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

     Purpose: The amendments will improve client and provider understanding of the agency's policies and practices. The department is updating and clarifying agency policy regarding:

•	Out-of-state medical care;
•	Requirements for out-of-state providers; and
•	Out-of-country medical care.

     In addition to the amended sections, below, the department is adding new sections WAC 388-501-0182 and 388-501-0184.

     Citation of Existing Rules Affected by this Order: Amending WAC 388-501-0180, 388-502-0120, 388-535-1550, 388-546-0800, 388-546-0900, and 388-546-5100.

     Statutory Authority for Adoption: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 74.09.035.

     Other Authority: RCW 74.04.050, 74.04.057, 74.08.090, and 74.09.500.

      Adopted under notice filed as WSR 08-03-112 on January 22, 2008.

     A final cost-benefit analysis is available by contacting Jonell O. Blatt, Rules and Publications, P.O. Box 45504, 626 8th Avenue, Olympia, WA 98504-5533, phone (360) 725-1571, fax (360) 586-9727, e-mail blattj@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     Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 2, Amended 6, Repealed 0.

     Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0;      Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 2, Amended 6, Repealed 0.

     Date Adopted: March 31, 2008.

Robin Arnold-Williams

Secretary

     (1) ((The department considers cities bordering Washington state and listed in WAC 388-501-0175 the same as in-state cities for:

     (a) Medical care coverage under all medical programs administered by the 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).

     (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 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) A service that is in a covered category, but has been determined to be experimental or investigational under WAC 388-531-0550; or

     (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.

     (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)) Subject to the exceptions and limitations in this section, WAC 388-501-0182 and 388-501-0184, the department covers emergency and nonemergency out-of-state healthcare services provided to eligible Washington state medical assistance clients when the services are:

     (a) Within the scope of the client's healthcare program as specified under chapter 388-501 WAC;

     (b) Allowed to be provided outside the state of Washington by specific program WAC; and

     (c) Medically necessary as defined in WAC 388-500-0005.

     (2) The department does not cover services provided outside the state of Washington under the involuntary treatment act (chapter 71.05 RCW and chapter 388-865 WAC), including designated bordering cities.

     (3) When the department pays for covered healthcare services furnished to an eligible Washington state medical assistance client outside the state of Washington, its payment is payment in full according to 42 CFR 447.15. The department does not pay when the provider refuses to accept the department's payment as payment in full.

     (4) The department determines coverage for transportation services provided out of state, including ambulance services, according to chapter 388-546 WAC.

     (5) With the exception of designated bordering cities (see WAC 388-501-0175), if the client travels out of state expressly to obtain healthcare, the service(s) must be prior authorized by the department. See WAC 388-501-0182 for requirements related to out-of-state nonemergency treatment and WAC 388-501-0165 for the department's medical necessity determination process.

     (6) The department does not cover healthcare services provided outside the United States and U.S. territories, with the exception of British Columbia, Canada. See WAC 388-501-0184 for limitations on coverage of healthcare provided to medical assistance clients in British Columbia, Canada.

     (7) See WAC 388-502-0120 for provider requirements for payment of healthcare provided outside the state of Washington.

[Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. 06-24-036, § 388-501-0180, filed 11/30/06, effective 1/1/07. 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.]

     (a) Healthcare services that the department has prior authorized for a client; and

     (b) Healthcare services obtained by the client, independent of the department, while traveling or visiting.

     (2) In accordance with the prior authorization process described in WAC 388-501-0165, except as specified in subsection (3) of this section, the department pays for covered nonemergency healthcare services provided to an eligible Washington state medical assistance client in another state or U.S. territory to the same extent that it pays for covered nonemergency services provided within the state of Washington when the department determines that:

     (a) Services are medically necessary and the client's health will be endangered if the client is required to travel to the state of Washington to receive the needed care;

     (b) Medically necessary services are not available in Washington state or designated bordering cities (see WAC 388-501-0175) and are more readily available in another state; or

     (c) It is general practice for clients in a particular Washington state locality to use medically necessary resources in a bordering state.

     (3) The department pays for covered nonemergency healthcare services furnished to an eligible Washington state medical assistance client in another state or U.S. territory, unless the out-of-state provider is unwilling to accept the department's payment as payment in full according to 42 CFR 447.15. The department does not pay when the provider refuses to accept the department's payment as payment in full.

     (4) The department does not pay for medically necessary, nonsymptomatic treatment (i.e., preventive care) furnished outside the state of Washington unless it is furnished in a designated bordering city, which is considered the same as an in-state city for the purposes of healthcare coverage (see WAC 388-501-0175). Covered nonemergency services requiring prior authorization, when provided in the state of Washington, also require prior authorization, when provided in a designated bordering city (see WAC 388-501-0165 for the department's medical necessity determination process).

