significant facial growth impact (e.g., juvenile rheumatoid arthritis (JRA)); or
(iv) Post-traumatic, post-radiation, or post-burn jaw deformity.
(b) Other severe handicapping malocclusions, including one or more of the following:
(i) Deep impinging overbite when lower incisors are destroying the soft tissues of the palate;
(ii) Crossbite of individual anterior teeth when destruction of the soft tissue is present;
(iii) Severe traumatic malocclusion (e.g., loss of a premaxilla segment by burns or by accident, the result of osteomyelitis, or other gross pathology);
(iv) Overjet greater than 9mm with incompetent lips or reverse overjet greater than 3.5mm with reported masticatory and speech difficulties; or
(v) Medical conditions as indicated on the Washington
Modified Handicapping Labiolingual Deviation (HLD) Index Score
that result in a score of twenty-five or higher. On a
case-by-case basis, ((MAA)) the department reviews all
requests for treatment for conditions that result in a score
of less than twenty-five, based on medical necessity.
(2) ((MAA)) The department may cover requests for
orthodontic treatment for dental malocclusions other than
those listed in subsection (1) of this section when ((MAA))
the department determines that the treatment is medically
necessary.
(3) ((MAA)) The department does not cover:
(a) Lost or broken orthodontic appliances;
(b) Orthodontic treatment for cosmetic purposes;
(c) Orthodontic treatment that is not medically necessary (see WAC 388-500-0005);
(d) Out-of-state orthodontic treatment; or
(e) Orthodontic treatment and orthodontic-related services that do not meet the requirements of this section or other applicable WAC.
(4) ((MAA)) The department covers the following
orthodontic treatment and orthodontic-related services,
subject to the limitations listed (providers must bill for
these services according to WAC 388-535A-0060):
(a) Panoramic radiographs (X rays), once per client in a three-year period.
(b) Interceptive orthodontic treatment, once per the client's lifetime.
(c) Limited transitional orthodontic treatment, up to one year from date of original appliance placement (see subsection (5) of this section for information on limitation extensions).
(d) Comprehensive full orthodontic treatment, up to two years from the date of original appliance placement (see subsection (5) of this section for information on limitation extensions).
(e) Orthodontic appliance removal only when:
(i) The client's appliance was placed by a different provider; and
(ii) The provider has not furnished any other orthodontic treatment to the client.
(f) Other medically necessary orthodontic treatment and
orthodontic-related services as determined by ((MAA)) the
department.
(5) A request to exceed stated limitations or other
restrictions on covered services is called a limitation
extension (LE), which is a form of prior authorization. ((MAA)) The department evaluates and approves requests for LE
for orthodontic services when medically necessary, under the
provisions of WAC 388-501-0165.
(6) ((MAA)) The department evaluates a request for any
orthodontic service not listed as covered in this section
under the provisions of WAC ((388-501-0165)) 388-501-0160.
(7) ((MAA)) The department reviews requests for
orthodontic treatment for clients who are eligible for
services under the EPSDT program according to the provisions
of WAC 388-534-0100.
[Statutory Authority: RCW 74.08.090, 74.09.520 and 74.09.035, 74.09.500. 05-01-064, § 388-535A-0040, filed 12/8/04, effective 1/8/05. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.520, 74.09.500, 42 U.S.C. 1396d(a), C.F.R. 440.100 and 225. 02-01-050, § 388-535A-0040, filed 12/11/01, effective 1/11/02.]
(2) The only sections of chapter 388-538 WAC that apply to GAU clients described in this section are incorporated by reference into this section.
(3) To receive department-paid medical care, GAU clients must enroll in a managed care plan as required by WAC 388-505-0110(7) when they reside in a county designated as a mandatory managed care plan county.
(4) GAU clients are exempt from mandatory enrollment in managed care if they:
(a) Are American Indian or Alaska Native (AI/AN); and
(b) Meet the provisions of 25 U.S.C. 1603 (c)-(d) for federally recognized tribal members and their descendants.
(5) In addition to subsection (4), the department will exempt a GAU client from mandatory enrollment in managed care or end an enrollee's enrollment in managed care in accordance with WAC 388-538-130(3) and 388-538-130(4).
(6) On a case-by-case basis, the department may grant a GAU client's request for exemption from managed care or a GAU enrollee's request to end enrollment when, in the department's judgment:
(a) The client or enrollee has a documented and verifiable medical condition; and
(b) Enrollment in managed care could cause an interruption of treatment that could jeopardize the client's or enrollee's life or health or ability to attain, maintain, or regain maximum function.
(7) The department enrolls GAU clients in managed care effective on the earliest possible date, given the requirements of the enrollment system. The department does not enroll clients in managed care on a retroactive basis.
(8) Managed care organizations (MCOs) that contract with the department to provide services for GAU clients must meet the qualifications and requirements in WAC 388-538-067 and 388-538-095 (3)(a), (b), (c), and (d).
(9) The department pays MCOs capitated premiums for GAU enrollees based on legislative allocations for the GAU program.
(10) GAU enrollees are eligible for the scope of care as
described in WAC ((388-529-0200)) 388-501-0060 for medical
care services (MCS) programs. Other scope of care provisions
that apply:
(a) A client is entitled to timely access to medically necessary services as defined in WAC 388-500-0005;
(b) MCOs cover the services included in the managed care contract for GAU enrollees. MCOs may, at their discretion, cover services not required under the MCO's contract for GAU enrollees;
(c) The department pays providers on a fee-for-service basis for the medically necessary, covered medical care services not covered under the MCO's contract for GAU enrollees; and
(d) A GAU enrollee may obtain emergency services in accordance with WAC 388-538-100.
(11) The department does not pay providers on a fee-for-service basis for services covered under the MCO's contract for GAU enrollees, even if the MCO has not paid for the service, regardless of the reason. The MCO is solely responsible for payment of MCO-contracted health care services that are:
(a) Provided by an MCO-contracted provider; or
(b) Authorized by the MCO and provided by nonparticipating providers.
(12) The following services are not covered for GAU enrollees unless the MCO chooses to cover these services at no additional cost to the department:
(a) Services that are not medically necessary;
(b) Services not included in the medical care services scope of care;
(c) Services, other than a screening exam as described in WAC 388-538-100(3), received in a hospital emergency department for nonemergency medical conditions; and
(d) Services received from a nonparticipating provider requiring prior authorization from the MCO that were not authorized by the MCO.
(13) A provider may bill a GAU enrollee for noncovered services described in subsection (12), if the requirements of WAC 388-502-0160 and 388-538-095(5) are met.
(14) The grievance and appeal process found in WAC 388-538-110 applies to GAU enrollees described in this section.
(15) The hearing process found in chapter 388-02 WAC and WAC 388-538-112 applies to GAU enrollees described in this section.
[Statutory Authority: RCW 74.08.090 and 74.09.522. 06-03-081, § 388-538-063, filed 1/12/06, effective 2/12/06. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.522, and 2003 1st sp.s. c 25 § 209(15). 04-15-003, § 388-538-063, filed 7/7/04, effective 8/7/04.]
(a) A client is entitled to timely access to medically necessary services as defined in WAC 388-500-0005.
(b) The managed care organization (MCO) covers the services included in the MCO contract for MCO enrollees. MCOs may, at their discretion, cover additional services not required under the MCO contract. However, the department may not require the MCO to cover any additional services outside the scope of services negotiated in the MCO's contract with the department.
(c) The department covers medically necessary
((categorically needy)) services described in ((chapter
388-529)) WAC 388-501-0060 and WAC 388-501-0065 that are
excluded from coverage in the MCO contract.
(d) The department covers services through the fee-for-service system for enrollees with a primary care case management (PCCM) provider. Except for emergencies, the PCCM provider must either provide the covered services needed by the enrollee or refer the enrollee to other providers who are contracted with the department for covered services. The PCCM provider is responsible for instructing the enrollee regarding how to obtain the services that are referred by the PCCM provider. The services that require PCCM provider referral are described in the PCCM contract. The department informs enrollees about the enrollee's program coverage, limitations to covered services, and how to obtain covered services.
(e) MCO enrollees may obtain certain services from either
an MCO provider or from a ((medical assistance provider with
a)) department-enrolled provider with a current core provider
agreement without needing to obtain a referral from the PCP or
MCO. These services are described in the managed care
contract, and are communicated to enrollees by the department
and MCOs as described in (f) of this subsection.
(f) The department sends each client written information about covered services when the client is required to enroll in managed care, and any time there is a change in covered services. This information describes covered services, which services are covered by the department, and which services are covered by MCOs. In addition, the department requires MCOs to provide new enrollees with written information about covered services.
