Effective Date of Rule: January 1, 2011.

     Purpose: Upon order of the governor, the medicaid purchasing administration (MPA) must reduce its budget expenditures for the current fiscal year ending June 30, 2011, by 6.3%. To achieve this expenditure reduction, MPA is eliminating a number [of] optional medical services from program benefits packages for clients twenty-one years of age and older. These medical services include vision, hearing, and dental care. Sections in chapter 388-501 WAC are being amended to reflect and support these program cuts.

     Citation of Existing Rules Affected by this Order: Amending WAC 388-501-0050, 388-501-0060, 388-501-0065, 388-501-0070, and 388-502-0160.

     Statutory Authority for Adoption: RCW 74.08.090.

     Under RCW 34.05.350 the agency for good cause finds that immediate adoption, amendment, or repeal of a rule is necessary for the preservation of the public health, safety, or general welfare, and that observing the time requirements of notice and opportunity to comment upon adoption of a permanent rule would be contrary to the public interest; that state or federal law or federal rule or a federal deadline for state receipt of federal funds requires immediate adoption of a rule; and that in order to implement the requirements or reductions in appropriations enacted in any budget for fiscal years 2009, 2010, or 2011, which necessitates the need for the immediate adoption, amendment, or repeal of a rule, and that observing the time requirements of notice and opportunity to comment upon adoption of a permanent rule would be contrary to the fiscal needs or requirements of the agency.

     Reasons for this Finding: Governor Gregoire issued Executive Order 10-04 on September 13, 2010, under the authority of RCW 43.88.110(7). In the executive order, the governor required DSHS and all other state agencies to reduce their expenditures in state fiscal year 2011 by approximately 6.3%. As a consequence of the executive order, funding will no longer be available as of January 1, 2011, for the benefits that are being eliminated as part of these regulatory amendments. Delaying the adoption of these cuts to optional services could jeopardize the state's ability to maintain the mandatory medicaid services for the majority of DSHS clients.

     Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

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

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

     Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 5, Repealed 0.

     Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0;      Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 5, Repealed 0.

     Date Adopted: December 23, 2010.

Katherine I. Vasquez

Rules Coordinator

     (((1))) (a) "Benefits package" means the set of healthcare service categories included in a client's eligibility program. See the table in WAC 388-501-0060.

     (b) "Healthcare service categories" means the groupings of healthcare services listed in the table in WAC 388-501-0060. Healthcare service categories are included or excluded depending on the client's benefits package.

     (c) "Covered service" means a specific healthcare service within a service category that the department will pay for when all healthcare program requirements have been met.

     (d) "Noncovered service" means a specific healthcare service within a service category that the department will not pay for. Noncovered services are identified in WAC 388-501-0070 and in specific health-care program rules.

     (2) Healthcare service categories listed in WAC 388-501-0060 do not represent a contract for healthcare services.

     (((2))) (3) For the provider to receive payment, the client must be eligible for the covered healthcare service on the date the healthcare service is performed or provided.

     (((3))) (4) Under the department's fee-for-service programs, providers must be enrolled with the department and meet the requirements of chapter 388-502 WAC to be paid for furnishing healthcare services to clients.

     (((4))) (5) The department pays only for the healthcare services that are:

     (a) ((Within the scope of)) Included in the client's ((medical program)) healthcare benefits package as described in WAC 388-501-0060;

     (b) Covered - see subsection (((9))) (10) of this section;

     (c) Ordered or prescribed by a healthcare provider who meets the requirements of chapter 388-502 WAC;

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

     (e) Submitted for authorization, when required, in accordance with WAC 388-501-0163;

     (f) Approved, when required, in accordance with WAC 388-501-0165;

     (g) Furnished by a provider according to chapter 388-502 WAC; and

     (h) Billed in accordance with department program rules and the department's current published billing instructions and numbered memoranda.

     (((5))) (6) The department does not pay for any healthcare service requiring prior authorization from the department, if prior authorization was not obtained before the healthcare service was provided; unless:

     (a) The client is determined to be retroactively eligible for medical assistance; and

     (b) The request meets the requirements of subsection (4) of this section.

     (((6))) (7) The department does not reimburse clients for healthcare services purchased out-of-pocket.