     (5) See WAC 388-501-0180 for additional information regarding healthcare services provided outside the state of Washington.

     (6) The department's health and recovery services administration's (HRSA) assistant secretary or designee reviews all exception to rule (ETR) requests.

[]

     (1) The provisions of WAC 388-501-0182 apply to this section.

     (2) The department does not pay for healthcare services furnished in a foreign country, except for medical services furnished in the province of British Columbia, Canada, under the conditions specified in this section. The department pays for medical services furnished in British Columbia to the following Washington state medical assistance clients only:

     (a) Those who reside in Point Roberts, Washington;

     (b) Those who reside in Washington communities along the border with British Columbia, Canada (see subsection (3) of this section for further clarification); and

     (c) Members of the Canadian First Nations who live in Washington state.

     (3) For those medical assistance clients identified in subsection (1) of this section, the department covers emergency and nonemergency medical services provided in British Columbia, Canada, when the services are:

     (a) Within the scope of the client's healthcare program as specified in chapter 388-501 WAC;

     (b) Allowed to be provided outside the United States and U.S. territories by specific program WAC; and

     (c) Medically necessary as defined in WAC 388-500-0005.

     (4) For those medical assistance clients identified in subsection (1) of this section, the department covers nonemergency medical services in British Columbia, Canada, only when:

     (a) It is general practice for Washington state medical assistance clients residing in these particular localities to use medically necessary resources across the Canadian border; or

     (b) The medical services in British Columbia are closer or more readily accessible to the client's Washington state residence. As applied to nonemergency medical services, the phrase "closer or more readily accessible to the client's Washington state residence" means:

     (i) There is not a United States provider for the same service within twenty-five miles of the client's Washington state residence; and

     (ii) The closest Canadian provider of service is closer than the closest U.S. provider of the service.

     (5) The department does not cover services provided outside of the United States under the involuntary treatment act (chapter 71.05 RCW and chapter 388-865 WAC).

     (6) When the department pays for covered medical services furnished to a Washington state medical assistance client in British Columbia, its payment is payment in full according to 42 CFR 447.15. The department does not pay when the provider refuses to accept the department's payment as payment in full.

[]

     (2) ((MAA does not authorize payment for out-of-state medical care furnished to clients in state-only funded medical programs)) With the exception of hospital services and nursing facilities, the department pays the provider of service in designated bordering cities as if the care was provided within the state of Washington (see WAC 388-501-0175).

     (3) ((MAA applies the three-month retroactive coverage as defined under WAC 388-500-0005 to covered medical services that are furnished to eligible clients by out-of-state providers)) With the exception of designated bordering cities, the department does not pay for healthcare services provided to clients in medical care services (MCS) programs outside the state of Washington (see WAC 388-556-0500).

     (4) ((MAA requires out-of-state providers to obtain a valid provider number in order to be reimbursed.

     (a) MAA requires a completed core provider agreement, and furnishes the necessary billing forms, instructions, and a core provider agreement to providers.

     (b) MAA issues a provider number after receiving the signed core provider agreement.

     (c) The billing requirements of WAC 388-502-0100 and 388-502-0150 apply to out-of-state providers)) With the exception of hospital services (see subsection (5) of this section), the department pays for healthcare services provided outside the state of Washington at the lower of:

     (a) The billed amount; or

     (b) The rate established by the Washington state medical assistance programs.

     (5) ((For Medicare-eligible clients, providers must submit Medicare claims, on the appropriate Medicare billing form, to the intermediary or carrier in the provider's state. If the provider checks the Medicare billing form to show the state of Washington as being responsible for medical billing, the intermediary or carrier may either:

     (a) Forward the claim to MAA on behalf of the provider; or

     (b) Return the claim to the provider, who then submits it to MAA)) The department pays for hospital services provided in designated bordering cities and outside the state of Washington in accordance with the provisions of WAC 388-550-3900, 388-550-4000, 388-550-4800 and 388-550-6700.

     (6) ((For covered services for eligible clients, MAA reimburses approved out-of-state nursing facilities at the lower of:

     (a) The billed amount; or

     (b) The adjusted statewide average reimbursement rate for in-state nursing facility care)) The department pays nursing facilities located outside the state of Washington when approved by the aging and disability services administration (ADSA) at the lower of the billed amount or the adjusted statewide average reimbursement rate for in-state nursing facility care, only in the following limited circumstances:

     (a) Emergency situations; or

     (b) When the client intends to return to Washington state and the out-of-state stay is for:

     (i) Thirty days or less; or

     (ii) More than thirty days if approved by ADSA.