(2) For services covered by the department through PCCM contracts for managed care:
(a) The department covers medically necessary services included in the categorically needy scope of care and rendered by providers who have a current core provider agreement with the department to provide the requested service;
(b) The department may require the PCCM provider to obtain authorization from the department for coverage of nonemergency services;
(c) The PCCM provider determines which services are medically necessary;
(d) An enrollee may request a hearing for review of PCCM provider or the department coverage decisions (see WAC 388-538-110); and
(e) Services referred by the PCCM provider require an authorization number in order to receive payment from the department.
(3) For services covered by the department through contracts with MCOs:
(a) The department requires the MCO to subcontract with a sufficient number of providers to deliver the scope of contracted services in a timely manner. Except for emergency services, MCOs provide covered services to enrollees through their participating providers;
(b) The department requires MCOs to provide new enrollees with written information about how enrollees may obtain covered services;
(c) For nonemergency services, MCOs may require the enrollee to obtain a referral from the primary care provider (PCP), or the provider to obtain authorization from the MCO, according to the requirements of the MCO contract;
(d) MCOs and their providers determine which services are medically necessary given the enrollee's condition, according to the requirements included in the MCO contract;
(e) The department requires the MCO to coordinate benefits with other insurers in a manner that does not reduce benefits to the enrollee or result in costs to the enrollee;
(f) A managed care enrollee does not need a PCP referral to receive women's health care services, as described in RCW 48.42.100 from any women's health care provider participating with the MCO. Any covered services ordered and/or prescribed by the women's health care provider must meet the MCO's service authorization requirements for the specific service.
(g) For enrollees temporarily outside their MCOs service area, the MCO is required to cover enrollees for up to ninety days for emergency care and medically necessary covered benefits that cannot wait until the enrollees return to their service area.
(4) Unless the MCO chooses to cover these services, or an appeal, independent review, or a hearing decision reverses an MCO or department denial, the following services are not covered:
(a) For all managed care enrollees:
(i) Services that are not medically necessary;
(ii) Services not included in the categorically needy scope of services; and
(iii) Services, other than a screening exam as described in WAC 388-538-100(3), received in a hospital emergency department for nonemergency medical conditions.
(b) For MCO enrollees:
(i) Services received from a participating specialist that require prior authorization from the MCO, but were not authorized by the MCO; and
(ii) Services received from a nonparticipating provider that require prior authorization from the MCO that were not authorized by the MCO. All nonemergency services covered under the MCO contract and received from nonparticipating providers require prior authorization from the MCO.
(c) For PCCM enrollees, services that require a referral from the PCCM provider as described in the PCCM contract, but were not referred by the PCCM provider.
(5) A provider may bill an enrollee for noncovered services as described in subsection (4) of this section, if the requirements of WAC 388-502-0160 are met. The provider must give the original agreement to the enrollee and file a copy in the enrollee's record.
(a) The agreement must state all of the following:
(i) The specific service to be provided;
(ii) That the service is not covered by either the department or the MCO;
(iii) An explanation of why the service is not covered by the MCO or the department, such as:
(A) The service is not medically necessary; or
(B) The service is covered only when provided by a participating provider.
(iv) The enrollee chooses to receive and pay for the service; and
(v) Why the enrollee is choosing to pay for the service, such as:
(A) The enrollee understands that the service is available at no cost from a provider participating with the MCO, but the enrollee chooses to pay for the service from a provider not participating with the MCO;
(B) The MCO has not authorized emergency department services for nonemergency medical conditions and the enrollee chooses to pay for the emergency department's services rather than wait to receive services at no cost in a participating provider's office; or
(C) The MCO or PCCM has determined that the service is not medically necessary and the enrollee chooses to pay for the service.
(b) For ((limited-English proficient)) enrollees with
limited English proficiency, the agreement must be translated
or interpreted into the enrollee's primary language to be
valid and enforceable.
(c) The agreement is void and unenforceable, and the enrollee is under no obligation to pay the provider, if the service is covered by the department or the MCO as described in subsection (1) of this section, even if the provider is not paid for the covered service because the provider did not satisfy the payor's billing requirements.
[Statutory Authority: RCW 74.08.090 and 74.09.522. 06-03-081, § 388-538-095, filed 1/12/06, effective 2/12/06. Statutory Authority: RCW 74.08.090, 74.09.522, 2003 E1 c 25 § 201(4), 2004 c 276 § 201(4), 42 USC 1396N (section 1915 (b) and (c) of the Social Security Act of 1924). 05-01-066, § 388-538-095, filed 12/8/04, effective 1/8/05. Statutory Authority: RCW 74.08.090, 74.09.522. 03-18-109, § 388-538-095, filed 9/2/03, effective 10/3/03. Statutory Authority: RCW 74.09.080, 74.08.510, [74.08.]522, 74.09.450, 1115 Waiver, 42 U.S.C. 1396. 02-01-075, § 388-538-095, filed 12/14/01, effective 1/14/02. Statutory Authority: RCW 74.08.090. 01-02-076, § 388-538-095, filed 12/29/00, effective 1/29/01. Statutory Authority: RCW 74.08.090, 74.09.510 and [74.09.]522 and 1115 Federal Waiver, 42 U.S.C. 1396 (a), (e), (p), 42 U.S.C. 1396r-6(b), 42 U.S.C. 1396u-2. 00-04-080, § 388-538-095, filed 2/1/00, effective 3/3/00. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. 98-16-044, § 388-538-095, filed 7/31/98, effective 9/1/98. Statutory Authority: RCW 74.08.090 and 1995 2nd sp.s. c 18. 95-18-046 (Order 3886), § 388-538-095, filed 8/29/95, effective 9/1/95. Statutory Authority: RCW 74.08.090. 93-17-039 (Order 3621), § 388-538-095, filed 8/11/93, effective 9/11/93.]
(a) In-facility dialysis;
(b) Home dialysis;
(c) Training for self-dialysis;
(d) Home dialysis helpers;
(e) Dialysis supplies;
(f) Diagnostic lab work;
(g) Treatment for anemia; and
(h) Intravenous drugs.
(2) Covered services are subject to the limitations
specified by ((MAA)) the department. Providers must obtain
prior authorization (PA) or expedited prior authorization
(EPA) before providing services that exceed specified limits
in quantity, frequency or duration (refer to WAC 388-501-0165
((for the PA process)) and WAC 388-501-0169).
[Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520, 74.09.522, and 42 C.F.R. 405.2101. 03-21-039, § 388-540-130, filed 10/8/03, effective 11/8/03.]
(a) Blood and blood products (refer to WAC 388-540-190);
(b) Personal care items such as slippers, toothbrushes, etc.; or
(c) Additional staff time or personnel costs. Staff time is paid through the composite rate. Home dialysis helpers are the only personnel cost paid outside the composite rate (refer to WAC 388-540-160).
(2) ((MAA reviews all initial requests)) The department
evaluates a request for any service listed as noncovered
((services based on WAC 388-501-0165)) in this chapter under
the provisions of WAC 388-501-0160.
[Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520, 74.09.522, and 42 C.F.R. 405.2101. 03-21-039, § 388-540-140, filed 10/8/03, effective 11/8/03.]
(a) Composite rate payments -- This is a payment method in which all standard equipment, supplies and services are calculated into a blended rate.
(i) A single dialysis session and related services are reimbursed through a single composite rate payment (refer to WAC 388-540-160).
(ii) Composite rate payments for continuous ambulatory peritoneal dialysis (CAPD) or continuous cycling peritoneal dialysis (CCPD) are limited to thirty-one per month for an individual client.
(iii) Composite rate payments for all other types of dialysis sessions are limited to fourteen per month for an individual client.
(b) Noncomposite rate payments -- End-stage renal disease
(ESRD) services and items covered by the ((medical assistance
administration (MAA))) department but not included in the
composite rate are billed and paid separately (refer to WAC 388-540-170).
(2) Limitation extension request -- ((MAA)) The department
evaluates billings for covered services that are subject to
limitations or other restrictions, and approves such services
beyond those limitations or restrictions when medically
necessary((,)) under the ((standards)) provisions of WAC 388-501-0165 and WAC 388-501-0169.
(3) Take-home drugs -- ((MAA)) The department reimburses
kidney centers for take-home drugs only when they meet the
conditions described in WAC 388-540-170(1). Other drugs for
at-home use must be billed by a pharmacy and be subject to
((MAA)) the department's pharmacy rules.
(4) Medical nutrition -- Medical nutrition products must be billed by a pharmacy or a durable medical equipment (DME) provider.