     (((7))) (8) The department does not pay for the replacement of department-purchased equipment, devices, or supplies which have been sold, gifted, lost, broken, destroyed, or stolen as a result of the client's carelessness, negligence, recklessness, or misuse unless:

     (a) Extenuating circumstances exist that result in a loss or destruction of department-purchased equipment, devices, or supplies, through no fault of the client that occurred while the client was exercising reasonable care under the circumstances; or

     (b) Otherwise allowed under chapter 388-500 WAC.

     (((8))) (9) The department's refusal to pay for replacement of equipment, device, or supplies will not extend beyond the limitations stated in specific department program rules.

     (((9))) (10) Covered healthcare services

     (a) Covered healthcare 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 healthcare service for medicaid clients; or

     (ii) "State-option" - means the state of Washington is not federally mandated to cover the healthcare 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 healthcare services. Limitation extensions are authorized according to WAC 388-501-0169.

     (((10))) (11) Noncovered healthcare services

     (a) The department does not pay for any healthcare service((:

     (i) That federal or state laws or regulations prohibit the department from covering; or

     (ii))) listed as noncovered in WAC 388-501-0070 or in any other program rule. The department evaluates a request for a noncovered healthcare service only if an exception to rule is requested according to the provisions in WAC 388-501-0160.

     (b) When a noncovered healthcare service is recommended during the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) exam and then ordered by a provider, the department evaluates the healthcare service 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. 10-07-116, § 388-501-0050, filed 3/22/10, effective 4/22/10. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. 09-23-112, § 388-501-0050, filed 11/18/09, effective 12/19/09; 06-24-036, § 388-501-0050, filed 11/30/06, effective 1/1/07. 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.]

*Clients enrolled in the State Children's Health Insurance Program and the Children's Health Program receive CN scope of medical care)) This rule provides a table that lists:

     (a) The categorically needy (CN) medicaid, medically needy (MN) medicaid, and medical care services (MCS) programs; and

     (b) The benefits packages showing what service categories are included for each program.

     (2) Within a service category included in a benefits package, some services may be covered and others noncovered.

     (3) Services covered within each service category included in a benefits package:

     (a) Are determined, in accordance with WAC 388-501-0050 and 388-501-0055 when applicable.

     (b) May be subject to limitations, restrictions, and eligibility requirements contained in department rules.

     (c) May require prior authorization (see WAC 388-501-0165), or expedited authorization when allowed by the department.

     (d) 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) Other programs:

     (a) Early and periodic screening, diagnosis, and treatment (EPSDT) services are not addressed in the table. For EPSDT services, see chapter 388-534 WAC and WAC 388-501-0050(10).

     (b) Alien emergency medical (AEM) services are not addressed in the table. For AEM services, see chapter 388-438 WAC.

     (6) Scope of service categories. The following table lists the department's categories of healthcare services.

     (a) Under the CN and MN headings there are two columns - one addressing clients twenty years of age and younger and the other addresses clients twenty-one years of age and older.

     (b) Under the MCS heading, "DL" refers to the disability lifeline medical program.

     (c) The letter "I" means a service category is included for that program. Services within each service category are subject to limitations and restrictions listed in the specific medical assistance program WAC and department issuances.

     (d) The letter "E" means a service category is excluded under that program.

     (e) Refer to WAC 388-501-0065 for a description of each service category and for the specific program WAC containing the limitations and restrictions to services.