     (7) ((For covered services for eligible clients, MAA reimburses approved out-of-state hospitals at the lower of)) To receive payment from the department, an out-of-state provider must:

     (a) ((The billed amount)) Have a signed agreement with the department; ((or))

     (b) ((The adjusted statewide average reimbursement rate for in-state hospitals)) Meet the functionally equivalent licensing requirements of the state or province in which care is rendered;

     (c) Meet the conditions in WAC 388-502-0100 and 388-502-0150;

     (d) Satisfy all Medicaid conditions of participation;

     (e) Accept the department's payment as payment in full according to 42 CFR 447.15; and

     (f) If a Canadian provider, bill at the U.S. exchange rate in effect at the time the service was provided.

     (8) For covered services for eligible clients, MAA reimburses other approved out-of-state providers at the lower of:

     (a) The billed amount; or

     (b) The rate paid by the Washington state Title XIX Medicaid program.

[Statutory Authority: RCW 74.08.090. 01-02-076, § 388-502-0120, filed 12/29/00, effective 1/29/01. Statutory Authority: RCW 74.04.050 and 74.08.090. 00-01-088, § 388-502-0120, filed 12/14/99, effective 1/14/00.]

     (4) Dental providers who are out-of-state must meet the same criteria for payment as in-state providers, including the requirements to contract with MAA. See WAC 388-535-1070, Dental-related services provider information)) See WAC 388-501-0180, 388-501-0182, and 388-501-0184 for services provided outside the state of Washington. See WAC 388-501-0175 for designated bordering cities.

[Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.500, 74.09.520, 42 U.S.C. 1396d(a), 42 C.F.R. 440.100 and 440.225. 02-13-074, § 388-535-1550, filed 6/14/02, effective 7/15/02. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.520 and 74.09.700, 42 USC 1396d(a), CFR 440.100 and 440.225. 99-07-023, § 388-535-1550, filed 3/10/99, effective 4/10/99. Statutory Authority: Initiative 607, 1995 c 18 2nd sp.s. and 74.08.090. 96-01-006 (Order 3931), § 388-535-1550, filed 12/6/95, effective 1/6/96.]

     (6) MAA pays ambulance providers the agreed upon amount for each medically necessary interstate ambulance trip that has MAA's prior authorization. The provider is responsible for ensuring that all necessary services associated with the transport are available and provided to the client. In transports involving negotiated rates, the provider is responsible for the costs of all services included in the contractual amount. The contractual amount for an air ambulance transport may include ground ambulance fees at the point of pickup and the point of destination)) The department pays for emergency ambulance transportation provided to eligible Washington state fee-for-service medical assistance clients who are in another state or U.S. territory when the emergency medical situation occurs according to the provisions of WAC 388-501-0180, 388-501-0182, and 388-502-0120.

     (2) To receive payment from the department, an out-of-state ambulance provider must:

     (a) Meet the licensing requirements of the ambulance provider's home state or province; and

     (b) Have a signed agreement with the department.

     (3) The department pays for emergency ambulance transportation provided out of state for an eligible Washington state medical assistance client under fee-for-service when the transport is:

     (a) Within the scope of the client's medical care program;

     (b) Medically necessary as defined in WAC 388-500-0005; and

     (c) To the nearest appropriate treatment facility.

     (4) The department does not pay for an ambulance transport provided in another state for a fee-for-service Washington state medical assistance client when:

     (a) The client's medical eligibility program covers medical services within Washington state and/or designated bordering cities only. See WAC 388-546-0150 and 388-546-0200(5);

     (b) The ambulance transport was nonemergent and was not prior authorized by the department.

     (5) The department pays for emergency ambulance transportation at the lower of:

     (a) The provider's billed amount; or

     (b) The rate established by the department.

     (6) To receive payment from the department for a nonemergency transport, an ambulance provider, who transports a Washington state medical assistance client to a facility that is out of state or brings a client into the state from a location that is out of state, must obtain prior authorization from the department.

     (7) The department pays a negotiated rate for a medically necessary nonemergency interstate ambulance transport that the department has prior authorized. The ambulance provider is responsible for ensuring that all medical services necessary for the client's safety during the transport are available on-board the vehicle or aircraft. The contractual amount for a nonemergency air ambulance transport may include:

     (a) The cost of medically necessary ground ambulance transport from the discharging facility to the point-of-pickup (airstrip); and

     (b) The cost of medically necessary ground ambulance transport from the landing point (airstrip) to the receiving facility.