(5) Medicare eligible clients -- ((MAA)) The department
does not reimburse kidney centers as a primary payer for
Medicare eligible clients.
[Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520, 74.09.522, and 42 C.F.R. 405.2101. 03-21-039, § 388-540-150, filed 10/8/03, effective 11/8/03.]
The following sections of the Washington Administrative Code are repealed:
| WAC 388-501-0300 | Limits on scope of medical program services. |
| WAC 388-529-0100 | Scope of covered medical services by program. |
| WAC 388-529-0200 | Medical services available to eligible clients. |
(1) The ((medical assistance administration (MAA)))
department covers DME and related supplies, prosthetics,
orthotics, medical supplies, related services, repairs and
labor charges when they are:
(a) Within the scope of an eligible client's medical care
program (see ((chapter 388-529)) WAC 388-501-0060 and WAC 388-501-0065);
(b) Within accepted medical or physical medicine community standards of practice;
(c) Prior authorized as described in WAC 388-543-1600, 388-543-1800, and 388-543-1900;
(d) Prescribed by a physician, advanced registered nurse practitioner (ARNP), or physician assistant certified (PAC). Except for dual eligible Medicare/Medicaid clients, the prescription must:
(i) Be dated and signed by the prescriber;
(ii) Be less than six months in duration from the date the prescriber signs the prescription; and
(iii) State the specific item or service requested, diagnosis, estimated length of need (weeks, months, or years), and quantity;
(e) Billed to the department as the payor of last resort
only. ((MAA)) The department does not pay first and then
collect from Medicare and;
(f) Medically necessary as defined in WAC 388-500-0005. The provider or client must submit sufficient objective evidence to establish medical necessity. Information used to establish medical necessity includes, but is not limited to, the following:
(i) A physiological description of the client's disease, injury, impairment, or other ailment, and any changes in the client's condition written by the prescribing physician, ARNP, PAC, licensed prosthetist and/or orthotist, physical therapist, occupational therapist, or speech therapist; and/or
(ii) Video and/or photograph(s) of the client demonstrating the impairments as well and client's ability to use the requested equipment, when applicable.
(2) ((MAA)) The department evaluates a request for any
equipment or device((s that are)) listed as noncovered in WAC 388-543-1300 under the provisions of WAC ((388-501-0165))
388-501-0160.
(3) ((MAA)) The department evaluates a request for a
service that is in a covered category, but has been determined
to be experimental or investigational under WAC 388-531-0550,
under the provisions of WAC 388-501-0165 ((which relate to
medical necessity)).
(4) ((MAA)) The department evaluates requests for covered
services in this chapter that are subject to limitations or
other restrictions and approves such services beyond those
limitations or restrictions ((when medically necessary, under
the standards for covered services in)) under the provisions
of WAC 388-501-0165 and WAC 388-501-0169.
(5) ((MAA)) The department does not reimburse for DME and
related supplies, prosthetics, orthotics, medical supplies,
related services, and related repairs and labor charges under
fee-for-service (FFS) when the client is any of the following:
(a) An inpatient hospital client;
(b) Eligible for both Medicare and Medicaid, and is staying in a nursing facility in lieu of hospitalization;
(c) Terminally ill and receiving hospice care; or
(d) Enrolled in a risk-based managed care plan that includes coverage for such items and/or services.
(6) ((MAA)) The department covers medical equipment and
related supplies, prosthetics, orthotics, medical supplies and
related services, repairs, and labor charges listed in
((MAA's)) the department's published issuances, including
Washington Administrative Code (WAC), billing instructions,
and numbered memoranda.
(7) An interested party may request ((MAA)) the
department to include new equipment/supplies in the billing
instructions by sending a written request plus all of the
following:
(a) Manufacturer's literature;
(b) Manufacturer's pricing;
(c) Clinical research/case studies (including FDA approval, if required); and
(d) Any additional information the requester feels is important.
(8) ((MAA)) The department bases the decision to purchase
or rent DME for a client, or to pay for repairs to
client-owned equipment on medical necessity.
(9) ((MAA)) The department covers replacement batteries
for purchased medically necessary DME equipment covered within
this chapter.
(10) ((MAA)) The department covers the following
categories of medical equipment and supplies only when they
are medically necessary, prescribed by a physician, ARNP, or
PAC, are within the scope of his or her practice as defined by
state law, and are subject to the provisions of this chapter
and related WACs:
(a) Equipment and supplies prescribed in accordance with an approved plan of treatment under the home health program;
(b) Wheelchairs and other DME;
(c) Prosthetic/orthotic devices;
(d) Surgical/ostomy appliances and urological supplies;
(e) Bandages, dressings, and tapes;
(f) Equipment and supplies for the management of diabetes; and
(g) Other medical equipment and supplies((, as)) listed
in ((MAA)) department published issuances.
(11) ((MAA)) The department evaluates a BR item,
procedure, or service for its medical appropriateness and
reimbursement value on a case-by-case basis.
(12) For a client in a nursing facility, ((MAA)) the
department covers only the following when medically necessary.
All other DME and supplies identified in ((MAA)) the
department's billing instructions are the responsibility of
the nursing facility, in accordance with chapters 388-96 and
388-97 WAC. See also WAC 388-543-2900 (3) and (4). ((MAA))
The department covers:
(a) The purchase and repair of a speech generating device (SGD), a wheelchair for the exclusive full-time use of a permanently disabled nursing facility resident when the wheelchair is not included in the nursing facility's per diem rate, or a specialty bed; and
(b) The rental of a speciality bed.
(13) Vendors must provide instructions for use of equipment; therefore, instructional materials such as pamphlets and video tapes are not covered.
(14) Bilirubin lights are limited to rentals, for at-home newborns with jaundice.
[Statutory Authority: RCW 74.04.050, 74.04.57 [74.04.057], and 74.08.090. 05-21-102, § 388-543-1100, filed 10/18/05, effective 11/18/05. Statutory Authority: RCW 74.08.090, 34.05.353. 03-12-005, § 388-543-1100, filed 5/22/03, effective 6/22/03. Statutory Authority: RCW 74.08.090, 74.09.530. 02-16-054, § 388-543-1100, filed 8/1/02, effective 9/1/02; 01-01-078, § 388-543-1100, filed 12/13/00, effective 1/13/01.]
(1) Antiseptics and germicides:
(a) Alcohol (isopropyl) or peroxide (hydrogen) - one pint per month;
(b) Alcohol wipes (box of two hundred) - one box per month;
(c) Betadine or pHisoHex solution - one pint per month;
(d) Betadine or iodine swabs/wipes (box of one hundred) - one box per month;
(e) Disinfectant spray - one twelve-ounce bottle or can per six-month period; or
(f) Periwash (when soap and water are medically contraindicated) - one five-ounce bottle of concentrate solution per six-month period.
(2) Blood monitoring/testing supplies:
(a) Replacement battery of any type, used with a client-owned, medically necessary home or specialized blood glucose monitor - one in a three-month period; and
(b) Spring-powered device for lancet - one in a six-month period.
(3) Braces, belts and supportive devices:
(a) Custom vascular supports (CVS) - two pair per six-month period. CVS fitting fee - two per six-month period;
(b) Surgical stockings (below-the-knee, above-the-knee, thigh-high, or full-length) - two pair per six-month period;
(c) Graduated compression stockings for pregnancy support (pantyhose style) - two per twelve-month period;
(d) Knee brace (neoprene, nylon, elastic, or with a hinged bar) - two per twelve-month period;
(e) Ankle, elbow, or wrist brace - two per twelve-month period;
(f) Lumbosacral brace, rib belt, or hernia belt - one per twelve-month period;
(g) Cervical head harness/halter, cervical pillow, pelvic belt/harness/boot, or extremity belt/harness - one per twelve-month period.
(4) Decubitus care products:
(a) Cushion (gel, sacroiliac, or accuback) and cushion cover (any size) - one per twelve-month period;
(b) Synthetic or lambs wool sheepskin pad - one per twelve-month period;
(c) Heel or elbow protectors - four per twelve-month period.
(5) Ostomy supplies:
(a) Adhesive for ostomy or catheter: Cement; powder; liquid (e.g., spray or brush); or paste (any composition, e.g., silicone or latex) - four total ounces per month.
(b) Adhesive or nonadhesive disc or foam pad for ostomy pouches - ten per month.
(c) Adhesive remover or solvent - three ounces per month.
(d) Adhesive remover wipes, fifty per box - one box per month.
(e) Closed pouch, with or without attached barrier, with a one- or two-piece flange, or for use on a faceplate - sixty per month.