Service Categories	CN1		MN		MCS
	20-	21+	20-	21+	DL
Adult day health	I	I	I2	E	E
Ambulance (ground and air)	I	I	I	I	I
Blood processing / administration	I	I	I	I	I
Dental services	I	E	I	E	E
Detoxification	I	I	I	I	I
Diagnostic services (lab & x-ray)	I	I	I	I	I
Healthcare professional services	I	I	I	I	I
Hearing evaluations	I	I	I	I	I
Hearing aids	I	E	I	E	E
Home health services	I	I	I	I	I
Hospice services	I	I	I	I	I
Hospital services - inpatient/outpatient	I	I	I	I	I
Intermediate care facility/services for mentally retarded	I	I	I	I	I
Maternity care and delivery services	I	I	I	I	E
Medical equipment, durable (DME)	I	I	I	I	I
Medical equipment, nondurable (MSE)	I	I	I	I	I
Medical nutrition services	I	I	I	I	I
Mental health services:
• inpatient care	I	I	I	I	I
• outpatient community mental health services	I	I	I	I	I3
• psychiatrist visits	I	I	I	I	I4
• medication management	I	I	I	I	I
Nursing facility services	I	I	I	I	I
Organ transplants	I	I	I	I	I
Out-of-state services	I	I	I	I	E
Oxygen/respiratory services	I	I	I	I	I
Personal care services	I	I	E	E	E
Prescription drugs	I	I	I	I	I
Private duty nursing	I	I	I	I	E
Prosthetic/orthotic devices	I	I	I	I	I
Psychological evaluation5	I	I	I	I	E
Reproductive health services (includes family planning and TAKE CHARGE	I	I	I	I	I
Substance abuse services	I	I	I	I	I
Therapy - occupational, physical, and speech	I	I	I	I	I
Vision care - exams, refractions, and fittings	I	I	I	I	I
Vision - frames and lenses	I	E	I	E	E
1 Clients enrolled in the children's health insurance program and the apple health for kids program receive CN-scope of medical care.
2 Restricted to 18-20 year olds.
3 Restricted to DL clients enrolled in managed care.
4 DL clients can receive one psychiatric diagnostic evaluation per year and eleven monthly visits per year for medication management.
5 Only two allowed per lifetime.

.

[Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. 06-24-036, § 388-501-0060, filed 11/30/06, effective 1/1/07.]

     Reviser's note: RCW 34.05.395 requires the use of underlining and deletion marks to indicate amendments to existing rules. The rule published above varies from its predecessor in certain respects not indicated by the use of these markings.

     Reviser's note: The typographical 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 06-24-036, filed 11/30/06, effective 1/1/07)

WAC 388-501-0065   Healthcare coverage -- Description of ((covered)) categories of service.   This rule provides a brief description of the medical, dental, mental health, and substance abuse service categories listed in the table in WAC 388-501-0060. The description of services under each category is not intended to be all inclusive.

     (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, restrictions, 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 388-71-0776])) A supervised daytime program providing skilled nursing and rehabilitative therapy services in addition to the core services of adult day care. Adult day health services are for adults with medical or disabling conditions that require the intervention or services of a registered nurse or licensed rehabilitative therapist acting under the supervision of the client's physician or ARNP. [WAC 388-71-0706, 388-71-0710, 388-71-0712, 388-71-0714, 388-71-0720, 388-71-0722, 388-71-0726 and 388-71-0758]

     (b) Ambulance -- Emergency medical transportation and ambulance transportation for nonemergency medical needs. [WAC 388-546-0001 through 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 388-550-1500]

     (d) Dental services -- Diagnosis and treatment of dental problems including emergency treatment and preventive care. [Chapters 388-535 and 388-535A WAC]

     (e) Detoxification -- Inpatient treatment performed by a certified detoxification center or in an inpatient hospital setting. [WAC 388-800-0020 through 388-800-0035; and 388-550-1100]

     (f) Diagnostic services -- Clinical testing and imaging services. [WAC 388-531-0100; 388-550-1400 and 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))) (h) Hearing ((care)) evaluations -- Audiology; diagnostic evaluations; hearing exams and testing((; and hearing aids)). [WAC ((388-544-1200 and 388-544-1300; 388-545-700; and)) 388-531-0100 and 388-531-0375]

     (i) Hearing aids--[chapter 388-547 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 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 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, family planning services and community health worker visits. [WAC ((388-533-0330)) 388-533-0300]

     (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. [Chapters 388-553 and 388-554 WAC]

     (r) Mental health services -- ((Inpatient and outpatient psychiatric services and community mental health services. [Chapter 388-865 WAC])) Crisis mental health services are available to state residents through the regional support networks (RSNs).

     (i) Inpatient care--Voluntary and involuntary admissions for psychiatric services. [WAC 388-550-2600]

     (ii) Outpatient (community mental health) services--Nonemergency, nonurgent counseling. [WAC 388-531-1400, 388-865-0215, and 388-865-0230]

     (iii) Psychiatrist visits--[WAC 388-531-1400 and 388-865-0230]

     (iv) Medication management--[WAC 388-531-1400]

     (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 388-550-2000, and 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 388-501-0180; 388-531-1100; and 388-556-0500])) See WAC 388-502-0120 for payment of services out-of-state.