     (8) The department does not pay to transport clients under the involuntary treatment act (ITA) program to or from locations outside the state of Washington. For ITA purposes, transports to or from designated bordering cities are not covered. See WAC 388-546-4000.

     (9) The department requires out-of-state ground ambulance providers who transport a Washington state medical assistance client into, within, or outside the state of Washington, to comply with RCW 18.73.180 regarding stretcher transportation.

[Statutory Authority: RCW 74.04.057, 74.08.090, and 74.09.510. 04-17-118, § 388-546-0800, 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, § 388-546-0800, filed 1/16/01, effective 2/16/01.]

[Statutory Authority: RCW 74.04.057, 74.08.090, and 74.09.510. 04-17-118, § 388-546-0900, filed 8/17/04, effective 9/17/04.]

     (2) Licensed ambulance providers, who contract with ((MAA's)) HRSA's transportation brokers, may be reimbursed for nonemergency transportation services under WAC 388-546-5200 as administrative services.

     (3) ((MAA)) HRSA covers nonemergency transportation under WAC 388-546-5000 through 388-546-5500 as an administrative service as provided by the Code of Federal Regulations (42 CFR 431.53 and 42 CFR 440.170 (a)(2)). As a result, clients may not select the transportation provider(s) or the mode of transportation (service mode).

     (4) Prior authorization by ((MAA)) HRSA is required for all out-of-state nonemergency transportation. Border areas as defined by WAC 388-501-0175 are considered in-state under this section and subsequent sections.

     (a) HRSA reviews requests for out-of-state nonemergency transportation in accordance with regulations for covered healthcare services, including WAC 388-501-0180, 388-501-0182 and 388-501-0184.

     (b) Nonemergency transportation is not provided to or from locations outside of the United States and U.S. territories, except for the limitations for British Columbia, Canada, identified in WAC 388-501-0184.

     (5) ((MAA)) HRSA requires all nonemergency transportation to and from covered services to meet the following:

     (a) The covered service must be medically necessary as defined in WAC 388-500-0005;

     (b) It must be the lowest cost available service mode that is both appropriate and accessible to the client's medical condition and personal capabilities; and

     (c) Be limited to the local provider of type as follows:

     (i) Clients receiving services provided under ((MAA's)) HRSA's fee-for-service program may be transported only to the local provider of type. ((MAA's)) HRSA's transportation broker is responsible for considering and authorizing exceptions.

     (ii) Clients enrolled in ((MAA's)) HRSA's managed care (healthy options) program may be transported to any provider supported by the client's managed care plan. Clients may be enrolled in a managed care plan but are obtaining a specific service not covered under the plan. The requirements in subsection (5)(c)(i) apply to these fee-for-service services.

     (6) ((MAA)) HRSA does not cover nonemergency transportation services if the covered medical services are within three-quarters of a mile walking distance from the client's residence. Exceptions to this rule may be granted by ((MAA's)) HRSA's transportation broker based on the client's documented medical condition or personal capabilities, or based on safety or physical accessibility concerns, as described in WAC 388-546-5400(1).

     (7) A client must use personal or informal transportation alternatives if they are available and appropriate to the client's needs.

     (8) If a fixed-route public transportation service is available to the client within three-quarters of a mile walking distance, the broker may require the client to use the fixed-route public transportation system unless the need for more specialized transportation is present and documented. Examples of such a need are the client's use of a portable ventilator, a walker or a quad cane.

     (9) ((MAA)) HRSA does not cover any nonemergency transportation service that is not addressed in WAC 388-546-1000 or in 388-546-5000 through 388-546-5500. See WAC 388-501-0160 for information about obtaining approval for noncovered transportation services, known as exception to rule (ETR).

     (10) If a medical service is approved by ETR, both the broker and MAA must separately prior approve transportation to that service.

     (11) ((MAA)) HRSA may exempt members of federally recognized Indian tribes from the brokered transportation program. Where ((MAA)) HRSA approves the request of a tribe or a tribal agency to administer or provide transportation services under WAC 388-546-5000 through 388-546-5400, tribal members obtain their transportation services as provided by the tribe or tribal agency.

     (12) A client who is denied service under this chapter may request a fair hearing per chapter 388-02 WAC.

[Statutory Authority: RCW 74.08.090, 74.09.500, 74.04.050, 74.04.055, and 74.04.057. 01-06-029, § 388-546-5100, filed 3/2/01, effective 4/2/01.]

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