(f) Closed ostomy pouch with attached standard wear barrier, with built-in one-piece convexity - ten per month.
(g) Continent plug for continent stoma - thirty per month.
(h) Continent device for continent stoma - one per month.
(i) Drainable ostomy pouch, with or without attached barrier, or with one- or two-piece flange - twenty per month.
(j) Drainable ostomy pouch with attached standard or extended wear barrier, with or without built-in one-piece convexity - twenty per month.
(k) Drainable ostomy pouch for use on a plastic or rubber faceplate (only one type of faceplate allowed) - ten per month.
(l) Drainable urinary pouch for use on a plastic, heavy plastic, or rubber faceplate (only one type of faceplate allowed) - ten per month.
(m) Irrigation bag - two every six months.
(n) Irrigation cone and catheter, including brush - two every six months.
(o) Irrigation supply, sleeve - one per month.
(p) Ostomy belt (adjustable) for appliance - two every six months.
(q) Ostomy convex insert - ten per month.
(r) Ostomy ring - ten per month.
(s) Stoma cap - thirty per month.
(t) Ostomy faceplate - ten per month. ((MAA)) The
department does not allow the following to be used on a
faceplate in combination with drainable pouches (refer to the
billing instructions for further details):
(i) Drainable pouches with plastic face plate attached; or
(ii) Drainable pouches with rubber face plate.
(6) Supplies associated with client-owned transcutaneous electrical nerve stimulators (TENS):
(a) For a four-lead TENS unit - two kits per month. (A kit contains two leads, conductive paste or gel, adhesive, adhesive remover, skin preparation material, batteries, and a battery charger for rechargeable batteries.)
(b) For a two-lead TENS unit - one kit per month.
(c) TENS tape patches (for use with carbon rubber electrodes only) are allowed when they are not used in combination with a kit(s).
(d) A TENS stand alone replacement battery charger is allowed when it is not used in combination with a kit(s).
(7) Urological supplies - diapers and related supplies:
(a) The standards and specifications in this subsection apply to all disposable incontinent products (e.g., briefs, diapers, pull-up pants, underpads for beds, liners, shields, guards, pads, and undergarments). See subsections (b), (c), (d), and (e) of this section for additional standards for specific products. All of the following apply to all disposable incontinent products:
(i) All materials used in the construction of the product must be safe for the client's skin and harmless if ingested;
(ii) Adhesives and glues used in the construction of the product must not be water-soluble and must form continuous seals at the edges of the absorbent core to minimize leakage;
(iii) The padding must provide uniform protection;
(iv) The product must be hypoallergenic;
(v) The product must meet the flammability requirements of both federal law and industry standards; and
(vi) All products are covered for client personal use only.
(b) In addition to the standards in subsection (a) of this section, diapers must meet all the following specifications. They must:
(i) Be hourglass shaped with formed leg contours;
(ii) Have an absorbent filler core that is at least one-half inch from the elastic leg gathers;
(iii) Have leg gathers that consist of at least three strands of elasticized materials;
(iv) Have an absorbent core that consists of cellulose fibers mixed with absorbent gelling materials;
(v) Have a backsheet that is moisture impervious and is at least 1.00 mm thick, designed to protect clothing and linens;
(vi) Have a topsheet that resists moisture returning to the skin;
(vii) Have an inner lining that is made of soft, absorbent material; and
(viii) Have either a continuous waistband, or side panels with a tear-away feature, or refastenable tapes, as follows:
(A) For child diapers, at least two tapes, one on each side.
(B) The tape adhesive must release from the backsheet without tearing it, and permit a minimum of three fastening/unfastening cycles.
(c) In addition to the standards in subsection (a) of this section, pull-up pants and briefs must meet the following specifications. They must:
(i) Be made like regular underwear with an elastic waist or have at least four tapes, two on each side or two large tapes, one on each side;
(ii) Have an absorbent core filler that is at least one-half inch from the elastic leg gathers;
(iii) Have an absorbent core that consists of cellulose fibers mixed with absorbent gelling;
(iv) Have leg gathers that consist of at least three strands of elasticized materials;
(v) Have a backsheet that is moisture impervious, is at least 1.00 mm thick, and is designed to protect clothing and linens;
(vi) Have an inner lining made of soft, absorbent material; and
(vii) Have a top sheet that resists moisture returning to the skin.
(d) In addition to the standards in subsection (a) of this section, underpads are covered only for incontinent purposes in a client's bed and must meet the following specifications:
(i) Have an absorbent layer that is at least one and one-half inches from the edge of the underpad;
(ii) Be manufactured with a waterproof backing material;
(iii) Be able to withstand temperatures not to exceed one hundred-forty degrees Fahrenheit;
(iv) Have a covering or facing sheet that is made of nonwoven, porous materials that have a high degree of permeability, allowing fluids to pass through and into the absorbent filler. The patient contact surface must be soft and durable;
(v) Have filler material that is highly absorbent. It must be heavy weight fluff filler or the equivalent; and
(vi) Have four-ply, nonwoven facing, sealed on all four sides.
(e) In addition to the standards in subsection (a) of this section, liners, shields, guards, pads, and undergarments are covered for incontinence only and must meet the following specifications:
(i) Have channels to direct fluid throughout the absorbent area, and leg gathers to assist in controlling leakage, and/or be contoured to permit a more comfortable fit;
(ii) Have a waterproof backing designed to protect clothing and linens;
(iii) Have an inner liner that resists moisture returning to the skin;
(iv) Have an absorbent core that consists of cellulose fibers mixed with absorbent gelling materials;
(v) Have pressure-sensitive tapes on the reverse side to fasten to underwear; and
(vi) For undergarments only, be contoured for good fit, have at least three elastic leg gathers, and may be belted or unbelted.
(f) ((MAA)) The department covers the products in this
subsection only when they are used alone; they cannot be used
in combination with each other. ((MAA)) The department
approves a client's use of a combination of products only when
the client uses different products for daytime and nighttime
use (see ((MAA's)) department billing instructions for how to
specify this when billing). The total quantity of all
products in this section used in combination cannot exceed the
monthly limitation for the product with the highest limit (see
subsections (g), (h), (i), (j), (k), (l), and (m) of this
section for product limitations). The following products
cannot be used together:
(i) Disposable diapers;
(ii) Disposable pull-up pants and briefs;
(iii) Disposable liners, shields, guards, pads, and undergarments;
(iv) Rented reusable diapers (e.g., from a diaper service); and
(v) Rented reusable briefs (e.g., from a diaper service), or pull-up pants.
(g) Purchased disposable diapers (any size) are limited to:
(i) Three hundred per month for a child three to eighteen years of age; and
(ii) Two hundred forty per month for an adult nineteen years of age and older.
(h) Reusable cloth diapers (any size) are limited to:
(i) Purchased - thirty-six per year; and
(ii) Rented - two hundred forty per month.
(i) Disposable briefs and pull-up pants (any size) are limited to:
(i) Three hundred per month for a child age three to eighteen years of age; and
(ii) One hundred fifty per month for an adult nineteen years of age and older.
(j) Reusable briefs, washable protective underwear, or pull-up pants (any size) are limited to:
(i) Purchased - four per year.
(ii) Rented - one hundred fifty per month.
(k) Disposable pant liners, shields, guards, pads, and undergarments are limited to two hundred forty per month.
(l) Underpads for beds are limited to:
(i) Disposable (any size) - one hundred eighty per month.
(ii) Purchased, reusable (large) - forty-two per year.
(iii) Rented, reusable (large) - ninety per month.
(8) Urological supplies - urinary retention:
(a) Bedside drainage bag, day or night, with or without anti-reflux device, with or without tube - two per month. This cannot be billed in combination with any of the following:
(i) With extension drainage tubing for use with urinary leg bag or urostomy pouch (any type, any length), with connector/adapter; and/or
(ii) With an insertion tray with drainage bag, and with or without catheter.
(b) Bedside drainage bottle, with or without tubing - two per six month period.
(c) Extension drainage tubing (any type, any length), with connector/adapter, for use with urinary leg bag or urostomy pouch. This cannot be billed in combination with a vinyl urinary leg bag, with or without tube.
(d) External urethral clamp or compression device (not be used for catheter clamp) - two per twelve-month period.
(e) Indwelling catheters (any type) - three per month.
(f) Insertion trays:
(i) Without drainage bag and catheter - one hundred and twenty per month. These cannot be billed in combination with other insertion trays that include drainage bag, catheters, and/or individual lubricant packets.
(ii) With indwelling catheters - three per month. These cannot be billed in combination with: Other insertion trays without drainage bag and/or indwelling catheter; individual indwelling catheters; and/or individual lubricant packets.