     (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, [388-106-]0300, [388-106-]0400, [388-106-]0500, [388-106-]0600, [388-106-]0700, [388-106-]0720 and [388-106-]0900)) 388-106-0010, 388-106-0200, 388-106-0300, 388-106-0400, 388-106-0500, 388-106-0700, 388-106-0720 and 388-106-0745]

     (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 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))) Psychological evaluation--Complete diagnostic history, examination, and assessment, including the testing of cognitive processes, visual motor responses, and abstract abilities. [WAC 388-865-0610]

     (bb) Reproductive health services--Gynecological exams; contraceptives, drugs, and supplies, including prescriptions; sterilization; screening and treatment of sexually transmitted diseases; and educational services. [WAC 388-532-530]

     (cc) Substance abuse services -- Chemical dependency assessment, case management services, and treatment services. [WAC 388-533-0701 through 388-533-0730; 388-556-0100 and 388-556-0400; and 388-800-0020]

     (((cc))) (dd) Therapy -- Occupational/physical/speech -- Evaluations, assessments, and treatment. [WAC ((388-545-300, 388-545-500, and 388-545-700)) 388-531-1725 and chapter 388-545 WAC]

     (((dd))) (ee) Vision care -- Eye exams, refractions, ((frames, lenses)) fittings, visual field testing, vision therapy, ocular prosthetics, and surgery. [WAC ((388-544-0250 through 388-544-0550)) 388-531-1000]

     (ff) Vision hardware - frames and lenses--[Chapter 388-544 WAC]

[Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. 06-24-036, § 388-501-0065, filed 11/30/06, effective 1/1/07.]

     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 09-23-112, filed 11/18/09, effective 12/19/09)

WAC 388-501-0070   Healthcare coverage -- Noncovered services.   (1) The department does not pay for any healthcare service not listed or referred to as a covered healthcare service under the medical programs described in WAC 388-501-0060, regardless of medical necessity. For the purposes of this section, healthcare services includes treatment, equipment, related supplies, and drugs. Circumstances in which clients are responsible for payment of healthcare services are described in WAC 388-502-0160.

     (2) This section does not apply to healthcare services provided as a result of the early and periodic screening, diagnosis, and treatment (EPSDT) program as described in chapter 388-534 WAC.

     (3) The department does not pay for any ancillary healthcare service(s) provided in association with a noncovered healthcare service.

     (4) The following list of noncovered healthcare services is not intended to be exhaustive. Noncovered healthcare services include, but are not limited to:

     (a) Any healthcare service specifically excluded by federal or state law;

     (b) Acupuncture, Christian Science practice, faith healing, herbal therapy, homeopathy, massage, massage therapy, naturopathy, and sanipractice;

     (c) Chiropractic care for adults;

     (d) Cosmetic, reconstructive, or plastic surgery, and any related healthcare services, not specifically allowed under WAC 388-531-0100(4).

     (e) Discography;

     (f) Ear or other body piercing;

     (g) Face lifts or other facial cosmetic enhancements;

     (h) Fertility, infertility or sexual dysfunction testing, and related care, drugs, and/or treatment including but not limited to:

     (i) Artificial insemination;

     (ii) Donor ovum, sperm, or surrogate womb;

     (iii) In vitro fertilization;

     (iv) Penile implants;

     (v) Reversal of sterilization; and

     (vi) Sex therapy.

     (i) Gender reassignment surgery and any surgery related to trans-sexualism, gender identity disorders, and body dysmorphism, and related healthcare services or procedures, including construction of internal or external genitalia, breast augmentation, or mammoplasty;

     (j) Hair transplants, epilation (hair removal), and electrolysis;

     (k) Marital counseling;

     (l) Motion analysis, athletic training evaluation, work hardening condition, high altitude simulation test, and health and behavior assessment;

     (m) Nonmedical equipment;

     (n) Penile implants;

     (o) Prosthetic testicles;

     (p) Psychiatric sleep therapy;

     (q) Subcutaneous injection filling;

     (r) Tattoo removal;

     (s) Transport of Involuntary Treatment Act (ITA) clients to or from out-of-state treatment facilities, including those in bordering cities;

     (t) Upright magnetic resonance imaging (MRI); and

     (u) Vehicle purchase - new or used vehicle.