(g) Intermittent urinary catheter - one hundred twenty per month. These cannot be billed in combination with: An insertion tray with or without drainage bag and catheter; or other individual intermittent urinary catheters.
(h) Irrigation syringe (bulb or piston) - cannot be billed in combination with irrigation tray or tubing.
(i) Irrigation tray with syringe (bulb or piston) - thirty per month. These cannot be billed in combination with irrigation syringe (bulb or piston), or irrigation tubing set.
(j) Irrigation tubing set - thirty per month. These cannot be billed in combination with an irrigation tray or irrigation syringe (bulb or piston).
(k) Leg straps (latex foam and fabric). Allowed as replacement only.
(l) Male external catheter, specialty type, or with adhesive coating or adhesive strip - sixty per month.
(m) Urinary suspensory with leg bag, with or without tube - two per month. This cannot be billed in combination with: a latex urinary leg bag; urinary suspensory without leg bag; extension drainage tubing; or a leg strap.
(n) Urinary suspensory without leg bag, with or without tube - two per month.
(o) Urinary leg bag, vinyl, with or without tube - two per month. This cannot be billed in combination with: A leg strap; or an insertion tray with drainage bag and without catheter.
(p) Urinary leg bag, latex - one per month. This cannot be billed in combination with an insertion tray with drainage bag and with or without catheter.
(9) Miscellaneous supplies:
(a) Bilirubin light therapy supplies - five days' supply.
((MAA)) The department reimburses only when these are provided
with a prior authorized bilirubin light.
(b) Continuous passive motion (CPM) softgoods kit - one, with rental of CPM machine.
(c) Eye patch with elastic, tied band, or adhesive, to be attached to an eyeglass lens - one box of twenty.
(d) Eye patch (adhesive wound cover) - one box of twenty.
(e) Lice comb (e.g., LiceOut TM, or LiesMeister TM, or combs of equivalent quality and effectiveness) - one per year.
(f) Nontoxic gel (e.g., LiceOut TM) for use with lice combs - one bottle per twelve month period.
(g) Syringes and needles ("sharps") disposal container for home use, up to one gallon size - two per month.
(10) Miscellaneous DME:
(a) Bilirubin light or light pad - five days rental per twelve-month period.
(b) Blood glucose monitor (specialized or home) - one in a three-year period.
(c) Continuous passive motion (CPM) machine - up to ten days rental and requires prior authorization.
(d) Diaphragmatic pacing antennae - four per twelve month-period.
(e) Lightweight protective helmet/soft shell (including adjustable chin/mouth strap) - two per twelve-month period.
(f) Lightweight ventilated hard-shell helmet (including unbreakable face bar, woven chin strap w/adjustable buckle and snap fastener, and one set of cushion pads for adjusting fit to head circumference) - two per twelve-month period.
(11) Prosthetics and orthotics:
(a) Thoracic-hip-knee-ankle orthosis (THKAO) standing frame - one every five years.
(b) Preparatory, above knee "PTB" type socket, nonalignable system, pylon, no cover, SACH foot plaster socket, molded to model - one per lifetime, per limb.
(c) Preparatory, below knee "PTB" type socket, nonalignable system, pylon, no cover, SACH foot thermoplastic or equal, direct formed - one per lifetime, per limb.
(d) Socket replacement, below the knee, molded to patient model - one per twelve-month period.
(e) Socket replacement, above the knee/knee disarticulation, including attachment plate, molded to patient model - one per twelve-month period.
(12) Positioning devices:
(a) Deluxe floor sitter/feeder seat (small, medium, or large), including floor sitter wedge, shoulder harness, and hip strap - one in a three-year period.
(b) High-back activity chair, including adjustable footrest, two pairs of support blocks, and hip strap - one in a three-year period.
(c) Positioning system/supine boards (small or large), including padding, straps adjustable armrests, footboard, and support blocks - one in a five-year period.
(d) Prone stander (child, youth, infant or adult size) - one in a five-year period.
(e) Adjustable standing frame (for child/adult thirty - sixty-eight inches tall), including two padded back support blocks, a chest strap, a pelvic strap, a pair of knee blocks, an abductor, and a pair of foot blocks - one in a five-year period.
[Statutory Authority: RCW 74.04.050, 74.04.57 [74.04.057], and 74.08.090. 05-21-102, § 388-543-1150, filed 10/18/05, effective 11/18/05. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and Public Law 104-191. 03-19-082, § 388-543-1150, filed 9/12/03, effective 10/13/03. Statutory Authority: RCW 74.08.090, 74.09.530. 01-16-141, § 388-543-1150, filed 7/31/01, effective 8/31/01.]
Reviser's note: The spelling error in the above section occurred in the copy filed by the agency and appears in the Register pursuant to the requirements of RCW 34.08.040.
Reviser's note: The spelling error in the above section occurred in the copy filed by the agency and appears in the Register pursuant to the requirements of RCW 34.08.040.
AMENDATORY SECTION(Amending WSR 05-13-038, filed 6/6/05,
effective 7/7/05)
WAC 388-544-0010
Vision care -- General.
(1) The
((medical assistance administration (MAA))) department covers
((the)) vision care ((listed in this chapter only,)) services
subject to the exceptions, restrictions, and limitations
listed in this chapter. Vision care is covered when ((they
are)) it is:
(a) Within the scope of the eligible client's medical
care program (see ((chapter 388-529)) WAC 388-501-0060 and WAC 388-501-0065); and
(b) Medically necessary as defined in WAC 388-500-0005.
(2) ((MAA)) The department evaluates a request for any
service that is listed as noncovered in this chapter under the
provisions of WAC 388-501-0160.
(3) ((MAA)) The department evaluates requests for covered
services that are subject to limitations or other restrictions
and approves such services beyond those limitations or
restrictions ((when medically necessary,)) under the
((standards for covered services in WAC 388-501-0165))
provisions of WAC 388-501-0169.
(4) ((MAA)) The department evaluates a request for a
service that is in a covered category, but has been determined
to be experimental or investigational under WAC 388-531-0550,
under the provisions of WAC 388-501-0165.
[Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520 and 42 C.F.R. 440.120 and 440.225. 05-13-038, § 388-544-0010, filed 6/6/05, effective 7/7/05.]
(2) For prior authorization (PA), a provider must call or
send the department a fax ((MAA)) using the appropriate
telephone or fax number listed in ((MAA's)) the department's
published vision care billing instructions.
(3) For expedited prior authorization (EPA), a provider
must create an EPA number. The process and criteria used to
create this authorization number are explained in ((MAA's))
the department's published vision care billing instructions. The EPA number must be used when the provider bills ((MAA))
the department.
(4) ((MAA)) The department denies payment for vision care
submitted without the required PA or EPA number, or the
appropriate diagnosis or procedure code as indicated by the
EPA number.
(5) Upon request, a provider must provide documentation
to ((MAA)) the department showing how the client's condition
met the criteria for PA or EPA.
(6) ((MAA)) The department may recoup any payment made to
a provider under this chapter if ((MAA)) the department later
determines that the service was not properly authorized or did
not meet the EPA criteria. Refer to WAC 388-502-0100 (1)(c).
(7) When a client's situation does not meet the EPA criteria for vision care, or a requested service or item exceeds the limit indicated in this chapter, a provider must follow the requirements of WAC 388-501-0165 and WAC 388-501-0169.
(8) ((MAA)) The department evaluates a request for any
service that is listed as noncovered in this chapter under the
provisions of WAC 388-501-0160.
[Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520 and 42 C.F.R. 440.120 and 440.225. 05-13-038, § 388-544-0450, filed 6/6/05, effective 7/7/05. Statutory Authority: RCW 74.08.090, 74.09.510 and 74.09.520. 01-01-010, § 388-544-0450, filed 12/6/00, effective 1/6/01.]
(2) ((MAA)) The department evaluates requests for covered
services ((listed as noncovered or)) that are subject to
limitations or other restrictions ((according to the
provisions)) and approves such services beyond those
limitations or restrictions as described in WAC
((388-501-0165)) 388-501-0169.
(3) ((MAA)) The department evaluates requests for any
service listed as noncovered in this chapter under the
provisions in WAC 388-501-0160.
(4) The department reimburses providers at the maximum
allowable rates established by ((MAA)) the department.
[Statutory Authority: RCW 74.08.090. 00-23-068, § 388-544-1100, filed 11/15/00, effective 12/16/00.]
(a) The purchase of batteries, ear trumpets, or tinnitus maskers;
(b) Group screenings for hearing loss, except as provided under the Healthy Kids/EPSDT program under WAC 388-534-0100;
(c) Computer-aided hearing devices used in school;
(d) Hearing aid charges reimbursed by insurance or other payer source;
(e) Digital hearing aids; or
(f) FM systems or programmable hearing aids for:
(i) Adults;
(ii) Children when the device is used in school; or
(iii) Children whose hearing loss is adequately improved with hearing aids.
(2) ((MAA)) The department evaluates a request for any
service listed in this section ((according to)) as noncovered
under the provisions of WAC ((388-501-0165)) 388-501-0160.
[Statutory Authority: RCW 74.08.090. 00-23-068, § 388-544-1400, filed 11/15/00, effective 12/16/00.]
(a) Neurodevelopmental centers that may be reimbursed
((as such)) by the ((medical assistance administration (MAA)))
department;
(b) Clients who may receive covered services at a neurodevelopmental center; and
(c) Covered services that may be provided at and reimbursed to a neurodevelopmental center.
(2) In order to provide and be reimbursed for the
services listed in subsection (4) of this section, ((MAA)) the
department requires a neurodevelopmental center provider to do
all of the following:
(a) Be contracted with the department of health (DOH) as a neurodevelopmental center;
(b) Provide documentation of the DOH contract to ((MAA))
the department;
(c) Sign a core provider agreement with ((MAA)) the
department; and
(d) Receive a neurodevelopmental center provider number
from ((MAA)) the department.
(3) Clients who are twenty years of age or younger and who meet the following eligibility criteria may receive covered services from neurodevelopmental centers:
(a) For occupational therapy, refer to WAC 388-545-300(2);
(b) For physical therapy, refer to WAC 388-545-500(2);
(c) For speech therapy and audiology services, refer to WAC 388-545-700(2); and
(d) For early and periodic screening, diagnosis and
treatment (EPSDT) screening by physicians, refer to WAC
((388-529-0200)) 388-534-0100.
(4) ((MAA)) The department reimburses neurodevelopmental
centers for providing the following services to clients who
meet the requirements in subsection (3) of this section:
(a) Occupational therapy services as described in WAC 388-545-300;
(b) Physical therapy services as described in WAC 388-545-500;
(c) Speech therapy and audiology services as described in WAC 388-545-700; and
(d) Specific pediatric evaluations and team conferences that are:
(i) Attended by the center's medical director; and
(ii) Identified as payable in ((MAA's)) the department's
billing instructions.
(5) In order to be reimbursed, neurodevelopmental centers
must meet ((MAA's)) the department's billing requirements in
WAC 388-502-0020, 388-502-0100 and 388-502-0150.
[Statutory Authority: RCW 74.09.080, 74.09.520 and 74.09.530. 01-20-114, § 388-545-900, filed 10/3/01, effective 11/3/01.]
(a) Within the scope of an eligible client's medical care
program (see ((chapter 388-529 WAC, Scope of medical
services)) WAC 388-501-0060);
(b) Medically necessary as defined in WAC 388-500-0005 based on the client's condition at the time of the ambulance trip and as documented in the client's record;
(c) Appropriate to the client's actual medical need; and
(d) To one of the following destinations:
(i) The nearest appropriate MAA-contracted medical provider of MAA-covered services; or
(ii) The designated trauma facility as identified in the emergency medical services and trauma regional patient care procedures manual.
(2) MAA limits coverage to medically necessary ambulance transportation that is required because the client cannot be safely or legally transported any other way. If a client can safely travel by car, van, taxi, or other means, the ambulance trip is not medically necessary and the ambulance service is not covered by MAA. See WAC 388-546-0250 (1) and (2) for noncovered ambulance services.
(3) If Medicare or another third party is the client's primary health insurer and that primary insurer denies coverage of an ambulance trip due to a lack of medical necessity, MAA requires the provider when billing MAA for that trip to:
(a) Report the third party determination on the claim; and
(b) Submit documentation showing that the trip meets the medical necessity criteria of MAA. See WAC 388-546-1000 and 388-546-1500 for requirements for nonemergency ambulance coverage.
(4) MAA covers the following ambulance transportation:
(a) Ground ambulance when the eligible client:
(i) Has an emergency medical need for the transportation;
(ii) Needs medical attention to be available during the trip; or
(iii) Must be transported by stretcher or gurney.
(b) Air ambulance when justified under the conditions of this chapter or when MAA determines that air ambulance is less costly than ground ambulance in a particular case. In the latter case, the air ambulance transportation must be prior authorized by MAA. See WAC 388-546-1500 for nonemergency air ambulance coverage.
[Statutory Authority: RCW 74.04.057, 74.08.090, and 74.09.510. 04-17-118, § 388-546-0200, filed 8/17/04, effective 9/17/04. Statutory Authority: RCW 74.08.090, 74.09.500, 74.04.050, 74.04.055, and 74.04.057. 01-03-084, § 388-546-0200, filed 1/16/01, effective 2/16/01.]
(a) Not medically necessary based on the client's condition at the time of service (see exception at WAC 388-546-1000);
(b) Refused by the client (see exception for ITA clients in WAC 388-546-4000(2));
(c) For a client who is deceased at the time the ambulance arrives at the scene;
(d) For a client who dies after the ambulance arrives at the scene but prior to transport and the ambulance crew provided minimal to no medical interventions/supplies at the scene (see WAC 388-546-0500(2));
(e) Requested for the convenience of the client or the client's family;
(f) More expensive than bringing the necessary medical service(s) to the client's location in nonemergency situations;
(g) To transfer a client from a medical facility to the client's residence (except when the residence is a nursing facility);
(h) Requested solely because a client has no other means of transportation;
(i) Provided by other than licensed ambulance providers (e.g., wheelchair vans, cabulance, stretcher cars); or
(j) Not to the nearest appropriate medical facility.
(2) If transport does not occur, ((MAA)) the department
does not cover the ambulance service, except as provided in
WAC 388-546-0500(2).
(3) ((MAA)) The department evaluates requests for
services that are listed as noncovered in this chapter under
the provisions of WAC 388-501-0160.
(4) For ambulance services that are otherwise covered
under this chapter but are subject to one or more limitations
or other restrictions, ((MAA)) the department evaluates, on a
case-by-case basis, requests to exceed the specified limits or
restrictions. ((MAA)) The department approves such requests
when medically necessary, ((in accordance with)) according to
the provisions of WAC 388-501-0165 and WAC 388-501-0169.
(5) An ambulance provider may bill a client for noncovered services as described in this section, if the requirements of WAC 388-502-0160 are met.
[Statutory Authority: RCW 74.04.057, 74.08.090, and 74.09.510. 04-17-118, § 388-546-0250, filed 8/17/04, effective 9/17/04. Statutory Authority: RCW 74.08.090, 74.09.500, 74.04.050, 74.04.055, and 74.04.057. 01-03-084, § 388-546-0250, filed 1/16/01, effective 2/16/01.]
(a) Pharmacy - After the first two hundred dollars per day in total allowed charges for any combination of pharmacy services that includes prescription drugs, total parenteral nutrition (TPN) therapy, IV infusion therapy, and/or epogen/neupogen therapy;
(b) Radiology services;
(c) Nuclear medicine services;
(d) Computerized tomographic (CT) scan;
(e) Operating room services;
(f) Anesthesia services;
(g) Blood storage and processing;
(h) Blood administration;
(i) Other imaging services - Ultrasound;
(j) Pulmonary function services;
(k) Cardiology services;
(l) Recovery room services;
(m) EKG/ECG services;
(n) Gastro-intestinal services;
(o) Inpatient hemodialysis; and
(p) Peripheral vascular laboratory services.
(2) ((MAA)) The department uses the appropriate inpatient
or outpatient payment method described in other published WAC
to reimburse providers other than LTAC facilities for services
and equipment that are covered by ((MAA)) the department but
not included in the LTAC fixed per diem rate. The provider
must bill ((MAA)) the department directly and ((MAA)) the
department reimburses the provider directly.
(3) Transportation services that are related to transporting a client to and from another facility for the provision of outpatient medical services while the client is still an inpatient at the LTAC facility, or related to transporting a client to another facility after discharge from the LTAC facility:
(a) Are not covered or reimbursed through the LTAC fixed per diem rate;
(b) Are not reimbursable directly to the LTAC facility;
(c) Are subject to the provisions in chapter 388-546 WAC; and
(d) Must be billed directly to the:
(i) Department by the transportation company to be reimbursed if the client required ambulance transportation; or
(ii) Department's contracted transportation broker, subject to the prior authorization requirements and provisions described in chapter 388-546 WAC, if the client:
(A) Required nonemergent transportation; or
(B) Did not have a medical condition that required transportation in a prone or supine position.