     (5) For a specific list of noncovered healthcare services in the following service categories, refer to the WAC citation:

     (a) Ambulance transportation and nonemergent transportation as described in chapter 388-546 WAC;

     (b) Dental services for clients twenty years of age and younger as described in chapter 388-535 WAC;

     (c) ((Dental services for clients twenty-one years of age and older as described in chapter 388-535 WAC;

     (d))) Durable medical equipment as described in chapter 388-543 WAC;

     (((e))) (d) Hearing ((care services)) aids for clients twenty years of age and younger as described in chapter 388-547 WAC;

     (((f))) (e) Home health services as described in WAC 388-551-2130;

     (((g))) (f) Hospital services as described in WAC 388-550-1600;

     (((h))) (g) Physician-related services as described in WAC 388-531-0150;

     (((i))) (h) Prescription drugs as described in chapter 388-530 WAC; ((and))

     (((j))) (i) Vision care ((services)) hardware for clients twenty years of age and younger as described in chapter 388-544 WAC; and

     (j) Vision care exams as described in WAC 388-531-1000.

     (6) A client has a right to request an administrative hearing, if one is available under state and federal law. When the department denies all or part of a request for a noncovered healthcare service(s), the department sends the client and the provider written notice, within ten business days of the date the decision is made, that includes:

     (a) A statement of the action the department intends to take;

     (b) Reference to the specific WAC provision upon which the denial is based;

     (c) Sufficient detail to enable the recipient to:

     (i) Learn why the department's action was taken; and

     (ii) Prepare a response to the department's decision to classify the requested healthcare service as noncovered.

     (d) The specific factual basis for the intended action; and

     (e) The following information:

     (i) Administrative hearing rights;

     (ii) Instructions on how to request the hearing;

     (iii) Acknowledgement that a client may be represented at the hearing by legal counsel or other representative;

     (iv) Instructions on how to request an exception to rule (ETR);

     (v) Information regarding department-covered healthcare services, if any, as an alternative to the requested noncovered healthcare service; and

     (vi) Upon the client's request, the name and address of the nearest legal services office.

     (7) A client can request an exception to rule (ETR) as described in WAC 388-501-0160.

[Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. 09-23-112, § 388-501-0070, filed 11/18/09, effective 12/19/09; 07-04-036, § 388-501-0070, filed 1/29/07, effective 3/1/07.]

     (a) Fee-for-service or managed care clients can choose to self-pay for medical assistance services; and

     (b) Providers (as defined in WAC 388-500-0005) have the authority to bill fee-for-service or managed care clients for medical assistance services furnished to those clients.

     (2) The provider is responsible for:

     (a) Verifying whether the client is eligible to receive medical assistance services on the date the services are provided;

     (b) Verifying whether the client is enrolled with a department-contracted managed care organization (MCO);

     (c) Knowing the limitations of the services within the scope of the eligible client's medical program (see WAC 388-501-0050 (4)(a) and 388-501-0065);

     (d) Informing the client of those limitations;

     (e) Exhausting all applicable department or department-contracted MCO processes necessary to obtain authorization for requested service(s);

     (f) Ensuring that translation or interpretation is provided to clients with limited English proficiency (LEP) who agree to be billed for services in accordance with this section; and

     (g) Retaining all documentation which demonstrates compliance with this section.

     (3) Unless otherwise specified in this section, providers must accept as payment in full the amount paid by the department or department-contracted MCO for medical assistance services furnished to clients. See 42 CFR § 447.15.

     (4) A provider must not bill a client, or anyone on the client's behalf, for any services until the provider has completed all requirements of this section, including the conditions of payment described in department's rules, the department's fee-for-service billing instructions, and the requirements for billing the department-contracted MCO in which the client is enrolled, and until the provider has then fully informed the client of his or her covered options. A provider must not bill a client for:

     (a) Any services for which the provider failed to satisfy the conditions of payment described in department's rules, the department's fee-for-service billing instructions, and the requirements for billing the department-contracted MCO in which the client is enrolled.