(4) ((MAA)) The department evaluates requests for covered
transportation services that are subject to limitations or
other restrictions, and approves such services beyond those
limitations or restrictions ((when medically necessary,))
under the ((standards)) provisions of WAC 388-501-0165 and WAC 388-501-0169.
[Statutory Authority: RCW 74.08.090. 03-02-056, § 388-550-2596, filed 12/26/02, effective 1/26/03; 02-14-162, § 388-550-2596, filed 7/3/02, effective 8/3/02.]
(a) Chronic long-term care skilled nursing visits or
specialized therapy visits for a medically stable client when
a long-term care skilled nursing plan or specialized therapy
plan is in place through the department of social and health
services' aging and ((adult)) disability services
administration (((AASA) or division of developmental
disabilities (DDD))) (ADSA).
(i) ((MAA)) HRSA considers requests for interim chronic
long-term care skilled nursing services or specialized therapy
services for a client while the client is waiting for ((AASA
or DDD)) ADSA to implement a long-term care skilled nursing
plan or specialized therapy plan; and
(ii) On a case-by-case basis, ((MAA)) HRSA may authorize
long-term care skilled nursing visits or specialized therapy
visits for a client for a limited time until a long-term care
skilled nursing plan or specialized therapy plan is in place. Any services authorized are subject to the restrictions and
limitations in this section and other applicable published
WACs.
(b) Social work services.
(c) Psychiatric skilled nursing services.
(d) Pre- and postnatal skilled nursing services, except as listed under WAC 388-551-2100 (2)(e).
(e) Well-baby follow-up care.
(f) Services performed in hospitals, correctional facilities, skilled nursing facilities, or a residential facility with skilled nursing services available.
(g) Home health aide services that are not provided in conjunction with skilled nursing or specialized therapy services.
(h) Health care for a medically stable client (e.g., one who does not have an acute episode, a disease exacerbation, or treatment change).
(i) Home health specialized therapies and home health aide visits for clients in the following programs:
(i) CNP - emergency medical only; and
(ii) LCP-MNP - emergency medical only.
(j) Skilled nursing visits for a client when a home health agency cannot safely meet the medical needs of that client within home health services program limitations (e.g., for a client to receive infusion therapy services, the caregiver must be willing and capable of managing the client's care).
(k) More than one of the same type of specialized therapy and/or home health aide visit per day.
(l) ((MAA)) HRSA does not reimburse for duplicate
services for any specialized therapy for the same client when
both providers are performing the same or similar
procedure(s).
(m) Home health visits made without a written physician's order, unless the verbal order is:
(i) Documented prior to the visit; and
(ii) The document is signed by the physician within forty-five days of the order being given.
(2) ((MAA)) HRSA does not cover additional administrative
costs billed above the visit rate (these costs are included in
the visit rate and will not be paid separately).
(3) ((MAA)) HRSA evaluates a request for any service that
is listed as noncovered under the provisions of WAC
((388-501-0165)) 388-501-0160.
[Statutory Authority: RCW 74.08.090, 74.09.520, 74.09.530, and 74.09.500. 02-15-082, § 388-551-2130, filed 7/15/02, effective 8/15/02. Statutory Authority: RCW 74.08.090 and 74.09.530. 99-16-069, § 388-551-2130, filed 8/2/99, effective 9/2/99.]
(1) "Private duty nursing" means four hours or more of continuous skilled nursing services provided in the home to eligible clients with complex medical needs that cannot be managed within the scope of intermittent home health services. Skilled nursing service is the management and administration of the treatment and care of the client, and may include, but is not limited to:
(a) Assessments (e.g., respiratory assessment, patency of airway, vital signs, feeding assessment, seizure activity, hydration, level of consciousness, constant observation for comfort and pain management);
(b) Administration of treatment related to technological dependence (e.g., ventilator, tracheotomy, bilevel positive airway pressure, intravenous (IV) administration of medications and fluids, feeding pumps, nasal stints, central lines);
(c) Monitoring and maintaining parameters/machinery (e.g., oximetry, blood pressure, lab draws, end tidal CO2s, ventilator settings, humidification systems, fluid balance, etc.); and
(d) Interventions (e.g., medications, suctioning, IV's, hyperalimentation, enteral feeds, ostomy care, and tracheostomy care).
(2) To be eligible for private duty nursing services, a client must meet all the following:
(a) Be seventeen years of age or younger (see chapter 388-71 WAC for information about private duty nursing services for clients eighteen years of age and older);
(b) Be eligible for categorically needy (CN) or medically
needy (MN) scope of care (see WAC ((388-529-0100 and
388-529-0200 for client eligibility)) 388-501-0060 and WAC 388-501-0065);
(c) Need continuous skilled nursing care that can be provided safely outside an institution; and
(d) Have prior authorization from the department.
(3) The department contracts only with home health agencies licensed by Washington state to provide private duty nursing services and pays a rate established by the department according to current funding levels.
(4) A provider must coordinate with a division of developmental disabilities case manager and request prior authorization by submitting a complete referral to the department, which includes all of the following:
(a) The client's age, medical history, diagnosis, and current prescribed treatment plan, as developed by the individual's physician;
(b) Current nursing care plan that may include copies of current daily nursing notes that describe nursing care activities;
(c) An emergency medical plan which includes notification of electric, gas and telephone companies as well as local fire department;
(d) Psycho-social history/summary which provides the following information:
(i) Family constellation and current situation;
(ii) Available personal support systems;
(iii) Presence of other stresses within and upon the family; and
(iv) Projected number of nursing hours needed in the home, after discussion with the family or guardian.
(e) A written request from the client or the client's legally authorized representative for home care.
(5) The department approves requests for private duty nursing services for eligible clients on a case-by-case basis when:
(a) The information submitted by the provider is complete;
(b) The care provided will be based in the client's home;
(c) Private duty nursing will be provided in the most cost-effective setting;
(d) An adult family member, guardian, or other designated adult has been trained and is capable of providing the skilled nursing care;
(e) A registered or licensed practical nurse will provide the care under the direction of a physician; and
(f) Based on the referral submitted by the provider, the department determines:
(i) The services are medically necessary for the client because of a complex medical need that requires continuous skilled nursing care which can be provided safely in the client's home;
(ii) The client requires more nursing care than is available through the home health services program; and
(iii) The home care plan is safe for the client.
(6) Upon approval, the department will authorize private duty nursing services up to a maximum of sixteen hours per day except as provided in subsection (7) of this section, restricted to the least costly equally effective amount of care.
(7) The department may authorize additional hours:
(a) For a maximum of thirty days if any of the following apply:
(i) The family or guardian is being trained in care and procedures;
(ii) There is an acute episode that would otherwise require hospitalization, and the treating physician determines that noninstitutionalized care is still safe for the client;
(iii) The family or guardian caregiver is ill or temporarily unable to provide care;
(iv) There is a family emergency; or
(v) The department determines it is medically necessary.
(b) ((If)) After the department ((determines it is
medically necessary)) evaluates the request according to the
((process explained in)) provisions of WAC 388-501-0165((,
Determination process for coverage of medical equipment and
medical or dental services)) and WAC 388-501-0169.
(8) The department adjusts the number of authorized hours when the client's condition or situation changes.
(9) Any hours of nursing care in excess of those authorized by the department are the responsibility of the client, family or guardian.
[Statutory Authority: RCW 74.08.090 and 74.09.520. 01-05-040, § 388-551-3000, filed 2/14/01, effective 3/17/01.]
(a) Home infusion supplies, limited to one month's supply per client, per calendar month.
(b) Parenteral nutrition solutions, limited to one month's supply per client, per calendar month.
(c) One type of infusion pump, one type of parenteral pump, and/or one type of insulin pump per client, per calendar month and as follows:
(i) All rent-to-purchase infusion, parenteral, and/or insulin pumps must be new equipment at the beginning of the rental period.
(ii) ((MAA)) The department covers the rental payment for
each type of infusion, parenteral, or insulin pump for up to
twelve months. (((MAA)) The department considers a pump
purchased after twelve months of rental payments.)
(iii) ((MAA)) The department covers only one purchased
infusion pump or parenteral pump per client in a five-year
period.
(iv) ((MAA)) The department covers only one purchased
insulin pump per client in a four-year period.
(2) Covered supplies and equipment that are within the described limitations listed in subsection (1) of this section do not require prior authorization for reimbursement.
(3) Requests for supplies and/or equipment that exceed the limitations or restrictions listed in this section require prior authorization and are evaluated on an individual basis according to the provisions of WAC 388-501-0165 and WAC 388-501-0169.
(4) ((MAA's)) Department reimbursement for equipment
rentals and purchases includes the following:
(a) Instructions to a client or a caregiver, or both, on the safe and proper use of equipment provided;
(b) Full service warranty;
(c) Delivery and pickup; and
(d) Setup, fitting, and adjustments.
(5) Except as provided in subsection (6) of this section,
((MAA)) the department does not pay separately for home
infusion supplies and equipment or parenteral nutrition
solutions:
(a) When a client resides in a state-owned facility (i.e., state school, developmental disabilities (DD) facility, mental health facility, Western State Hospital, and Eastern State Hospital).
(b) When a client has elected and is eligible to receive
((MAA's)) the department's hospice benefit, unless both of the
following apply:
(i) The client has a preexisting diagnosis that requires parenteral support; and
(ii) The preexisting diagnosis is not related to the diagnosis that qualifies the client for hospice.
(6) ((MAA)) The department pays separately for a client's
infusion pump, parenteral nutrition pump, insulin pump,
solutions, and/or insulin infusion supplies when the client:
(a) Resides in a nursing facility; and
(b) Meets the criteria in WAC 388-553-300.
[Statutory Authority: RCW 74.08.090, 74.09.530. 04-11-007, § 388-553-500, filed 5/5/04, effective 6/5/04.]
(a) Prior authorization requirements under WAC 388-554-700;
(b) Duration periods determined by the ((medical
assistance administration (MAA))) department;
(c) Delivery requirements under WAC 388-554-400(2); and
(d) The provisions in other applicable WAC.
(2) Except as provided in subsection (3) of this section,
((MAA)) the department does not pay separately for orally
administered enteral nutrition products:
(a) When a client resides in a state-owned facility (i.e., state school, developmental disabilities (DD) facility, mental health facility, Western State Hospital, and Eastern State Hospital).
(b) When a client has elected and is eligible to receive
((MAA's)) the department's hospice benefit, unless both of the
following apply:
(i) The client has a pre-existing medical condition that requires enteral nutritional support; and
(ii) The pre-existing medical condition is not related to the diagnosis that qualifies the client for hospice.
(3) ((MAA)) The department pays separately for a client's
orally administered enteral nutrition products when the
client:
(a) Resides in ((the)) a nursing facility;
(b) Meets the criteria in WAC 388-554-300; and
(c) Needs enteral nutrition products to meet one hundred percent of the client's nutritional needs.
(4) ((MAA)) The department does not cover or
((reimburse)) pay for orally administered enteral nutrition
products when the client's nutritional need can be met using
traditional foods, baby foods, and other regular grocery
products that can be pulverized or blenderized and used to
meet the client's caloric and nutritional needs.
(5) ((MAA)) The department:
(a) Determines reimbursement for oral enteral nutrition products according to a set fee schedule;
(b) Considers Medicare's current fee schedule when determining maximum allowable fees;
(c) Considers vendor rate increases or decreases as directed by the Legislature; and
(d) Evaluates and updates the maximum allowable fees for oral enteral nutrition products at least once per year.
(6) ((MAA)) The department evaluates a request for orally
administered enteral nutrition products that are ((not covered
or are)) in excess of the enteral nutrition program's
limitations or restrictions, according to the provisions of
WAC 388-501-0165 and WAC 388-501-0169.
(7) The department evaluates a request for orally administered enteral nutrition products that are listed as noncovered in this chapter according to the provisions of WAC 388-501-0160.
[Statutory Authority: RCW 74.08.090, 74.09.530 and chapter 74.09 RCW. 05-04-059, § 388-554-500, filed 1/28/05, effective 3/1/05.]
(a) Tube-delivered enteral nutrition products;
(b) Tube-delivery supplies;
(c) Enteral nutrition pump rental and purchase;
(d) Nondisposable intravenous (IV) poles required for enteral nutrition product delivery; and
(e) Repairs to equipment.
(2) The ((medical assistance administration (MAA)))
department covers up to twelve months of rental payments for
enteral nutrition equipment. After twelve months of rental,
((MAA)) the department considers the equipment ((to be))
purchased and it becomes the client's property.
(3) ((MAA)) The department requires a provider to furnish
clients new or used equipment that includes full manufacturer
and dealer warranties for one year.
(4) ((MAA)) The department covers only one:
(a) Purchased pump per client in a five year period; and
(b) Purchased nondisposable IV pole per ((a)) client for
that client's lifetime.
(5) ((MAA's)) The department's reimbursement for covered
enteral nutrition equipment and necessary supplies includes
all of the following:
(a) Any adjustments or modifications to the equipment that are required within three months of the date of delivery. This does not apply to adjustments required because of changes in the client's medical condition;
(b) Fitting and set-up; and
(c) Instruction to the client or the client's caregiver in the appropriate use of the equipment and necessary supplies.
(6) A provider is responsible for any costs incurred to have another provider repair equipment if all of the following apply:
(a) Any equipment that ((MAA)) the department considers
purchased requires repair during the applicable warranty
period;
(b) The provider is unable to fulfill the warranty; and
(c) The client still needs the equipment.
(7) If ((the)) a rental equipment the department
considers to have been purchased must be replaced during the
warranty period, ((MAA)) the department recoups fifty percent
of the total amount previously paid toward rental and eventual
purchase of the equipment delivered to the client. All of the
following must apply:
(a) The provider is unable to fulfill the warranty; and
(b) The client still needs the equipment.
(8) ((MAA)) The department rescinds any authorization for
prescribed equipment if the equipment was not delivered to the
client before the client:
(a) Loses medical eligibility;
(b) Becomes covered by a hospice agency and the equipment is used in the treatment of the terminal diagnosis or related condition(s);
(c) Becomes eligible for ((an MAA)) a
department-contracted managed care plan; or
(d) Dies.
(9) Except as provided in subsection (10) of this
section, ((MAA)) the department does not pay separately for
tube-delivered enteral nutrition products or necessary
equipment or supplies when a client:
(a) Resides in a state-owned facility (i.e., state school, developmental disabilities (DD) facility, mental health facility, Western State Hospital, and Eastern State Hospital).
(b) Has elected and is eligible to receive ((MAA's)) the
department's hospice benefit, unless both of the following
apply:
(i) The client has a pre-existing medical condition that requires enteral nutritional support; and
(ii) The pre-existing medical condition is not related to the diagnosis that qualifies the client for hospice.
(10) ((MAA)) The department pays separately for a
client's tube-delivered enteral nutrition products and
necessary equipment and supplies when:
(a) The client resides in ((the)) a nursing facility;
(b) The client meets the eligibility criteria in WAC 388-554-300; and
(c) Use of enteral nutrition products meets one hundred percent of the client's nutritional needs.
(11) ((MAA)) The department determines reimbursement for
tube-delivered enteral nutrition products and necessary
equipment and supplies using the same criteria described in
WAC 388-554-500(5).
(12) ((MAA)) The department evaluates a request for
tube-delivered enteral nutrition products and necessary
equipment and supplies that are ((not covered or are)) in
excess of the enteral nutrition program's limitations or
restrictions, according to the provisions of WAC 388-501-0165
and WAC 388-501-0169.
(13) The department evaluates a request for tube-delivered enteral nutrition products and necessary equipment and supplies, that are listed as noncovered in this chapter, under the provision of WAC 388-501-0160.
[Statutory Authority: RCW 74.08.090, 74.09.530 and chapter 74.09 RCW. 05-04-059, § 388-554-600, filed 1/28/05, effective 3/1/05.]
(1) The department of social and health services (DSHS)
covers only the medically necessary services within the
((notated)) applicable program limitations listed in the MCS
column under WAC ((388-529-0200)) 388-501-0060.
(2) DSHS does not cover medical services received outside the state of Washington unless the medical services are provided in a border area listed under WAC 388-501-0175.
[Statutory Authority: RCW 74.08.090 and 74.09.035. 01-01-009, § 388-556-0500, filed 12/6/00, effective 1/6/01.]
(1) Alcohol/drug treatment services and support described under WAC-388-800-0080.
(2) Shelter services as described under WAC 388-800-0130.
(3) Medical care services as described under WAC 388-556-0500 ((and 388-529-0200)), WAC 388-501-0060, and WAC 388-501-0065.
[Statutory Authority: RCW 74.50.080 and 2002 c 64. 03-02-079, § 388-800-0045, filed 12/30/02, effective 1/30/03. Statutory Authority: RCW 74.08.090, 74.50.80 [74.50.080]. 00-16-077, § 388-800-0045, filed 7/28/00, effective 9/1/00.]