     (b) A covered service even if the provider has not received payment from the department or the client's MCO.

     (c) A covered service when the department denies an authorization request for the service because the required information was not received from the provider or the prescriber under WAC 388-501-0165 (7)(c)(i).

     (5) If the requirements of this section are satisfied, then a provider may bill a fee-for-service or a managed care client for a covered service, defined in WAC ((388-501-0050(9))) 388-501-0050(10), or a noncovered service, defined in WAC ((388-501-0050(10))) 388-501-0050(11) and 388-501-0070. The client and provider must sign and date the DSHS form 13-879, Agreement to Pay for Healthcare Services, before the service is furnished. DSHS form 13-879, including translated versions, is available to download at http://www1.dshs.wa.gov/msa/forms/eforms.html. The requirements for this subsection are as follows:

     (a) The agreement must:

     (i) Indicate the anticipated date the service will be provided, which must be no later than ninety calendar days from the date of the signed agreement;

     (ii) List each of the services that will be furnished;

     (iii) List treatment alternatives that may have been covered by the department or department-contracted MCO;

     (iv) Specify the total amount the client must pay for the service;

     (v) Specify what items or services are included in this amount (such as pre-operative care and postoperative care). See WAC 388-501-0070(3) for payment of ancillary services for a noncovered service;

     (vi) Indicate that the client has been fully informed of all available medically appropriate treatment, including services that may be paid for by the department or department-contracted MCO, and that he or she chooses to get the specified service(s);

     (vii) Specify that the client may request an exception to rule (ETR) in accordance with WAC 388-501-0160 when the department denies a request for a noncovered service and that the client may choose not to do so;

     (viii) Specify that the client may request an administrative hearing in accordance with WAC 388-526-2610 to appeal the department's denial of a request for prior authorization of a covered service and that the client may choose not to do so;

     (ix) Be completed only after the provider and the client have exhausted all applicable department or department-contracted MCO processes necessary to obtain authorization of the requested service, except that the client may choose not to request an ETR or an administrative hearing regarding department denials of authorization for requested service(s); and

     (x) Specify which reason in subsection (b) below applies.

     (b) The provider must select on the agreement form one of the following reasons (as applicable) why the client is agreeing to be billed for the service(s). The service(s) is:

     (i) Not covered by the department or the client's department-contracted MCO and the ETR process as described in WAC 388-501-0160 has been exhausted and the service(s) is denied;

     (ii) Not covered by the department or the client's department-contracted MCO and the client has been informed of his or her right to an ETR and has chosen not to pursue an ETR as described in WAC 388-501-0160;

     (iii) Covered by the department or the client's department-contracted MCO, requires authorization, and the provider completes all the necessary requirements; however the department denied the service as not medically necessary (this includes services denied as a limitation extension under WAC 388-501-0169); or

     (iv) Covered by the department or the client's department-contracted MCO and does not require authorization, but the client has requested a specific type of treatment, supply, or equipment based on personal preference which the department or MCO does not pay for and the specific type is not medically necessary for the client.

     (c) For clients with limited English proficiency, the agreement must be the version translated in the client's primary language and interpreted if necessary. If the agreement is translated, the interpreter must also sign it;

     (d) The provider must give the client a copy of the agreement and maintain the original and all documentation which supports compliance with this section in the client's file for six years from the date of service. The agreement must be made available to the department for review upon request; and

     (e) If the service is not provided within ninety calendar days of the signed agreement, a new agreement must be completed by the provider and signed by both the provider and the client.

     (6) There are limited circumstances in which a provider may bill a client without executing DSHS form 13-879, Agreement to Pay for Healthcare Services, as specified in subsection (5) of this section. The following are those circumstances:

     (a) The client, the client's legal guardian, or the client's legal representative:

     (i) Was reimbursed for the service directly by a third party (see WAC 388-501-0200); or

     (ii) Refused to complete and sign insurance forms, billing documents, or other forms necessary for the provider to bill the third party insurance carrier for the service.

     (b) The client represented himself/herself as a private pay client and not receiving medical assistance when the client was already eligible for and receiving benefits under a medical assistance program. In this circumstance, the provider must:

     (i) Keep documentation of the client's declaration of medical coverage. The client's declaration must be signed and dated by the client, the client's legal guardian, or the client's legal representative; and

     (ii) Give a copy of the document to the client and maintain the original for six years from the date of service, for department review upon request.

     (c) The bill counts toward the financial obligation of the client or applicant (such as spenddown liability, client participation as described in WAC 388-513-1380, emergency medical expense requirement, deductible, or copayment required by the department). See subsection (7) of this section for billing a medically needy client for spenddown liability;

     (d) The client is under the department's or a department-contracted MCO's patient review and coordination (PRC) program (WAC 388-501-0135) and receives nonemergency services from providers or healthcare facilities other than those to whom the client is assigned or referred under the PRC program;

     (e) The client is a dual-eligible client with medicare Part D coverage or similar creditable prescription drug coverage and the conditions of WAC 388-530-7700 (2)(a)(iii) are met;

     (f) The services provided to a TAKE CHARGE or family planning only client are not within the scope of the client's benefit package;

     (g) The services were noncovered ambulance services (see WAC 388-546-0250(2));

     (h) A fee-for-service client chooses to receive nonemergency services from a provider who is not contracted with the department after being informed by the provider that he or she is not contracted with the department and that the services offered will not be paid by the client's healthcare program; ((and))

     (i) A department-contracted MCO enrollee chooses to receive nonemergency services from providers outside of the MCO's network without authorization from the MCO, i.e., a nonparticipating provider; and

     (j) The service is within a service category excluded from the client's benefits package. See WAC 388-501-0060.

     (7) Under chapter 388-519 WAC, an individual who has applied for medical assistance is required to spend down excess income on healthcare expenses to become eligible for coverage under the medically needy program. An individual must incur healthcare expenses greater than or equal to the amount that he or she must spend down. The provider is prohibited from billing the individual for any amount in excess of the spenddown liability assigned to the bill.

     (8) There are situations in which a provider must refund the full amount of a payment previously received from or on behalf of an individual and then bill the department for the covered service that had been furnished. In these situations, the individual becomes eligible for a covered service that had already been furnished. Providers must then accept as payment in full the amount paid by the department or managed care organization for medical assistance services furnished to clients. These situations are as follows:

     (a) The individual was not receiving medical assistance on the day the service was furnished. The individual applies for medical assistance later in the same month in which the service was provided and the department makes the individual eligible for medical assistance from the first day of that month;

     (b) The client receives a delayed certification for medical assistance as defined in WAC 388-500-0005; or

     (c) The client receives a certification for medical assistance for a retroactive period according to 42 CFR § 435.914(a) and defined in WAC 388-500-0005.

     (9) Regardless of any written, signed agreement to pay, a provider may not bill, demand, collect, or accept payment or a deposit from a client, anyone on the client's behalf, or the department for:

     (a) Copying, printing, or otherwise transferring healthcare information, as the term healthcare information is defined in chapter 70.02 RCW, to another healthcare provider. This includes, but is not limited to:

     (i) Medical/dental charts;

     (ii) Radiological or imaging films; and

     (iii) Laboratory or other diagnostic test results.

     (b) Missed, cancelled, or late appointments;

     (c) Shipping and/or postage charges;

     (d) "Boutique," "concierge," or enhanced service packages (e.g., newsletters, 24/7 access to provider, health seminars) as a condition for access to care; or

     (e) The price differential between an authorized service or item and an "upgraded" service or item (e.g., a wheelchair with more features; brand name versus generic drugs).

[Statutory Authority: RCW 74.08.090. 10-19-057, § 388-502-0160, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090 and 42 C.F.R. 447.15. 10-10-022, § 388-502-0160, filed 4/26/10, effective 5/27/10. Statutory Authority: RCW 74.08.090, 74.09.055, 2001 c 7, Part II. 02-12-070, § 388-502-0160, filed 5/31/02, effective 7/1/02. Statutory Authority: RCW 74.08.090. 01-21-023, § 388-502-0160, filed 10/8/01, effective 11/8/01; 01-05-100, § 388-502-0160, filed 2/20/01, effective 3/23/01. Statutory Authority: RCW 74.08.090 and 74.09.520. 00-14-069, § 388-502-0160, filed 7/5/00, effective 8/5/00.]

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